Fourth Edition

Rehabilitation

Techniques for

Sports Medicine

and Athletic Training

William E. Prentice,Ph.D.,P.T.,A.T.C.
Professor. Coordinator of the Sports Medicine Program

Department of Exercise and Sport Science

Clinical Professor, Division of Physical Therapy

Department of Medical Allied Professions

Associate Professor of Orthopedics

School of Medicine

The University of North Carolina

Chapel Hill, North Carolina

Boston Burr Ridge, IL Dubuque, IA Madison, WI New York

Sa n Francisco St. Louis Bangkok Bogota Caracas Kuala Lumpur

Lisbon London Madrid Mexico City Milan Montreal New Delhi

Santiago Seou l Singapore Sydney Ta ipei Toronto

 The McGraw'HiII Companies •

II
REHABlLlTATlONTECHNIQUES FOR SPORTS MEDICINE AND ATHLETIC TRAINING.
FOURTH EDITTON

Published by McGraw-Hill. a business unit of The McGraw-Hill Companies. Inc .. 1221 Avenue
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This book is printed on acid-free paper.

1234567890 QPF/QPF 0 98 76543 2

ISBN 0-07-246210-8
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Vice presid ent and editor-in-chief: Thalia Dorwick
Publisher: Jane E. Karpacz
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Library or Congress Cataloging-in-Publication Data

Prentice. William E. 8
Rehabilitation techniques for sports medicine and ath letic training / William E. Prentice.­
4th ed .
p.cm .

Includes bibliographica[ references and index.

9
ISB:-.I 0-07-246210-8 (alk. paper)

1. Sports injuries-Patients-Rehabilitation. 1. Tit[e

RD97.P7382 004
617.1·027--dc21 PART
2003042208

This text was based on the most up-to-date research and suggestions made by individuals
knowledgeable in the field of athletic training. The authors and publisher disclaim any
responsibility for any adverse effects or consequences from the misapplication or injudicious 10
use of information contained within this text. It is also accepted as judicious that the coach
and / or athletic trainer performing his or her duties is. at all limes. working under the guidance
of a licensed physician.

wlVw.rnhhe.com
:~...!:.(7 ...:'''' ;
 Brief Contents

PART ONE The Basis ofInjury Rehabilitation 11 Plyometrics in Rehabilitation 22 5

12 Open- versus Closed-Kinetic-Chain Exercise

in Rehabilitation 242

1 Essential Considerations in Designing a

13 Isokinetics in Rehabilitation 263

Rehabilitation Program for the Injured

14 JOint Mobilization and Traction Techniques

Athlete 2
in Rehabilitation 276

2 Understanding and Managing the Healing

15 PNF and Other Soft-Tissue Mobilization

Process through Rehabilitation 17

Techniques in Rehabilitation 303

3 The Evaluation Process in

16 Aquatic Therapy in Rehabilitation 326

Rehabilitation 48
17 Functional Progressions and Functional

4 Psychological Considerations for Rehabilita­

Testing in Rehabilitation 347

tion of the Injured Athlete 73

PART TWO Achieving the Goals ofRehabilitation PART FOUR Rehabilitation Techniques for
.Specific Injuries
5 Reestablishing Neuromuscular Control 100

6 Restoring Range of Motion and Improving

18 Rehabilitation of Shoulder Injuries 368

Flexibility 121
19 Rehabilitation of Elbow Injuries 419

7 Regaining Muscular Strength, Endurance,

20 Rehabilitation of Wrist, Hand, and Finger

and Power 13 8
Injuries 452

8 Regaining Postural Stability and Balance

21 Rehabilitation of Groin, Hip, and Thigh

156
Injuries 485

9 Maintaining Cardiorespiratory Fitness dur­

22 Rehabilitation of Knee Injuries 526

ing Rehabilitation 186

23 Rehabilitation of Lower-Leg Injuries 579

24 Rehabilitation of Ankle and Foot

Injuries 608

PART THREE The Tools of Rehabilitation 25 Rehabilitation of Injuries to the Spine 649

Glossary 692

10 Core Stabilization Training in

Index 697

Rehabilitation 200

THE UBRARY III

UNIVERSITY OF weST FLORIDA

 Contents
6

Documentiug Findings - 66

PART ONE The Basis ofInjuryRehabilitation Summary-70

1 Essential Coo.s iderations in Designing a Rehabili­ 4 Psychological Considerations for Rehabilitatio n of

tntion Program for the Injured Ath lete the Injured Athlete

William E. Prm/ice Elizabeth G. Hedgpeth

The Rehabil itation Team - 2

Joc Gieck 7
The Philosophy of Sport, lI.l\edicinc Rehabilitation - 4 Acculturation -74

Establishing Short- and Long-Term Goals in a Predictors of Injury - 75

Rehabilitation Program - 6 Progressive Reactions Depend on Length of

Documentation in Rehabilit.ation -14 Rehabilitation - 78

Legal Considerations in Supervising a Rehabilitation Dealing with Short-Term Injury - 78

Program- r 5
Dealing with Long-Term Injury - 80

Summary - IS
Dealing with Chronic Injury - 85

Deali ng with a Career-Ending InJury- 87

Compliance and Adherence to Rehabilitation - 88

Pain as a Deterrent to Compliance - 90

2 Understanding and Managing the Healing

Return to Competition - 92

Process through Rehabi litation

Interpersonal Relationship between Athlete and

William H. Prenlice Athletic Trainer - 93

Understanding the Healing Process - 18 Summary-95

Pathophysiology of Injury to Variolls Body Tissues - 25

Ligamen t Sprains - 28
Fractures of Bone - 30 PART TWO Achievinij :the Goals ofRehabilitation
Cartilage Damage - 32
Injuries to Musculotendinous Structures - 33
Injury to Nerve Tissue - 37 5 Reestablishing Neuromuscular Control
Additional Musculoskeletallnjuries - 38 Scott Lephu rt
Managing the Healing Process through C. BLiZ S\IIanik
8
Rehabilitation - 40
Freddie FLI

Using Medications to Effect the Healing Process - 41

The Sports Medicine Approach to the Healing Kellie Huxe/

Process-43
"'''by Is Neuromuscular Control Critical to the
Summary-44
Rehabilitation Process? - lOO

What Is Neuromuscular Control ? -1 02

The Physiology of Mechanoreceptors - ] 02

eural Pathways of Peripheral Afferents - 103

3 The Evaluation Process in Rehab ilitation

Feed-Forw(lrd and Feedback Neuromuscular Control ­
Dari'l A. Padua 103

The Systematic Differential Eva luation Process - 49 Reestablishing Neuromuscular Control- 104

Injury Preven tion Screening - 65 Summary - 115

iv

6 Restoring Range of r-.,lotion and Improving
Flexibility
William E, Prentice
The Importance of Flexibility to the Athlete - 121
An,a tomic Factors Ihat Limit Flexibility - 122
Active and Passive Range of Molion -123
Stretching Techniques - 124
Speciflc Stretching Exercises - 127
Neurophysiological Basis of Stretching - 130
The Effects of Stretching on the Physical and
Mechanical Properties of Muscle -132
The E[kcts of Stretching on tbe Kinetic Chain -13 2
Tbe Impor tance of Wa rm-Up Prior to Stretching - 133
The Relationship between St rength and FlexibiUty -13 3
Guidelines and Precautions for Stretching - 134
lUtti n of Summary - 1 34
7 Regaining Muscular Strength. Endurance,
and Power
William E, Prentice
\\Thy Is Regaining Strength, Endurance, and Power
Essential to the Rehabilitation Process? -138
Types of Skeletal Muscle Contraction - 139
Faclors That Determine Levels of Muscular Strength,
Endurance, and Power - 139
The Physiology of Strength Development-141
Techniques of Resistance Training - 142
Core Stabil.ization Strengthening - 150
Open- versus Closed-Kinetic-Chain Exercises - 151
eand Training for Muscular Strength versus Muscular
Endurance-lSI
Resistance Training Differences between Males and
Females - 151
ilitation Resistance Training in tbe Young Athlete - 152
Specific Resistive Exercises Used in Rehabilitation - 152
Summary - 152
8 Regaining Postural Stability and Balance
Kevin M. Guskiewicz
The Postural Control Sys tem - 157
Control of Balance - 157
the Somatosensation as It Relates to Balance - 159
Balance as It Relates to the Closed Kinetic Cbain - 160
Balance Disruption - 160
- 10 ~ Assessment of Balance -161
-103 Injury and Balance -1 66
arC ntrol­ Balance Training -168
Clinical Value of High-Tech Training and Assessment­
-104 179
Using Closed-Kinetic-Ohain Exercises to Regain
Summary - 180
Neuromuscular Control- 244
Contents V
9 Maintaining Cardiorespiratory Fitness during
Rehabilitation
William E, Prentice
Why Is It Important 10 Maintain Cardiorespiratory
Fitness during the Rehabilitation Process? -186
Training Effects on the Cardiorespiratory System - 187
Maximal Aerobic Capacity -1 89
Producing Energy for Exercise - 190
Techniques for Maintaining Cardiorespiratory
Endurance - 191
Summary-194
PART THREE The Tools of Rehabilitation
10 Core Stabilization Training in Rehabilitation
Mike Clark
What Is the Core? - 201
Core Stabilization Training Concepts - 201
Review of Functional Anatomy - 202
Postural Considerations - 206
Muscular Imbalances - 207
Neurom uscular Considerations - 207
Assessment of the Core - 208
Scientific Rationale for Core Stabilization Training - 209
Guidelines for Core Stabilization Training - 210
Core Stabilization Training Program - 21 J
Summary - 221
11 Plyometrics in Rehabilitation
Steve Tippett
Michael Voigllt
What Is Plyometric Exercise? - 22 5
Biomechanical and Physiologica l PrinCiples of
Plyomelric Training - 226
Program Development - 229
Plyometric Program Design - 231
Guidelines for Plyometric Programs - 233
Integrating Plyometrics into the Rehabilitation
Program: Clinical Concerns - 235
Summary - 238
12 Open- versus Closed-Kinetic-Chain Exercise in
Rehabilitation
William E, Prentice
The Concept of the Kinetic Cbain - 243
Advantages and Disadvantages of Open- versus Closed­
Kinetic-Chain Exercises - 244
vi Contents

Biomechanics of Open- versus Closed-Kinetic-Chain Advantages and Benefits of Aquatic

Activities in the Lower Extremity - 245 Rehabilitation - 331

Closed-Kinetic-Chain Exercises for Rehabilitation of Disadvantages of Aquatic Rehabilitation - 333

Lower-Extremity Injuries - 247 Facilities and Equipment - 334

Biomechanics of Open- versus Closed-Kinetic-Chain AquaticTechniques- 335

Activities in the Up per ~xtremity - 253 Special Techniques - 342

2
Open- and Closed-Kinelic-Chain Exercises for Conclusions - 343

Rehabilitation of Upper-Extremity Injuries - 254 Summary - 344

Summary-259
17 Functional Progressions and Functional Testing
in Rehabilitation
13 Isokinetics in Rehabilitation MiclJael McGee
Janine Omall The Role of Functional Progressions in
[sokinetic Exercise - 263
Rehabilitation - 348

Isokinetic Dynamometers - 264

Benellts of Using Functional Progressions - 348

Isokinetic Eva.iuation - 266

Psychological and Social Considerations - 349

Isokioctic Training - 271

Components of a Functional Progress ion - 350

Sample Progression - 272

Designing a Functional Progression - 351

Summary - 272
Functional Testing - 352

Examples of Functional Progressions and Testing - 353

Carolina Functional Performance Index (CFPI) - 364

14 Joint Mobilization and Traction Techniques Conclusion - 365

in Rehabilitation Summary - 365

William E. Prentice
The Relationship between Physiological and Accessory
Motions-277
Rehabilitation Techniques for
Joint Arthrokinematics - 277
Joint Positions - 278
PART FOUR Specific Injuries
Joint Mobilization Techniques - 279
Joint Traction Techniques - 284 18 Rehabilitation of Shoulder Injuries
Mobilization and Traction Techniques - 285
Rob Schneider

Summary - 300
William E. Prentice

Functional Anatomy and Biomechanics - 368

15 PNF and Other Soft-Tissue Mobilization Tech­ Rehabilitation Techniques for the Shoulder - 379

niques in Rehabilitation Rehabilitation Techniques for Specific Injuries - 392

Summary-414

William E. Prel1tice
Proprioceptive Neuromuscular Facilitation - 304 19 Rehabilitation of Elbow Injuries
The Neurophysiological Basis of PNF - 304
Pete Llilia

Techniques of PNF - 307

Muscle Energy Techniques - 31. 9 William E. Prentice

Strain-Counterstrain Technique - 320 Functional Anatomy and Biomech anics - 419

Positional Release Therapy - 321 Rehabilitation Techniques for the Elbow Complex - 423

Ac.tive Release Technique - 321 Rehabilit ation Techniques for Specific Injuries - 434

Sports Massage - 322 Aquatic Therapy Techniques to Assist in the

Summary - 323 Rehabilitation of the Elbow - 445

Throwing Program for Return to Sport - 447

Summary - 448

16 Aquatic Therapy in Rehabilitation

Barbara Hooyenboom
20 Rehabilitation of Wrist. Hand. and Finger Injuries
Nancy Lomax
Anile Mari e Schneider
Physical Properties and Resistive Forces - 327 Functional Anatomy and Biomechanics - 452
 Contents vii

Rehabilitation Techniques - 454 Rehabilitation Techniques for Specil1c

Rehabilitation Techniques for Specil1c [njuries - 462 [njuries - 590
J31 Summary-481 Summary - 603

21 Rehabilitation of Groin. Hip. and Thigh Injuries 24 Rehabilitation of Ankle and Foot Injuries
Bernie DePalma Skip Hunter

Functional Anatomy and Biomechanics - 486 William E. Prentice

Rehnbilitation Techniques for Groin. Hip. and Functional Anatomy and Biomechanics - 608
Thigh-487 Rehabilitation Techniques - 612
Rehabilitation Techniques for Specil1c [njuries - 500 Rehabilitation Techniques for Specific [njuries - 622
Summary - 522 Summary - 645

22 Rehabilitation of Knee Injuries 25 Rehabilitation of Injuries to the Spine

William I-:. Prentice
Daniel N. Hooker

James A. Onate
William E. Prentice

Functional Anatomy and Biomechanics - 526
RehabUitation Techniques - 529
Rehabilitation Techniques for Ligamentous and
Meniscal Injuries - 545
Rehabilitation Techniques for Patelloremora l and
Extensor Mechanism InjurIes - 559
Summar - 574
Functional Anatomy and Biomechanics - 650
The Importance of Eva luation in Treating
Back Pain - 651
Rehabilitation Techniques for the Low Back - 654
Rehabilitation Techniques for Low Back Pam - 668
Rehabilitation Techniques for the Cervical Spine - 684
Summary - 689

23 Rehabilitation of Lower-Leg Injuries Glossary 692

Christopher f. Hirth
............ .....

~
Functional Anatomy and Biomechanics - 579 Index 697
Rehabilitation Techniques for the Lower Leg - 580
 Preface
s the aet and science of sports medicine becomes more so­
A phisticated and spec i,dized, the need arises for textbooks
that deal with specific aspects uf sport injuty management.
Rehabiliwtion is certainly one of t he major areas uf responsibility
for the athlet ic trainer. For the c1assroum instructor. there are a
number of texts iJ\'ajJable that present a general overvicw of the
various aspects of sport s med icine. This fourth edition. now titled
RelwbiliwUvll Tccillliqucs jor Sports Medicille allLl 11thlcUc Traillillg. is
for the studelll of athl etic training who is intereste.d in gaining
more in-depth exposure Lo the theory a nd practica l applicatiun of
rehabilitation techniques used in a sports medicine environment.
The purpose of Lh.is text is to provide the athletic trainer with
a comprchensive guide to the design. implementatiun. and super­
vision uf rehabilitation programs forsp0rl-rcJated injuries. lt is in­
tended for use in advanced courses in athl etic tr<linin g that deal
with practical upplicallon uf theury in a clini cal setting. The con­
tribUting <lnthors havc coliecUvely attempted to combine th eir ex­
pertise and knuwledge tu produce a si ngle text that cncompusses
all aspect s of sports medlc in.e reh a.bilitation .
ADDRESSING THE ATHLETIC
TRAINING EDUCATIONAL
COMPETENCIES
In 1998. the National Athletic Trainers' Association (NATA ) cre­
ated the Education CouncH and charged it with the responsibility
fur idcntifying knowledge and skills that must be inclu ded in edu­
cational programs that prepare the student to enter the a thlellc
training profeSSion. Tu mel'.t 11lis charge. the Education Con neil
developed a list of educational competencies and clinic,d profi­
ciencies categurized accurding tu twelvc dumains that constitute
the roLe of the athleti c trainer. The athleti c training edu cot ional
programs that have bcen acc redited by the Commission
un Accreditati on of Allied Health Ed ucaLiun Progr<lms (C/\A­
IlEP). as well as those seeking accreditation. have been charged
with the daunting task of finding ways to integrate the extensivc
list of educallooal competencies and clinical prollciencies into
their curriculum s. This move tuward competency-based athletic
training education programs ha s enhanced the neecd for a text
that focu ses on a "collection of the knowledge. skills. and values
t.hat the entry-lc\lcJ certilled athletic trainer must possess tu plan.
implemen!. document nnd evnluate the efficacy of th empelltic ex­
ercise programs for the rehabilitation and reconditioning of the
viii
injuries and illn esses of athletes and oth ers involved in physical
activity" as identifIed by the National Athletic Trainers' Associa­
tion. 1\'ly goal in this fourth edition was to make certain that each
and everyone of the educational competencies and c1in.ical proll­
ciencies relative to therapeutic exercise and injury rehabilitati on
as identified by the Edu ca tion Council is specillcally covered at
some point in this text. At the end uf this section. you will also find
a discussiun. Ma stering the Cumpetencies. that details the evolu­
tion of the competenCies.
It was suggested that including a complete lisling uf all the ed­
ucational competenCies and clinical proficiencies and an ind ex of
the page numbers where spedllc competcncies ur proltciencies
are discussed would provide an excellent. logical. and useful 're­
sou rce for bot.h the instructor and the athletic training student.
Unfortunately. copyright laws prevented us from reprodUCing the
lIthletic Tminillg Edllcntiollal Competencies in this tex\.
NEW TO THIS EDITION
Chapter 10. "Core Stabilization Training in Rehabilitation."
presents thc latcst information about how to strengthen
and enhance neuromuscular control of the lumbo­
pelvic-hip complcx of muscles to establish a base of sup­
purt and st.ability fur movements of the extremities.
Content is co nsistently presented using the format identifled
by the NATA Educational Competencies. and the ac­
compa.nying domains and clinical prol"iciencies.
Content is reorganized to present Chapter 3. "The Evaluation
Process in Rehabilitation. " earlier in the tex t. This chap­
ter now focuses specifica Ill' on the effective design and
progression of rehabilitatiun programs based o n both
subj ective and objective lIndings of the evaluntions.
New Rehabilitation Plan s present case studies in each of the
body region chapters in Part Four of the text to further
apply the ehnpter content.
New Clinical Decisiun i\,laking Exerci ses and Solutions are in­
cluded ill every ,hapter to help students apply the content
prese nted.
The new tnboratoru ;Vlalllw! to accompany Rehabilit.ation Tech­
niqllrsjor Sparls Medicine Ilnd AlIlleric 7'railling is packaged
at no charge with each nell' purchase of the fourth edi­
tion . It provides laboratory ex perien ces to give students
practi cal reinforcement of the content and to assess their
competency with a Variety of rehabilitation techniques.
 ORGANIZATION
This fourth edition has a new organization and is now divided into
four part s. Petrt One discusses the basics of the rehabilitation
process. ft begins by discussing the important considerations in
designing u rehabilitalion program for the injured athlete. provid­
ing a basic overview of the rehabilitation process (Chapter 1). ft is
essential for the athletic trainer to understand the importance of
the healing process and how it should dictate the course of reha­
bilitation (Chapter 2). The evaluation process is critical in first de­
termining the exact nature of an existing injury and then
designing a rehabilitation program based on the fmdings of that
evaluation (Chapter 3). It is abo essential to be aware of the psy­
chological aspects of rehabilitation that the injured athlete must
deal with (Chapter 4).
Part T\\'o deals with achieving the goals of rehabilitalion. The
chapters address primary goa ls of any sports medicine rehabilita­
tion program: reestab li sh ing neuromuscular control (Chapte r 5),
restoring range of motion and improving Oexibilily (Chapter 6), re­
gaining muscular strength . endurance. and power (Chapter 7), re­
all the ed­ gaining postural sta bility and balance (Chapter 8). and
dn index of maintaining card iorespiratory lilness during rchabLiitation (Chap­
ficlencies ter9).
. d useful re­ Athletic trainers have many rehabilitation "tools" with
which they can choose to treat an injured athlete. How they
choose to use these tools is often a matter of personal preference.
Part Three discusses in detail how these tools can be best incor­
porated into a rehabilitation program to achieve the goals iden­
tified in the first section. The chapters in Part Th.ree focm on
primary tools of rehabilitation: "core stabilization training"
iChapter 10), plyomelriCs (Chapter 11). open- versus closed-ki­
~ilitation." netic-chain exercise (Chapter 12), isokinetics (Chapter 13). joint
strengthen mobilization and traction techniques (Chapter 14), propriocep­
the lumbo­ tive neuromuscular facilitation and other soft-tissue mobiliza­
tion techniques (Chopter 15). aquatic therapy (Chapler lh), and
functional progressions and functional testing (Chapter 17).
Part ['our of this text goes into great detail on specUtc rehabil­
itation tec hniques that are llsed in treating a vmiety of injuries.
_ • ies. peCUtC rehabilitation techniques are included for the shoulder
_ Evaluation IChapter 18), the elbow (Chapter 19), the wrist, hand, and finger s
I . This chap­ Chapter 20), the groin, hip. and th.igh (Chapler 21), the knee
Ch apter 22). the lower leg (Chapter 23). thc ankle and foot (Chap­
;er 1 4). and the spine (Chapter 2 5). Each chapter begins with a dis­
rossion of the pertinent functional anatomy and biomechanics of
.bat region. An extensive series of photographs illustrating a wide
ariety of rehabilitative exercises is presented in each chapter. The
I portion of each chapter involves in-depth discussion of the
utions arc in­ thomechanics. injury mechanism. rehabilitation co ncerns, rc­
y the con ten t i1 iWtion progreSSions, and finally, criteria for return to activity
speCific injuries.
iliwc.ion Tech­ As will become read ily apparent. the reorganized and up­
added to each chapter in Part Four as examples of case
.Q is packaged ed fo urth edition of Rehabilitatioll TechlliqllesJor Sports Medi­
:.he ~ urth edi­ and tlllrtiC Training offers a comprehensive reference and
trainer should usc in developing and implementlng a re­
gi~e students e emphasizing the most current techniques of sport injury
habilitation program.
to assess their abil il.atiol1 for the athletic trainer overseeing programs of re­
rechniques. ·li tat ion.
COMPREHENSIVE COVERAGE OF
RES'EARCH·BASED MATERIAL
Compared to some of the other health-care speciali~ations. ath­
lette training is still in its infancy. Growth dictates the necessity
for expanding our research efforts to idcnliCv new and Jllore ef­
fecti ve methods and techniques for dealing with spor t-related in­
jury. Any ath lctic trainer charged with the responsibility of
supervising u rehabilitation prognlln knows th8lthe most cur­
rently acccpted and up-to-date reha bilitation protocols tcnd to
change rapidly. A sincere effort has been made by the contribut­
ing authors to present the most recent information on the vari­
ous aspect s of in jury rehabilitation currently available for the
literature.
Additionally, this manuscript has been critically reviewed by
selected athletic trainers who are well-respected clinicians, edu­
cators. and researchers in this field to further ensure that the ma­
terial presented is aeeurate and current.
PERTINENT TO THE ATHLETIC
TRAINIER
Many texts are curren tly available on the subj ec t of rehabilitation
of injury in Various .patient popUlations. However, the fourth edi­
tion of this text concentrates exclusively on the application of re­
hilbilitatio ll tech niques in a sport-related setting for a unique
sports medicine emphasis.
PEDAGOGICAL AIDS
The teaching aids provided in this text to assist the student include
the following:
Objectives, These goals are listed at the beginning of
eac h chapter Ito introduce students to Lhe points
that will be emphaSized.
Figures and 1((/)/eo5. The number of figures and tables included
throughout the text has been significantly increased in
an effort to provide as much visual and graphic demon­
stration of speeinc rehabilitation techniques and exer­
cises as possible.
Clinical Dedsio/[ Making J.::xcrciscs. Approximately 150 new
clinical decision making excrcises have been added
throughout to challenge the student to integrate and ap­
ply the information presented in this text to clinical cases
that typically occur in an athletic training Selting. Solu­
tions lilr each exercise arc presented at the end of each
chapter.
Rehabilitation Plans. New Rehabilitation Plans have been
studies that help apply the thought process an athletic
Summary. Each chapter has a summary list that reinforces the
major poinLs prescnted.
x Preface
ReJerences. A comprehensive list of up-to-date references is
presented at the end of each chapter to guide the reader
to additional information about the chapter content.
Glossary. A glossary of terms is proVided for quick reference.
ANCILLARIES
Laboratory Mal1l1al. A new Laboratory Manua[ accompanies
the fourth edition of Rehabilitation Tec/zrziljues Jor Sports
Medici/!e and Athletic Training. It has been prepa'r ed by Dr.
Tom Kaminski of the University of Delaware to provide
hands-on directed learning experiences for students us­
ing the text. It incJudes practical laboratory exercise.s de­
signed to enhance student understanding. The Lab
Manual is packaged at no charge with each new pur­
chase of the fourth edition.
Image Presentation CD-ROM. The Image Presentation CO­
RaM is an electronic library of visual resources. The CO­
RaM contains images from the text displayed in
PowerPoint, whieh allows the user to view, sort. search,
use, and print catalog images. It also includes a complete,
ready-to-use PowerPoint presentation. which allows
users to play chapter-specific slideshows.
PowerPoint Presentation. A comprehensive and extensively iI­
'l ustrated PowerPoint presentation accompanies this text
for use in classroom discussion . The PowerPoint presen­
tation may also be converted to outlines and given to stu­
dents as a handout. You can easily download the
PowerPoint presentation from the McGraw-Hili website
at www.mhhe.com /prentice4e. Adopters of the text can
obtain the login and password to access tllis presentation by
contacting your local McGraw-Hili sales representative.
eSims. eSims is an online assessment tool that provides stu­
dents with computerized simulation tests with instant
feedback that emulate the actual athletic training certifi­
cation exam. Check out eSims at www.mhhe.com/esims.
And much more . ..
Check out the competency information found at
wWVI'. mhhe.com /prentice4e For more online study resources.
visit the McGraw-Hill Hea[ th and Human Performance website at
www.mhhe.com / hhp.
ACKNOWLEDGMENTS
The preparation of the manu script for a textbook is a long-term
and extremely demanding effort that requires input and coopem­
tion on the part of many individu als. [ would like to personally
thank each of the contributin g authors. They were asked to con­
tribute to this text' because I have tremendous respect for them
both personally and professionally. These individuals h ave distin­
guished themselves as educators and clinicians dedicat ed to the
field of ath let ic training. I am exceedingly grateful for their input.
Michelle Turenne. my developmental editor at McGraw-Hili.
has been persistent an d diligent in the compl etion of this text. She
has patien tly encouraged me along. and I certainly have appreci­
ated her support. I have come to reiy heavily on Christine \Va lker.
my project manager at McGraw-llili . She makes certain that a ll of
the det ails 011 a project such as thi s are taken care of and I greatly
appreci ate her input a nd opinions.
The followin g individuals have invested a Significant amount
of time and energy as reviewers for this manu script, and [ appre­
ciate their efforts.
Dawn M. Hankins
McKendree College (IL)
Joseph A. Miller
New York Chiropractic College
Rene Revis Shingles
Central Michi gan University
Barbara j. Hoogenboom
Gran d Valley State Universi ty (MI)
L. Tony Ortiz
Wright State University
Aric Warren
University of Kansas at Lawrence
Finally. and most importantly. this is for my family- Tena.
Brian. and Zachary-who make an effort such as this worth­
while.
Bill Prentice
Division or ~
The Univers
Chapel Hill,
I
 Contributors

Bernard DePalma, M.Ed., P.T., A.T.C. Barbara Hoogenboom, M.H.S., P.T.,

Head Athletic Trainer
S.C.S., A.T.C.
Cornell University
Assistant Professor
Hhaca, New York
School of Health Professions
Grand Valley State University
Michael Clark, M.S., P.T., A.T.C., Allendale, Michigan
P.E.S., C.S.C.S.
Chief Execulive Officer Daniel N. Hooker, Ph.D., P.T., S.C.S.,
National Academy of Sports Medicine A.T.C.
Calabasas, California Coordinator of Alhletic Training and Physical Therapy
Division of Sports Medicine
Joe Gieck, Ed.D., P.T., A.T.C. The University of North Carolina
Chapel Hill, North Carolina
Professor, Departmenl of Human Services, Curry School
of Education
Assistant Clinical Professor, Department of Orthopaedics Stuart L. (Skip) Hunter, P.T., A.T.C.
and Rehabilitation Director, Clemson Physical Therapy
Head Athletic Trainer Clemson, South Carolina
The University of Virginia
Charlottesvil le, Virginia
Kellie Huxel, M.S., A.T.C.
Kevin Guskiewicz, Ph.D., A.T.C. Biokinetics Research Laboratory; Athletic Training Divi­
sion
Associate Professor. Department of Exercise and Sport Kinesiology Department
. y- Tena,
Science Temple University
th is \\'orth-
The University of North Carolina Philadelphia, Pennsylvania
Chapel Hill , North Carolina
Bill Prentice
Scott M. Lephart, Ph.D., A.T.C.
Elizabeth Hedgpeth, Ed.D.
Professor, Education
Lecturer, Sport Psychology Assistanl Professor of Orthopaedic Surgery
The University of North Carolina Director, Neuromuscular Research Laboratory
Chapel Hill. North Carolina Sports Medicine Program
University of Piltsburgh
Chris Hirth, M.S., P.T., A.T.C. Pittsburgh, Pennsylvania

Athletic Trainer/Physical Therapist

Division of Sports Medicine
The University of North Carolina
Chapel Hill. North Carolina
xi
xii Contributors

Nancy E. Lomax, P.T. Rob Schneider, M.S., P.T., A.T.C.

Staff Physical Therapist Co-Owner/ Clinical Jnstructor
Spectrum Health Rehabilitation and Sports Medicine Progress of Chapel HiJI
Services Wellness and Physical Therapy
Grand Rapids. Michigan Division of Sports Medicine
The University of North Carolina
Chapel Hi11. North Carolina
Michael McGee, M.A., A.T.C.
Director of Sports Medicine
Associate Professor. School of Health Sciences
C. Buz Swanik, Ph.D., A.T.C.
Lenoir Rhyne Director. Graduate Athletic Training/Sports Medicine
Hickory. North Carolina Temple University
Department of Kinesiology
Philadelphia. Pennsylvania
Janine Oma.n, M.S., P.T., A.T.C.
Athletic Trainer/ Physical Therapist
The Ohio State University
Steve Tippett, Ph.D., P.T., S.C.S.,
Columbus. Ohio A.T.C.
Associate Professor
Department of Physical Therapy and Health Sciences
Darin Padua, Ph.D., A.T.C. Bradley University
Assistant Professor. Department of Exercise and Sport Peor,ia . JIIinois
Science
The University of North Carolina
Chapel Hi'll . North Carolina Michael L. Voight, D.P.T., P.T., S.C.S.,
O.C.S., A.T.C.
William E. Prentice, Ph.D., P.T., A. T.C. Associate Professor. School of Physical Therapy
Belmont University
Professor. Coordinator of the Sports Medicine Program Nashville. Tennessee
Department of Exercise and Sport Science
Clinical Professor. Division of Physical Therapy
Department of Medical Allied Professions Pete Zulia, P.T., S.C.S., A.T.C.
Associate Professor. Department of Orthopaedics Owner. Oxford Physicall Therapy and Rehabilitation. Lnc.
School of Medicine Oxford. Ohio
The University of North Carolina
Chapel Hill. North Carolina

Ann Marie Schneider, O.T.R., C.H.T.

Coordinator. Hand Center
Raleigh Orthopaedic and Rehabilitation Specialists
Raleigh. North Carolina

I
· C. The NATA's Athletic Training
Education Competencies
he Na.tional. At hletic Trainers' Associatio!~ (NATA)
'cine
T AthletIc TramIng EducatIOnal CompetencIes OrIgI­
nated from th e need to h ave specific educational
knowledge and skills common to all entry-level athletic
trainers. These skills are deemed necessary by the NATA
for all newly graduated athletic trainers and demonstrate
:.5., to the public that the athletic trainer has been educated
and has showl1 proficiency on specifIc standards prior to
sitting for the National Athletic Trainers' Association
Board of CerWlcation (NATABOC) exam.
ences
EVOLUTION OF THE
COMPETENCIES
., S.C.S.,
Th e original competencies were written in the form of be­
havioral objectives in 1983 by Gary Dellorge of the Profes­
sional Educa[,ion Committee of the National Athletic
Trainers' Association. They were published in GlIidelinesJor
Development and Implementation oj NATA Approved Under­
graduate Athletic Training Educatioll Programs. This flfSt gen­
.... . eration of behavioral objectives was first revised in 1988.
In 1992, renamed Competencies in AtlIletic Training, tJh ey
.. 'tation, Inc.
were revvritten by the Professional Education Committee
and reviewed by the Joint Review Conunillee on Educa­
tional Programs in Athletic Training (}lRC-AT). The 1992
revision divided the competencies into six areas pertaining
to injuries and illnesses common to athletes: Prevention;
Recogni ~,i on and Evaluation; Managementi Treatment and
Disposition; Rehabilitation; Organization and Administra­
tion; and Education and Counseling. Within each area
were three domains: cognitive (knowledge), psychomotor
(motor skills), and affective (attitudes and va1lues). Each
area had specifle behavioral objectives assigned to each do­
main. Students graduating from NATA-approved educa­
tional programs were introduced to the competencies in
classes and during clinical assignments.
In 1997, the Education Council fo rmed the Competen­
cies in Education Committee, consisting of ten certified
a thletic trainers from all over the country representing all
levels of education (high school through college) as well as
the clinical setting. This committee worked for a year to
identify current skills and knowledge vital for the entry­
level athletic train er. Corresponding to the revision of the
competencies was t he new focus on competency-based ed­
ucation for the undergraduate preparation of the athletic
trainer. The committee identified twelve general areas of
knowledge and skills that all athletic tminers should pos­
sess after completing their formal education and clinical
experience. These content areas are Risk Man agement and
Injury Prevention; Pathology of Injury and Illnesses; As­
sessment and Evaluation; Acute Care of Injury and []]ness;
Pharmacology; Therapeutic Modalities; Therapeutic Exer­
cise; General Medical Conditions and Disabilities; Nutri­
tional Aspects of Injury and Illnesses; Psychosocial
Intervention and Referral; Health Care Administration;
and Professional Development an d Responsibili ty. The
competencies were written according to content area and
domain (cognitive, psychomotor, and affective), and a sep­
arate committee worked on clinical proficiencies for each
content area.
Clinical profleiencies are linked to the content areas
and consist of th e common skills that all entry-level athletic
trainers need to possess. The majority of the clinical profi­
ciencies are psychomotor in nature, requiring demonstra­
tion of the ability to physically evaluate or treat an injury
and cr eate or use a particular item such as a protective de­
vice. The addition of clinical proi1ciencies to the Competen­
cies document signifies the move from a purely qu an titative
education to an outcomes-based education.
Drafts of both the competencies an d the clinical profi­
ciency documents were sent for review to subject-area ex­
perts . as well as posted on the athletic training education
websites. By 1999 the competencies and clinical profi­
ciencies, revised through several drafts and approved by
the NATA board of directors, were publ1shed as the Na­
tional Athletic Trainers' Association Athletic Training Educa­
tional Competencies. The difference in the 1999 edition is
the inclusion of clinical proficiencies as well as newly
identified content area that athletic trainers saw as criti­
cal for entr y-level athletic trainers to possess when they
enter the workforce.
xiii
xiv The NATA:s Athletic Training Education Competencies
The new competency-based model of learning ensures
that no maHer where students do their athletic training
education-whether at a big university or small college­
they will have a common knowledge base and skill profi­
ciency in specilk areas. Certified athletic trainers
currently work in many different environments, induding
high schools, clinics, industry, corporations, and with pro­
fessional teams, and they bring to their work the same fun­
damental proficiencies.
TODAY'S COMPETIENCY·BASE'D
EDUCATION
Competency-based education now sets a baseline of profi­
ciency that aU athletic trainers must be able to achieve.
Regarding curricula, the athletic training educational
programs that have been accredited by the Commission
on Accreditation of Allied Health Education Programs
(CAAHEP), or seek this accreditation, have been charged
with the task of finding a way to integrate the extensive
list of educational competencies and clinical proficiencies
into their curricula. Students who seek certification must
learn and demonstrate all of the competencies and mas­
ter the proficiencies over time in order to take the NATA
Board of Certification Examination.
To access an index that correlates the educational
competencies and clinical prolkiencies related to the ther­
apeutic modalities, visit the McGraw-HIll website for Reha­
bilitation Techniques for Sports Medicine and Athletic Training,
fourth edition: www.mhh.com/prentice4e.
Katie Walsh, Ed.D. A.'I'.C.-L.
Director of Sports Medicine/Athletic Training
East Carolina University
Greenville, North Carolina
 PART ONE

The Basis of Injury

Rehabilitation

1 Essential Considerations in Designing a Rehabilitation Program

for the Injured Athlete

2 Understanding and Managing the Healing Process

through Rehabilitation

3 The Evaluation Process in Rehabilitation

4 Psychological Considerations for Rehabilitation of the Injured

Athlete
 CHAPTER 1
Essential Considerations i'n
Designing a Rehabilitation
Program for the Injured Athlete
William E. Prentice
Study Resources
To become Inorc familiar with the knowledge and skills
necessary to design. implement. and document therapeu­
tic rehabilitation programs as idenlil1ed in the SATA Ath­
letic Training Educational Competencies and Clinical
Projlciencies' Therupeutic Exercise content arca. visit
www.mhhe.com/prenlicelle. Also. refer to the lab exer­
cises in the new Laboratory Manual and to eSims. which
simulates the athletic training certil1cation exam. at
www.mhhe.com/esims. Par more online study resources.
visit our Heilllh and Human Performance website at
www.mhhe.com/hhp.
After Completion of This
Chapter, the Student Should
Be Able to Do the Following:
• Describe the relationships among the
members of the rehabilitation team:
the athletic trainers, team physicians,
coaches, strength and conditioning
specialists. athlete, and athlete's family.
• Express the philosophy of the rehabili­
tative process in a sports medicine
environment.
• Realize the importance of understand­
ing the healing process, the biome­
chanics, and the psychological aspects
of a rehabilitation program.
• Arrange the individual short-term
and long-term goals of a rehabilitation
program.
• Discuss the components that should
be included. in a well-designed
rehabilitation program.
• Propose the criteria and the decision­
making process for determining ""hen the
injured athlete lllay return to full activity.
ne of the primary goals of every sports medicine pro­
O fessional is to create a playing environment for the ath­
le.le that IS as s~lje as It can possibly be. Regardless of
that effort. the nature of athletic participation dictates that
injuries will eventually occur. Fortunately. rew of the in­
juries that occur in an athletic setting are life-threatening.
The majority of the injuries are not serious and lend them­
selves to rapid rehabilitation. When injuries do occur. the
focus of the athietic trainer shifts from injury prevention to
injury treatment and rehabilitation. In a sports medicine
sett ing, the athletic trainer generally assumes primary re­
sponsibility for the design. implementation. and supervi­
sion of the rehabilitation program for the injured athlete.
The athletic trainer responsible for overseeing an exer­
cise rehabilitation program mu~t have as complete an un­
derstanding of the injury as pos~ible, including knowledge
of how the injury was sustained. the major anatomical
structures affected. the degree or grade of trauma. and the
stage or phase of the injury's healing. l .l l

 CHAPTER 1 Essential Considerations in Designing a Rehabilitation Program for the Injured Athlete
THE REHABILITATION TEAM
Providing a comprehensive rehabilitation program to the
athlete requires a group effor! to be most effective. The re­
habilitation team involves a number 0[' individuals, each of
wbom must perform specific functions relative to caring
for the injured athlete. Under ideal conditions, the athletic
trainer (and the sludent athletic trainers), the athlete, the
physician, the coaches. the strength and conditioning spe­
te
cialist, and the athlete's family will communicate freely
and function as a team . This group is intimately involved
with the rehabilitative process, beginning with patient as­
sessment. treatment selection, and implementation and
ending with functional exercises and return to activity.
The athletic trainer directs the post-acute phase of the re­
habilitation, and it is crucial that the athlete understand
that this part of' the recovery is just as crucial as surgical
sm technique to the return of normal joint function and the
. a tion subsequent return to athletic competition. The major con­
cern of everyone on the rehabiHtation team should always
be the athlete. If not for the athlete, the athletic trainer,
team physician, coach. and strength and conditioning spe­
h uld cialist would have nothing to do in sports. All decisions
made by the physician, athlet-ic trainer, and coaches ulti­
mately affect the athlete.
n­ I CLINICAL DECISION MAKING Exercise 1-1
\ -hen the
activity. A team physician has diagnosed a swimmer with tho­
racic outlet syndrome. The athletic trainer is developing a
rehabllitillion plall lor thls athlete. What considerations
must be taken into acconnt?
_m icine pro­
t fo r the ath­
Regardless of Of aU the members of the rehabilitation team charged
dictates that with providing health care for the athlete. perhaps none is
ew of the in­ more Lntimately involved than the athletic trainer. The
e-threatening. athletic trainer is the one individual who deals with the
and lend them­ athlete throughout the entire period of rehabilitation,
- do occur, the [rom the time of the initial injury until the athlete's com­
prevention to plete, unrestricted return to practice or competition. The
rls medicine athletic trainer is most directly responsible for all phases of
m primary re­ health care in an athletic environment. including prevent­
and supervi­ ing injuries from occurring. providing initial ftrst aid and
W'ed athlete. in jury management, evaluating injuries. and designing
~i ng an exer­ an d supervising a timely and effective program of rehabil­
~ roplete an un­ itation that can facilitate the safe and expeditious return of
ng -nowledge Lhe athlete to activity.
r anatomical Tn 1999 the National Athletic Tminers Association
"1llllila. and the Board of Certification (NATABOC) completed the latest
role delineation study, which redefined the profession of
3
athletic training. This study was designed to examine the
primary tasks performed by the entry-Ilevel atbletic trainer
and the knowledge and skills required to perform each
task. The panel determined that the roles of the practicing
athletic tTainer could be divided into six major areas or per­
formance domains: prevention of ath'lelic injuries; recog­
nilion, evaluation. and assessment of injuries; immediate
care of injuries; health care administration; professional
development and responsibility; and treatment, rehabilita­
tion , and reconditioning of athletic injuries.
An athletic trainer must work closely with and under
the supervision of the team physician with respect to de­
signing rehabilitaUon and reconditioning protocols that
make use of appropriate therapeutic exercise. rehabilita­
tive equipment. manual therapy techniques, or therapeu­
tic modalities. The athletic trainer should then assume the
responsibility of overseeing the rehabilitative process, ulti­
mately returning the athlete to full activity.
Certainly, the athletic trainer has an obligation to the
injured athlete to understand the nature of the injury, the
function of the structures damaged, and the differen t tools
available to safely rehabilitate the athlete. Additionally. the
athletic trainer must understand the treatment philosophy
of the athlete's physician and be careful in applying differ­
ent treatment regimens because what may be a safe but
outdated technique in the opinion of one physician may be
the treatment of choice to another. The successful athletic
trainer must demonstrate flexibility in his or her approach
to rehabilitation by incorporating techniques that are
sound and effective but somewhat variable from athlete to
athlete and physician to phYSician.
Communication is crucial to prevent misunderstand­
ings and a subsequent loss of rapport with either the ath­
lete or the physician. The injured athlete must always be
informed and made aware of the lVily, how, and whe/1 fac­
tors that collectively dictate the course of an injury reha­
bilitation program.
Any personal relationship tal(es some time to grow and
develop. The relationship between the coach and the athletic
trainer is no different. The athletic lrainer must demonstrate
to the coach his or her capability to correctly manage an in­
jury and guide the course 0(' a rehabilitation progranl. It will
take some time for the coach to develop trust and confidence
in the athletic tTainer. The coach mustllndcrsland that what
the athletic trainer wants for the athlete is exactly the same
as what the coach wants-to get an athlete healthy and back
to practice as quickly and safely as possible.
This is not to say, however. that the coaches should not
be involved with the decision-making process. For exam­
ple, when the athlete is rehabilitating an injury, there may
be drills or technicail instruction sessions that the athlete
4 PAIn ONE The Busis of Injury Rehabilitation
cun participate in without exacerbating the injury. 'Thus
the coaches, athletic trainer, and team physician should be
able to negotiate whattbc athlete can and cannot do safely
in the cow'se of a practice.
Athlc.tcs aTe frequently caught in the middle between
coaches who tell them to do one thing and medical slaff who
tell them something else. The athletic trainer must respe.c t
the job Lhatthe coach has to do and should do whatever can
be done to support the coach. Close communication between
the coach and the (Jthletic trainer is essential so that every­
one is on the same page.
CLINICAL DECISION MAKING Exercise 1-2
i\ gymnast has just had an anterior cruciatc ligament
(ACL) reconstruction. The orthopedist has prescribed
some active range of motion (AROl<.fi exercises t[l start
the rehabilitation process. The athlete is progressing very
quickly and wants to increase the intenSity of her activity.
What should the athletic trainer do to address the ath·
lete's request?
\IVhen rehabilitating an injured athlete, particularly in
a high school or junior high school selling, the athletic
trainer. Lhe coach, and the physician must take the Lime to
explaill and inform the athlete's parents about the course
of the injury rehabilitation process. With an athlete of sec­
ondary school age. the parents' decisions regarding health
care must be of primary consideration. [n certain situa­
tions, particularly at the high school and junior high lev­
els, many parents will insist that their child be seen by their
famj],y phYSician rather than by the individual who may be
designated as the team physician. This creates a situation
ill which the athletic Ir(Jiner must work and communicate
with many different "team physicians." The opinion of the
family phYSician must be respected even if that individual
has little or no expedence with injuries related to sports.
It should be clear that the physician working in coopera­
tion with the athleLic trainer assumes the responsibility of
making the final decisions relative to the course of rehabili­
tation fCJr the athlete from the timc of injury until full return
to activity. The coaches must defer to and should support the
deCisions of the medical staff in any matter regarding the
course of the rehabilitative process for the injw'ed athlete.
THE PH ILOSOPHY OF SPORTS
M EDICINE REHABIILlTATION
The approach to rehabilitation is considerably different in a
sports medicine environment than in most other rehabilita­
tion settings.] The competitive nature of athletics necessi­
tates an aggressive approach to rehabihtation. BeCclUse the
competitive season inmost sports is relatively short, the ath­
lete does not have the luxury of being able to sit around and
do nothing until the injury heals. The goal is to retw'n to ac­
tivity as soon as is safely possible. Consequent:ly, the athletic
trainer tends to play games with the healing process, never
really allowing enough lime for an injury to completely
heal. The athletic trainer who is supervising the rehabilita­
tion program usually performs a "balancing act"-wa.lking
along a thin line between not pushing the athlete hard
enough or fast enough and being overly aggressive. In either
case, a mistake in judgment on the part of the athletic
trainer can hinder the athlete's return to activity.
Understanding the Healing Process
Decisions as to when and how 10 alter or progress a reha­
bilitation program should be based primarily on the
process of injury healing. 'fhe athletic trainer must possess
a sound understanding of both the sequence and the time
frames for the various phases of healing, realiZing that cer­
tain physiological events must occur during each of the
phases. Anything that is done during a rehabilitation pro­
gram th.a t interferes with this healing process wHllikcly in­
crease tbe length of time required for rehabilitation and
slow return to full activity. The healing process must have
an opportunity to accomplish what it is supposed to. At
best the athletic trainer can only try to create all environ­
ment that is conducive to the healing process. Little can be
done to speed up the process physiologically, but many
things can impede healing (see Chapter 2).
Exercise Intensity. The SAID Principle (an acronym
for specUlc adaptation to imposed del11(/rI(l) states that when
an injured structure is subjected to stresses and overloads
of varying intensities, it will gradually adapt over time to
whatever demands are placed upon il.14 During the reha­
bilitation process, the stresses of reconditioning exercises
must not be so great as to exacerbate the injury before the
injured structure has had a chance to adapt speCifically to
tbe increased demands. Engaging in exercise that is too in­
tense or too prolonged can be detrimental to the progress
of rehabilitation. lndications that the intensity of the exer­
cises being incorporated into the rehabilitation prog.r am
exceed the limits of the healing process include an increase
in the amount of swelling, an increase in pain, a loss or a
plateau in strength. a loss or a plateau in ra·nge of motion.
or an increase in the laxity of a healing ligament. 21 If an
exercise or activity causes any of these signs, the athletic
trainer must back off and become less aggressive in the re­
habilitation program.
 CHAPTER 1 Essential Considerations in Designing a Rehabilitation Program for the Injured Athlete
CLINICAL DECISION MAKING Exercise 1-3
A baseball player recently underwen t surgery to repair a
uperior labrum anterior and posterior (SLAP) lesion and
torn rolalor culT. He wants to know why he can't start
throwing right away. What Is your reason [or why he
must progress lowly?
In most injury situations, early exercise rehabilitation
involves submaximal exercise performed in short bouts
that are repeated several times daily. Exercise intensity
must be commensurate with healing. As recovery in­
creases, the intensity of exercise also increases, with the
exercise performed 'less often. Finally, the athlete returns to
a rcha­ a conditioning mode of exercise, which often includes
on the high-intensity exercise three to four times per week.
Understanding the Pathomechanics
of Injury
When a joint or other anatomic structure is damaged by
injury, normal biomechanical function is compromised.
Adaptive changes occur that a lter the manner in which
m ust have various forces collectively act upon that joint to produce
sed to. At motion. Thus the biomechanics of joint motion are
an cnviron­ changed as a result of that injury.! J
Litlle can be It is critical that the athletic trainer supervising a re­
. bUL many habilitation program has a solid foundation in biome­
chanics and functional human anatomy. to be clTeclive in
lan acronym designing a rehabilitation program. An athletic trainer
that when who does not understand the biomechanics of normal mo­
'1d overloads tion will find it very difficult to idenlif)f existing adaptive or
o\'er time to compensatory changes in motion and then to know what
n g the reha­ must be done in a rehabilitation program to correct the
ing exercises pathomechanics.
ury before the
<pecifically to Understanding the Concept
lhal is too in-
of the Kinetic Chain
the progress
IY of tbe exer­ The athletic trainer must understand the concept of the ki­
'on program netic chain and must realize that the entire kinetic chain is
",de an increase a integrated functional unit. The kinetic chain is com­
. . a loss or a posed of not only muscle, tendons. fascia, and ligaments,
'BJlg of motion, but also the articular system and neural system. Each of
. ment. 23 If an these systems functions simultaneously with the others to
_ . the athletic aJlow for structllral and functi onal efficiency. rf any sys­
-h'e in the re- tem within the kinetic chain is not working effiCiently, the
other systems are forced to adapt and compensate; this can
5
Ilead to tissue overload, decreased performance, and pre­
dictable patterns of injury.3
The functiona'l integration of the systems allows for
optimal neuromuscular efficiency during functional activ­
ities. Optimal functioning of all contr.ibulil'lg components
of the kinetic chain results in appropriate length-tension
relationships. opUmal force-couple relationships, precise
arthrokinematics, and optimal neuromuscular control. Ef­
ficiency and longevity of the kinetic chain requ,ires opti­
mal integration of each system. J
Injury to the kinetic chain rarely involves only one
structure. The kinetic chain functions as an integrated
unit. Dysfunction in one system leads to compensations
and adaptations in other systems. The myofascial. neuro­
muscular, and articular systems all playa significant role
in the functional pathology of the kinetic chain. Concepts
of musclc hnbalances, myofascial adhesions, altered
arthrokinematics, and abnormal neuromuscular control
need to be addressed by the athleUc trainer when develop­
ing a comprehensive rehabilitation program. 3
Understanding the Psychological
Aspects of Rehabilitat,ion
The psychological aspects of how the individual ath'lete
dealls with an injury are a critical yet often neglected factor
in the rehabilitation process. Injury and illness produce a
wide range of emotional reactions; therefore the ath letic
trainer needs to develop an understanding of the psyche of
each athlete. Athletes vary in terms of pain threshold, co­
operation and compliance, competitiveness. denial of dis­
ability, depression, intrinsic and extrinsic motivation,
anger. fear. guilt, and the ability to adjust to injury. Besides
dealing with the mental aspect of the injury. sports psy­
chology can also be used to improve total athletic perfor­
mance through the use of visualization. self-hypnosis, and
relaxation techniques (see Chapter 4).
Using the Tools of Rehabilitation
Athletic trainers have many tools at their disposal- such
as manual therapy techniques. therapeutic modalities,
aquatic therapy, and the use of physiCian-prescribed med­
ications-that can indiVidually or collectively facilitate the
rehabilitative process. How different athletic trainers
choose to utilize those tools is often a matter of individual
preference and experience.
Additionally. athletes differ in their individual responses
to VariOllS treatment techniques. Thus the athletic trainer
should avoid "cookbook" rehabilitation protocols that can
be ,foHowed like a recipe. In fact, use of rehabilitation
6 P'I\RT ONE The Basis of Injury Rehabilitation
"recipes" should be strongly discouraged . Instead the ath­
letic trainer must develop a broad theoretical knowledge
base from which specil1c techniques or tools of rehabilita­
tion can be selected and practically applied to each individ­
ual case.
Using Therapeutic Modalities in Rehabilitation.
AthLetic trainers use a wide variety of therapeutic tech­
niques in the treatment and rehabilitation of sport-related
injuries. One of the more important aspects of a thorough
treatment regimen is the use of therapeutic modalities. At
one time or another. virtually all athletic trainers make use
of some type of therapeutic modality. This might invo'\ve a
relatively simple technique. such as uSing an ice pack as a
l1rst aid treatment for an acute injury, or more complex
techniques such as the stimulation of nerve and muscle
tissue by electrical currents. There is no question that ther­
apeutic modalities are useful tools in injury rehabilitation .
When used appropriately. these modalities can greatly en­
hance the athlete's chances for a safe and rapid return to
athletic competition. The athletic trainer must have
knowledge of the scientific basis of the various modalities
and their physiological effects on a specil1c injury. '''' hen
applied to practical experience. this theoretical basis can
produce an extremely effective clinical method.
A comprehensive rehabilitation program should focus
on achieving specific short-term and long-term objectives.
Modalities, though important. arc by no means the single
most critical factor in accomplishing these objectives.
Therapeutic exercise that forces the injured anatomic
structure to perform its normal function is the key to suc­
cessful rehabilitation. However. therapeutic modalities
certainly play an important role and are extremely useful
as adjuncts to therapeutic exercise.
It must be emphasized that the use of therapeutic
modalities in any treatment program is an inexact science.
There is no way to "cookbook" a treatment plan that in­
volves the use of therapeutic modalities. Athletic trainers
should make every effort to understand the basis for using
each different type of modality and then make their own
decisions as to which will be most effective in a given clin­
ical situation .
Despite the fact that therapeutic modalities are com­
monly used by athletic trainers as an integral tool in the
rehabilitation process. they will not be discussed further
in this text. (The reader is referred to W. Prentice, Thera­
peutic iVlodalWes for Sports Medicine and il.thleUc Training.
5th ed .. New York. McGraw-Hili. 2003. for detailed
information relative to the use of speCific modalifies in
rehabilitation.)
Using Medications to Facilitate Healing. Pre­
scription and over-the-counter medications can effectively
aid the healing process during an athlete's rehabilitation
program. An athletic trainer supervising a program of re­
habilitation mus! have some knowledge of the potential ef­
feels of certain types of drugs on performance during the
rehabilitation program . Athletes might be expected to re­
spond to medication just as anyone else would. butlhe ath­
lete's situation is not normal. Intense physical activity
requires that special consideration be given to the effects of
certain types of medication. On occasion. the athletic
trainer, working with guidance from the team physician,
must make decisions regarding the appropriate use of
medications based on knowledge of the indications for use
and' the possible side e!'fects in athletes who are involved in
rehabilitaLloll programs.
Those medications commonly used to aid the healing
process are discussed in detail in Chapter 2.
Therapeutic Exercise versus
Conditioning Exercise
Exercise is an essential factor in fitness conditioning. in­
jury prevention. and injury rehabiHtation. To compete
successflllly at a high level. the athlete must be fit. An ath­
lete who is not Ilt is more likely to sustain an injury.
Coaches and athletic trainers both recognize that im­
proper conditioning is one of the major causes of sport in­
juries. It is essential that the athlete engage in training and
conditioning exercises that minimize the possibility of in­
jury while maximizing performance. In
The basic principles of training and conditioning ex­
ercises also apply to techniques of therapeu tic. rehabili­
tative. or reconditioning exercises that arc specifical1ly
concerned with restoring normal body function follow­
ing injury. The term therapeutic exercise is perhaps most
widely used to indicate exercises that are used in a reha­
bilitation program. I O
ESTABLISHING SHORT· AND
LONG·TERM GOALS IN A
REHABILITATION PROGRA'M
Designing an effective rehabilitation program is relatively
simple if the athletic trainer routinely integrates several
basic components. These basic components can also be
considered the short-term goals of a rehabilitation pro­
gram. They should include (1) prov,iding correct immedi­
ate Ilrst aid and management following injury to limit or
control swelling; (2) reducing or minimizing pain;
(3) reestablishing neuromuscular control; (4) restoring
full range of motion; (5) restoring or increasing muscular
 CHAPTER 1 Essential Considerations in Designing a Rehabilitation Program for the Injured Athlete 7

i1ita tion strength. endurance. and power; (6) improving postural
m ol' re- stability and balance; (7) maintaining cardiorespiratory
fitness: and (8) incorporating appropriate funclional pro­
gressions. The long-term goal is almost invariably to re­
turn the injured athlete to practice or competition as
quickly and safely as possible.
Establishing reasonable. attainable goals and integrating
specific exercises or activities to address these goals is tbe
easy part of overseeing a rehabilitation program. The diffi­
cult part comes in knowing exactly when and how to
progress. change. or alter the rehabilitation program to most
effectively accomplish both long- and short-term goals.
CLINICAL DECISION MAKING Exercise 1-4
A volleyball player has a second-degree an klcspral n.
The one problem all injuries have in common is
swelling. Swelling can be caused by any number of factors.
including bleeding. production of synovial fluid. an accu­
mulation of inflammatory by-products. edema. or a com­
bination of several factors. IO matter which mechanism is
involved. swelling produces all increased pressure in the
injured area. and increased pressure causes pain. 24
Swelling can also cause neuromuscular inhibiLion. which
results in weak muscle contraction. Swelling is most likely
during the first 72 hours after an injury.
Once swclling has occurred . the healing process is sig­
niJlcantly retarded. The injured area cannot return to nor­
mal until all the swelling is gone. Therefore everything that is
d()ne inJirst aid management ()f an!) ()f these conditi()ns sh()uld
be directed Loward colltrolling the swelling.10 II' the swelling
can be controlled initially in the acute stage of injury. the

time required for rehabilitation is likely to be significantly

X rays reveal 00 fraclure. Tbe athletic (ratner wants to be­

reduced .
gin rehabilitation right away so tba t the athlete may be

To control and significantly limit the amount of

able to play again before the season is over. What are the

swelling. the PRICE principk~proLec tioll. restricted activity.

short- ancllong-term goals for tWs athlete?

ice. c()mpression. and elevation-should be applied (Figure

1-1). Each factor plays a critical role in limiting swelling.
and all of these clements should be used simultaneously.
Athletes tend to be goal-oriented individuals. Thus. the Protection. The injured area should be protected
athletic trainer should design a goal-oriented rehabilita­ [rom additional injury by applying appropniate splint~.
tion program in which the athlete can have a series of pro­ braces. pads. or other immobilizaLion devices. If the iojury
of sport in­ gressive "successes" in achieving attainable short-term involves the lower extremity. it is recomrnended that the
tra ining and goals throughout the rehabilitation process. Injured ath­ athlete go non-weight-bearing on crutches at least until
ili ty of in­ letes are almost always most concerned to know precisely the acute inTIammatory response has subsided.
how long they will be out and when exactly they can ce­
. ti o ning ex­ turn to full activiLy. The athletic trainer should not make
r .c. rebabili­ the mistake of giving an injured athlete an exact time
~ pecifieally frame or date. Instead. the athlete should be given a series
lion follow­ of sequenced challe.nges. involving increasing skill and
rh aps m ost ability. that must be met before progreSSing to the next
in a reha- le vel in his or her rehabilitation program. It is critical that
he athlete be activel.y involved in planning the process of
'cnabilitating his or her injury.1K
D
The 'Importance of Controlling
M Swelling
I relatively The process of rehabilitation ibegins immediately after in­
_ rates several ury. Thus. in addition to understanding exactly how the
- can also be mj ury occurred. the athletic trainer must be competent in
ili tion pro­ ;m>viding correct and appropriate initial care. Initial first
• reet immedi­ d and management techniques are perhaps the most
ury to limit or ...Titlcal part of any rehabilitation program. The manner in
nimizi ng pain: hich the injury is initially managed unquestionably has
14:) restorin g -' gnificant impact on the course of the rehabilitative Figu.re 1·1 The PRfCE technique should be used lmme­
. . g muscular ess.20 diately following injury to limit swelling.
8 PART ONE The Basis of Injury Rehabilitation
Restricted Activity (Rest). The period of restricted
activity following any type of injury is absolutely critical in
any treatment program. Once an anatomical structure is
injured. it immediCltely begins the healing process. In an in­
jured structure that is not rested and is subjected to unnec­
essary external stress and strains. the healing process never
really gets a chance to begin. Consequently, the injury does
not get well, and the lime required for rehabilitation is
markedly increased. This is not to minimize the importance
of early mobility. Controlled mobility has been shown to be
superior to immobilization for scar formation. revascular­
ization , muscle rege neration, and reorientation of muscle
fibers and tensile properties.16 The amount of lime neces­
sary for resting varies with the severity of the injury, but
most minor injuries should rest for approximately 24to 48
hours before an active rehabilitation program is begun.
It must be emphasized that rest does not mean that the
athlete does nothing. The term rest applies only to the in­
jured body part. During tbis period, the athlete should con­
tinue to work on cardiovascular fitness and strengthening
and f1exibilily exercises for the other parts of the body not
affected by tbe injury.25
Ice. The use of cold is the iniLialtreatment of choice
for Virtually all conditions imlol{Ting injuries to the muscu­
loskeletal system. 20 It is most commonly used immediately
after injury to decrease pain and promote local vasocon­
striction, thus controlling hemorrhage and edema . Cold
applied to an acute injury will lower metabolism in the in­
jured area, and thus the tissue demands for oxygen, thus
redUCing hypoxia. 'fhis benefit extends to uninjured tissue,
preventing injury-related tissue death from spreading to
adjacent normal cellular structures. II is also used in the
acute phase of inflammatory conditions. such as bursitis,
tenosynovitis. an d tendinitis, in which heat can cause ad­
ditional pain and swelling. Cold is also used to reduce the
reflex muscle guarding and spastic conditions that accom ~
pany pain. Its analgeSic effect is probably one of its great­
est benefits. One explanation of the analgeSiC effect is that
cold decreases the velocity oli nerve conduction. although
it does not entirely eliminate it. Cold can also bombard cu­
taneous sensory nerve receptor areas with so many cold
impulses that pain impulses are lost. With ice treatments,
the athlete reports an uncomfortable sensation of cold. fol­
lowed by burning. all aching sensation, and finally com­
plete numbness 13 . 20
Beca use of the low thermal conductivity of underlying
,s ubcutaneolls fat tissues. applications of cold for short
periods are ineffective in cooling deeper tissues. Por this
reason longer treatments of 20 to 30 minutes are recom­
mended. Cold treatments are generally believed to be more
effective in reaching deeper tissues than most forms of
heat. Cold applied to the skin is capab\e of signilkantly
lowering the temperature of tissues at a considerable
depth. The extent of this lowered tissue temperature de­
pends on the type of cold applied to the skin, the duration
of its application. the thickness of the subcutaneolls fat,
and the region of the body to which it is applied. Ice should
be applied to the injured area until the signs and symptoms
of inflammation have disappeared and there is little or no
chance that swelling will be increased by using some form
of heat. Ice should be used for at least 72 hours after an
acute injury. I J. 20
Compression. Compression is likely the single most
important technique for controlling ini,ial swelling. The
purpose of compression is to mechanically reduce the
amount of space available for swelling by applying pres­
sure around an injured area. The best way of applying
pressure is to use an elastic wrap. sllch as an Ace bandage,
to apply firm but even pressure around the injury.
Because of the pressure buildup in the tissues. having
a compression wrap in place for a long time can become
painful. However, the wrap must be kept ·in place despite
significant pain because it is so important in the control of
swelling. The compression wrap should be left in place con­
tinuously for at least 72 hours after an acute injury. In
many overuse problems. slIch as tendInitis. tenosynovitis,
and particularly bursitis, which involve ongoing in flam·
rnation, the compression wrap should 'be worn until the
swelling is almost entirety gone.
ElevO}tion. The fifth factor that assists in controlling
swelling is elevation. The injured part. parlicwlarly an ex­
tremity, should be elevated to eliminate the effects of grav­
ity on blood pooling in the extremities. ISlevation assists
venous and lymphatic drainage of blood and other fluids
from the injured area back to the central circulatory sys­
tem. The greater the degr.ee of elevation. the more effective
the reduction in swelling. Por cxample, in an ankle sprain.
,t he leg should be placed in such a position that the ankle is
virtually straight up in tbe air. The injured part should be
elevated as much as possible during the I1rst 72 hours.
CLINICAL DECISION MAKING Exercise 1-5
A soccer player has been successfully manilging Achilles
tendiniUs with PRlCE, exercises. a nd anli-inllammato­
ries. The athlelic trainer has decided that the athlete
should begin playing again . What can the atbletic trainer
do to help the athlete prevent further injury?
 CHAPTER 1 F~~sential Considerations in Designing a Rehabilitation Program for the Injured Athlete 9

The appropriate technique for initial management of

, fo rms of
th e acute injuries discussed in this chapter, regardless of
where they occur, would be the following;

1, Apply a compression wrap directly over the injury,

Wrapping should be from distal to proximaL Tension
should be firm and consistent. Wetting the clastic
wrap to facilitate the passage of cold from ice packs
symptoms might be helpfuL
little or no 2, Surround the injured nrea entirely with ice bags, and
!i!o some form secure them in pLace, Ice bags should be left on lar 4­ Figure 1-2 Several modalities, including electrical
"ur5 after an minutes initially <lnd then 1 hour off and 30 minutes stimulating currents. may be used to modulate pain,
on as much as possible over the next 24 hours, Dur­
Ie ' gle most ing the following 48-hour period, ice should be ap­
,\\ lIing, The plied as often as possible, Reestablishing Neuromuscular Control
red uce the 3, The injured part should be elevated as much as possi­
Reestablishing neuromuscuJ(lr control should be of prime
plying pres­ ble during the initial 72-hour period after injury,
r applying concern to the athletic trainer in all rehabilitation pro­
Keeping the injured part elevated while sleeping is
grams / (see Chapter 5) . The ability to sense the pOSition of
ceban dage, particularly important
a jOint in space is mediated by mechanoreceptors found b1
ury, 4 , Allow the injured part to rest for approximately 24

both muscles and joints, in addition to cutaneous, visual.

ues, having hours after the injury,

and vestibulaJ" input. leurotUuscu lar control relics on the

• an become
centra l nervous system LO interpret and integrate proprio­
place despite
Cont,rolling Pain ceptive and kinesthetic information and then to control in­
~e control of
dividual muscles and joints to produce coordinated
n pL ce con­
\"' hen an injury occurs, the athletic trainer must realize movement. l 3
ute inj ury, In
that the athlete will experience some degree of pain, The Following injury and subsequent rest and immobiliza­
.rna ynovitis,
extent of the pain will be determined in part by the sever­ tion , the central nervous system "forgets" how to pulto­
ing inOam­
ity of the injury, by the athlete's individual response to and gether information coming from muscle and joint
until the
perception of pain, and by the circumstances in which the mechanoreceptors, and from cuLaneous. visual. and
injury occurred. The athlete's pain is reaL The athletic vestibular input. Regaining neuromuscular control means
n controHing
trainer can effectively modulate acute pain by using the regaining the ability to follow some previously established
cularly an ex·
PRICE technique immediately after injury, If> A physician sensory pattern.; Neuromuscular control is the mind's at­
. 'eets of grav­
can also make use of various medications to help ease tempt to teach the body conscious control of a specific
"Yation assists
pain. movement. Successfuf repetition of a patterned movement
olher Ouids
Persistent pain can make strengthening or flexibility makes its performance progressively less difficult. thus re­
a lary sys­
exercises more difficult, thus interfering with the rehabilli­ quiring less concentration, until the movement becomes
m re effective
, ankle sprain, tation process, The athletic trainer should routinely ad­ automat ic. l'his requires many repetitions of the same
dress pain during each individual treatment session. movement, progressing step-by-step [rom simple to mare
- t the ankle is
Making use of appropriate therapeutic modalities-in­ complex movements. Strengthening exercises, particu­
l . howd be
cluding various techniques of cryotherapy, thermother­ larly those that tend to be more functional. such as closed­
- 2 ho urs.
apy, and electrica l stimulating currents-will help kinetic-chain exerc ises, are essential for reestabHshing
modulate pain throughout the rehabilitation process 20 neuromuscular contral. 2l Addressing neuromuscular
(Figure 1-2). control is crilicalthroughoutthe recovery process, but it is
To a great extent. pain will dictate the rate of progres­ perhaps most critical during the early stages of rehabilita­
sion . With initial injury, pain is intense and tends to de­ tion to avoid reinjury. ;
crease and eventually subside altogether as healing
progresses. Any exacerbation of either pain, swelling, or Restoring Range of Motion
other clinical symptoms during or following a particular
exercise or aclivityindicates that the load is too great for Following injury to a jOint. there will always be some asso­
the level of tissue repair or remodeling. ciated loss of motion, That loss of movement can usually
10 PART O::\E The Basis of Injury Rehabilitation
Figure 1-3 Stretching techniques are used with tight
musculotendinous structures to improve physiological
range of motion.
be attributed to a number of pathological factors, includ­
ing resistance of the musculotendinous uni( (i.e., muscle,
tcndon, fascia) to stretch; contracture of connective tissue
(i.e., ligaments, joint capsule); or some combination of the
two. Muscle imbalances, postural imbalance, neural ten­
sion, and joint dysfunction can also lead to a loss in range
of motion.
It is critical for the athletic trainer to closely evaluate the
injured joint to determine wh.ether motion ,is limited due to
physiological movement constraints involving musculo­
tendinous units or due to limitation in accessory motion
Uoint arthrokinematics) involving the joint capsule and lig­
aments. If physiological movement is restricted, the athlete
should engage in stretching activities designed to improve
flexibility (Figure 1-3) (see Chapters 6 and] 5). Stretching
exercises should be used whenever there is musculotendi­
nous resistance to stretch. If accessory motion is limited due
to some restriction of the joint capsule or the ligaments, the
athletic trainer should incorporate joint mobilization and
traction techniques into the treatment program (Hgure
il -4) (see Chapter 14). Mobilization techniques should be
used whenever there are tight articular struc.tures. 16 1"radi­
tionally, rehabilitation programs tend to concentrate more
on passive physiological movements without paying much
attention to accessory molions.
Restoring Muscular Strength,
Endurance, and Power
Muscular strength, endurance and power are among the
most essential factors in restoring the function of a body
part vo preinjury status. [sometric, progressive resistive
(isotonic), isokinetic, and plyometric exercises can bene-
Figure 1-4 Joint mobilization techniques are used with
tight ligamentous or capsular structures to improve ac­
cessory motion.
fit rehabilitation. A major goal in performing strengthen­
ing exercises is to work through a fuU pain-free range of
motion.
Most strength-training programs involve single-plane
force production using either free weights or exercise ma­
chines. A runctional rehabilitative strengthening pro­
gram should involve exercises in all three planes of
motion, concentrating on a combination of concentric,
eccentric, and isometric exercises designed both to in­
crease strength through a full multiplanar range of mo­
tion and to improve core stabilization and neuromuscular
control. 3
Isometric Exercise. Isometric exercises are com­
monly performed in the early phase of rehabilitation when
a joint is immobilized for a period of time. They are useful
when using resistance training though a full range of mo­
tion might make the injury worse. Isometrics increase
static strength and assist in decreasing the amount of at­
rophy. Isometrics also can lessen swelling by causing a
muscle pumping action to remove fluid and edema (see
Chapter 7).
Progressive Resistive Exercise. Progressive resis­
tive exercise (PRE) is the most commonly used strengthen­
ing technique in a rehabilitation program. PRE may be
done using free weights, exercise machines, or rubber tub­
ing (Figure 1-5). Progressive resistive exercise uses isotonic
contractions in which force is generated whl1le tbe muscle
is changing in length. Isotonic contractions may be either
concentric or eccentric. In a rehabilitation program the
athletic trainer should incorporate both eccentric and con­
centrk strengthening exercises. Traditoionally, progressive
 CHAPTER 1 Essential Considerations in Designing a Rehabilitation Program for the Injured Athlete 11

Figure 1-6 lsokinelic exercise is most often used in the

later stages of rehabilitation.

Figure 1-5 Progressive resistive exercise using isotonic

contractions is the most widely used rehabilitative
strengthening technique.

resistive exercise has concentrated primarily on the con­

centric component and has to some extent minimized the
importance of the eccentric component (see Chapter 7).
lsokinetic Exercise. [sokinetic exercise is com­
monly used in the rehabilitative process. I? It is most often
.Dcorporated during the later phases of a rehabilitation
rogra m. [sokinetics uses a fixed speed with accommo­
dat ing resistance to provide maximal resistance through­
ut the range of motion (Figure 1-6) . The speed of
!Ilovement can be altered in isokinetic exercise. Isokinetic
"lleasures are commonly used as a criteria for return of
~e athlete to functional activity following injury (see
apl.er 13).
Plyometric Exercise. Plyometric exercises, also re­
_'rJ'ed lo as reactive neuromuscular training, are most of­
incorporated inlo the later stages of a rehabilitation
ra m. Plyometrics use a quick eccentric stretch to facil­ Figure 1-7 Plyometric exercise focus es on improving
k a subsequent concentric contraction. Plyometric ex­ dynamic, power movemen ts.
_ - s are usdul in restoring or developing the athlete's
l)' to produce dynamic movements associated with sport activities. It is critical to address the clement of mus­
~ u lar power (Figure 1-7). The ability to generate force cular power in rehabilitation programs for the injured ath­
_ ra pidly is a key to successful performance in many lete (see Chapter 1 1).
12 PART 00iE The B<l~is of Injury Rehabilitation

Figure 1-8 Closed-kinetic-chain exercises are widely

used in rchabilitation.

Core Stabilization. Core stability is absolutely es­

sentia l to developing functional strength. The core is con­
sidered to be the lumbo-pelvic-hip complex, which
functions to dynamically stabilize the entire kineti c chain
durin g functional movements. Without proximal or core
stability, the distal movers canoot function optimally to ef­
ficiently utilize their strength and power. Chapter 10 will
discuss the concept of core stabilizalion in grcat detail. 3,9
Open- versus Closed-Kinetic-Chain Exercise.
The concept of the kin etic chain deals with the anatomical Figure 1-9 Reestablish ing neuromuscular control and
functional relationships that exist in the upper and lower balance is critical to regaining functional performance
extremities (sec Chapter J 2). An open kinetic chain exists capabilities.
when the foot or hand is not in contact with the ground or
some other surface. 6 In a closed kinetic chain. the foot or
hand is weight-bearing (Figure 1-8 ). In rehabilitation. the can limil th e ability to generClte an effective correction re­
use of closed-chain strengthening techn iques has become sponse when there is not equilibrium. 1\ rehabilitation pro­
the treatment of choice for many athletic trainers. Closed­ gram must include functional exercises that incorporate
kinelic-chain exercises use varying combinations of iso­ balance and proprioceptive training that prepares the ath­
metric, concentric, and eccentric contractions that must lete for return tei activity (Fig ure 1-9). FaUure to address
occur simultaneously in different muscle groups within balance problems can predispose the athleLe to reinjury
the chai n. (sec Chapter 7).

Restoring Postural Control Maintaining Cardiorespiratory Fitness

and Stability (Balance)
Postural stability involves the cornplex integration of mus­
cular forces, neurological sensory information received
from the mechanoreccptors, und biomechanical informa­
tion.4.7 The abUity to maintain postural stability and bal­
ance is essentia l to Dcquiring or reacquiring complex
motor skills.13 /\thletes who show a decreased sense of bal­
ance or a lack of postural stabi lity !()]Jowing injury might
lack s ufllcicnt proprioceptive and kinesthetic informDtion
and/ or might h ave muscular weakness, either of wluch
Maintaining card iorespirCltory fitnes~ is perhaps the sin­
gle most neglected component of a rehabilitation pro­
gram (see Chapter 8). An athlete spends a considerable
amount of time preparing the cardiorespiratory system to
be able to handle the increased demands made upon it
during a com petitive season. When injury occurs and the
athlete is forced to miss training lime, cardiorespiratory
fitness can decrease rapidly. Thus the ath letic trainer must
design or substitute aLternative activities that allow the
athlete to maintain existing levels of ca rdi orespiratory fit­
 CHAPTER 1 Essential Considerations in Designing a Rehabilitation Program for the Injured Athlete
Figure 1-10 Every rehabilitation program must in­
clude some exercise designed to maintain cardiorespira­
tory fitness.
ness as early as possible in th e rehabilitation period l5
(Figure 1-10).
Depending on the nature of the injury. a number of
possible activities can help the athlete maintain fitness
levels. When there is a lower-extremity injury. non­
weight-bearing activities should be incorporated. Pool
cont rol and activities provide an excellent means for injury rehabili­
rm ance tation. Cycling also can positively stress the cardiorespi­
ralory system.
functional Progressions
The purpose of any program of rehabilitation is to restore
normal function following injury.s Functional progres­
sions involve a series of graduaUy progressive activiLies de­
Signed to prepare the individual for return to a specific
sport 22 (see Chapter 17). Those skills necessary for suc­
cessful participation in a given sport are broken down into
component parts. and the athlete gradually reacquires
those skills within the limitations of his or her own indi­
vidual progress. 2J Every new activity introduced must be
careFully monitored by the athletic trainer to determine
the athlete's ability to perform and her or his physicaltol­
erance. If an <Jctivity does not produce additional pain or
swelling. the level should be advanced; new activiLies
should be introduced as quicldy as possible.
functional progressions will gradually help the in­
jured athlete achieve normal pain-free range of motion.
restore adequate strength levels. and regain neuromuscu­
lar control throughout thl' rehabilitation program.
13
Figure 1-11 Performance on functional tests can de­
termine the ath lete's capability to return to full activity.
Functional Testing
Functionaltesling uses functional progression drills to as­
Sess the athlete's ability to perform a specific activity (Fig­
ure 1-11). Functional testing involves a single maximal
effort performed to indicate how elose the athlete is to a full
return to aclivity. For years athletic trainers have assessed
athletes' progress with a variety of functional tests. in·
eluding agility runs (figure eights, shuttle run, carioca).
sidestepping, vertical jump. hopping for lime or distance,
and co-contraction tests 21 (see Chapter 17).
Criteria for Full Recovery
All exercise rehabi'litation plans musl determine whal is
meant by complete recovery from an injury.21 Often it
means that the athlete is fully reconditioned and has
achieved fuLl range uf movement. strength. neuromuscu­
lar control, cardiovascular fitness. and sport-specine func­
tional skills. Besides physical well-being. the alhlete must
also have regained fun confldence to return to his or her
sport.
For example. speCific criteria for a return to full activity
after rehabilitation of thc injured knee is largely dcter­
mined by the nature and severity of the spccific injury. but
it also depends on the philosophy <Jnd judgment of both
the physician and the athletic tminer. 'f'raditional[]y. return
14 PART ONE The Basis of Injury Rehabilitation
to activity has been dictated through both objective a nd
subjective evaluations. Objective evaluation techniques
have made usc primarily of isokinetic testin g and
arthrometry. The advantage of testing with an isokinetic
device that indicates levels of strength and an arthrometer
that measures joint laxity is that the athletic trainer is pro­
vided with some hard, quanti!lable da ta relative to th e a th­
lete's progress in the rehabilitation program. Recently,
however, considerable debate has taken place in the sports
medicine community on the functional application of iso­
kinetic testing. The question has been raised whether the
ability to generate torque at a l1xed speed is indicative of
the athlete's capability of returning to an activity in which
success more often depends on the ability to generate force
at a high velocity.
For th e athlete. it migbt be more practical to base crite­
ria for return on functional capabilities as indicated by per­
formance on spcci!lc functional tests Lhat are more closely
rel ated to the demands of a particula r sport. Performance
on functional tests, such as those described in Chapter 17
(hop test, co-contraction tes t), should scrve as primary de­
term inants of the athlete's capability Lo return to full activ­
ity. Data on the majority of these tests are well documented.
A number of data-based research studies have objectively
quantified performance on various functional tests. These
fu nctional tests are extremely useful and valuable tools for
determining readiness to return to full activity.
The decision to release a n athlete recovering from in­
jury to a full return to athletic activity is the l1nal stage of
the rehabilitation / recovery process. The decision should
be carefully considered by each member of the sports med­
icine tea m involved in the reh abilitation process. The team
physician should be ultimately responsibl e for deCiding
that the athlete is ready to return to practice an d!or com­
petition. That decision should be based on collective input
from the athletic trainer, the coach, an d the athlete.
In co nsidering the athlete's return to activity. the fol­
lowing concerns should be addressed:
PhYSiological healing constraillts. Has rehabilitation pro­
gressed to the later stages of the hea ling process?
Pain statuS. Has pain disa ppeared, or is the athlete able
to play within her or his own levels of pain tolerance?
Swelling. Is th ere still a chance that swelling could be
exacerbated by return to activity?
Range of motioll. Is ROM adequate to allow the athlete
lLo perform botb effectively and with minimized risk of
reinjury ?
Strellgth. Is strength , endurance, OF power great
enough to protect the injured structure from reinjury?
Neuromuscular COIl trollproprioception!kinesthesia. Has
th e athlete "relea rned" how to use the injured body
part?
Ca rdiorespiratory fitness. Has the athlete been able to
ma intain cardiorespiratory fitness at or near th e level
necessary for competition ?
Sport-specific dema11ds. Are the demands of the sport or
a specific position such that the athlete will not be at
risk of reinjury?
Functiolllli testing. Does performance on appropriate
functional tests indicate that the extent of recovery is
sufi1cient to allow successful performance?
Prophylactic strappi11g, bracing, paddi11g. Are any addi­
tional supports necessary for the injured athlete to re­
turn to activity?
Responsibility of the athlete. Is the athlete capable of lis­
tening to his or her body and recognizing situations
that present a potenti al for rei njuty?
Predisposition to illjury. Is this a thlete prone to reinjury
or a new injury when she or he is not 100 percent
recovered?
PsychologiCillfactors. Is the athlete capable of returning
to activity and competing at a high level without fear
of reinjury?
Athlete edllCiltioll and preve11tive mainte11ance program.
Does the athlete understand the importa nce of contin­
uing to engage in conditioning exercises that can
greatly reduce lLhe chances of rcinjury ?
CLINICAL DECISION MAKING Exercise 1-6
After a week of managing a first-degree hamstring strain.
a track athlete has decided that she is ready to compete.
She has no signs of inl1ammallon. She h as regained full
strength and ROM . WhaL other things should be laken
into consideration before she Is allowed to compete again?
DOCUMENTATION IN
REHABILITATION
Athletic trainers must develop prolkiency not only in their
ability to constantly evaluate an injury, but also in their
ability to generate an accurate report of the I1ndings from
that evaluation. Accurate an.d detajled record keeping that
documents initial injury evaluations, treatment records,
and notes on progress throughout a rehabilitation program
is critical for the athletic trainer. This is particu,larly true
considering the number of malpractice lawsuits in health
care. For tbe athletic trajner working in a clinical setting,
clear, concise, accurate record keeping is necessa ry for
third-party reimbursement. Although this may be difficult
and time-consuming for the athletic trainer who treats and
 CHAPTER 1 Essential Considerations in Designing a Rehabilitation Program for the Injured Athlete
deals with a large number of ath:letes each day, it is an area
that simply cannot be neglected. Documentation and
record keeping will be discussed in detail in Chapter 3.
sport or
not be at LEGAL CONSIDERAT,IONS
IN SUPERVISING A
REHABIUTATION PROGRAM
Regarding the treatment and rehabUitation of athletic in­
juries, curren tly there is con troversy over the specific roles
Summary
1. The athletic trainer is responsible for the design, imple­
mentation. and supervision of the rehabilitation pro­
gram for the injured alhlete.
2. The rehabilitation philosophy in sports medicine is ag­
gressive, with the ultimate goal being 10 reI urn the in­
jured athlete to full activity as quickly and safely as
progmm. possible.
r contin­ 3. To be effective in overseeing a rehabilitation program,
that can the athletic trainer must have a sound understanding
of the healing process. the biomechanics of normal
movement, and the psychological aspects of the reha­
bilitative process.
4. The athletic trainer must develop a broad theoretical
knowledge base from which specific techniques or
tools of rehabilitation can be selected and practically
applied to each individual case without relying on
"recipe" rehabilitation protocols.
:;. Therapeutic exercises are rehabilitative, or recondi­
tioning, exercises that arc specifica'ily concerned with
restoring normal body ['u nction follOWing injury.
References
l.. Buschbacher, R.. and R. Braddom. 1994. Sports medicine and
only in their rehabilitatioll: A sport specific approach. Philadelphia: Hanley &
also in their Belfus.
fm dings from , Canavan. P. Rehabilitation ill sports medicine. 1997. New York:
keeping that \·[cGraw-Hill.
3. Clark, M. Integratcd tminingfor tli e new millenllillm. 2001. Cal­
eot records,
abasas, CA: National Academy of Sports Medicinc.
ti
.;,. Guskicwicz, K. and D. Perrin. 1 996. Research and clinical ap­
plications of assessing balance. Joumal of Sport Relwbilitation
5(1): 45-63.
- . Hertel, j. and C. Denegar. 1998. A rehabilitation paradigm for
restoring ncuromuscular control following athletic injury.
Jo urnal oj Sport RehaiJilit11tion 3( 5): 12.
15
of individuals with various combinations of educational
background, certification, and licensure. States vary con­
siderably ·i n their laws governing what an athletic lrainer
may and may not do in supenr,ising a program of rehabili­
taLion for an injured athlete. Many states have specific
guidelines in their licensure act that dictate how the ath­
letic trainer may incorporate a variety of treatment tools
into the treatment regimen. Each athletic lrainer should
make sure that any use of a speciftc tool or technique of
rehabilitation is within the limits allowed by the laws of his
or her particular state.
6. Short-term goals of a rehabilitation program: (1) pro­
viding correct immediate first aid and management
following injury to limit or control swelling; (2) reduc­
ing or minimizing pain; (3) reestablishing neuromus­
cular control; (4) restoring full range of motion;
(.5) restoring or increasing muscular strength , en­
durance, and power; (6) improving postural stability
and balance: (7) maintaining cardiorespiratory fit­
ness: and (8) incorporating appropriate functional
progressions.
7. Controlling swelling immediately follOWing injury is
perhaps the single most important aspect of injllfY re­
habilitation in a sports medicine setting. If the swelling
can be controliled initially in the acute slage of injury,
the time required for rehabilitation is likely to be sig­
nificantly reduced.
6. Hillman, S. 1994. Principles and techniques of open kinetic
chain rehabilitation. Journal of Sport Rehabilitation 3(4):
.319-30.
7. Irrgang, J., S. Whitney, and E. Cox. 1994. Balance and pro­
prioceptive training for rehabilitation of the lower extremity.
Journal of Sport Rehabilitation 3(1): 68-83.
8 . Kibler, B. 1998. Functional rehabilit11lion of sports and muscu­
loskeletal injuries. New York: Aspen .
9. King, M. 2000. Core stability: Creating a foundation for func­
tional rehabilitation. Athletic Themp!! Today 5(2) :6.
10. Kisner, C. and A. Colby. 1996. Thempel/tic exercise: Forme/a­
liolls and techniques. Philadelphia: F. A. Davis.
16 PART ONE The Basis of Injury Rehabilitation
11. Kirkendall, D. 1., W. E. Prentice, and W. E. Garretl. 2001. Re­
habilitation of muscle injuries. [n RehabilitaliOl! oj sports in­
juries: ClIrrmt COllcept s, edited by G. Puddu, A. Giombini, and
A. Selvanetti. Berlin: Springer.
12. Knight, K. J. J 98 5. Guidelin es for rehabilitation of sports in­
juries. In Rehabilitation oj the illjured athlet e: Clinics ill sports
medicine, vol. 4, no. 3 , edited by). S. Harvey. Philadelphia:
W. B. Saunders.
13 . Knight, K. L. 1995 . Cryotherapy in sport injury management.
Champaign.iL: Human Kinetics.
14. Logan, G. A .. and E. L. Wallis. 1960. Recentfiluun{Js in lea rning
and perJormancc. Paper presented at the Southern Section
Meeting, California Association for Health, Physical Educa­
tion und Recreation, Pasadena, CA.
15. Magnusson, p', and M. McHugh. ] 995. Current concepts on
reh abilitution in sports medicine. [n The lower extremity and
spine in sports medicine, edited by J. Nicholas and E.
Hirschman. 5t. Louis: Mosby.
16. Malone, T., ed. ] 996. Orthopedic and sports physical therapy. 5t
Louis: lvlosbylYearbook.
SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES
1-1 The athletic train er's decisions about a rehabilitation
progression should be based on the follOWing as­
pects: healing process, pathomechanics of the in­
jury, cardiovascular fitness, and the equipment
available. A good understanding of these things will
ensure that the athletic trainer is progressing the
athletc at an appropriate rate.
1-2 Her concerns sh.ould be discussed with the orthope­
dist. The doctor and athletic trainer should maintain
open communication throughout a patient's reha­
bilitation so that a good working relationship is
maintained and tbe doctor's philosophy persists
throughout the rehabilitation process.
1-3 He should understand the SAID principle. The mus­
cles and sofltissue will adapt gradually to increasing
demands placed on it. If the demands are too great.
they can be detrimental to the healing process.
1-4 In general. the short-term goals for re'habilitation of
an acute injury are to target innammation and re­
17. Perrin, D. 1993. IsokineUc exercise and assessment. Cham­
paign, IL: Hum an Kinetics.
18. PicciniUni, J.. and J. Drover. 1999. Athlete-patient education
in rchabilitation: Developing a selr-directed program. Athletic
Therapy Today 4(6):51.
19. Prentice, W. 2003. Anrireilns principles oj athletic trailling.
II th ed. New York: McGraw-Hill.
20. Prentice, W. 2003. Th erapeutic //Iodalities in sports lIle(Ucineand
athletic training. New York: McGraw-HilI.
21. Shamus, E. anti J. Shamus. 2001. Sports injury: Prevention and
rehabilitatio n. New York: 1"leGraw-Hill.
22. Tippett. S. J 990. Sports rehabilitation concepts . In Sports
physical therapy, edited by B. Sanders. Norwalk. CT: Appleton
& Lange.
23. Tippett, S .. and M. Voight. 1999. Functional pl'Ogressions for
sport rehabilitaLiol1. Champaign, 11: Human Kinetics.
24. Wells. P. E., V. Frumpton, and D. Bowsher. 1988. Painlllanage­
mellt ill physiml tlJerapy. Norwalk, CT: Appleton & Lange.
25. Zachazcwski. J.. D. Magee, and 5. Quillen . 1996. Athletic in­
juries and rehabilitation. Philadelphia: W. B. Saunders.
store ROM. More specifically, pain and swelling
should be controlled using PRICE. Once the athlete
progresses through the innammatory phase, the
goals become to restore muscular strength, en­
durance, and power. Neuromuscular control, bal­
ance, and cardiorespiratory fi tness must also be
regained . Long-term goal s are to regain functional
ability and return to playas soon as possible.
1- 5 The athlete should be Laped and encouraged to keep
up with the therapeutic exercise program, while con­
tinuing to use ice and anti-innammatories.
1-6 She should have sunkient neuromuscular control!
balance. Her cardiovascular e.ndurance should be at
a level that will allow her to be competitive again
without reinjury. She should be able to perform a se­
ries of functional tests that indicate she will with­
stand the demands of competition without rein jury.
She should also be able to perform with confidence
and know when to stop if she is in danger of reiDjury.
 CHAPTER 2
L trai ning. Understanding and Managing
""Inlifine alld
the IH ealliln g Process
~'t'mio nand

-. In Sport.s
through Rehabilitation
( I: Appleton
William E. Prentice
ssions for

Study Resources • Compare heali ng proces es r lative to

To become more familiar with the knowledge and skills specific musculoskeletal structures.
necessary to design. implement. and document therapeu­
tic rehabilitation programs as identified in the .'YATA Ath­ • Explain the importance of initial first
letic Training Fdumtional Competencies and Clillical aid and injury management of these
d swelling ProJiciencirs' Therapeutic Exercise content area. visit
,:'ethe a thlete injuries and their impact on the reha­
www.mhhe.com / prentice lle. Also. refer to the lab exer­
_ pbase. the cises in the new Laboratory Manual and to eSims, which bilitation process.
ngth. en­ simulates the athletic training certification exam. at
, .:nnlrol. baI­ www.mhhc.com/esims. For more online study resources.
• Discuss the use of various analgesics.
t also be visit our Health and Human Performance website at anti-inflammatories, and antipyretics
functional www.mhhe.com/hhp. in facilitating the healing process dur­
-ble.
raged to keep ing a rehabilitation program.
After Completion of This Chapter,

. while con­
the Student Should Be Able

to Do the Following:

neLirive again
• Describe the pathophysiology of the
ehabilitalion of sporl-relaled injuries requires sound
perfo rm a se­
e will with­
OUl reinjury.
healing process.
• Identify the factors that can impede the R knowled ge and understanding of the etiology and
pathology involved in va rious musculoskeletal in­
juries that might occur. 7 22, B4 When injury occurs. the ath­
con l1dence healing process. letic trainer is charged with designing. implemen ti ng. and
~of reinjury. supervising the rehab ilitation program. Rehabilitation
• Distinguish the four types of tissue in protocols and progressions must be based primarily on the
the human body. physiological responses of the tissues to injury and on an
lg
understanding of how various tissues heal. .4 (1 Thus the
• Discuss the etiology and pathology of athletic lrainer must understand the healing process to ef­
various musculoskeletal injuries asso­ fectively super vise the rehabilitative process. This chapter
ciated with various types of tissue. discusses the healing process relative to the va rious mus­
cuJoskeletal inj uries th a t might be encountered in a sports
medicine setllng.

17
18 PART ONE The Basis of Injury Rehabilitation

TRAUMA

+
PRIMARY INJURY
Blood
Greater risk of reinjury / Damaged tissue ~Reduced risk of reinjury

Hematoma __ SECONDARY RESPONSE __ Scab

7
~
dema
Hypoxic damaged tissue
Bleeding

Return to activity + Return to full activity

INFLAMMATION

( Pain ')
Spasm

Less than optimal

REPAIR PHASES Optimal recovery
recovery
Substrate

\ /

Fibroplastic
Maturat ion

Inadequate
~
ATROPHY Adequate

Figure 2-1
~REHABluLON
A cycle of sport-related injury.

(From Booher and Thibadcau, Athletic Injury Assessment, Mosby. ] 994.)

UNDERSTANDI'NG maturation-remodeling phase. It must be stressed that al­

THE HEALING PROCESS
Rehabilitation programs must be based on the cycle of the
healing process (Figure 2-1). The athletic trainer must have
a sound understanding of the sequence of the various
phases of the healing process. The physiological responses
of the tissues to trauma follow a predictable sequence and
time frame. 40 Decisions on how and when to alter and
progress a rehabilitation program should be primarily
based on recognition of signs and symptoms. as well as on
an awareness of the time frames associated with the vari­
ous phases of healing. 58 .75
The healing process consists of the inflammatory
response phase, the fibroblastic-repair phase. and the
though the phases of healing are presented as three sep­
arate entities. the healing process is a co ntinuum. Phases
of th e healing process overlap one another and have no
definitive beginning or end points. ~7
The Primary I "jury
In the athletic population, injuries most often involve the
musculoskeletal system and in fewer instances the nervous
system. In sports medicine. pI'imary injuries are almost al­
ways described as being either chroniC or acute in nature
resulting from macrotrawl1aUc or microlralll1Ultic forces.
Injuries classified as macrotraumatic occur as a result of
acute trauma and produce immediate pain and disability.
 CHAPTER 2 Understanding and Managing the Hea'ling Process through Rehabilitation
Macrotraurnatic injuries include fractures. dislocations.
subluxations. sprains, strains, and contusions. :v licrotrau­
matic injuries are most often called overuse injuries and re­
sult from repetitive overloading or incorrect mechanics
associated with continuous training or compelilion. hO IVli­
crotraumatic injuries include tendinitis, tenosynovitis. bur­
sitis, etc. A secondary il1jury is essentially the inflammatory
or hypoxia response that occurs with the primary injury.
Inflammatory Response Phase
Once a lissue is injured. the process of healing begins im­
rnediatelyl,ll (Figure 2-2/\.). The destruction of tissue pro­
duces direct injury to the cells of the various soft tissues, Ii
ity Cellular injury results in Clltered metabolism and the liber­
ation of materials that initiate the inflammatory response.
It is characterized symptomatically by redness, swelling,
tenderness, and increased temperalure. I 5,i2 This il1itial in­
j7ammatory respol1se is critical to the entire healing process. If
this response does not acc01l1plish what it is supposed to or if it
does not subside, normal healing call1lot take place.
Inflammation is a process through which leukocytes
and other phagocytic cells and exudate are delivered to the
injured tissue. This cellular reaction is generally protective,
tending to localize or dispose of injury by-products (e.g.,
blood and damaged cells) through phagocytosis and thus
selting the stage for repair. LocHI vascular effects. distur­
bances of l1uid exchange, and migration of leukocytes
from the blood to the tissues occur.
CLINICAL DECISION MAKING Exercise 2-1
A physical education student fell on his wrist playing nag
football. It is ve.ry swollen , and he ha~ decreased strength
and ROM. The athletic trainer does not suspect a fracture.
A decision is made to provide an initial treatment as op­
posed to sending the student to the emergency room.
What should the athletic trainer's goals be at this time?
, three sep­
m. Phases
Vascular Reaction, The vascular reaction involves
'aSC ular spasm. formation of a platelet plug, blood coagula­
n . and growth of fibrous tissue.~1 The immediate response
tissue damage is a vasoconstricUon of the vascular walls
leu involve the 1 lasts for approximately 5 to 10 minutes. This spasm
~s the opposing endothelial linings together to produce
al anemia that is rapidly replaced by hyperemia of the
a due to dilation. This increase in blood flow is transitory
gives way to a slovving of the flow in the dilated vessels,
h then progresses to stagnation and stasis. The initial ef­
n of blood and plasma lasts for 24 to 36 hours,
19
Chemical mediators. Three chemical mediators,
histamine. leukotaxin. and necrosin. arc important in limit­
ing the amount of exudate and thus swelling after injury.
Histamine re'leased from the injured mast cells causes va­
sodilation and increased cell permeability. owing to swelling
of endotheliClI cells and lhen separation between the cells,
Leukotaxin is responsible for margination. in whicl1 leuko­
cytes line up along the cell walls, It also increases cell per­
meability locally. thus affecLing passage of the fluid and
white blood cells through cell walls via diapedesis to form ex­
udate. Therefore vasodilation and active hyperemia are im­
portant in exudate (plasma) formation and supplying
leukocytes to the injured area. Necrosin is responsible for
phagocytic ClcLivity. The amount of swelling that occurs is
directly relateclto the extent of vessel damage.
Formation of a Clot. Platelets do not normally ad­
here to the vascular wal!. However, ilnjury to a vessel dis­
rupts the endothelium and exposes the coHagen fibers .
PICltelets adhere to the collagen fibers to create a sLicky ma­
tr'ix on the vClscular wall. to whicb additional platelets and
leukocytes adhere and eventually form a plug. 'nhese plugs
obstruct local lymphatic fluid drainage and thus localize
the in jury response.
The initial event that precipitates clol ilormation is the
conversion of fibrinogen to/Tbrill, This transformation occurs
because of a cascading effect beginning with the release of a
protein molecule caUed thromboplastin from the damaged
cell. Thromboplastin causes prothrombin to be changed into
thrombin, which in turn causes the conversion of fibrinogen
into a very slicky fibrin clot that shuts off blood supply to the
injured area. Clot formalion begins around 12 hours after in­
Jury and is compleled within 48 hours,
As a result of a combination of these factors, the in­
jured area becomes walled off during the innammatory
stage of healing. The leukocytes phagocytize most of the
foreign debriS towClrd the end of the inl1al11matory phase,
setling the stage for the fibroblaslic phase. This initial in­
llammCltory response lasts for approximately 2 to 4 days af­
ter initial injury.
CLINICAL DECISION MAKING Exercise 2-2
A barkstroker suffered a second-degree latissimus dorsi
strain. The coach wan ts to know why he can't be rcady to
compete the next day. What should the athletic trainer
tell the coach about the healing process and how long it
may take the strain to heal:'
Chronic Inflammation. A distinction must be made
between the acute lnflammatory response as described
above and chronic inflammation. Chronic inj7ammatiol1
 Clot in wound defect

Capillary

Mononuclear leukocyte

Polymorphonuclear leukocyte

Dilated venule with leukocyte

emigration and plasma leakage
through endothelial gaps

Figure 2-2 The healing process. A. lnOanlli1C:llory response phase.

20
 Scab

Epidermis

Epithelial cells migrating

beneath scab, br idg ing wound

Capillary

Fibroblasts migrating into

wound along fibrin strands

erentiated Fibrin strands

Mononuc lear leukocyte

Polymorphonuclear leukocyte

Collagen bundles

Venule

Endothelial buds

figure 2-2 (continued) The healing proce s. B, Fibroblastic-repa ir phase.

21
 Scab

Pro liferation of epithelia l

cells in wound beneath scab

Capillary

Fibrob'last

New collagen fibers elaborated

by fibroblasts in wound defect

New vessel in wound defect

Venule

Projection of endothelial
buds into wound

Figure 2-2 (continued) The healing process. C, Maturation -remodeling phase.

22
 CHAPTER 2 Understanding and Managing the Healing Process through Rehabilitation
occurs when the aCllle inOammatory response does not
eliminate the injuring agent and restore tissue to its normal
physiological state. Chronic inllanunation involves the re­
Kob placement of leukocytes with macrop/wges, lymphocytes,
and plasma cells. These cells accumulale in a highly vascu­
larized and innervated loose connective tissue matrix in the
area of injury.i l
The specific mechanisms that convert an acute inl1am­
malory response to a chronic inl1ammatory response are
to date unknown; however, they seem to be associated
ra ted with situations tbat involve overuse or overload with cu­
:::; defect mulative microtrauma to a particular structure. 26 . Sl Like­
wise. tbere is no specific time frame in whicb a
classification of acute inflammation is cbanged to chronic
:I'~I
inf1alrunation.
It does appear that chronic inf1ammalion is resistant to
both physica'! and pharmacological trcatments. 43
The Use of Anti-inflammatory Medications. A This normal sequence of events in thc repair phase
sports medicine physician wHl routinely prescribe non­
steroidal anti-inf1ammatory drugs (~S /UU) for an athlete
who has sustained an injury.J These medications are cer­
tainly effective in minimizing pain and swelling associated
with inflammation and can enhance return to full activity.
However. th ere are some concerns that use of NSAIl)
acutely follOWing injury might actually interfere with in­
l1ammation. thus delaying the healing process.
Fibroblastic·Repair Phase
During the fibroblaslic phase of healing. prolliferative
and regenerative activity leading to scar formation and
repair of the injured tissue follows (he vascular and ex­
udative phenomena of inl1ammat,i onJ (j (Figure 2-2B).
The period of' scar formation referred to as Jibroplasia be­
gins within the first few hours after injury and can last
as long as 4 to 6 weeks. During this period. many of the
signs and symptoms associated with the inflammatory
respons e subside. The athlete might still indicate some
tenderness to touch and will usually complain of pain
when particular movements stress the injured structure.
As scar formation progresses. complaints of tenderness
or pain gradually disappear. 2 ~
During this phase, growth of endothelial capillary
buds into the wound is stimulated by a lack of oxygen, af­
ter which the wound is capable of healing aerobically.ls
Along with increased oxygen delivery comes an increase in
blood now. which delivers nutrients essential for tissue re­
generation in the area. J4
The formation of a delicate connective tissue called
yratllliation tissue occurs with the breakdown of the Ilbrin
clot. Granulation tissue consists of fibroblasts, collagen.
23
and capillaries. It appears as a reddish granular mass of
connective tissue that fills in the gaps during the healing
process.
As the capillaries contil lUe to grow into the area, fi­
broblasts accumulate at the wound site, arranging them­
selves parallel to the capillaries. Fibroblastic cells 'begin to
synthesize an extracellular matrix that contains protein
fibers of collagen and elastin, a ground substance that con­
sists of nonfibrous proteins called proteoglycans. gly­
cosaminoglycans. and Ouid. On about day 6 or 7.
fibroblasts also begin producing collagen fibers that arc de­
posited in a random fashion throughout the forming scar.
As the collagen continues to prolirerate. the tensile
strength of the wound rapidly increases in proportion to
the rate of collagen synthesis. As the tensile strength in­
creases, the number of fibroblasts diminishes. signaling
the beginning of the maturation phase.
leads to the formation of minimal scar tissue. Occasionally,
a persistent inl1ammatory response and continued release
of inl1ammatory products can promote extended fibropla­
sia and excessive fibrogenesis. which can lead to irre­
versible tissue damage.9 ' Fibrosis can occur in synovial
structures. as with adhesive capsulHis io the shoulder. in
extra-articular tissues including tendons and ligaments, in
bursa , or in muscle.
CLINICAL DECISION MAKING Exercise 2-3
A cross-country run ner strained her quadriceps. How
wtllthe healing process ror this injury differ from the
process for a ltgamenlous injury?
Maturation·Remodeling Phase
The maturation-remodeling phase of healing is a long­
term process (Figure 2-2C). This phase features a realign­
ment or remodeling of the collagen fibers that make up
scar tissue accord,ing to the tensile forces to which that
scar is subjected . Ongoing breakdown and synthesis of
collagen occur with a steady increase in the tensile
strength of the scar matrix. With increased stress and
strain, the collagen fibers realign in a position of maxi­
mum efficiency parallel to the lines of tension. The tissue
gradually C1$sumes normal appearance and function, al­
though a scar is rarely as strong as the normal injured tis­
sue. Usually by the end of approximately 3 weeks. a firm,
24 PART ONE The Basis of Injury Rehabilitation
strong, contracted, nonvascular scar exists. The matura­
tion phase of healing might require several years to be to­
tally complete.
The Role of Progressive Controlled
Mobility During the Healing Process
Wolff's law states thaI bone and soft lissuc will respond to
the physical demands pluced on them, causing them to re­
model or realign along lines of tensile force.'!Y Therefore it is
critical that injured structures be exposed to progressively
increasing loads throughout the rehabiHtatlve process. 71
In animal models, controlled mobili7.ation is superior
to immobilization [or scar formation. revascularization.
muscle regeneration, and reorientation of mu scle fibers
and tensile properties. 74 However, a brief period of immo­
bilizatjon of the injured tissue during the in!lammatory re­
sponse phase is recommended and will likely facilitate the
process of healing by controlling in!lammati on. thus re­
ducing clinical symptoms. As healing progresses to the re­
pair phase, controlled activity directed toward return to
normal !lexibility and strength should be combined with
protective support or bracing. 47 Generally, clinical signs
and symptoms disappear at the end of this phase.
As the remodeling phase begins, aggressive active
range-of-motion and strengthening exercises should be in­
corporat(!d to faciJitate tissue remodeling and realignment.
To a great extent. pain wUl dictate rate of progression. With
initial injury. pain is intense: it lends to decrease and even­
tually subside altogether as healing progresses. Any exac­
erbation or pain, swelling. or other clinical symptoms
during or after a particular exercise or activity indicates
that the load is too great ror the level of Ussue repa ir or re­
modeling. The athletic trainer must be aware of the time re­
quired for the healing process and realize that being overly
aggressive can in terfere with that process.
CLINICAL DECISION MAKING Exercise 2-4
A trllck athlete is recovering from a grade "[ ankle sprain.
Beginning exercises as soon as possi ble will increase the
injured runner's chances of recovering quickly and
strongly. Why is this so?
Factors That Impede Healing
Extent of Injury. The nature of the inflammatory
response is determined by th e extent of the tissue injury.
Microtcilrs of soft tissu e involve only minor damage and
are most often associated with overuse. :vlilcroleilrs involve
gignil1cantly greater destruction of soft tissue and result in
clinical symptoms and functional alterations. Macrotears andu;
are generally caused by acute trauma. 17
Edema, The increased pressure caused by swelling
retards the healing process, causes separation of tissues,
inhibits neuromuscular control , produces reflexive neuro­
logical changes, and impedes nutrition in the injured part.
Edema is best controlled and man aged d'uring the initial
first-aid management period as described previously. 11
Hemorrhage. Bleeding occurs with even the small­ fIn
est amount of damage to the capillaries. Bleeding produces
the same negative crfects on healing as does the accumu­
lation of edema, and its presence produces additional tis­
sue damage and thus exacerbation of the injury. 70
Poor Vascular Suppl}'. Injuries to tissues with a poor
vascular supply heal poorly and ala slow rate. This response
is likely related to a failure in the initial delivery of phago­
cyTic cells and fibroblasts necessary for scar rormation. 7o
Sep aration of Tissue. Mechanical separation of
tLssue can signillcantiy impact the course of healing. A
wound that. has smooth edges in good apposition will tend
to heal by primary intention with minimal scarring. Con­
versely, a wound that has jagged, separated edges must
heal by secondary intention. with granulation tissue fill­
ing the defect and excessive scarring. i~
Muscle Spasm. Muscle spasm causes traction on
the torn tissue, separates th e two endS', and prevents ap­
proximation. Locall and generalized ischemia can result
from spasm.
Atrophy. Wasting away of muscle tissue begins im­
mediately with injury. Strengthening and early mobiliza­
tion of the injured structure relard atrophy.
Corticosteroids , Use of corticosteroids in the treat­
ment of il)!lammation is controversial. Steroid use in the
early stages of healing has been demonstrated to inhibit 11­
broplasia, capillary proliferation, collagen synthesis. andl
increases in tensile strength of the hea'ling scar. Their use
Ln the later stages of healing and' with chronic inflamma­
tion is debatable.
Keloids and Hypertrophic Scats. Keloids occur
when the rate of collagen production exceeds the rate of
collagen breakdown during th e maturation phase of heal­
ing. Thjs process lea ds to hypertrophy of scar tissue. par­
ticularly around the periphery of the wound.
Infection. The presence of bacteria in tbe wound
can delay heaHng, causes excessive granulation tissue, and
frequently causes large. deformed scars. 9
Hum id ity, Climate, and Oxygen Tension. Hu­
midity Significantly influences the process of epitheJiza­
 CHAPTER 2 l:nderstanding and Managing trw Healing Process through Rehabilitation 2S

damage and tion. Occlusive drcssings stimulatc the epithelium to mi­ genation. and climination of waste products. Most sport­
rs involve grate twice as fast without crust or scab formation. The related injrUries to this type ()f tissue are traumatic, includ­
d re LIlt in formation of a scab occurs with dchydrHtion of the wound ing abrasions. lacerations. puncturcs. and avulsions.
\lacro tears and traps wound drainage. which promotes infection. Other injuries 10 this tissuc can include infection . inllam­
Kecping the wound moist provides an advantage for thc mati(lIl. or disease.
necrotic debris to go to the surface and be shcd.
Oxygen tension relates to the ncovascularizalion of the Connective Tissue
-h'e neuro­ wound. which translates into optimal saturation and max­
;.n ured part. imal tensile strength development. Circulation to the The functions of connective tissue in the body are to sup­
~ :0 the initial wound can be affectcd by ischemia. venous stasis. port. providc a fram ew() rk . fill space. store fat. hclp rcpair
u ly.12 hematomas. and vessel tra uma. tissues. producc blood cells. and protect against iI1 fection.
the small­ Health, Age. and Nutrition. The clastic qualities Conncctivc tissue cOl1sists of various types of cells sepa­
of the skin decrease with aging. Degcnerative diseases. rated from onc another by some type of cxtracellular ma­
such as diabetcs and arteriosclerosis. also become a con­ trix. This matrix consists of fibers al1d ground substancc
cern of the older athlcte and can affect wound healing. and can be solid. scmisolid. or fluid. The primary types of
-0
Nutrition is important for wound healing~ in particular. connective tissue cells are macrophages. which function
\\;th a poor vitamins C (for collagen synthesis and immune system). K as phagocytcs to clean up dcbris; mast cells. which release
is response (for clolLing). and i\ (for the immune system); zinc (for·the chcmicals (histamine and heparin) associated with in­
_or ph ago, enzyme systems) and amino acids play critical roles in the flammation; and the Ilbroblasts. which are the principal
alio n. 70 healing process . cells of the conncctivc tissuc.
..eparation of Collagen . Fibroblasts produce collagen and elastin
heali ng. A found in varyin g proportions in different connectivc tis­
n will tend PATHOPHYSIOLOGY OF INJURY sues. Collagen is a major structural protein th at forms
~ring. Con­
TO VARIOUS BODY TISSUES strong. rlexible. inelastic structures thal hold conncctive
~ edges must tissue togethcr. Collagen enable a tissue to resis t mcchan­
11 £issue 1111­ ical forccs and deformation. Elastin. howevcr. produccs
Classifica,tion of Body Tissues
highly clastic tissues that assist in recovery from deforma­
:raction on There are four types of fundamental tissues in thc human tion. Collage n fibrils arc the load-bcaring element.s of con­
ewnts ap­ body: cpithelial. conncctive. muscular. and ncrvous ~H nective tiss ue. They arc arranged to accommodate tensile
an result (Tablc 2-1). According to Guyton. al'l tissucs of thc body strcss but arc not as capable of resisLing shear or compres­
except bone can be defined as soft tissue. lH Caillict. how­ sive stress. Consequently the directioo of orientation of
begins 'im­ ever. more Lechnically del1ncs soft tissue as thc matrix of collagen I1bers is along lines of tensile stres.s.
mobiliza­ the human body comprised of cc llular elcmcnts within a Collagen has several mechanical and physical proper­
ground substance. Furthermore. Cailliet beUeves that soft ties that allow it to respo nd to loading and deformation,
n the trea t- tissue is the most commOll site of funcLional impairmcnt of permitting it to withstand high tcnsile stress. The mechan­
thc musculoskele t.al systelIl .J2 Most sport-rclated inj l1ries ical properties of colLagen include elasticity. which is thc
occur to the soft tissues. capability to recovcr normal length after elongation ; vis­
thesis. and coe/asticity, which allows for a slow re turn to normal
r. Theiruse length and shape after deformation; and plasticity. which
- mflamma­
Epithelial Tissue
allows for permanent change or deformation. The physical
-The first fundamental tissuc is epithcLial tissuc (Pigure 2-3). properties include force -relaxation. which indicates the dc­
wills occur This specil1c tissue covers all intcrnal and cxternal body crcase in the amount of force needed to maintain a tissue
. the rate of surfaccs and therefore cncompasses structures such as the at a sct tlmount of displacement or deformation over time;
~ o r heal­ skin, the outer layer of the internal organs. and the inner the creep response. which is the abiHty of a tissue to dcform
.- tiss ue, par- lining of thc blood vessels and glands. A basic purpose of over time While a constant load is imposed; and hysteresis.
epithelial tissue. is to protect and form structure for other which is the amount or relaxation a tissue has undergone
the wound tissues and organs. In addition. this tissue functions in ab­ during deformation and displacement. If the mechanical
o ti ue. and sorption (e.g .. in the digestive tract) and secretion (as in and physical limitations of connective tissue are exceeded.
glands). A principal phYSiological characteristic of epithe­ injury results.
r Dsion. Hu­ Ilial tissue is that it contains no blood supply per 5C. so it Types of Connective Tissue. There are several
epitheliza­ must depend on the process of diffusion for nutrition. oxy­ types of connective tissuc. 7.4UJ Fibrous cOllnective tissue is
 26 PART ONE The Basis of Injury Rehabilitation

• TABLE 2·1 Tissues.

Tissue Location Function

Epithelial

Simple squamous Alveoli of lungs Absorption by diffusion of respiratory

gases between alveolar air and blood
Lining of blood and Absorption by diffusion, filtration, and
lymphatic vessels osmosis
Stratified squamous Surface of lining of mouth and Protection
esophagus
Surface of skin (epidermis)
Simple columnar Surface layer of lining of stomach, Protection; secretion; absorption
in testines, and parts of respiratory
tract
Stratified transitional Urinary bladder Protection

Connective (most widely distributed of all tissues)

Areolar Between other tissues and organs Connection

Adipose (fat) Under skin Protection
Padding at various points fnsulation; support; reserve food
Dense fibrous Tendons; ligaments Flexible but strong connection
Bone Skeleton Support; protection
Cartilage Part of nasal septum; covering articular Firm but flexible support
surfaces of bones; larynx; rings in
trachea and bronchi
Disks betwecn vertebrae
External ear
Blood Blood vess.cls Transportation

Muscle

Skeletal (striated voluntary) !vluscles that attach to bones Movemen( of bones

Cardiac (striated involuntary)
Visceral (nonstriated
involuntary or smooth)
Eyeball muscles
Upper third of esophagus
Wall of heart
fn walls of tubular viscera of digestivc,
respiratory, and genitourinary tracts
In walls of blood vessels and large
lymphatic vessels
Jn ducts of glands
fntrinsic eye muscles (iris and ciliary
body)
Arrector muscles of hairs
Eye movemen ts
First part of swallowing
Contmction of heart
Movement of substances along
respective tracts
Changing of diameter of blood vessels
Movement of substances along ducts
Changing of diameter of pupils and
shape of lens
Erection of hairs (gooseflesh)

Nervous

Brain; spinal cord; nerves [rritabilily; conduction

.... '
 CHAPTER 2 Understanding and Managing the llealing Process through Rehabilitation
Stratified transitional
epithelial cells
Figure 2-3 EpiLhelia ~ cells ex ist in several layers.
com[Josed of strong collagenous fibers that bind tissues to­
gethe r. There are two types of fibrous connective tissue.
Dense COl1l1ective tissue is COI11[Joscd primarHy of collagcn
and is found in tendons. fascia. aponcurosis. ligaments.
and joint capsule. Tendons connect muscles to bone. An
aponeurosis is a thin. sheetlike tendon. A fascia iq a thin
membrane of connective tissue that surrounds individual
muscles and tendons or muscle groups. Ligaments connect
bone to bone. AlJ synovial joints arc s urrounded by a joint
capsule, which is a type of co nnective tissuc similar to a lig­
ament. The orientations of collagcn fibers in ligaments
and joint capsules are less parallel than in tendons. Loose
conl1ective tissue forms many types of thin membranes
found beneath the skin, between muscles. and between or­
gans. Adipose tissue is a S[Jeciallzed form of Iloose connective
tissue that storcs fat, insulates. and acts as a shock ab­
sorber. The blood supply to fibrous connective tiSSllC is rel­
atively poor. so healing and repair are slow processes.
Cartilage is a type of rigid connective tissuc that pro­
'sels vides support and acts as a framework in many structures.
It is composed of chondrocyte cells contained in smaLl
d ucts chambers called lacunae surro unded com[Jletely by an in­
and tra cellular matrix. The matrix consists of varying ratios of
collagen and elasLin and a ground substance made of pro­
teoglycans and glycosaminoglYl:ans. which arc nonfibrous
protein molecules. These proteoglycans act as sponges and
trap large quantities of water. which allows cartilage to
spf'ing back after being compressed. Cartilage has a poor
blood supply, thus healing after injury is very slow. There
are three types of cartilage. H!Jalinc cartilage is found on the
articulating surfaccs of bone and in the soft part of the
nose. It contains large quantities of collagen and [Jroteo-
27
Epiphysis
Secondary
epiphysis
Medullary cavity
contoining yellow
marrow Diophysis
Periosteum
Figure 2·4 Structure of bone shown in cross section.
glycan. Fibrocartilagc forms the intervertebral disks and
menisci located in several joint spaces. [t has greater
amounts of collagen than proteoglycan and is capable of
Withstanding a great deall of pressure. Elastic cartilage is
found in the auricle of the car and the laryn x. It is more
flexible than the other types of cartilage and consists of
collagen. proteoglycan. and elastin.
He/.icl/lar cOImective tissue is also composed [Jrimarily of
collagen. It provides the support structure of th e walls of
various internal or.guns. including the liver and kidneys.
Elastic connective tissue is com[Joscd primarily of elastic
f1bcrs. It is found primarily in the walls of blood vessels. air­
ways. a nd hollow internal organs.
Bone is a type of connective tissue consisting of both
li ving cells an d minerals deposited in a matrix (Figure 2-4).
Each bone consis ts of three major com[Jonents. The epiph­
!Jsis is an expanded portion at each end of the bone that ar­
ticulates with another bone. Each articu.laLing surface is
covered by an articular. or hyaline, cartilage. The diaphysis
is the shaft of the bone. The epiphyseal or growth Jllate is the
major site of bone growth aDd elongation. Once bone
growth cea es, the platc ossifies and forms thc cpiphyseal
IInc. With the exception of the articulating surfaces, the
28 PART ONE The Basis of Injury Rehabilitation
bo ne is completely enclosed by the periosteum. a tough.
highly vascularized and innervated fibrous tissue.;-I
The two lypes of bone material arc canceLlous, or
spongy, bone and cortical. or compact. bone. Cctncellous
bone contains a series of air spaces referred to as trabecu­
lae. wherea s cortical bone is relatively solid. Cortical bone
in the diaphysis forms a hollow medullary canal in long
bone, which is lined with endostculJl and fllled with bone
morrow. Bone has a rich blood supply that cerLa in ly facili­
tates tbe healing process after injury. 130ne has the func­
tions or support. movement. and protection . Furthermore.
bone stores and releases calcium into the bloodstream and
manufactures red blood c"!lls.
One additional type of connective tissue in Lhe body is
blood. Blood is composed of various cells suspended in a
nuid intracellular matrix referred to as plasma. Plasma
contains red blood cells. white blood cells. and platelets.
Although this component does not function in structure, it
is essential for the nutrition, cleansing, and physiology of
the body.
With connective tissue playing such a major role
throughout the human body, it is not surprising that
many sport-related injuries involve structures composed
of connective tissue. Although tendons are classified as
Nerve //A: J I/
Meniscus I:: iiI
Bursal wall
.•","'_ ' _
., C'-
Tendon
Figure 2-5 Structure of a synovial joint.
connective tissue, injuries to tendons and tendon healing
wi1l be incorporated into the discussion of the musculo­
tendinous unit.
LIGAMENT SPRAINS
A sprain involves damage to a ligament that provides sup­
port to a joint. A ligament is a tough, relatively ,i nelastic
baud of tissue that connects one bone to another. A liga­
men t's primary function is threefold: to provide stability to
a joint. to pwvide control of tbe position or one articulat­
ing bone to anolher during normal joint motion, and to
provide proprioceptive input or a sense or joint posiLion
through the function of free nerve end 'i ngs or mechanore­
ceplors located within the Jjgament.
Before discussing injuries to liga ments, a review of
jOint structure is in order 69 (Figure 2-5). All synovial joints
are composed of two or more bones tha t articulate with .:
one another to allow motion in one or more places. The ar­
ticulatin g surfaces of the bone are lined with a very thin,
smooth, cartilaginous covering called a hyal,i ne cartilage.
All joints are entirely surrounded by a thick, liga mentous
joint capsule. The inner surface of this joint capsule is lined
by a very thin s!JnovioI111cm/Jrane that is highly vascuJar-
Artery
Synovial fringe
L F ibrous capsule
l! ! Fat pad
Synovial membrane
Articular cavity
_ ~'=...."._ ~_ ~ containing synovial fluid
.-.. - ~ Articular cartilage
( Eplphy",' Uee
 CHAPTER 2 Underslanding and Managing the Healing Process through Rehabilitation 29

n he aling Grade 2 sprain: There is some tearing and separation

mu sc ulo­ of th e ligame ntous fibers and moderate instability
of the j~int. Moderate to severe pain, swelling,
and joint stiffness should be expected.

Cruciate ligaments

vides up­ CLINICAL DECISION MAKING Exercise 2-5

inelastic
er. li ga­ A basketball player twisted his ankle today in practice.
stabi lity to Collateral ligament sprain The mechanism and the location of pain suggest an in­
~ ar ticulat­
version sprain. There is gross la xity w it h the anterior
on . a nd to drawer test and talar tilt test. The swelling is severe and
nt position profuse over the lateral side of the ankle. The athlete is in­
mech a nore­ capable of dorsiflexion and has only a few degrees of
plantar l1exion. He is experiencing very little pain. How
a re\riew of
would you grade the severity of this injury?
1I01'ill i joints

f igure 2-6 Example of a ligament sprain in the knee

'ulate wi th

joint.
'e . Th e ar­
Grade 3 sprain: There is total rupture of the jrigamen t,
a \'ery thin,
manifested primarily by gross instability or the
cart ilage.. joint. Severe pain might be present initially, fol­
ized and innervated. The synovial membrane produces
igamenlOus lowed by little or no pain due to total disruption of
synovial j1uid, the functions of which include lubrication,
ule is lined nerve fibers. Swelling might be profuse. and thus
shock absorption, and nutrition of the joint.
_. \'asc ular- the joint tends to become very stiff some hours af­
Some joil'lts contain a thick fibrocartilage called a
ter the injury. A third-degree sprain with marked
meniscus. The knee joint, for example, contains two wedge­
instability usually requires some form of immobi­
shaped menisci that deepen th e articulation and provide
lization lasting several weeks. Frequently the force
shock absorption in that joint. Finally. the main structural
producing the ligamen t injury is so great that
support and joint stability is provided by the ligaments.
other ligaments or structures surrounding the
which may be either thickened portions of a joint capsule
joint are also injured. With cases in which there is
or totally separate bands. Ligaments are composed of
injury to multiple joint structures, surgical repair
dense connective tissue arranged in parallel bundles of
or reconstruction may be necessary to conect an
collagen composed of rows of t1broblasts. Although bun­
instability.
dles arc arranged in parallel. not all collagen t1bers are
arranged in parallel.
Ligaments and tendons are very similar in structure. CLINICAL DECISION MAKING Exercise 2-6
However, ligaments are usually more !1allened than ten­
dons, and collagen t1bers in l'igaments arc more compact. Why is it likely tha t an athlete with a grade 3 ligament
The anatomical positioning of the ligamen ts determines in sprain initially will experience little pain. relative to the
part what motions a joint can make. severity of the injury?
If stress is applied to a joint th at forc es motion beyond
its normal limits or planes of movement, injury to th e lig­
ament is likely14 (Figure 2-6). The severity of damage to
the ligament is classified in many different ways; however, Ligament Healing
the most commonly used system involves three grades (de­
The heali ng process in the sprained ligamen tc follows the
grees) of ligamentous sprain:
same course of repair as with other vascular tissues. Im­
Grade 1 sprain: T here is some stretching or perhaps mediately after injury and for approximately 72 hours
tearing of the ligamentous fibers, with little or no there is a loss of b ~ood from damaged vessels and attrac­
joint instability. :Vlild pain, little swelling, and joint tion of inflammatory cells into Ihe injured area. If a liga­
stiffness might be apparent. ment is sprained outside of a joint capsule (extra-articular
30 PART ONE The Basis of Injury Rehabilitation
ligament). bleeding occurs in a subcutaneous space. If an
intra-articul'ar ligament is injured. bleeding occurs inside
of the joint capsule until either clotting occurs or the pres­
sure becomes so great that bleeding ceases.
During the next 6 weeks. vascular proliferation with
new capillary growth begins to occur along with fibro­
blastic aclivity. resulting in the formation of a fibrin clot.
It is essential that the torn ends of the ligament be recon­
nected by bridging of this clot. Synlhesis of collagcn and
ground substance of proteoglycan as constituents of an
intracellular matrix contributes to the proliferation of the
scar that bridges between the torn ends of the ligament.
This scar initially is soft and viscous bu,t eventually be­
comes more elastic. Collagen fibers arc arran ged in a ran­
dom woven pattern with little organizalion. Gradually
there is a decrease in fibroblastic activity. a decrease in
vascularity. and an increase to a maximum in collagen
density of the scar.3 FaUure to produce enough scar and
failure to reconnect the ligament to the appropriate loca­
tion on a bone are the two reasons why ligaments are
likely to fail.
Over the next several months the scar continues to ma­
ture. with Ihe realignment of coHagen occurring in re­
sponse to progressive st.resses and strains. The maturation
of the scar may require as long as 12 months to complete.3
The exact length of time required for maturation depends
on mechanical factors such as apposition of torn ends and
length of the period of immobilization.
Factors Affecting Ligament Healing. Surgically re­
paired c>..' tra-articuJar ligaments have healed with decreased
scar iormation and are generally stronger than unrepaired
ligaments initially. although this strength advantage might
not be maintained as time progresses. Nonrepaired liga­
ments heal by fibrous scarring effectively lengthening the
ligament and producing some degree of joint instability.
With intra-articular ligament tears. the presence of synovial
nuid dilutes the hematoma. thus preventing formation of a
Ilbrin clot and spontaneous heaHng.H
Several studies have shown that actively exercised lig­
aments are stronger than those that are immobilized. Lig­
aments that are immobilized for periods of several weeks
after injury tend to decrease in tensile strength and also ex­
hibit weakening of the insertion of the ligament to bone. i i
Thus it is important to minimize periods of immobilization
and progressively stress the injured ligaments while exer­
cising caution relati ve to biomechanical considerations for
specific ligaments. 3.6,
It is not likely that the inherent stability of the jOint
provided by the ligament before injury will be regained.
Thus. 10 restore stability to tbe joint. the other structures
that surround that joint. primarily muscles and their ten­
dons. must be strengthened . The increased muscle tension
provided by strength training can improve stability of the
injured joint. 86 .87
FRACTURES OF BONE
Fractures are extremely common injuries among the ath­
letic population. They can be generally classilled as being
either open or closed. i\ closed fracture involves Uttle or no
displacement of bones and thus little or no soft-tissue dis­
rupti.on. An open fracture involves enough displacement
of the fractured ends that the bone actually disrupts the
cutaneous layers and breaks through the skin. 130th frac­
tures can be relatively serious if not managed properly. but
an increased possibility of infection exists in an open frac­
ture. Fractures may also be considered complete. in which
the bone is broken into at least two fragments. or incom­
plete. where the fracture does not extend completely across
the bone.
The varieties of fractures that can occur include green­
stick. transverse. oblique. spiral. comminu ted. impacted.
avulsive. and stress. A greenstickfracLure (Figure 2-7 A) oc­
curs most often ,in children whose bones are still growing
and have not yet had a chance to calcify and harden. It is
called a greenstick fracture because of the resemblance to
the splintering that occurs to a tree twig that is bent to the
point of breaking. :Because the twig is green . it splinters
but can be bent without causing an actual break.
CLINICAL DECISION MAKING Exercise 2-7
A LillIe League player collided with the catcher when slid­
ing home. Radiographs did not show a fracture. but a
bone scan shows Ll hot spot. WhCl t type of fracture wou ld
you suspect this young athlete has?
A transverscfracturr (Figure 2-7B) involves a crack per­
pendicular to the longitudin al axis of the bone that goes a'll
the way through the bone. Displacement might occur;
however. because of the shape of the frac tured ends. the
surrounding soft tissue (for example. muscles. tendons.
and fat) sustains relatively liU'le damage. t\ linenr fracture
runs parallel to the long axis of a bone and is similar in
severity to a transverse fracture.
An obliqlleji-acture (Figure 2-7C) results in a diagonal
crack across the bone and two very jagged. pointed ends
that. if displaced. can potentially cause a good bit of soft­
 CHAPTER 2 Understanding and Managing the Healing Process through Rehabilitation 31

and th eir ten­

uscle tension
Hi ty of the

Ilg the ath­

led as bein g
lill Ie or no
l-tisSLle dis­
. d' placement
. r u pts the
A B c D E F G

. Both frac­
Figure 2-7 Fractures of bone. A, Greenstick. B, Transverse. C, Oblique.
pro perly, but D, Spiral. E, Comminuted. F, Impacted, G, Avulsion.
open frac­
"It'. in which
-. or incom­
etely across Ussue damage. Oblique and spiral fractures are the two
types most likely to result in compound fractures.
lude green­ A spiral fracture (Figure 2-7D) is similar to an oblique
. im pacted, fracture -in that the angle of the fracture is diagonal across
_ re 2-7 A) oc­ the bone. In addition, an element of twisting or rotation
~~ till growing causes the fractu re to spiral along the longitudina!l axis 01
harden . It is the bone. Spiral fractures used to be fairly common in ski
~ mb lance to injuries occurrillg just above the top of the boot when the
bent to the bindings on the ski failed to release when the foot was ro­
it splinters tate&. These injuries are now less common due to improve­
ments in equipment design.
A comminutedfracture (Figure 2-7£) is a serious problem
that can require an extremely long time for rehabilitation. In
the comminuted frac ture, multiple fragments of bone must
be surgically repaired and fIXed with screws and wires. If a
fracture of Ihis type occurs to a weight-bearing bone in the
leg. a permanent discrepancy in leg length can develop.
In an impacted fracture (Figure 2-71'). one end of the
fractured bone is driven u p in lo the other end. As with the
comminuted fracture, correcting discrepancies in the
length of the extremity can require long periods of inten­
acrack per­ sive rehabilitation.
e that goes all An aVlIlsionjr-acture (Figure 2-7G) occurs when a frag­
migh t occur: ment of bone is pulled away at the bony a ttachment of a
ured ends, the muscle. tendon, or ligament. Avulsion fractures are com­
Il,:; les. tendons, mon in the ,fingers and some 01' the smaller bones but can
Iinenr Facture also occur in larger bones whose tendinous or ligamentous
and is similar in attachments are subjected to a large amount of force.
Perhaps the most common fracture resulting from
in a diagona l physical activity is the stressjracture. Unlike the other types
~. poi nted ends of fractures that have been discussed, the stress fra cture
=-ood bit of soft- res ulis from overuse or fatigue rather than acute
trauma. 50 . 64 Common sites for stress fractures include the
weight-bearing bones of the leg and foot. In either case,
repetitive forces transmitted through the bones produce ir­
ritations and microfractures at a specific area in the bone.
The pain usually begins as a dull ache thal becomes pro­
gressively more painful day aner day. Initial1ly, pain is most
severe during activ ity. However, when a stress fracture ac­
tually develops, pain tends to become worse after the ac­
tivity is stopped.
The biggest problem with a stress fracture is that often
it does not show up on an X-ray film u ntil the osteoblasts
begin laying down subperiosteal callus or bone. at which
point a small white line, or a callus. appears. However. a
bone scan might reveal a potential stress fracture in as lil­
tie as 2 days after onset of symptoms. If a stress fracture is
suspected, the athlete should, for a minimum of 14 days,
stop any activity that produces added stress or fatigue to
the area. Stress fractures do not usually require casting but
might become norma~ fractures that must be immobilized
if handled incorrectly. If a fracture occurs, it should be
managed and rehabilitated by a qualified orthopedist and
athletic trainer.
Bone Healing
Healing of injured bone tissu e is simllar to soft-tissue
healing in that all phases of the healing process can be
identified, although bone regeneration capabilities are
somewhat limited. However, the functional elements of
hea'iing differ Significantly from those of son tissue. Ten­
sile strength of the scar is the single most critical factor in
soft-tissue healing, whereas bone has to contend with a
32 PART ONE The Basis of Injury Rehabilitation
number of additional forces. including torsion . bending.
and compression. 29 Trauma to bone can vary from contu­
sions of the periosteum to closed. nondisplaced fractures
to severely displaced open fra ctures that also involve sig­
nifkant soft-tissue damage. When a fracture occurs.
blood vessels in the bone and the periosteum are dam­
aged . resulting in bleeding and subsequent clot forma­
tion. Hemorrhaging from the marrow is contained by the
periosteum and the surrounding soft tissue in the region
of the fracture. In about 1 week. fibroblasts have begun
laying down a fibrous collagen network. The fibrin
strrands within the clot serve as the framework for prolif­
erating vessels. Chondroblast cells begin producing fibro­
cartilage. creating a callus between the broken bones. At
first. the callus is soft and firm because it is composed pri­
mari ly of collagenous fibrin. The caHus becomes firm and
more rubbery as cartilage begins to predominate. Bone~
producing cells cCllled osteoblasts begin to proliferate and
enter tIle callus. forming cancellous bone !.rClbeculae.
which eventually replace the cartilage. Finally the callus
crystalizes into bone. at which point remodeling of the
bone begins. The callus can be divided into two portions.
the external callus located around the periosteum on the
outside of the fmcture and the internal callus found be­
tween the bone fragments. The size of the callus is pro­
portiona l both to the damage (lIld to the amount of
irritaUon to the fracture site during the healing process.
Also during this time. osteoclasis begin to appear in the
area to resorb bone fragments and clean up debris.4l.R I
The remodeling process is similar to the growth
process of bone in that the fibrous cartilage is gradually re­
placed by fibrous bone and th en by more structurally em­
cient lamellar bone. Remodeling involves an ongoing
process during which osteoblasts lay down new bone and
osteoclasts remove Clnd break down bone according to the
qi
forces placed upon the healing bone. Wolffs law main­
tains that a bone wii'! adapt to mechanical stresses and
strains by changing size, shape. and structure. Therefore.
once the cast is removed. the bone must be subjected to
normal stresses and strains 50 that tensile strength can be
regained before the heaUng process is complete. 1h .Rq
The time required for bone healing is variable and
based on a number of factors. such as severity of the frac­
ture. site of the fracture. cxtensil'eness of the trauma. and
age of the patient. Normal periods of immobilization range
from as short as 3 weeks for the small bones in the hands
and feet to as long as 8 weeks for the long bones of the up­
per and lower extremities. Tn some instances. such as frac­
tures in the four sfIl.alltoes. immobilization might not be
required for healing. The healing process is certainly not
complete when the splint or cast is removed. Osteoblastic
and osteoclastic activity might continue for 2 to 3 years af­
ter severe fractures.
CARTILAGE DAMAGE
Osteoarthrosis is a degenerative condition of bone and car­
tilage in and about the joint. Arthritis should be defined as
primarily an inflammatory condition with possible sec­
ondary destruction. 5 Arthrosis is primarily a degenerative
process with destruction of cartilage. remodeling of bone.
and possible secondary innamm ato ry components.
Cartilage fibrillates- th at is. releases fibers or groups
of fibers and ground substance into the joint. Peripheral
cartilage that is not exposed to weight-bearing or
compressioo-decompression mechanisms is particularly
likely to f1 brillate. Fibrillation is typica lly found in the de­
generative process associated with poor nutrition or dis­
use. This process can then extend even to weight-bearing
areas. with progressive destru cti on of cartilage propor­
tional to stresses applied on it. When forces are increased.
thus increasing stress. osteochondral or subchondral
fractures can occur. Concentration of stress on small ar­
eas can produce pressures that overwhelm the tissue 's
capabilitjes. Typically. lower-limb joints have to handle
greater stresses. but th ei r surface area is usually larger
than t.he surface area of upper limbs. The articu lar carti­
lage is protected to some extent by the sy novial fluid.
which acts as a lubricant. IL is also protected by the sub­
chondral bOlle. which responds to stresses in an elastic
fashion. It is more compliant than compact bone. and
microfractures can be a means of force absorption. Tra­
beculae might fracture or might be displaced due to pres­
sures applied on the subchondrfll bone. [n compact bone.
fracture can be a means of defense to dissipate force. Tn
the joint. forces might be absorbed by joint movement
and eccentric contraction of musc les.
In the majority of joints where the surfaces are not
congruen t. the applied forc es ten d to concentrate in cer­
tain areas. which increases join t degeneration. Osteop/7!Jto­
sis occurs as a bone allempts to increase its surface area to
de~creasc. contact forces. Typically people describe tllis
growth as "'bone spurs." Clwl1r1roll1a/llcia is tbe nOll'pro­
gressive transformation of cartilage with irregular sur­
faces and areas of softening. Typically it occurs first in
non-weight-bearing areas and may pwgress to areas of
excessive stress.
In athletes. certain joints may be more susceptible to a
response resembling osteoarthrosis 71 The proportion of
body weight resling on the joint, the pull of musculotendi­
nOlls unit. and any significant external force applied to the
joint arc predisposing factors. Altered joint mechanIcs
 CHAPTER 2 Understanding and Managing the Healing Process through Rehabilitation
3 years af­ -sed by laxi! ' or previous trauma are also factors that
c into play."" The intensity of forces can be great. <lS in
hip. where the previously mentioned factors can pro­
e pressures or forces lour times that of body weight and
len times that of body weight on the knee.
Typically. muscle forces generate more stress than
y weight itself. Particular injuries are conducive to os­
'lart hritic changes such as subluxation and dislocation
the patella. osteochondritis dissecans. recurrent syn­
aJ effusion. a nd hemarthrosis. Also. ligamentous in­
can bring about a disruption ·o f proprioceptive
ha ni ms.loss of adequate jOint alignment. and men is­
dama ge in the knees with removal of the injured
eni CUS. l 9 Other factors that have an impact are loss of
ull range of motion. poor muscular power and strength.
and a ltered biomechanics on the joint. In sport participa­
Lio n. spurring and spiking of bone arc not synonymous
with osteoarthrosis if the joint sp<lce is maintained and the
ar tilage lining is int<lct.lt may simply be an adaptation to
the increased stress of physical activity.
Cartilage Healing
artila ge h as a relatively limited healing capacity. v\Thcn
chondrocytes are destroyed and the matrix is disrupted,
the course or healing is variable. depending on whether
damage is to cartilage alone or also to subchondral bone.
Injuries to articular cartilage alone fail to elicit clot forma­
tion or a cellular response. For the most part the chondro­
cytes adjacent to the injury arc the only cells that show
lion . Tra­ any signs of prolireration and synthesis of matrix. Thus
ue to pres­ the defect fails to heal. although the extent of the d<lmage
pact bone. tends to remain the s<lme. ll .;9
'c rorc e. In If subchondral bone is also affected. inflammatory
-nm'ement cells enter the damaged area and formuliate granulation
tissue. In this case. the healing process proceeds normally.
are not with differenLiation of granulation tissue cells into chon­
u-ate in ccr­ drocytes occurring in about 2 weeks. At approximately 2
• OSleop1zy to­ months normal collagen has been formed.
ace a rea to Injuries to the knee articular cartilage are extremcly
ribe this common. and until recently methods for treatment did
"Ie non pro­ not produce good long-term results. A bettcr under­
eg uJar sur­ standing of how articular cartilage responds to injury
urs first in has produced V<lriOllS techniques that hold promise for
Lo areas of long-term success. 91 One such technique is autologous
chondrocyte implantation. in which a patient's own car­
1 epUble to a tilage cells arc harvested , grown ex vivo. and reimplanted
p!'oportion of in a full-thickness arlicular surface uefect. Results arc
u 'c ulotendi­ available with up to 10 ye<lrs' follow-up. and more than
ilpplied to the 80 percent of patients have shown improvement with
t mechanics rclatively few complications.
33
INJURIES TO
MUSCULOTENDINOUS
STRUCTURES
Muscle is oflen conSidered to be a type of connective tissue.
but here it is treated as the third of the fundamental tis­
sues. The three types of muscles are smooth (involuntary),
cardiac. and skeletal (voluntary ). Smooth nll/sele is found
within the viscew. where it forms the walls of the internal
organs. and within many hollow chambers. Cardiac 1I111scle
is found only in the heart and is responsible for its contrac­
tion. A Significant characteristic of the cardiac muscle is
that it contracts as a single fiber. unlike smooth tlnd skele­
tal mnscles, which contract as separate nnits. This charac­
teristic forces t.he heart to work <lS a single unit
continuously: therefore. if one portion of the muscle
should die (as in myocardial infarction ). contraction of the
heart docs not cease.
Skeletal muscle is the stritlted muscle within the body re­
sponsible for the movement of bony levers (Figure 2-8).
Skeletal muscle consists of two portions: (1) the muscle belly
and (2) its tcndons. which are collectively referred to as a
musculotendinoLls unit. The muscle belly is composed of
separate. para[[el clastic fibers called myofibrils. ~Vlyofibrils
are composed of thousands of small sarcomeres. IVh.ich arc
the fUl1cLionalunits of the muscle. Sarcomercs contain the
contractile clements of the muscle. <lS well as a substantial
amount of connective tissue that holds the fibers together.
Myofilaments arc small contractile elements of protein
within the sarcomere. There are two distLnct types of my­
ofilamcnts: thin actin myofilaments and thicker myosin my­
ofilaments. Fingcrlike projections. or crossbridges. connect
the actin and myosin myofilaments. Whcn a muscle is stim­
ulated to contract. thc crossbridges pull the myol1laments
closer together. thus shortening the muscle and producing
movemcnt at the joint that the muscle crosses. l l
The muscle tendon aLtaches muscle directly to bone. The
muscle tendon is composed primarily of collagen fibers and
a matrix of proteoglycan. which is produced by the teno­
cyte cel\. The collagen fibers are grouped together into pri­
mary bundles. Groups.of pr.i mary b u.ndles join together to
form hexagon a l haped secondar!l bUlldles. Secondary bun­
dles are held together by intertwined loose connective tis­
sue containing elastin called the el1dotel1ol1. The entire
tendon is surrounded by a connective tissue layer called the
epitenol1. The outermost layer of the tendon is thc paratenol1.
which is a double-layer connective tissue sheath lined on
the inside wit.h synovial membrane ;" (Figure 2-9).
All skeletal muscles exhibit four characteristics:
(1) elasticity. the ability to ch<lnge in length or stretch:
34 PART ONE The Basis of injury Rehabilitation

Muscle

Actin myahlament

Myosin
crossbridge

=~

~1E ex> ~(1) CP~

C
Myosin myofilament
Myosin thick
filament

Figure 2-8 Parts of a muscle. A, Muscle is composed of muscle fasciculi, which can be seen by the unaided eye
as striations in the muscle. The fasciculi are composed of bundles of individual muscle fibers (muscle cells). B.
Each muscle fiber contains myoflbrils in which the banding patterns of the sarcomeres are seen. C, The myofibrils
are composed of (lclin myofil(lment and myosin myofilaments, which are formed from thousands of individual
actin and myosin molecules.
 CHAPTER 2 Understanding and Managing the Healing Process through Rehabilitation 3S

Endotenon

Tendon fiber

Primary fascicles .,----..,C/./,C...

Paratenon

Epitenon

Figure 2-9 Struct ure of a tendon.

(2) extensibility. the ability to shorten and return to nor­

mal length; (3) excitability. the ability to respond to stimu­
lation from the nervous system; and (4) contractility. the
ability to shorten and contract in response to some neural
command. 54
Skeletal muscles show considerable variation in size
and shape. Large muscles generalIy produce gross motor
movements at ~Iarge joints. such as knee flexion produced
by contraction of the large. bulky hamstring muscles.
Smaller skeletal muscles, sueh as the long flexors of the
fmgers. produce fine motor movements. Muscles produc­
ing movements that are powerful in nature are usually
thicker and longer. whereas those producing finer move­
ments requiring coordination are thin and relatively
shorter. Other muscles may be flat. round, or fan­
shaped. 4 1.S1 Muscles may be connected to bone by a single
tendon or by two or three separate tendons at either end.
Muscles that have two separate muscle and tendon attach­
ments are caned biceps. and muscles with three separate
muscle and tendon attachments are called triceps.
Muscles contract in response to stimulation by the cen­
tral nervous system. An electrical impulse transmitted from
the central nervous system through a single motor nerve to
a group of muscle fibers causes a depolarization of those
fibers. The motor nerve and the group of muscle fibers that
it innervates are referred to collectively as a motor unit. An
impulse comlng [rom the central nervous system and trav­
eling to a group of fibers through a particular motor nerve
causes all the muscle fibers in that motor unit to depolarize
and contract. This is referred to as the all-or-none re­
sponse and applies to all skeletal muscles in the body.41
Muscle Strains
If a musculotendinous unit is overstretched or forced to
contract against too much resistance. exceeding the exten­
sibility limits or the tensile capabilities of the weakest com-
Strained hamstring
muscles
Figure 2-10 A muscle strain results in tearing or sepa­
ration of fibers.
ponent within the unit. damage can occur to the muscle
fibers, at the musculotendinous juncture. in the tendon. or
at the tendinous attachment to the bone. 14.43 Any of these
injuries may be referred to as a strain (Figure 2-10). lvluscles
strains, Wee ligament sprains. are subject to various classifi­
cation systems. The following is a simple system of classifi­
cation of muscle strains:
Grade 1 strain: Some muscle or tendon fibers have been
stretched or actually torn. Active motion produces
some tenderness and pain. Movement is painful.
but full range of motion is usually possible.
Grade 2 strain: Some muscle or tendon fibers have
been torn. and active contrac(.ion of the muscle is
extremely painfu:l. Usually a palpable depression
or divot exists somewhere ,in the muscle belly at
the spot where the muscle fibers have been torn.
Some swelling might occur because of capillary
bleeding.
Grade 3 strain: There is a complete rupture of muscle
fibers in the muscle belly, in the area where the
muscle becomes tendon. or at the tendinous at­
tachment to the bone. The athlete has significant
impairment to, or perhaps total loss of, move­
ment. Pain is intense ,initialLy but diminishes
36 Pl\R'I' ONE The Basis of Injury Rehabilitation
quickly because of complete separCllion of the
nerve fib ers. Musculol"endinous ruptures are most
common in the biceps tendon of the upper arm or
in the Achilles heelcord in the back of the calf.
When either of th ese tendons ruptures. the mus­
cle tends to bunch towa rd its proximal attach­
ment. With th e exceptio n of an Achille~ rupture,
which is frequently surgic,llly repa ired. the major­
ity of third-degree strains me treated conserva­
tively with some period of immobilization.
Muscle Healing
Inj mil's to muscle tissue involve similar processes of heal­
ing and repair as discussed wi1h other tissues. Initially
there will be hemorrhage and edema fo]Jowed almost im­
mediately by phagocytosis to cleHr debris. Within a few
days there is a proliferation of ground substance. and fi­
broblasts begin producing a gel-type matrix lhat sur­
rounds the connective tissue. leading to fibrosis and
scarring. At the same time, myoblHslic cells form in the
area of injury, which willI eventually lead to regeneration
of new rnyol1brils . Thus regeneration of both connective
tissue and muscle tissue has begun. 100
Collagen fibers undcrgo maturation and orient them­
selves alon g lines of tensile force according to Wolff's law.
Active con tra ction of the muscle is criti cal in regaining
normal tensile strength. , ·" l
Regardless of the severity of the sLrain , the time re­
quired for rehabilitation is fairly lengthy. In maoy in­
stances. rehabilitation time for a muscle strain is longer
than for a ligament sprain. These incapacitating muscle
strains OCCllr most frequently in the large. force-producing
hamstring and quadriceps muscles of the lower extremity.
The treatment of hamstring strains requires a healing pe­
riod of at least 6 to 8 weeks and a considerable amount of
patience. i\Llempts to return to activity too soon frequently
cause reinjury to the area of th e musculotendinous unit
that has been strained . a nd lh_e he.a ling process must begin
again.
Tendinitis
Of all the overuse problems associated with physical activ­
ity. tendinitis is among th e most common. 4 () Tendinitis is a
catchall term that can describe many different pathologi­
cal conditions of a tendon . It essentially describes any
inflammatory response within the tendon without inflam­
mation of the pa ratenon. H; ParrltcllOl1itis involves inflam­
mation of the outer layer of the tendon only and usually
occurs when !.he tendon rubs over a bony prominence.
Tendill()sis describes a tendon that has significant degener­
ative changes with no clinical or histological signs of an in­
flammatory response. I 8
In cases of what is most often called chronic tendinitis,
there is evidence of Significant tcndon degeneration, loss
of normal collagen structure, loss of cellularity in th e a rea.
Ib ut absolutely no inflammatory cellular response in the
tendon. 8 2 The inflammatory process is an essential part of
healing. Inflammation is supposed to be a brief process
with an end point after its function in the healing process
has been fulni'led. The point or the cause in th e pathologi­
cal process where the acute inflammatory cellular re­
sponse terminates and the chronic degeneration begins is
dimcult to determine. As mentioned previously. with
chronic tendinitis the cellular response imlo'lves a replace­
ment of leukocytes with macrophages and plasma cells.
During muscle activity a tendon must move or slid e on
other structures around it whenever the muscle contracts.
If a particular movement is performed repeatedly. th e ten­
don becomes irritated and intrlamed. This intlammation is
manifested by paiJ1 on movement. swelling. possibly some
warmth. and usually crepitus. Crepitus is a cruckling
sound similar to the sound produced by rolling bair be­
tween the fingers by the ear. Crepitus Is usually caused by
the adherence of the paratenon to the surrounding stru c­
tures while it slides back and forth. This adhesion is caused
primarily by the cbemical products of inflammation th at
accumulate on the irritated tendon JH
The key to treating tendinitis is rest. If th e repetitive
motion causing irritation to the tendon is eliminated.
chances are the inflammatory process wm allow the ten­
don to heal. 6 7 Unfortunately, an athlete who is seriously in­
volved with some physical activity might have dirt1 culty in
resting for 2 weeks or more while the tendinitis subsides.
Anti-inflammatory medications and th erapeutic modaH­
lies arc also helpful in redUCing the inflammatory re­
sponse. An alternative activity. such as bicycling or
swimming, is necessary to maintain fitn ess levels to a cer­
tain degree while allowing the tendon a chance to heal. 28
Tendinitis most commonly occurs in the Achilles ten­
don in the back of the lower leg in runners or in the rota­
tor cuff tendons of the shoulder joint in swimmers or
throwers. although it can certainly fI(1[ c up in any tendon
in whicb overuse and repetitive movements occur.
Tenos'ynovitis
Tenosynovitis is very simi·lar to tendinitis in that the mus­
cle tendons are involved in inflammation. However, many
tendons are subject to an increased amount of fricti on due
to the tightness of the space through wh·ieh they must
move. In t.hese areas of high friclion. tendons are usually
surrounded by synovial sheaths that reduce friction on
 CHAPTER 2 Understanding and Managing the Healing Process through Rehabilitation 37

movement. If the tendon sliding through a synovial

sheath is subjected to O\'eruse. inllammation is likely to oc­
cur. The inllarnmaLory process produces by-products that
are "sticky" and tend to cause the sliding tendon to adhere
to the synovia l sheath surrounding it.
Symptomatically. tenosynovitis is very similar to ten­ Mitochondrion -:.:ii~~"1i
dinitis. with pain on movement. tenderness. swelling. and
crepitus. Movement may be more limited with tenosynovi­
Us because the space provided for the tendon and its syn­
ovial covering is more limited . Tenosynovitis occurs most
commonly in the long flexor tendons of the fingers as they
cross over the wrist joint clOd in the biceps tendon around
the shoulder joint. Treatment for tenosynovitis is the same
as for tendinitis. Because both conditions involve inllam­
malion. mild anti-inl1arrunatory drugs, such as aspirin,
might be helpful in chronic cases.

Tendon Healing
alion is
bly ome Un like most soft-tissue healing, tendon injuries pose a par­
:rackling ticular problem in rehabilitation. l9 The injured tendon re­
,; hair be­ quires dense fibrous union of the separated ends and both
au cd by extensibility and llexibility at the site of attachment. Thus
an abundance of collagen is required to achieve good ten­
Schwann cell
sile strength. Unfortunately, collagen synthesis can be­
come excessive. resulting in fibrosis. in which adhesions
form in surrounding tissues and interfere with the gliding
that is essential for smooth motion. Fortunately. over a pe­
Myelin sheath
riod of time the scar tissue of the surrounding tissues be­
of Schwann cell
comes elongated in its structure because of a breakdown
in the cross-links between fibrin units and thus allows the
necessary gliding motion. A tendon injury that occurs
where the tendon is surrounded by a synovial sheath can
be potentially devastating.
A typical time frame for tendon healing would be that
during the second week the healing tendon adheres Lo the
surrounding tissue to form a single mass, and during the
third week the tendon separates to varying degrees from
the surrounding tissues. However. the tensile strength is
not sufficient to permit a strong pu ll on the tendon for at
least 4 to 5 weeks. the danger being that a strong contrac­
tion can pull the tendon ends apart.

INJURY TO NERVE TISSUE

The final fundamental tissue is nerve tissue (Figure 2-11).
This tissue provides sensitivity and communication from
the central nervous system (brain and spinal cord) to the
muscles, sensory organs. various systems. and the periph­
ery. The basic nerve cell is the neuron. The neuron cell body
contains a large nuclells and branched extensions called Telodendria
dendrites, which respond to neurotransmitter substances Figure 2-11 Structural features of a nerve cell.
38 PART ONE The Basis of Injury Rehabilitation
released from other nerve cells. From each nerve celJ arises
a single axon, which conducts the nerve impulses. Large ax­
ons found in peripheral nerves are enclosed in sheaths com­
posed of Sclnvann cel/s, which are tightly wound around the
axon. A nerve is a bundle of nerve cells held together by
some connective tissue, usually a lipid-protein layer called
the myelin sheath on the outside of the axon. Neurology is
an extremely complex science, and' only a brief presenta­
tion of its relevance to sport-related injuries is covered
here. l l
In a sports medicine setting, nerve injuries usually in­
volve either contusions or inflammations. More serious in­
juries involve the crushing of a nerve or complete division
(severing). This type of injury can produce a lifelong phys­
ical disability, such as paraplegia or quadriplegia, and
should therefore not Ibe overlooked in any circLlmstance.
Of critical concern to the athletic trainer is the impor­
tance of the nervous system in proprioception and neuro­
muscular control of movement as an ,i ntegral part of a
rehabilitation program. This will be discussed in great de­
taill in Chapter 5.
Nerve Healing
Nerve cell tissue is speciallized and cannot ,r egenerate once
the nerve cell dies. In an injured peripheral nerve, how­
ever, the nerve fiber can regenerate significantly if the in­
jury does not affect the cell body. The proximity of the
axonal injury to the cell body can significantly affect the
time required for bealing. The closer an injury is to the cell
body, the more difficult the regenerative process. In the
case of a severed nerve, surgicall intervention can
markedly enhance regeneration.
For regeneration to occur, an optimal environment
for healing must exist. When a nerve is cut, several de­
generative changes occur that interfere with the neural
pathways. Within the first 3 to 5 days the portion of the
axon distal to the cut begins to degenerate and breaks
into irregular segments. There is also a concomitant in­
crease in metabolism and protein production by the
nerve cel] body to facilitate the regenerative process. 'fhe
neuron in the cell body contains the genetic material and
produces chemicals necessary for maintenance of the
axon. These substances cannot be transmitted to the dis­
tall part of the axon, and eventually there will be com­
plete degeneration.
In addition, the myelin portion of the Schwann cells
around the degenerating axon also degenerates, and the
myelin is phagocytized. The Schwann ceUs divide, forming
a column of cells in place of the axon. If the cut ends of the
axon contact this column of Schwann cells, the chances
are good that an axon may eventually reinnervate distal
structures. If the proximal end of the axon does not make
contact with the column of Schwann cells, reinnervation
will not occur.
The axon proximal to the cut has minimal degenera­
tion initially and then begins the regenerative process
with growth from the proximal axon. Bulbous enlarge­
ments and several axon sprouts form at the end of the
proximal axon. \lVithin about 2 weeks, these sprouts
grow across the scar that has developed in the area of the
cut and enter the column of Schwann cells. Only one of
these sprouts will form the new axon, while the others
will degenerate. Once the axon grows through the
Schwann cell columns, remaining Schwann cells prolif­
erate along the length of the degenerating fiber and form
new myelin around the growing axon, which will even­
tually reinnervate distal structures.
Regeneration is slow, at a rate of only 3 to 4 millime­
ters per day. Axon regeneration can be obstructed by scar
formation due to excessive fibroplasia. Damaged nerves
within the central nervous system regenerate very poorly
compared to nerves in the peripheral nervous system.
Central nervous system axons lack connective tissue
sheaths, and the myelin-producing Schwann cells fail to
proliferate. 41 .sl
ADDITIONAL MUSCULOSKELETAL
INJURIES
Dislocations and Subluxations
A dislocation occurs when at least one bone in an articu­
lation is forced out of its normal and proper alignment and
stays out until it is either manually or surgically put back
into place or reduced. Db Dislocations most commonly oc­
cur in the shoulder joint, elbow, and fingers, but they can
occur wherever two bones articulate.
A subluxation is like a dislocation except that in this
situation a bone pops out of its normal articulation but
then goes right back into place. Subluxations most com­
monly occur in the shoulder joint, as well as in the kneecap
in females.
Dislocations should never be reduced immediately, re­
gardless of where they occur. The athletic trainer should
take the athlete to an X-ray facility and rule out fractures
or other problems before reduction. Inappropriate tech­
niques of reduction might only exacerbate the problem.
Return to activity after dislocation or subluxation is
largely dependent on the degree of soft-tissue damage.
 CHAPTER 2 Understanding and Managing the Healing Process through Rehabilitation
the chances Bursitis
In many areas. particularly around joints. friction occurs
between tendons and bones. skin and bone. or two mus­
cles. Without some mechanism of protection in these
high-friction areas, chronic irritation would be likely.
Bursae are essentially pieces of synovial membrane
that contain small amounts of synovial fluid. This pres­
ence of synO\rium permits motion of surrounding struc­
tures without friction. If excessive movement or perhaps
some acute trauma occurs around these bursae. they be­
come irritated and inllamed and begin producing large
amounts of synovial fluid. The longer the irritation con­
tinues or the more severe the acute trauma. the more iluid
is produced. As the Iluid continues to accumulate in a lim­
ited space. pressure tends to increase and causes ,i rritation
of the pain receptors in the area.
Bursitis can be extremely painful and can severely re­
strict movement. especially if it occurs around a jOint. Syn­
oviailluid continues to be produced until the movement or
trauma producing the irritation ,is eliminated.
A bursa that occasionally completely surrounds a ten­
.... system. don to allow more freedom of movement in a tight area is
, jve Lissue referred to as a synovial sheath. Irritation of this syn­
::-ells fail to ovial sheath may restrict tendon motion.
All joints have many bursae surrounding them. Per­
haps the three bursae most commonly irritated as a result
of various types of physical activity arc the subacromial
LETAL bursa in the shoulder joint, the olecranon bursa on the tip
of the elbow, and the prepatellar bursa on the front surface
of the patella. All three of these bursae have produced
large amounts of synovial fluid, affecting motion at their
5 respective joints.
an articu­
<onment and Muscle Soreness
. put back
~o nly oc­ Overexertion in strenuous muscular exercise often results
ullhey can in muscular pain. At one time or another most everyone
has experienced muscle soreness. usually resulting from
bat in tbis some physical activity to which we are unaccustomed.
ulation but There are two types of muscle soreness. The first type
of muscle pain is acute and accompanies fatigue. It is tran­
sient and occurs during and immediately after exercise.
The second type of soreness involves delayed muscle pain
media tely. re­ that appears approximately 12 hours after injury. It be­
TGiner should comes most intense after 24 to 48 hours and then gradu­
OUl fractures ally subsides so that the muscle becomes symptom-free
priate tech­ after 3 or 4 days. This second type of pain may best be de­
the problem. scribed as a syndrome of delayed muscle pain. leading to
bluxation is increased muscle tension, edema formation, increased
edamage. stiffness, and resistance to stretching.62
39
The cause of delayed-onset muscle soreness (DOMS) has
been debated. Initially it was hypothesized that soreness
was due to an excessive buildup of lactic acid in exercised
muscles. However, recent evidence has essentially ruled
out this theory.25
It has also been hypothesized that DOMS is caused by
the tonic. localized spasm of motor units. varying in num­
ber wHh the sever,ity of pain. This theory maintains that
exercise causes varying degrees of ischemia in the work­
ing muscles. This ischemia causes pain . which results in
reflex tonic muscle contraction that increases and pro­
longs the ischemia . Consequently a cycle of increasing
severity is begun. 21 As with the lactic acid theory, the
spasm theory has also been discounted.
Currently there are two schools of thought relative to
the cause of DOMS. DOMS seems to occur from very small
tears in the muscle tissue. which seem to be more likely
with eccentric or isometric contractions. 2j It is generally
believed that the initial damage caused by eccentric exer­
cise is mechanical damage to either the muscular or the
connective tissue. Edema accumulation and delays in the
rate of glycogen repletion are secondary reactions to me­
chanical damage. 72
DOMS might be caused by structural damage to the
elastic components of connective tissue at the musculo­
tend,i nous junction. This damage results in the presence of
hydroxyproline, a protein by-product of collagen break­
down, in blood and urineY It has also been documented
that structural damage to the muscle fibers results in an
increase in blood serum levels of various protein/enzymes,
including creatine kinase. This increase indicates that
there is likely some damage to the muscle fiber as a result
of stren uous exercise. 25
Muscle soreness can best be prevented by beginning at
a moderate level of activity and gradually progressing the
intensity of the exercise over time. Treatment of muscle
soreness usually also involves some type of stretching ac­
tivity. As for other conditions discussed in this chapter, ice
is important as a treatment for muscle soreness, particu­
larly within the ftrst 48 to 72 hours.
Contusions
ContUSion is synonymous with bruise. The mechanism that
produces a contusion is a blow from some externall object
that causes soft tissues (e.g., skin. fat, muscle. ligaments,
joint capsule) to be compressed against the hard bone un­
derneath. 98 If the blow is hard enough , capillaries rupture
and allow bleeding into the tissues. The bleeding, if super­
ficial enough, causes a bluish-purple discoloration to the
skin that persists for several days. The contusion may be
 40 PART ONE The BClSis of Injury Rehabilitation

very sore to the touch. If damage has occurred to muscle,

pain mClY be elicited on active movement. In most cases the
pain ceClses within a few dClYs, and discoloration disap­
pears in usually 2 to 3 weeks.
The major problem with contusions occurs where an
area is subjeCled to repeated blows. If the same area. or
more specifically the same muscle. is bruised over and over
again. slllall calcium deposits might begin to accumulate
in the injured area. These pieces of calcium might be found
between several fibers in the muscle belly, or calcium
might form a spur that projects from the underlying bone.
These calcium formations. which can significantly impair
movement. are referred to as myositis ossilicans. In some
cases myositis ossiflcans develops from a single trauma.

CLINICAL DECISION MAKING Exercise 2-8

A field hockey player suffered a contusion from a ball Oil Figure 2-12 Musculoskeletal injuries should be treated
the elbow just superior (0 (he medial epicondyle. She sus­ initially with protection. restricted activity. ice. compres­
tained some ulnar nerve damage. In general. what is the sion, and elevation.
likelihood that t he nerve will repair itself?

Presurgical Exercise Phase

The key to preventing myositis ossificans from occur­
ring from repeated contusions is protection of the injured
area by padding. If the area is properly protected after the
first contusion, myositis ossificans might never devel'op.
Protection, along with rest. might allow the calcium to be
reabsorbed and eliminate any need for smgical interven­
tion. The two areas that seem to be the most vulnerable to
repeated contusions during physical activ ity are the
quadriceps muscle group on the front of t.he thigh and the
biceps muscle on the front of the upper arm.98 The forma­
tion of myositis ossificans in either of these or any other ar­
eas can be detected on X-ray I11ms.
MANAGING THE HEAUNG
PROCESS THROUGH
REHABILITATION
Rehabilitation exercise progressions in sports medicine
can generally be subdivided into three phases based pri­
marily on the three stages of the healing process: phase],
the acute phase; phase 2. the repair phase; and phase 3,
the remodeling phase. Depending on the type and extent of
injury and the individual response to healing. phases will
usually overlap. Each phase must include carefully consid­
ered goals and a criteria for progressing [rom one phase to
another.
This phase would apply only to th ose athletes who sustain
injuries that require surgery. If surgery can be postponed.
exercise may be used as a means to improve its outcome.
By allowing the initial innammatory response phase to re­
solve. by maintaining or, in some cases. increasing muscle
strength and flexibility. levels of cardiorespiratory fitness.
and improving neuromuscular control. the athlete may be
better prepared to continue the exercise rehabilitative pro­
gram after surgery.
Phase 1, the Acute Injury Phase
Phase 1 begins immediately when injury occurs and can
last as long as day 4 following injury. DUring this phase,
the inflammatory stage of the healing process is attempt­
ing to "clean up the mess," thus creating all environment
that is conducive to the fibroblastic stage. As indicated in
Chapter 1, the primary focus of rehabilitation during this
stage is to control swelling and to modulate pain by using
the PRICE techniql.le immediately following injury. lee.
compressioll. and elevation should be used as much as pos­
sible during this phase 76 (Figure 2-12).
Rest of the injured part is critical during this phase. It
is widely accepted that early mobility during rehabilitation
is essential. However. if the athletic trainer becomes overly
aggressive during the first 48 hours following injury. and
does not allow the injured part to be rested durLng the in­

:\ ~;
 CHAPTER 2 Understanding and ]vlanagin g th e Healing Process through Rehabilitation
l1ammatory stage of healing. the inflammatory process
never really gets a chance to accomplish what it is sup­
posed to. Consequently. the length of tim e required for in­
flammation might be extended. Therefore. immobility
during the first 24 to 48 hours following injury is neces­
sary to con.trol inflammation.
By day 3 or 4. swelling begins to subside and eventu­
ally stops altogether. The injured area may feel warm to the
touch. and some discoloration is usually apparenl. The in­
jury is still painful to the touch. and some pain is elicjted on
movement of the injured parL % At this point the athlete
should have already begun active mobility exercises, work­
ing through a pain-free range of motion. If the injury in­
volves the lower extremity. the athlete should be
encouraged to progressively bear more weight.
The team physician may choose to have the athlete
take nonsteroidal anti-infllammatory drugs (NSAIDs) to
help control swelling and inflammation. It is usually help­
ful to continue this medication throughout the rehabi\.ita­
ti ve process. I
Phase 2, the Repair ,Phase
Once the inflammatory response has subsided. the repair
phase begins. During this st.age of the healing process. fi­
broblastic celIs are laying down a mat.rix of co llagen
fibers and forming scar tissue. This stage might begi n as
early as 2 days after the injury and can last for several
weeks. At this point. swelling has Slopped completely. The
injury is still tender to the touch but is not as painful as
during the previous stage. Pain is also less on active and
passive motion. 7(,
As soon as inflammation is controlled. t.he athletic
t.rainer should immediately begin to incorporate into the
rehabilitation program activities that can maintain levels
of cardiorespiratory fitness, restore full range of motion.
and can restore or increase strength. and reestablish neuromuscu­
_ h" phase. lar control as discussed in Cbapter 1.
altempt­ As in the acute phase. modalities should be used to
control pain and swelling. Cryotherapy should still be used
during the early portion of this phase to reduce the likeli­
during this hood of swelling. Electrical stimulating currents can help
.., by using with controlling pain and improving strength and range of
nj ury. Ice, motion. 7&
uch as pos­
Phase 3, the Remodeling Phase
i phase. It
abilitation The remodeling pbase is the longest of the three phases
IfIl overly and can last for several years, depending on the severity of
=- mjury, and the injury. The ultimate goal during this maturation stage
rin g the in­ of the healing process is return to activity. The injury is no
41
longer painful to the touch. although some progressively
decreasing pain might still be felt on mot,ion. The collagen
I1bers must be realigned according to tensile stresses and
strains placed upon them during functional sport -specific
exercises.
The focus during this phase shouJd be on regaining
sport-specific skills. Dynamic functional activities related to
individual sport performance should 'be incorporated inLo
the rehabilitation program. Functional training involves
the repeated performance of an athletic skill for the pur­
pose of perfecting that skiI!. Strengthening exercises should
progressively place on the injured structures stresses and
strajns that would normally be encountered during that
sport. Plyometric strengthening exercises can be used to
improve muscle power and explosiveness. J~ Fonotional
testing should be done to determine specific skill weak­
nesses that need to be addressed prior to full return .
At this point some type of heating modality is benefi­
cial to the healing process. The deep-heating moda'lities.
ultrasound. or the diathermies shoulc] be used to increase
circulation to the deeper tissues. Massage and gentle mo­
bilization may also be used to reduce guarding. increase
circulation. and reduce pain. Increased blood flow delivers
the essential nutrients to the injured area to promote heal­
ing, and increased lymphatic flow assists in breakdown
and removal of waste products. 7"
USING MEDICATIONS TO EFFECT
THE HEALING PROCESS
Medications are most commonly used in a sports medicine
environment for pain relief. The athlete is continuously in
situations where injuries are very likely. Fortunately. most
of the injuries that occur are not serious and lend them­
selves to rapid rehabilitation . However. pain can be associ­
ated with even minor injury.
The over-the-counter nonnarcotic analgesics often used
include aspirin (salicylate). acetaminophen, naproxen
sodium ketoprofen. and ibuprofen . These belong to the
group of drugs called nOllsteroidal anti-inj7ammator!l drugs
(NSALDs). Aspirin is one of the most commonly used drugs
in the world. W Because of its easy availability, it is also likely
the most misused drug. Aspirin is a derivative of salicylic
acid and is used for its analgesic. anti-inflammatory. and
antipyretic capabilities.
Analgesia can result from several mechanisms. As­
pirin can interfere with the transmission of painful im­
pulses in the thalamus. 65 Soft-tissue injury leads to tissue
necrosis. This tissue inj ury causes the release of arachi­
donic acid from phospbolipid cell walls. Oxygenation of
42 PART ONE The Basis of fnjury Rehabilitation
arachidonic acid by cyclooxygenase produces a variety of
prostaglandins, thromboxane, and prostacyclilJ that medi­
ate the subsequent inl1ammatory reaction, 1 The predomi­
nant mechanism of action of aspirin and other KS A!Ds is
the inhibition of prostaglandin synthesis by blocking the
cyc!ooxygenase pathway.93 Pain and inflammation are re­
duced by the blockage of accumulation of proinflamma­
tory prostaglandins in the synovium or cartilage.
Stabilization of the lysosomal membrane also occurs,
preventing the eff111x of destructive lysosomal enzymes
into the joints. oj Aspirin is the only NSi\1D that irre­
versibly inhibits cyc!ooxygenase; the other NSAIDs provide
reversible inhibition. Aspirin also can reduce fever by al­
tering sympathetic outflow [rom the hypothalamus,
which produces increased vasodilation and heat loss
through sweating. Ii ;.90' Among the side effects of aspirin
usage are gastric distress, heartburn, some nausea. tinni­
tus, headache, and diarrhea. iVIore serious consequences
can develop with prolonged use or high dosages."
An athlete should be very cautious about selecting as­
pirin as a pain reliever, for a number of reasons. (,; /\spirin
inhibits aggregation of platelets and th us impairs the clot­
ting mechanism should injury occur,78 Aspirin's irre­
versible inhibition of cyclooxygenase. which leads to
reduced production of c!olling factors, creates a bleeding
risk not presen t with the other NSA IDs. 92 Prolonged
bleeding at an injured site will increase the amount of
swelling, which has a direct effect on the time required for
rehabilitation.
Use of aspirin as an anti-inl1ammatory should be rec­
ommended with caution. Other anti-in.ilammatory medica­
tions do not produce many of the undesirable side effecls of
aspirin. Generally. prescription anti-inOammatories are
considered to be equally effective.
Aspirin sometimes produces gastric discomfort. An
athlete's intense physical activity can exacerbate this side
effect. Buffered aspirin is no less irritating to the stomach
than regular aspirin, but enteric-coated tablets resist as­
pirin breakdown in the stomach and might minimize gas­
tric discomfort. Regardless of tbe form of aspirin ingested,
it should be taken with meals or with large quantities of
water (8 to 10 ounceslLablet) to reduce the likelihood of
gastric irritation.
Ibuprofen is classified as a NSAID; however, it also
has ana lgesic and antipyretic effects. including the po­
tential for gastric irritation. It docs not aftect platelet ag­
gregation as aspirin tloes. Ibuprofen administered at a
dose of 200 mg does not require a prcscripUon and at
that dosage may be used for analgesia. At a dose of 400
mg, the effects are both analgesic and anti-inflammatory.
Dosage forms greater than 2[)0 mg require a prescrip­ • TA
tion. For names and recommended doses of prescription
NSAJDs, refer to Table 2-2.
Acct,aminophen, like aspirin, has both analgesic and
antipyretic effects, but it does not have significant al1ti­
inflammatory capabilities 6 Acetaminophen is indicated
for relief of miltl somatic pain and fever reduction through
mechanisms similar to those of aspirin. 49
The primary advantage of acetaminophen for the ath­
lete is that it docs not produce gastritis, irritation, or gas­
trointestinal bleeding. Likewise, it does not affect platelet
aggregation and thus does not increase clotting lime after
an injrury.
For the athlete who is not in need of an anti­
inflammatory medication but who requires some pain­
relieving lHedkation or an antipyretic. aceta_minophen
should be the drug of choice. If inflammation ,is a consid­
eration, the team physician may elect to use a lype of
Ansai d
SAm. 1\10st NSAlDs are prescription medications that.
Toradol
like aspirin, have not only anti-inflammatory but also
Lodi nc
analgesic and antipyretic effects. 53 They are effective for
elebrcx
patients who cann ot tolerate aspirin because of associated
Vi oxx
gastrointestinal distress. Athletes who have the aspirin
Relafi n
allergy triad of (1) nasal polyps, (2) associated bron­
Myobic
chospasm/ asthma, and (3) history of anaphylaxis should
Daypro
not receive any NSAID. Caution i.s advised when using
SA IDs in persons who might be predisposed to dehydra­
tion during training and competition. NSAms inhibit
prostaglandin synthesis and therefore can compromise
the elaboration of prostaglandins within the kidney dur­
ing salt and / or water deficits. This can lead to ischemia
within the kidney.13.6 1 Adequate hydration is essential to
reduce the risk of rellal toxicity in c1.U1letes taking NSAIDs.
NSAID anti-inflammatory capabilities are thought to
be equall.o thosc of aspirin, their advantages being that
!SAIDs have fewer sidc effects and relatively longer dura­
tion of action. NSAIDs havc analgesic and antipyretic ca­
pabilities; the short-acting over-the-counter NSAfDs may
be used in cases of miltl heatlache or increased body tem­
peraturc in place of aspirin or acetaminophen. They ca n
be used to relieve many other mildly to moderately painful
somatic conditions like menstrual cramps and soft -tissue aUons. c,
injury." reduce
It has becn recommended that athletes receiving long­
acting NSAIDs have monitoring of liver function enzymes
during the course of therapy because of case reports of he­
patic failure associated with the use of long-acting
:--':SAIDs.77
The NSAIDs are used primarily for reducing the pain,
stiffness, swelling, rcdness, and fever associated with local­
 CHAPTER 2 Understanding and i\'lanaging the Healing Process through Rehabilitation 43

prescrip­ • TABLE 2-2 NSAIDs Frequently Used Among Athletes: Prescription Required.
esc ription
Drug Dosage Range (mg) and Frequency Maximum Dally Dose (mg)
• gesic and 325-650 mg every 4 hours
Aspirin 4,000
Voltaren 50-75 mg twice a day 200
ind icated
Cataflam 50-75 mg twice a day 200
n through
Dolobid 500-1,000 mg followed by 250-500 mg 2 to 3 times a day 1.500
Nalfon 300-600 mg 3 to 4 times a day 3.200
Motrin 400-800 mg 3 to 4 times a day 3,200
Ind'ocin 5-150 mg a day in 3 to 4 divided doses 200
Orudis 75 mg 3 times a day or 50 mg 4 times a day 300
c Lime after 500 mg followed by 2 50 mg every 6 hours
Ponstel 1,000
Naprosyn 250-500 mg twice a day 1,250
r an an,[j­
Anaprox 5 SO mg followed by 275 mg every 6 to 8 hours 1,375
.;orne pain­
Feldene 20 mg per day 20
, m inophen
Clinoril 200 mg twice a day 400
a consid­ 400 mg 3 to 4 times a day
Tolcctin 1,800
a type 01 50-100 mg 2 to 3 Limes a day
Ansaid 300
ations that. Toradol 10 mg every 4 to 6 hours for pain: ot to be used for more than 5 days 40
bu t a'l so
Lodine 200- 400 mg every 6 to 8 hours for pain 1,200
:Tective for 100-200 mg twice a day
Celebrex 200
r a ociated
Vioxx SO mg once a day 50
_ he aspirin
Relafin 1,000 mg once or twice a day 2.000
i1ted bron­ 7.5 mg once per day
Myobic 15
_ a\is should
Daypro 1,200 mg once per day 1,800
hen using
'0 de hydra­
"Us inhibit
i2ed ini~ ammation, mosllikely by inhibiting the synthesis
aSpIrIn and phenacetin or acetaminophen contributes
of prostaglandins.1 9 The athletic trainer m ust be aware
to the development of papillary necrosis and analgesic­
that inf1ammation is simply a response to some underlying
associated nephropathy. The presence of caffeine plays a role
gXSAlDs. trauma or condition and that the source of irritation must in dependency on these products leading to chronic use.
_ i.ho u ght to be corrected or eliminated for these anti-inl1ammatory
_ bei ng that medications to be effective. Both naproxen and ketoprofen
(now available wit hout a prescription) have been shown to THE SPORTS MEDICINE
ger dura­
"pyretic ca­ provide additional benefit when administered coneomi. APPROACH TO THE
tantly with physical therapy.63
. A IDs may
Muscle spasm and guard'ing accompany many muscu­
IHEALING PROCESS
body tem ~
. Tbey can loskeletal injuries. Elimination of this spasm and guarding In sports medicine, the rehabilitation philosophy relative to
Lely painful should facilitate programs of rehabilitation. In many situ­ inf1ammaLion and healing after injury is to assist (J1e natu­
d soft-tissue ations, centrally act.ing oral muscle relaxants are used to ral processes of the body while doing no harm. i IThe chosen
reduce spasm and guardin g. However. to date the efficacy course of rehabilitation must focus on the athletic trainer's
01' using muscle relaxants has not been substantiated, and knowledge of the healing process and its therapeutic modi­
ehi ng long­
n enzy mes they do not appear to be superior to analgesics or sedatives fiers to gUide, direct. and stimulate the structural function
por ts of he­ in either acute or chronic conditions. 24 and integrity of the injured part. The primary goal should be
long-acting Many analgesics and anti-inl1ammatory products are to have a positive inf1uence on the inflammation and repair
available over the counter in combination products (Le., process to expedite recovery of function in terms of range of
"ng the pain, those containing two or more nonnarcotic analgesics with motion, muscular strength and endurance, neuromuscular
Lerl with local- or without caffeine). Chronic use of analgesics containing control, and cardiorespiratory endurance. 29 The athletic
44 PART ONE The Basis of Injury Rehabilitation
trainer must try to minimize the early effects of excessive
inl1ammatory processes. including pain modulation,
edema control. and reduction of associated muscle spasm,
which can produce loss of joint motion and contracture.
Finally, the athletic trainer should concentrate on prevent­
ing the recurrence of injury by influencing the structural
Summary
1. The three phases of the healing process are the inflam­
matory response phase, the l1broblastic-rcpair phase,
and the maturation-remodeling phase. These occur in
sequence but overlap one another in a continuum.
2 . Factors that can impede the healing process include
edema, hemorrhage, lack of vascular supply, separa­
tion of tissue, muscle spasm. atrophy, corticosteroids,
hypertrophic scars, infection, climate and humidity,
age. health, and nutrition.
3. The four fundamental types of tissue in the human
body are epithe'lial. connective, muscle, and nerve.
4. Ligament sprains involve stretching or tearing the
flbers that proVide stability at the joint.
5. Fractures can be dassil1ed as greenstick, transverse,
oblique, spiral. comminuted, impacted, avulsive. or
stress.
6. Osteoarthritis involves degeneration of the articular
cartilage or subchondral bone.
7. Muscle strains i'l1volve a stretchillg or tearing of mus­
cle flbcrs and their tendons and cause impairment to
active movement.
8. Tendinitis, an inflammation of a muscle tendon that
causes pain on movement. usually occurs because of
overuse.
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 CHAPTER 2 Understanding and Managing the Healing !Process through Rehabilitation
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SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES
training.
2-1 Immediate action to con trol swelling can expedite
the heaHng process. The aLhleLic trainer should ftrst
provide compression and elevaLion. Applying ice,
which decreases thc metabolic demands of the unin­
jured cells, ca n prevent secondary 'hy poxic injury. Ice
also slows nerve conduction velocity. which will de­
crease pain and thus limit muscle guarding.
2·2 The athletic traioer should explain to the coach that
it can take up to 3 or 4 days for the inflammatory re­
sponse to subside. During this time. the muscle is ini­
tializing repair by containing the injury by clot
formation. Too much stress during this lime could in­
crease the time it takes the muscle Lo heal. After that,
it may take a couple of weeks before ftbroblastic and
myoblastic activity has restored tissue strength to a
~O flCOtl1- point where the tissue can withstand the stresses of
training.
). Tell(ijnitis: 2- 3 Muscle healing generally takes longer. While ftbro­
ity Press. blasts are laying down new collagen for connective
ctrical en­ tissue repair, myoblasts are working to replace the
contractile tissue.
_. aL 19H5.The
-rpair. Phusician
logy. Miami:
ec TI' tissue and
cise training.
- : S162-68.
47
97. Whiteside. J. A.. S. B. Fleagle. and A. Kalenak. 1981. Frac­
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369-77.
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cal therapy. edited by B. Sanders. Norwalk, CT: Appleton &
Lange.
2-4 Once the injured structure has progressed through
the inflammatory phase and repair has begun to take
place, sufl1cient tensile stress should be provided to
ensure optimal cepair and positioning of the new
fi bers (according to Wolff's law) . Efforts sho uld be
made right away to avoid the strength loss that
comes with immobility due to pain .
2-5 The presence of gross laxity would suggest a grade 3
sprain. The athlete should be referred to the team
physician for further evaluation.
2-6 In a complete ligament tear, it is likely that the nerves
in that structure will also be completely disrupted.
Therefore. no pain signals can be transmitted.
2-7 It is likely that this young boy has a greenstick frac­
ture. Such fractures are common in athletes of this
age.
2-8 Peripheral nerves are I'ikely to regenerate if the cell
body has not been damaged. The closer the injury is
to the cell body. the more difficult the healing process
is. If a nerve is severed, surgical ,i ntervenUon can sig­
nificantly improve chances of regeneration.
 CHAPTER 3
The Evaluation Process

in Rehabilitation
Darin A. Padua

Study Resources • DisCllSS special tests that should

To become more familiar with the knowledge and skills be incorporated into an evaluation

necessary to design. implement, and document therapeu­

scheme.

tic rehabilitation programs as identified in the NATA Ath­

letic Training Hducalional COl1lpelerzcies IIlId Clinical
ProJiciencies"l'herapeutic Exercise content area, visit
" 'ww. mh he.com/prenLicc 11 e. Also. refer to the lab exer­
cises in the new Laboratory Manual and to eSims, which
simulates the athletic training certification exam, at
www.mhhe.com/esims. For more online study resources.
visit our Health and Human Performance website at
www.mh he.coOl/ hhp.
• Review ways to perform injury risk
screenings and describe how the find­
ings can be incorporated into injury
prevention training programs.
• Recognize how to establish short-term
and long-term rehabilitation goals based
on the Ilndings of the injury evaluation.

After Completion of This Chapter,

the Student Should Be Able

to Do the Following:

njury evaluation is the foundation of the rehabilitation

• Identify the components of the system­
atic differential evaluation process.
• Explain the role of the systematic in­
jury evaluation process in establishing
a rehabilitation plan and treatment
goals.
I process. To effectively coord inate the rehabilitation
process, the athletic trainer must be able to perform a
systematic differential evaluation and identify the patho­
logical tissue. According to Cyriax, > the injury evaluation
process involves applying one's knowledge of anatomy to
differentiate between provoked and normal (issue:
Provoked tissue - Normal tissue = Pathological tissue

• Describe various ways to differentiate
between normal and pathological
tissue.
Once the pathological (issue is identified, the athletic
trainer must then consider the contra indications and de­
termine the appropriate course of treatment:
Pathological tissue - Contraindications =

Treatment (rehabilitation plan)

48


The athletic trainer determines the appropriate rehabili­
tation goals and plan based on the information gathered
from the evaluation. In designing the rehabilitation plan. the
athletic trainer must consider the severity, irritability, nature,
and stage of the injury. 21 Throughout the rehabilitation
process. the athletic trainer must continuous'!y reevaluate
the status of the pathological tissue in order to makc appro­
priate adjustments to the rehabUitatlon goals and plan.
The athletic tr<liner might conduct multiple injury
evaluations of the follOWing kinds for varying purposes
during the course of athletic injury management:
1. On-si~e evaluation <ltthe time of injury (on-field)
2. On-site evaluation iust follOWing injury (sideline)
3. Off-site evaluation that involves the injury assessment
and rehabilitation plan
4. Follow-up evaluation during the rehabilitation
lete. In addition to gathering information about the injury,
process to determine the patient's progress
the subjectiveevaluallon serves to establish a level of comfort
5. Prcparticipation physical eV<lluation (preseason
and trust between the athlete and the athletic trainer.
screening)
The injury history and the symptoms are the key ele­
All forms of injury evaluation will involve similar steps and
procedures. This chapter \<Irill focus on the steps and proce­
dures involved during the ofT-site injury evaluation and in­
d­
corporating this information into the rehabilitation plan.
ury
THE SYSTEMATIC DIFFERENTIAL
- erm EVALUATION PROCESS
based The key to a successful injury evaluation is to establish a se­
·alion. quential and systematic approach that is followed in every
case. A systematic approach allows the athletic trainer to be
confident that a thorough evaluation has been performed.
However, the a thletic trainer must keep in mind that each in­
jury may be uniqtle in some manner. Thus, the athletic
abUitatiol1 trainer must maintain a systematic approach but not be in­
abilitation flex ible durin g the evaluation process. The Injury Evaluation
perform a Checklist in Figure 3-1 is provided as an example of the steps
_ the patho­ and procedures that may be included a sequential and sys­
e\·aluatjon tematic evaluation scheme.
ana tomy to The systematic diHerential evaluation process is com­
'lIe: posed of subjective and objective elements. During the sub­
jective evaluation the athletic trainer gathers information
~ al tissue on the injury history and the symptoms experienced by the
me athletic oLhlete. This is performed through an initial interview with
ns and de- the athlete. The athletic trainer attempts to relate informa­
tion gathered during the subjective evaluation to observable
signs and other quantitative nndings obtained during the
objective eva[uation. The objective evaluation involves
observation and inspection, acute injury palpation, range of
CHAPTER 3 The IEvaluation Process in Rehabilitation 49
motion assessment (active and passive), muscle strength
testing, special tests, neurological aS5essmenl. subacute or
chronic injury palpation, and functionall testing. AfLer com­
pleting the subjective and objective evaluation. the athletic
trainer will arrive at an assessment of the injury based on
the information gathered.
Subjective Evaluation
The subjeclive evaluation is the foundation f()r the rest of the
evaluation process. Perhaps the single most revealing com­
ponent of the injury evaluation is the information gathered
during the subjective evaluation. Fss "nlia]]y, during the su b­
jective evaluation the athletic Lrainer engages in an orderly.
seq uential process of questions and dialogue \.vi.th the ath­
ments of the subjective evaluation. A detailed injury his­
tory is the most important porlion of the evall ualion. The
rem ainder of the evaluation will focus on confirming the
,i nformation taken from the patient's history.
History of Injury. In gathering a detailed history,
the alhletic trainer should fo cus on gathering ini'ormation
relative to the athlete's impressio n of the inju.ry, sile of itl­
jury, mechanism of injury, previous injuries. and general
medical health. The history should be taken in an orderly
seq uence. This information will then bc used to detennine
the appropriate components to incorporate during the ob­
jective evaluation.
When laking the athlete's history, the athletic trainer
should initially usc nonleading, open-en ded q~Jestions. /\s
the subjective evaluation progresses . Lhe athletic trainer
mny move to more close-ended questions once a clear pic­
ture of the injury h as bee n presented . Open-end d ques­
tions involve narr3live ittformation about the injury:
close-ended qu es tions ask for specil1c inlormation. l J
The history relics on the athletic trainer's ability to
clearly communicate with th e injured patient. Th us. the
athletic trainer should avoid th e llse of scientific nnd med­
ical jargon and use simple terminolog)' that is easy to un­
dersLand. The use of simple terminology ensures that the
patient will understand any close-ended questions the ath­
letic trahler may ask.
Athlete's impression, Mlow the athlete to describe in
his or her own words how Ule injury occurred, where the in­
jury is located, and how they feel. vVhile listening to the ath­
le te, th e athletic trainer sho uld be generating close-ended
SO PART ONE The Basis of Injury Rehabilitation

SUBJECTIVE PHASE
History
Patient's impression
Site of injury
Spec
Mechanism of injury
Previous injury
Behavior of symptoms (PQRST)
Provocation of symptoms
Quality of symptoms
Region of symptoms
Severity of symptoms
Timing of symptoms
OBJECTIVE PHASE
Observation and Inspection
Postural alignment (see postural alignment checklist)
Gait (lower-extremity injury) or upper-extremity functional motion (upper-extremity injury)
Signs of trauma
Deformity
Bleeding
Swelling
Atrophy
Skin color
Palpation
Temperature
Dermatome assessment
Bone palpation
Soft tissue palpation
Muscle

Tendon

Ligament and joint capsule

Superficial nerves

·Palpate all structures accessible in a specific position before repositioning patient.

·Palpate areas above and below the injured region.
Range of Motion
Active range of motion
Passive range of motion
Resistive range of motion
·Perform range-of-motion testing in all cardinal planes of motion.

·Assess end-feels by applying overpressure.

·Assess arthrokinematic motions if normal range of motion altered.

·Be aware of capsular patterns for specific joint tested

Resistive Strength Testing

Mid-range of motion muscle tests
Specific muscle tests
·Specific muscle tests should be based on results of mid-range of motion muscle tests
·Rate or grade strength assessment

Figure 3-1 Injury evaluation checklist.


Muscle Imbalances
__ Review range of motion and resistive strength testing findings
*Determine whether muscle imbalances appear to exist
Special Tests
Joil1t stability tests
Joint compression tests
Passive tendon stretch tests
Diagnostic tests
Neurologic Testing
Dermatomes
Myotomes
Reflexes
Deep tendon reflexes
__ Superficial reflexes
__ Pathologic reflexes
Functional Testing
Movement patterns that facilitate similar stresses as encountered during normal activity (i.e., activ­
ity specific)
Figure 3-1 (co ntinued)
questions. Once th e a thlete has given his or her impression of
the injury the athletic trainer should ask more specific ques­
tions that fIll in specifIc details.
Site of injury. Have the athlete describe the general
area where the injury occurred or pain is located. Further
isolate the site of injury by havi ng the athlete point with one
fInger to the exactlocation of injury or pain. If the athlete is
able to locale a specifIc area of injury or pain. the alhletic
trainer should make note of the anatomic structures in the
general area and consider this tissue as provoked tissue. A
major purpose of the remaining evaluation phases is to fur­
ther differentiate the identified provoked tissue from the nor­
mal tissue. i Differentiating between provoked tissue and
normal tiss ue a]l[ows the athletic trainer to identify the
pathological tissue.; 'fhe a thletic trainer must be able to
identif)' the pathological tissue in order to develop an appro­
priate rehabilitation plan.
Mechanism of injury. !vIuscu loskeletal injury results
from forces acting on the anatomic structures and ultimately
results in tissue failure. Thus. it is imperative to identif), the
nature of the forces acting on the body and relate these to the
anatomic function of the underlying anatomic structures.
The athletic trainer should determine whether the injury
was caused by a single traumatic force (macrotraum a) or re­
sulted from the accumulation of repeated forces (micro­
trauma). In dealing V\rith an acute injury. it is important to
identify the body position at time of injury. the direction of
applied force. the magnitude of applied force. and the point of
CHAPTER 3 The Evaluation Process in Rehabilitation 51
application of the applied force. The athletic trainer must
thcn apply knowledgc of anatomy. biomecha nics. and tissue
mechanics to determine which tissues may h ave been in­
jured. When dealing with recurrent or chronic injuries. it is
important to establish what factors influence the athlete's
symptoms. such as changes in training, routine. equipment
use. and posture. The accu mulation of this information
should be used to furth er identify the pathologicallisslle.
Any sound or sensation noted at the moment of or im­
med iately after injury is also important information to
gather. The athletic trainer may be able to relate certain
sounds and sensations with possible injuries. hence iden­
tify pathological tissue:
Pop = joint su bluxat io n. ligament tear
Clicking = cartilage or meniscal tear
Locking = cartilage or menisca l tear (loose body)
Giving way = reflex inhibi tion of muscles in an at­
tempt to minimize muscle or joi nt loading
Previous injury. Tissue reinjury or injury of tissue
surrounding previoll sly injured tissue is common. The
athletic trainer should determine whether th e cllrrenl in­
jury is similar to previous injuries. If so, what anatomic
structures were previously injured? How often h as the in­
jury rec urred? How was the previolls injury managed.
from a rehabilitation standpoint? Have there been any
res idual effects since the original injury? Was surgery or
medication given ror the previous injury? Who evaluated
the previous injury?
52 PART ONE The Basis of Injury Rehabilitation
Previous injuries may inOuence the evaluation process of
the current injury as well as the rehabilitation plan. Sec­
ondary pathology may be present in cases of recurrent injury,
such as excessive scar tissue development, reduced soft-tissue
elasticity, muscle contracture, inhibition or weakness of sur­
rounding musculature, altered postural alignment, increased
joint laxity, or diminished joint play/ accessory motions. The
athletic trainer must consider these possibilities and investi­
gate them during the objective evaluation.
Behavior of S~' mptoms. During the second phase
of the subjective evaluation . the athletic trainer explores
specifiC details of the symptoms discovered during the his­
tory. Again, this should be performed in a systematic
and sequential process. Moore 14 describes the PQRST
mnemonic to guide this phase of the subjective evaluation
(P = provocation or cause of symptoms; Q = quality or de­
scription of symptoms; R = region of symptoms; S =
severity of symptoms; T = lime symptoms occur or recur).
Provocation of symptoms. This information is pri­
marily gathered through a dctailed mechanism of injury
description by the athlete. Additional information may be
gathered by asking the athlete if they are able to recreate
their symptoms by performing certain movements. How­
ever. the athletic trainer should not have the athlete recre­
ate these movements at this phase of the evaluation. This
will be performed during range-of-motion assessment in
the objective evaluation.
Typically. musculoskeletal pain is worse with movement
and better with rest. Symptoms caused by excessive innam­
malion may be constant and not alleviated with rest. Symp­
toms associated with prolonged postures may be indicative of
prolonged stress being placed on the surrounding soft-tissue
structures, which ultimately causes breakdown.
Quality oJ symptoms. The athlete should be asked
to descrioe the quality of their symptoms. The patient
might describe their pain as being sharp, dull, aching.
burning, or tingling. The athletic trainer shou Id attempt to
relate the athlete description of the quality 01 symptoms to
possible pathological tissue. Magee 13 descrLbes different
deSCriptions of the quality of symptoms as being associ­
ated with different anatomic structures:
Nerve pain: sharp. bright. shooting (tingling). along
line of nerve distribution
Bone pain: deep. nagging. dull. localized
Vascular pain: diffuse. aching. throbbing. poorly local­
ized . may be referred
Nluseular pain: hard to localize, dull. aching. may be
referred
Region of symptoms. The majority of this infor­
mation is given during the athlete's description of the site
of injury. The region of symptoms might correlate with
underlying injured or pathological tissue. However, the
athletic trainer must be aware of possible referred pain
patterns and not assume that the pathological tissue is lo­
cated directly within the region of symptoms. Once the re­
gion of symptoms has been identified , there are several
other items that should be noted. Do the symptoms stay lo­
calized. or do they spread to peripheral areas ? Do the symp­
toms feel deep or superficial? Do the symptoms seem to be
located within the joint or in the surrounding area?
Pain that radiates to other areas may be due to pressure
on the nerve or from active tTigger points in the myofascial tis­
sue. Symptoms that are well localized in a small area might
indicate minor injury or chronic injury. Symptoms that are
diffuse in nature may be indicative of more severe injury.
Severity of symptoms. The severity of symptoms
may give insight into the severity of injury. However, the
athletic trainer should be cautions in equating the ath­
lete's description of severity with actual injury severity. In­
dividuals' perceptions of severity are highly subjective and
likely vary to a large extent form one person to the next.
Hence. information relative to perceived severity of symp­
toms is an unreliable indicator of injury severity. More ap­
propriately. reports of symptom severity may be used
during the rehabilitation process to track the athlete's
progress. Improvement of symptoms indicates that the re­
habilitation plan is succeeding. Worsening of symptoms
may indicate that the injury is getting worse or that the re­
habilitation plan is not appropriate at this lime.
The athlete should quantLfy their pain in order to 1110St ef­
fkiently track the athlete's progress during the rehabilitation
process. The athletic trainer should instruct the athlete to
rate their pain on a scale of 0 to 10, where 0 is no pain (nor­
mal) and lOis the worst pain imagina ble. Having the athlete
rate their pain does not provide an objective assessment.
Rather, this information will be used to make relative C0111­
parisons of the athlete's progress during rehabilitation. HI
Timing of symptoms. The onset of symptoms may
help detcmline the nature of the injury. Symptoms with a slow
and insidiollS onset that tend to progressively worscn over time
are often associated with repetitive microtrallma. In contrast.
macrotrauma injuries typically resu lt in a sudden. identifiable
onset of symptoms. Injuries resulting from repetitive micro­
trauma may include stress fractures, trigger point formation,
tendinitis. or other chronic inOalrunatory conditions. IVlacro­
traumatic injuries may result in ligament sprains. muscle
strains, acute bone fractures, or other acute soft-tissue injuries.
Duration and frequently of symptoms may be used to
determine whether the injury is progressing or worsening.
An improvement ill symptoms is demonstrated by reduc­
tions in their duration and frequency. The opposite may be
reported in the situation of a worsening injury.
Response of symptoms to activity or rcslmay also be
used to identify the nature of the injury. Magee]; describes

several injury classifications that may related to the re­
sponse of symptoms to activity or rest:
Joint adhesion = pain during activity that decreases
with rest
Chronic inflammation and edema = initial morning
pain and stiffness that is reduced with activity
Joint congestion = pain or aching that progressively
worsens throughout tbe day with activity
Acute inflammation = pain at rest and pain that is
worst at the beginning of activity in comparison to the
end of activity
Bone pahl or organic/systemic disorders = pain that is
not influenced by either rest or activity
Peripheral nerve entrapment = pain that tends to
worsen at night
"g lie ath­ Intervertebral disc involvement = pain that increases
-everity. In­ with forward or lateral trunk bending
tive and
1 the next. Objective Evaluation
. of ymp­
At the completion of t hc subjective evaluation the athletic
~ ),[ore ap­
trainer should have developed a list of potential provoked
b used
tissues. Jn some cases, the experienced athletic trainer may
e alhlete's
be able to identify the speCific injury and pathological tis­
sue at this point of the evaluation. During the objective
evaluation. the athletic trainer will perform several proce­
dures as a process of eliminating normal tissue from being
considered as provoked tissue. These procedures will serve
to differentiate between provoked and normal tissues, al­
lowing the pathological tissue to be identified.
The athletic trainer shouJd plan the objective evalua­
tion.14 After completing the subjective evaluation, the ath­
letic trainer should create a mental list of specific procedures
and tesb to perform during the objective evaluation . At this
point the athletic trainer may expect to get specific findings
during the objective evaluation. However, the athletic trainee
is reminded to stay open-minded and not become too focused
during this stage of the evaluation.
CUNICAL DECISION MAKING Exercise 3-1
While laking an injured athlete's history. the athletic
trainer records the lollowing information:
Site of pain : Knee joint
Mechanism of injllry: Direct blow to knee causing
knee to be forced Into excessive valgus and rotation
• Beha\10r of symptoms: Pain is described as "deep. nag­
worsening.
ging. dull. and localized." pain increases wiUI weight bear­
ed b_ reduc­
ite may be ing. reports a clicking and locking sensation in knee joint
Based on the findings from the history. what types of spe­
cial tests should the athletic trainer consider performing;
may also be
J describes
CHAPTER 3 The Evaluation Process in Rehabilitation 53
Observation and Inspection. The beginning of
the objective evaluation consists of a visual inspection of
the injured patient as they enter the medical facility. The
athletic trainer focuses on the athlete's overall appearance
and speCific body regions that were identified during the
subjective evaluation as being a potential provoked tissue.
For example, if the lower extremity is identilled as H poten­
tial area of injury, the athletic trainer will pay close atten­
tion to the athlete's gait patterns. If an upper-extremity
injury is suspected, the carrying position of the injured ex­
tremity and movement patterns when removing an item of
clothing would be noted. In observing the athlete's move­
ment pattern s, the athletic trainer should be looking for
compensatory patterns, muscle guarding. antalgic move­
ments, and facial expressions. All observations should be
made with a bilateral comparison of the uninvolved side.
Postural alignment. Overall postural alignment
should be assessed during the observation, especially in
athletes suffering from chronic or overuse-type in­
juries. 11. 1 l.22 Many chronic and overuse injuries are due to
postural malalignments that create repeated stress on a
specific tissue. Over time the repeatedly loaded tissue may
become pathological or lead to additional postural align­
ment alterations as compensatory mechanisms to reduce
tissue stress. In addition, postural alignment can influence
muscle function.
If postura'l malalignments are present, t he athletic
trainer should consider the patterns of muscle tightness and
weakness that would correspond to such a postural
malalignment. Altered postural alignment can be caused by
muscle imbalances, not just bony deformity.2.1 It is impor­
tant that the athletic trainer determine whether postural
mal alignments are due to muscle imbalances or bony defor­
mity, as this might inl1ucnce the rehabilitation options. Pos­
tural ma'lalignments that are due to muscle imbalances may
be addressed through physical rehabilitation using appro­
priate muscle flexibility and strengthening techniques to re­
store muscle balance, hence improve normal postural
alignment.
There are many elements involved with a detailed pos­
tural alignment assessmel1t. The athletic trainer may con­
sider using a checklist approach to ensure that all elements
are covered. It is important tha t the athlete be viewed in a
weight-bearing position (standing) from multiple vantage
points (anterior, posterior. medial, lateral). In general. the
athletic trainer should be checking for neutral alignment,
symmetry, balanced muscle tone. and specific postural de­
formities (genu valgum, genu varum, etc.). A detailed
checklist for postural alignment is provided as an example
in Figure 3-2.
Signs of trauma. During the postural alignment
assessment, the athletic trainer should also be checking for
S4 PART ONE The Basis of Injury Rehabilitation

Frontal View (Anterior): Arms relaxed, palms facing lateral thighs

Line bisecting: (plumb line)
Nose
Mouth
Sternum
Umbilicus
Pubic bones
Level :
Earlobes
Acromion process
Nipples
Fingertip ends
Anterior superior iliac spine
Greater trochanter
Patella
Medial malleoli
Neutral Rotational Alignment
Shoulder (d irection of olecranon process)
Patella

Feet (direction of toes)

Balanoed Muscle Tone

Deltoids
Trapezius
Pectoralis major
Quadriceps
Is there evidence of:
Cubitus valgus L R B
Cubitus varus L R B
Internal shoulder rotation L R B
External shoulder rotation L R B
Pes pl'a nus L R B
Pes cavus L R B
Forefoot valgus L R B
Forefoot varus L R B
Hallux valgus L R B
Genu valgus L R B
Genu varus L R B
Internal tibial rotation L R B
External tibial rotation L R B
Femoral anteversion L R B
Femoral retroversion L R B
Unequal weight bearing L R
Line bisecting: (plumb line)
External auditory meatus
Cervical vertebral bodies
Acromion process

Figure 3-2 Postural alignment checklist.

 CHAPTER 3 The Eva luation Process in Rehabili tation SS

Deltoid
_ _ Mid-thoracic region

Asymmetric stance width L R

Frontal view (posterior)

Line bisecting: (plumb line)

Head
_ _ Cervical through lumbar spinous processes
Sacrum
Level:
Earlobes
Acromion process
Inferior angle of scapula
Gluteal fold
Posterior superior lIiacs spine
Greater trochanter
Popliteal crease
Medial malleoli
Normal Scapular Alignment:
Vertebral borders rest against thorax
_ _ Superior and inferior angles are equal distance from vertebrae
_ _ Superior and inferior angles sit at ribs 2 and 7, respectively

Perpendicular to Floor
_ _ Line bisecting calcaneus
_ _ Line bisecting Achilles tendon

Balanced Muscle Tone

Trapezius
Deltoids
Rhombo.i ds
Latissimus dorsi
Erector spinae group
Gluteus maximus
Hamstrings
Triceps surae
Is there evidence of?
Winging scapula L R B
Rearfoot valgus L R B
Rearfoot varus L R B
Scoliosis L R S
Lateral shift L R
Saggital View (bilateral)

Line bisecting: (plumb line)

External auditory meatus
Cervical vertebral bodies
Acromion process

Figure 3-2 (continued)

S6 PART 01\E The Basis of Injury Rehabilitation

Deltoid
Mid-thoracic region
Greater trochanter
Lateral femoral condyle (slightly anterior)
Tibia (parallel to plumb line)
Lateral malleolus (slightly posterior)
Level:
ASIS and PSIS
General (normal)
Chin tucked slightly
Mild cervical curvature
Mild thoracic curvature
Mild lumbar curve
Knees straight, but not locked
Is there evidence of?
Genu recurvatum L R B
Hip flexor contracture L R B
(anterior pelvic tilt)
Forward head I shoulder L R B

Figure 3-2 (continued)

signs of Irauma. In acute injuries, observing for signs of

trauma might be the primary purpose of the observation.
Gross deformity along the bone's long axis or joint line may
be present in cases of fractures of joint dislocations. Visil7le
swelling, bleecUng, or signs of infection at the injury site
should also be noted. as should the nature of its onset.
Swelling that is rapid and im.mediate could be indicative of
acute trauma; gradual and slow-onset swelling may be
more indicative of chronic overuse injury. The athletic
trainer should atlcmptto quantify the amount of swelling
by taking girth or volumetric measurements. Quantifica­
tion of swelling can help establish rehabilitation goals and
aid in tracking rehabilitation progress. Atrophy of the sur­
rounding muscles may bc present in the case of chronic in­
jury. Skin color and tcXWre should also be assessed. The
athJete's skin might have red (infiammation), blue
(cyanosis. indicating vascular com.promise), or black-blue
(contusion). coloration. If the skin appears 10 be shiny, to
have lost elasticity. or to have lost overlying hair, or if there
is skin breakdown. there might be a peripheral nerve lesion.
The information collected during the observation
should be related to the findings of the subjective evalua­
tion. This will allow the athletic trainer to further confirm
or differentiate possible pathologicallissue.
CLINICAL DECISION MAKING Exercise 3-2
As you assess an athlete's postural alignment. you ob­
serve excessive anterior pelvic tilling and increased lum­
bar lordosis. How would these observations gUide your
eva luation during the range-or-motion and resistlve
strength-tes ting phases?
Palpation
The question of when palpation should be performed dur­
ing the objective evaluation is debatable. Some feel that pal­
pation should be performed immediately following the
observation; others feel that palpation should be performed
later during the objective evaluation. If an acute injury is
being evaluated. palpaUon may be appropriate immediately
following observation in order to detect any obvious, but not
visible. sofl-tissue or bony deformities. 14 Such I1ndings may
warrant termination of the evaluation and immediate re­
ferrallo a physician. However. if the injury is subacute or
chronic in nature, palpation may be performed later in the
objective evaluation. The disadvantage of performing pal­

pation early in lhe objective evaluation is that such.manual
probing can elicit a pain response thal will distract from
findings during the later subphases of the objeclive evalua­
tion (rangc-of-motion, strength, and special tests). 1 )
Regardless of when palpation is performed. the pri­
mary purpose of palpation is to localize as closety as possi­
ble the potential pathological tissues involved. To gain the
athlete's confidence, palpation should start with a gentle
and assuring touch and thc trainer should freq uendy com­
municate with the athlete. Palpalion should be performed
in a sequential manner and include the anatomic and joint
structures that are above and below the site of the injury.
Palpation should begin on the uninjured side so that the
athlete knows what to expect and the examiner knows
what is "normal" and has an objective comparison when
palpating the injured sidc. Palpation of the injured sidc be­
gins wHh the anatomic structures distal to the site of pain
and then progressively works toward the potential patho­
logical tissues. To systematically palpate all possible tis­
sues, it muy be helpful to develop a specific sequencing of
tissues to palpate. 12 Forexample, the athletic trainer might
first palpate all bones, then ligaments and tendons, and
then thc muscles and corresponding tendons. Considera­
tion should be given to positioning of the athlete as one de­
velops thc sequencing of tissues to palpate. Jvlinimizing
athlete movement is important. as excessive molion can
caLIse the athlete's symptoms to worsen. Thus, the athletic
trainer should palpate all possible anatomic slructures in a
given posiUon prior to repositioning the athlete.
During pEllpalion. the E1thletic trainer should take note of
point tenderness, lrigger pOints, tissue quality, crepitus, tem­
perature. and symmetry.9,] O,l l-H>,21.22 Point tenderness is
noted by indicEltions of p8in over the area being palpated. If
point tenderness is noted. the patient should be asked to rate
thelr point tenderness on a scale of 0 to 10. where 0 is no
pain (nonnal) and lOis lhe worst pain imaginable. Similar to
rating one's ss'mptoms. this does not provide an objective as­
sessment. Rather, this information will be used to make rela­
tive comparisons of the athlete's progress dwing
rehabilitation. Trigger points may be loc8ted in the muscle
)owingthe
and feel like a small nodule or muscle spasm. The trigger
be performed
point mEly be identil1ed as an area that upon palpation refers
::me injury is
pain to another body area. Illcreased tissue temperature may
immediately
be present if infection or inOammation is present. Calciftca­
ious. but not
tion or change in tissue density may be present in a poorly
managed hematoma formation. or might indicate effUSion
or hemarthrosis of the joint. Crepitus is a crunching or
, ubacute or
crackling sensa Lion along the tendon. bone. or joint. Crepi­
later in the
tus along the length of a tendon can indicElte tenosynovitis
onnlng pal­
or tendinitis. The presence of crepitus along the bone or joint
CHAPTER 3 The Evaluation Process in Rehabilitation 57
may indicate damage to the bone (fracture). cartilage, bursa,
or joint capsule. Rupture of a muscle or tendol'lmay present
as a gap at the point of separalion.
All information gathered durin.g palpation should be
used to further confirm the findings of the initial evalua­
tion steps. At this point thc athletic trainer should be fur­
ther able to differentiate between the normal and
provoked tissue. Before beginning the next subphase of
the objective evaluation, the athletic trainer should re­
view the findings 8nd further organize the rema,i oder of
the objective evaluation,
Special Tests
Range of Motion. R8nge-of-molion assessment in­
volves determining the athlete's abiJity to move a limb
through a specific pattern of motion. There are several gen­
eral principles that should be applied during range-of­
motion tesling. Motions will be performed passively, ac­
tively, and against resistance to fully quantify the athlete's
status. It,22 Testing should flrst be performed on the ath­
lete's uninjurcd loimb through each of the joint's cardinal
pl8nes of molion and the quantity of motion available
should be recorded. Then range-of-motion testing is re­
peated on the injured limb. The athletic trainer can then
compare the range of motion of the injured limb to that of
the uninjured limb and / or against established normative
data. 22 In addition, range-of-motion records will serve an
important role in tracking the athlete's progress during re­
habilitation. Active range-of-motion tesling should be
performod first. followcd by ptlssive. then resistive, range-or­
motion tlssessmenl. 14,22 If possible. the athletic trainer
should perform movement pallerns that facilitate pain at
the end to prevent a carryover effect to follOWing movement
palterns. This should be evident based on the previous steps
performed during the evaluation process. Range-of-motion
assessment should also be performed at the joints proximal
and disttll to lhe ,involved areEl for [] comprchensive evalua­
tion. 22 These general guiclelines allow the athletic trainer to
efncien tly assess range of motion.
One of lhe primary goals of range-of-mot'ion testing is
to assess the integrity of lhe inert tlnd contraclilc t,issue
components of the joinl complex. Inert tissues are some­
times referred to as anatomic joint structures and include
bone. ligament, c8psule, bursae, periosteum, cartilage,
and fElscia .) The contractile tissues. also referred to as
physiologicElI joint structures, include muscle, tendon, and
nerve structures.) Cyriax developed a method to differenti­
ate between inert and contractile pathological tissues as
part of the range-of-molion assessment. 5 Differentiating
 58 PART ONE The Basis of Injury Rehabilitation
between inert or contractile tissue pathology is performed
by selectively applying passive and active tension to joint
structures and maklng note of where pain is located .' The
ability to differentiate between inert and contraclile tissue
pathology is an important step in selling up the rehabilita­
tion plan and identirying the appropriate tissue to treat.
Inert tissue pathology is indicated when the Dthlete
reports pain occurring during both active and passive
range of motion in the same direction of movement. 5
1'ypically. pain due tu inert tissue pathology will occur
near the end of the range of motion as the tissue becomes
compressed between the bony segments. Example: The
athlete reports pain in the anterior shoulder region when
actively and passive moving the humerus into the end
range of shoulder flexion . Because pain was present in
the same direction of motion (direction of shoulder llex­
ion = anterior shoulder) during active and passive move­
ments. pathology of an inert tissue structure of the
shoulder would be indicated.
Contractile tissue pathology is indicated when the ath­
lete reports pain in the same direction of motion during ac­
tive range of motion, then reports pain in the opposite
direction of motion during passive frmge of motion.' Con­
tractile tissue pain occurs due to increased tension placed on
the tissue. However, th e cause of contractil e tissue tension
differs between active and passive range-of-motion tesl.ing.
During active range of motion, contractile tissue tension in­
creases due to the voluntary agonist muscle contraction
generated to move the limb. In contrast. passive range of
motion increases contractile tissue tension as the muscle is
stretched by the athletic tminer. f: x<lmple: The athlete re­
ports anterior shoulder pain when actively bringing the
humerus into shoulder llexion (pain in same directiol) as
motion) and when passively bringing the humerus into
shoulder extension as it is stretched by t.he athletic trainer
(pain in opposite direction as molion). It is not possible to de­
termine the specific location of either inert or contractile tis­
sue pathology through range-of-motion assessment. This is
accomplished by incorporating mflllual muscle and speCial
tests to locate the exact location of pathology.
Active range of motion. Havin g tb e athlete "ac­
tively" contract their muscles as they take their limb
through the desired cardinal plane of motion aSsesses ac­
tive range of motion, location of pain, and painful arcs. IS
A. painful arc is pain that occurs at some point during the
range of motion but later disappears as the limb moves
past this point in either direction. 1 , .22 Typically. a painful
arc is present due to impingement of tissue between bony
surfaces. Painful arcs may be present during either active
or passive range-of-motion testing.
Overpressure may be applied at the end range of mo­
tion to assess end point feels, if active range of motion is
~-
full and pain-free. 14 Pain or limited range of motion pro­
hibi ts applying overpressure during active range-of­ •
motion assessment and may indicate wailing until the pas­
sive range-of-motion testing. If range of motion is limited
or elicits pain. the athletic trainer should consider the
cause of these findings . as this will have direct impliculions
on the rehabilitation plan. Limited range of motion can be
caused by several factors, including swelliJlg, joint capsule
tightness, agonist muscle weakness/ inhibition, or antago­
nist muscle lightness/ contracture. 10
Passive mnge of motion. When passive range of mo­
tion is assessed. the athlete should be positioned so that Lhe
contractile tissues are relaxed and do not inOuence the find­
ings due to active muscle contraction. The athletic trainer
then takes the ,limb through thc desired passive movement
pattern until the point of pain or end range of motion. Upon
reaching the end range of motion, gentle overpressure
should be applied and particular atlention should be directed
toward Lhe sensation of the end-point feel.
The end-point feel encountered anhe end range of mo­
tion has been given several normal and ubnormal classifi­
cation schemes. S End-point feci assessment may be useful
ill helping determine the type of pathological tissue 5
(Table 3-1).
The athletic trainer should determine whether differ­
ences exist between the ranges of motion availabLe during
active and passive testing. Reduced range of motion dur­
ing active compared to passive tesLing may indicaLe defi­
ciency in the contractile tissue. Contractile tissue
deficiencies may be caused by muscle spasm or contrac­
ture, muscle weakness, neurological deficit, or muscle
pilin:'l Such deficiencies should be addressed during the
rehabilitation plan to restore normal range of motion.
The presence of crepitus or clicking is also of significance
during passive range of motion tesling. l " Crepitus or clicking
along the joint i1ine or bet ween two bones may indicate danl­
age to the articular cartilage or a possible loose body in the
joint. Similar sensations along the muscle or tendon may in­
dicate adhesion formation or tendon subluxation.
CLINICAL DECISION MAKING Exercise 3-3
During knee tlexion range-of-motion testing, an athlete
complains of pain in the same direel10n of motion during
active range of motion. but no pain during piJssive range
of motion. Upon testin g kn ee extension range of motion.
the athlete indicates that pain occurs in the opposite di­
rection of motion during passive range of Illation . What
type of tissue may be suspected to have been injured.
based on these lIndings?
 CHAPTER 3 The Evaluation Process in Rehabilit ation 59

• TABLE 3-1 End-Feel Categorization Scheme.

Normal End-Feels
Soft-tissue a[J[Jroximation Soft and spong}'. a gradual [Ja.inlcss stop (e.g .. elbow flexion)
Ca[Jsltl ar An abrupt, hard . firm end-point with only a lillIe give (e.g .. shou'lder rotation)
Bone-to-bone i\ distinct and abrupt end point where two hard surfaces come in contact with one another
(e.g., elbow extension)

Abnormal End-Feels
Empty Movement definiLely beyond the anatomical limil. or pain prevents the body part from
moving throu gh the available ran ge of 1110tion (e.g., ligament rupture)
Spasm Involuntary muscle contraction that prevents normal range of motion due Lo pain
(guarding) (e.g .. muscle s[Jasm)
Loose Extreme hypermobility (e.g .. ehronic ankle sprain, chron ic shoulder subluxation/dislocation)
S[Jringy block A rebound at the end point of moti on (e. g.. men iscal tear. loose body formation)

Capsular patterns oj motion. [rritalion to Lhe
joint capsule may cause a progressive loss of available mo­
tion in different card inal planes of motion. \,\7hen identify­
ing a ca[Jsular pallern. movcmcnt restrictions arc lisLed in
order, with the ftrst being the motion pattern that is most
ilier differ­ affected. 'i Each joint has a speCific pattern of progressivc
able during motion loss in different planes of motion. For example. the
otion dur­ capsular pattern of th e glenohumera l joint invo lves signif­
irate defi­ icant limitation to externa l roLation, followed by abduction
i1e tissue and internal rotaLion. Presence of a capsu lar pattern indi­
r contrac­ ca tes a total joint reaction that may involve muscle spasm,
or muscle joint capsule tightening (most common), and possible os­
during th e teophyte formation. ' J The athletic trainer must determine
:noti on. which jOint structures may be involved with the capsu lar
pattern in order La adequately plan the patient's rehabili­
tation. This will be performed through assess ment of joint
end-feels , muscle strength, and various specia ltcsts.
NOflcapsular patterns oj motion. Nonca psular
patterns of motion result from irritation to structures lo­
cated outside of the joint capsule and do not folIo\\' the pro­
gressive loss of motion pallerns as observed wit h a
capsular pallern. Cyriax has classified the I()\lowing le­
sions as producing noncapsular patterns of motion. >
Ligamentolls IIrlllesioll occurs after injury and may re­
su lt in a movement restriction in one plane. with a full
pain-free range in other planes.
Internal derall[jemelll involves a sudden onset of loca l­
ized pain resulting from the displacement of a loose
body within the joint. The mechanical block restricts
motion in one plane while allowing normal, pain-free
1110tion in th e opposi te direction. Movement restric­
tions can cha nge as the loose body shifts its position in
the joint space.
Extra-articular lesion resulLs from adhesions occurring
outside the joint. Movement in a plane that stret ches
that adhesion results in pain. whereas motion in the
opposite direction is pain-free and nonrestricted.
Accessory motion and joint play (arth rokinc­
matic motion). Accessory or joint play motions occ ur
between Joint surfaces as the jOint undergoes passive and
active motions.'l The motion occurring between the joint
surfaces is also rderred to as arthrokinematic motion.
Arlhrokinemalic motions are not actively produced by the
a thlete. However, arlhrokinematic motion is necessary for
full ac tive and passive joint range of motion to be achieved.
/\s s uch, accessory motion/jOint play assessment shou ld
be evaluated during a comprehensive assessment of joint
range of motion. l7
Three types of <trthrokinemalic motions can occur:
roll, glide, and spin . A detailed description of th e
a rth roki nematic motions is provided in Chapter 14.. In
brief. for normal joint motion to occur there must be nor­
mal arthrokinematic motion available. An example of
arthrokinematic motion can be easily demonstrated at the
knee in th e open-kinetic-chain position as the knee moves
from a fl exed position into fllll extension (fem ur is sta­
lionery. tibia is moving). During this motio n the tibia rolls
and glides anteriorly and spins externally (external rota­
tion) relati ve to the femur. Becausc arthrokinematic mo­
tions are involuntary, assessment requires speCific manual
techniques. Techniques used [or assessmen t of accessory
motion arc the same as those used in joint mobilization
treatment and are discussed in detail in Chapter 14.
During arthrokinemalic motion Clssessment, the ex­
aminer is lookin g for a lterations in eithe r hypomobility
(restricted arthrokinematic moUon ) or hypermobility
60 PART ONE The Basis or Injury RebahilitatJon
(excessive arthrokinematic motion). In addition to assess­
ing the amplitude of arthrokinematic rnotion, the exam­
iner should also note signs of joint stiffness, quaJily of
motion, end-feel. and pain. lO
It is particula.rly important to evaluate arthrokine­
malic motion in athletes that h8ve reduced p8ssive or ac­
tive range of motion. It is possible thai limited passive 8nd
active mnge of motion arises from altered arthrokinematie
motions. Reduced artl1rokinematic motions may be due to
joint capsule or ligamentous adhesions and tightn ess. To
restore normal p8ssive and acLive range of motion in the
athlete demonstrating reduced a.rthrokinematic motion. it
will be important to incorporate joint mobilization tec h­
niques during the rehabilitiltion process.
1 Lnvolvement or a tendon rupture should
CLINICAL DECISION MAKING Exercise 3-4
You determine that an athlete's active and pas~ive range
of motion is limiled. Based on this Inlormation you assess
the athlete's arthrokincmatic motion and !lnd that it is
hYPoJl1obile. What types of exercises would you consider
incorporating into the athlete's rehabilitation plan to ad­
dress these findings?
Resistive Strength Testing Resistive strength test­
ing is u sed to assess the state of contractile tissue (muscl e,
tendon, and nerve). I J. H Typically, resistive stre ngth testing
is performed as the athlete performs an isometric contrac­
tion while the athlet ic trainer performs a "break test." The
break test assesses the amount of isometric force the pa­
tien t can generate prior to allowing jOint moti on-i.e..
"breaking" the isometric contraction. In general. two
ty pes of resistive strength testing are used during the in­
jury evaluation process: midran ge-of-mot io n muscle test­
ing and speCific muscle testing. 14
Midrange-oJ-motion muscle testing. The athletic
trainer should perform midrange-of-motion muscle test­
ing before performing speci!1c muscle testing. It is impor­
tant to perform midrange motion to a llow for isolation of
contract ile tissue. i'l'fusclc testing performed llear the end
range of motion may involve the inert tissue st.ructures.
When pain or weakness is noted during muscle testing at
the end range of motio n, it will be difncult to det ermine
wh et.her pain a rises fr om contractile or inert tissues. 14 The
athletic trainer should be awa re of any type of com pensa­
tory motions the athlete may perform as an attempt to
compensate for weak or limited motion.
iVfidran ge-of-motion muscle testing is performed by
placing the joint in its approximate midran ge of motion for
• TABLE 3-2 Midrange-of-Motion Muscle
Testing Scheme.
Cyriax System for Differentiating Muscular Lesions
Strong and painless = norm al muscle
Strong and painful = minor lesion in some part of
muscle or tendon (first- or seco nd-degree strain)
Weak and painless = complete rupture' of muscle or
tendon or some nervous system disorder
Weak and painful = gross lesion of contractile tissue
(m uscle or tendon rupture, peripheral nerve or nerve
root involvemen t: if movement is weak and pain fre e.
neu rologica,
be first suspected)
a specinc movement pattern. 'fhe athletic trainer tells the
athlete "Don't let me move you," and the applies a manual
force to initiate the break t.est. Midrange-of-motion muscle
testi ng should be perl'ormed in eacb or the cardina,l planes
of motion and compared bilateraLly to Ihe uninjured Umbo
Midrange-of-motion muscle t.esting focuses on muscle
groups, not speCific muscles. Thus. performing specific
muscle testing of the agonist and synergistic muscles act­
ing in that cardinal plane of motion should be included as
a follow-up for noted weakness or pain during midra nge­
o[~motion muscle testing. 14 Essentially, the results of the
midrange-of-motion muscle testing will guide the exam­
iner through specific muscle testing.
During the midrange-of-motion muscle testing the
athletic trainer docs not "grade" strength, but instead as­
sesses the motion as strong, weak, painful. or painless. 14
According to Cyriax,' the athletic trainer can identify the
type of lesion through muscle testing Crable 3-2).
CLINICAL DECISION MAKING Exercise 3-5
During midrange-or-molion muscle testing. you note that
the athlete has pain and weakness when performing hip
extension . Based on this fi nding. what muscles shou ld be
tested during specific muscle testin g?
Specific muscle testing. SpeCific mu scle t.esting is
used to assess the strength and integrity of specific mus­
cles, not simply muscle groups. Muscles tested during spe­
cific muscle testing should be based upon inrormation
obtained from midrange-of- motion muscle testing, range­
of-motion assessment, and the patient's hist.ory. Similar to
 CHAPTER 3 The Evaluation Process in Rehabilitation 61

midrange-of~motion muscle testing, the athletic trainer • TAB,LE 3·3 Specific Muscle Testing
will apply a break test to assess muscle function. However, Grading Scheme.
the joint is placed in various positions in an attempt to iso­
late stress on the muscle of interest. Detailed positioning of Grade 5 Normal Com[Jlete AROM against gravity,
the joint to ,isolate speciftc muscles is described in de taU in with maximum resistance
Daniels and Worthingham 7 as well as Kendall. 12 Grade 4 Good Complete AROM against gravity,
During specific muscle testing the athletic trainer will with some resistance
note any pain and grade the patient's muscle strength. Grade 3 Fair Complete AROM against gravity,
This information will be compared to the injured side and with no re~istance
be used during rehabilitation to track the patient's Grade 2 Poor Complete AROM, with gravity
progress in regaining muscle strength. Several grading eliminated
scales have been reported; numerical systems are the most Grade 1 Trace Evidence of slight muscle
common 7 (Table 3-3). Weakness or pain elicited during re­ contraction, with no joint
sistive strength testing may be caused by several factors , mot·ion
including muscle strain, pain/reflex inhibition, [Jeripheral Grade 0 Zero No evidence of muscle
nerve injury, nerve rOOllesion (myotome), tendon strain, contraction
avulsion, or psychological overlay.lJ The athletic trainer
should always consider the source of lHuscular deficiency
and not simply focus on aSSigning a muscle strength
grade, Thro ugh appropriate usc of neurological tests and move into a more shortened position. Conversely, the an­
various special tests, the athletic trainer should be able to tagonist muscle is Ilengthened from its normal position. In­
accurately identify the source of muscular deficiency. This creasing the resting length of the antagonist muscle is
is imperative in order to emcientJy manage the injury believed to alter the normal length-tension relationship of
throughout the rehabilitation process. the muscle, which further reduces muscle the antagonist
Muscle Imbalances. After evaluating both range of muscle's ability to generate force. Reduced antagonist
motion and resistive strength testing, the athletic trainer muscle force generation due to lengthening is explained by
should review the flndings to determine whether muscle im­ the length-tension relationship. As the antagonist muscle
balances can be identifted. Muscle imbalances arise between is lengthened, there are fewer crossbridges that can be
the exam­ an agonist muscle and its functional antagonist muscle, dis­ aligned. hence reduced muscle force capacity. Reduced an­
rupting the normal force-couple relationship between the tagonist muscle force output further disrupts the norma'l
agonist and antagonist muscle. 2. 1. 1R Muscle tightness or hy­ force-couple relationship and may bring about additiona'l
peractivity of one muscle or muscle group is often the initial po~tural alignment alterations. 2.3
caLlse of muscle imbalances and initiates a predictable pat­ To compensate for weakness of the antago nist muscle
tern of kinetic dysfunction. H IS Tightness or hyperactivity group, the athlete might compensate by placing greater re­
in the agonist muscle can cause inhibition of the antagonist liance on muscles that acts as synergists to the weakened
muscle. This is explained by Sherrington's law of reciprocal muscles. This is referred to as synergistic dominance. 1 . 3
inhibition. Reciprocal inhibition causes decreased neural The synergist muscles are now forced to perform greater
drive to the antagonist muscle, which ultimately facilitates a work to accelerate and decelerate the bony segments. This
lIe that functional weakness of the antagonist muscles. Agonist places greater demands on the synergist muscles, which
~h ip
muscle tightness and hyperactivity combined with inhibi­ increases th e risk of injury to these muscles. 2 . 3 This series
uld be
tion and weakness of the antagonist muscles results in dis­ of events is summarized in Figure 3-3.
ruption of the nnrmal force-couple relationship between Janda has identified several common muscle imbal­
these muscles, hence a muscle imbalance.2.3 ances that may be observed by the athletic trainer. J I The
Initial disruption of the normal forc e-couple relation­ basic concept is to separate muscles into two basic
ship between agonist and antagonist muscles stimulates a groups based on their function: movement and stabiliza­
testing is series of events that further perpetuates the altered force­ tion. Movement group muscles are characterized as
ilk mus­ couple relationship. Vue to the force imbalance between being:
agonist and antagonist muscles, the jOiJlt tends to posi tion Prone to developing U!fl7tness (hyperactive)

itself in the direction of the tight agonist muscle and nor­ More active during functional movements (hyperactive)

mal postural alignmen t can be adversely affected. 2. 1 Alter­ More active when the individual becomes fatigue or

ations to postural alignment allow the agonist muscle to when performing new movement patterns (hyperactive)

62 PART ONE The Basis of Injury Rehabilitation

Synergistic
dominance
Prolonged postures or
/ repeated contraction i8
Agonist muscle Antagonist muscle
tightness weakness

2 l i 7
Altered length-tension
Reciprocal inhibition
relationship
3 l / i 6
Antagonist muscle tAntagonist muscle
inhibition-weakness ~ length
Altered postural
alignment

Figure 3-3 Muscle imbalance injury paradigm.

Stabilization group muscles are characterized as being:
Prone to developing inhibition and weakness (reduced
force capacity)
tess active during functional movements (reduced
force capacity)
Easily fatigued during dynamic movements (reduced
force capacity)
According to Janda. several specific muscles in the move­
ment and stabilization groups are extremely prone to de­
veloping tightness and weakness. respectively. 1] These
muscles are indicated in Table 3-4.
It is important for the examiner to address muscle im­
balances during the rehabilitation process in order to re­
store normal postural alignment and force-couple
relationships. The athletic trainer must pay special atten­
tion to whether limited range of motion in one muscle is
accompanied by weakness in its functional antagonist. If a
muscle imbalance is revealed . the athletic trainer must
work to restore the normal force-couple relationship dur­
ing rehabilitation in order to reestablish postural align­
ment. In general. restoring normal balance between
muscles is accomplished by fIrst stretching the tight mus­
cle to restore Dormal' range of motion before attempting to
strengthen the weak antagonist muscle. Failure to address
muscle imbalances can result in a failed rehabili tation pro­
gram where the examiner is constanUy treating the symp­
toms. but never the cause.
Special Tests
At this point in the evaluation. the athletic trainer should
have considerably narrowed the list of possible pathologi­
cal tissues involved and be judicious in choosing the spe­
cial tesls 10 perform . Suspicion of a fracture or joint
dislocatjon may contraindicate performance of various
special tests that could exacerbate the current injury. Also.
if the athlete is in a considerable amount of pain. perfor­
mance of spccia" tests may yield findings of questionable
validity. In cases where the athlete is in a considerable
amount of pain it is best to wait until the athlete 's symp­
toms have subsided to perform the special tests.
The special tests performed at this pbase should be
used to further differentiate between pathological and nor­
mal tissue. 14 The athletic trainer should perform special
tests only on those tissues that they suspect to be patho­
logical based on the findings from the previous evaluation
phases. 14 The experienced athletic trainer performs only
those speCial tests that conllrm their previous findings and
eliminate other tissues from being involved. To isolate
pathological tissue. special tests are designed to asses the
integrity of specific body tissues . such as muscle. ligament.
tendon. join t surface. and nerve.
There are several types of special tests. Joint stability
tests assess the integrity of the inert joint tissues. specifi­
cally the joint capsule and ligaments . Joint stability testing
is performed by applying to the joint a manuall force that
places strain on speCific capsular or ligamentous struc­
tures. The manual force is applied until reaching the end
point of the specific joint motion. The athletic trainer then
grades the amount of joint laxity (displacement) and end­
feci and notes the presence of pain. For example. the Ante­
rior Drawer Test at the knee assesses the integrity of the an­
terior cruciate ligament. Based on these findings the
athletic trainer may estimate the extent of injury to the spe­
cific capsuLar or Hgamentous structures tested. Table 3-1
indicates the grading system commonly used to assess joint
stability. Joint compression tests assess the ·integrity of
inert joint tissues that line the joint surrace. such as the ar­
 CHAPTER 3 The Evaluation Process in Rehabilitation 63

• TABLE 3-4 Janda Classification Another form of special tests that may be useful are
of Functional Muscle Groupings. anthropometric assessments of the patient of injured
area. 14 Anthropometric assessments range from being as
Muscles Prone to Tightness (Movement Group) simple as quaHtatively assessing the patient's somatotype
(general body structure) to as detailed as performing body
Gastrocnemius composition assessment (e.g., underwater weighing).
Soleus Such information may be useful in situations where the
Short hip adductors athlete will be required to miss a signif1cant amount of
Hamstrings physical activity for a prolonged period of time. The ath­
Rectus femoris letic trainer may be able to compare the athlete 's body
Itiopsoas composition pre- or immediately postinjury to their body
Tensor fascia latae composition during rehabilitation or before returning to
Piriformis activity. Anthropometric assessments might also be per­
Erector spinae (especially lumbar, thoracolumbar, and formed on the limb and might include measurements of
cervical portions) limb girth and volume. Limb anthropomctric measure­
Quadratus lumborum ments can be useful in tracking rehabilitation progress to
Pectoralis major assess swelling or muscle atrophy / hypertrophy. 14 .22
of various Upper trapezius Neurological Testing. There is some debate as to
jury. Abo, Levator scapulae how often neurological testing should be performed. Some
in. perfor­ Sternocleidomastoid believe that neurological testing should be performed any
ue tionable Scalenes time the athlete reports of symptoms thal affect theif distal
n iderable Flexors of the upper limb extremities, such as below the acromion process or gluteal
Muscles Prone to Weakness (Stabilization Group) folds 4 · IO--especially if the mechanism of injury was not di­
rectly witnessed. However, other professionals do not feel
Peroneals that neurological testing is warranted for orthopedic eval­
Anterior tibialis uations, unless the results [rom the previous evaluation
Posterior tibia Us phases suggest nervous system 'involvement. 8 . 14 Neurolog­
Gluteus maximus ical testing may be indicated from the history if the athlete
_ evaluation Gluteus medius describes unexplained loss of strength, paresthesia, or
orms only Abdominals numbness, or has sustained an injury to the vertebral re­
mdings and Serratus anterior gion that may have involved the spine.22
To isolate Rhomboids Neurological testing typically involves three compo­
Lower trapezius nents: sensory (dermatomes), motor (myotomes), and re­
e.ligament. Short cervical f1exors f1ex (deep tendon, superficial, and pathological ref1exes)
Extensors of the upper limb testing.s Neurological testing of these three components
assesses the integrity of the spinal nerve roots and periph­
eral nerves. The evaluator's challenge is to determine
whether the nerve root or peripheral nerve is thc source of
the symptoms. Nerve root damage typically involves ab­
ticular cartilage and meniscus. Joint compression testing is normal motor and sensory function over a large area. In
performed as the athletic trainer manually applies a com­ contrast, peripheral nerve damage will be confined to a
pressive load across the joint, typically combined with some more local,ized area innervated by the nerve. 14 Other pos­
form of rotary stress. This type of combined motion places sible neurological testing components include cranial
significant stress across the joint surface and may elicit a nerve assessment. neuropsychological assessment (cogni­
painful or crepitus/clicking sensation at the jOint level. The tive ability), and cerebellar function (coordinated move­
McMurray 's Test at the knee is an example of a joint com­ ments: finger to nose) .13.22
pression test. Passive tendon stretch tests are used to Dermatome testing. Dermatomes are areas of the
determine the presence of tendinitis or tenosynovitis. The skin whose sensory distribution is innervated by a specific
• assess joint athletic trainer applies a passive stretch along the tendon nerve root. Assessment of dermatomes involves a bilateral
integrity of that when positive elicits a painful or crepitus like sensation comparison of light touch discrimination. During der­
ch as the ar­ along the tendon. matome testing the examiner should alter or remove the
64 PART ONE The Basis of Injury Rehabilitation
Figure 3-4 Dermatome assessment.
pressure applied to one side in order to determine whether
the athlete can distinguish changes in pressure. Sensory
testing may also include sharp and dull discrimination,
hot and cold discrimination, and two-point discrimination
to assess peripheral nerve injury,n lDermatomes for the
body are illustrated in Figure 3-4.
Myotome testing. Myotomes represent a group of
muscles that are innervated from a specific nerve root. Es­
sentially, myotomes are the motor equivalent to der­
matomes. 14 Myotomes may be assessed for various muscle
groups of the upper and lower extremities. Myotome test­
ing is performed through sustained isomctric contraction
• TABLE 3·5 Myotome Assessment.
CS = Middle deltoid
Cn = Biceps brachii
C7 = Triceps brachii
C8 = ringer flexors
Tl = Finger interossei (DAB & PAD)
T12 - L3 = Hip flexion
L2 - L4 = Quadriceps
LS - SI = Hamstrings
L4 - LS = Ankle dorsiflexion
S] - S2 = Ankle plantar flexion
of a specific muscle. Common muscles tested during my­
otome assessment are listed in Table 3-S.
Reflex testing. Reflex testing may involve the assess­
ment of deep tendon reflexes. superficial reflexes, and
pathological reflexes. Testing for deep tendon reflexes as­
sesses the in tegrity of the stretch reflex arc for a specilk
nerve root and provides further information on the in­
tegrity oilhe specific nerve root. s Testing of deep tendon re­
flexes typically involves the use of a reflex hammer. The
athletic traincr strikes over the tendon in order to place a
slight quick-stretch on the tendon. If done properly. the
slight stretching of the tendon will elicit a reflex response
(Le., a muscle jerk response). Applying a quick stretch to al­
most any tendon can facilitate the reflex response, if done
properly. There are several upper- and lower-extremity deep
tendon reflexes that may be tested (,rable 3-6). However,
not all nerve roots have a specific deep t.endon reflex. The
common deep tendon reflexes assessed in the upper and
lower extremities include the biceps, brachioradialis, tri­
ceps, patella, hamstrings medial, hamstrings lateral, tib­
ialis posterior, and the Achilles tendon. Grading of deep
tendon reflexes uses a 5-point scale to characterize the
stretch reflex response and compare it bilaterally to the un­
injured limb (Table 3-7).
Superficial reflexes are assessed as the athletic
trainer provides a superficial stoking of the athlete's skin ,
usually using a sharp object. R. ll During this time the ex­
aminer notes the movement of the athlete's skin or distal
extremities. Several superficial reflexes commonly are
described. B. l l These include the upper-abdominal. lower­
abdominal. cremasteric. plantar. gluteal. and anal
reOexes.
Pathological reflexes normally are not present. The
presence of a pathological reflex is a sign that there might
be a lesion in either the upper or the lower motor neu­
ron. 8 .13 An upper motor neuron lesion may be present if

ent. • TABLE 3-6 Deep Tendon Reflex
Assessment.
Cn = Biceps brachii
C7 = Triceps brachii
C8 = Brachiradialis
L4 = Patella tendon
S I = Achilles lendon
• TABLE 3-7 Deep Tendon Reflex
Grading Scheme.
Grade 0 Absent: no reflex eliciled
Grade 1 Diminished: reflex elicited wibh reinforcement
(preconlracting muscle)
Grade 2 "annal
Grade 3 Exaggeraled: hyperresponsive reflex
Grade 4 Clonus: spasmlikc response followed by
relaxation
t place a the pathological renex is present bilaterally.13 A lesion of
rly. the the lower motor neuron lIlay be indicaled by the unilateral
presence of the palhological reflex. l l Assessment of
pathological reflexes can involve stoking. squeezing. tap­
ping. or pinching of various anatomical.structures to elicit
a response. t'erhaps the best-known pathological reflex is
the Babinski reflex.
The athletic trainer mllsl consider Lhe source of any al­
tered neurologicallesl findings. Neurological tesl findings
can be altered due to nerve rool compression. nerve root
sLretch. or motor neuron lesion. The examiner should uti­
lize the neurological lest findings lo further differentiate
lhe source of the athlete's symptoms. In addition. the in­
formation gained from the neurological assessment might
dictate the need for further medical evaluation or diagnos­
tic testing.
Functional Testing. Functional lesting is an im­
porlant component of the evaluation process. especially
during the follow-up evaluations to track the athlete's
progress and their polential lo relurn to previous activi­
ties. In sporls medicine. functional testing typically in­
volves observing the athlete perform various Functional
movement patterns. It is important that the functional as­
sessment reflect the type of stresses thaL the athlete will ex­
perience during normal activiLies (Le.. the assessment
should be sporl-specifIc). Examples of sport-specific move­
ment factors the alhletic trainer should consider in de-
CHAPTER 3 The Ev-aJualion Process in Rehabililation 6S
signing a functional lest·i ng protocol include explosive
movement. multijoint coordination. neuromuscular con­
lrol. fatigue. and repeated motions . Funclionallesting per­
formed on an offensive lineman who has sustained a knee
injury. for instance. may include observing the athlete rap­
idly get in and out of a three-point slance. perform block­
ing drills and side-shuffle maneuvers. and perform plant
and pivot maneuvers on the injured limb.
The ath 'letic trainer should make note of any pain or
discomfort experienced by the athlele. In addition. the ath­
letic lrainer must be looking for compensatory movement
patterns the athlele uses to achieve the goals of the func.­
tional test. Should compensalory movement patterns be
observed. the athletic trainer should address lhese defi­
ciencjes during the rehabililation process.
Optimally. functional lest, performed may be quanti­
fied or graded according 10 the athlete's performance. For
example. the alhletic lrainer' might use a timed lest to de­
lermine how quickly the athlete can perform the func­
tiorwl task. The athletic trainer might also consider
creating a grading system that focuses on body positioning
and errors committed during assessment. The Balance Er­
ror Scoring System (BESS) is an example of a grading sys­
lem where the examiner counts the number of errors lhe
patient commits during an assessment of ballance. l~ .20 Er­
rors are predefined and include such variables as taking
hands off of hips. opening eyes. excessive hip abduction.
taking a step to regain balance. or commilling a stumble or
fall. The greater the number of errors conlluilled during
testing. the worse the performance of the aUllele.
Functional tesling should not only be performed afler
injury has occurred. The alhletic lrainer might perform a
baltery of funclionallesls during preparticipation exami­
nations on the uninjured athlete in order Lo establish base­
lines for comparison during tbe rehabilitation process
should injury occur. Comparison of postinjuq' scores to
preinjury baseline measures can help the athletic trainer
determine whether the patient lis ready lo relurn lo activ­
ity. An objective crilerion might be set-for example. that
the patient be able to perform at 90 to 95 percent of their
preinjury levels before they wiII be allowed to perform
functional activities or return to play.
INJURY PREVENTION SCREENING
Injury prevention screening may be performed as part of
the preparticipalion physical examination in order lo iden­
tify individua'ls that may be al risk for injury. There is little
scientific research on what the athletic lrainer should lo­
cus on during injury risk screening. However. knowledge
of basic biomechanics and anatomy can help the athletic
66 PART ONE The Basis of Injury Reh abilitation
trainer identify movement patterns that put stress and
strain on tissue, hence increase risk of injury.
When the athletic trainer has identified movement pat­
terns that place the athlete at greater risk of injury, he or she
can devise an injury prevention training program to address
the cause of the inefflcient movements , By incorporating
training in injury prevention, the athletic trainer may be
able to reduce the incidence of injury ; this has been demon ­
strated in several research studies looking at the incidence of
lower-extremity injury, specifically ACL injury,1.6
Several clinicians have developed injury risk screening
protocols,1 In general, th ese protocols involve the individ­
ual performing a dynamic movement pattern in a slow and
controlled manner. The athletic trainer then observes the
individual's movement pattern at eac h of the involved
joints. By noting inefl1cient movement patterns, the ath­
letic trainer may be able to identify preexisting muscle im­
balances that alter the normal force-coupl e relationships,
postural alignment. jOint kinematics, and neuromuscular
control.
Essentially. the athletic train er observes whether the
individual can mai ntain a neutral alignment of limb seg­
ments while performing the dynamic movement patterns.
If the individual's limb segment moves out of neutral
alignment, this may be due to muscle tightness or weak­
•
ness . Muscle tightness may be present in the muscles in
the direction of limb motion. Excessively tight muscles arc
believed to pull the limb into the direction of tigh tness,
away from neutral alignment. Muscle inhibition or weak­
ness might also be present in the muscles acting in the op­
posite direction of limb motion. Weak and inhibited
mu scles are believed to be unable to genera te the magni­
tude of force necessary to maintain neutral alignment.
Both situations cause altered jOint kinematics that can
place greater st.ress on the surrounding tissues and push
these tissues closer to their point of failure during re­
peated movements. On pages 67 and 68. we provide two
examples of injury risk screenings that may be incorpo­
rated [or the lower extremity during preparticipation
physical examinations (Figures 3-5 and 3-6) .
DOCUMENTING FINDINGS
Oflen overlooked in the rehabilitation process is the fact
that good record keeping is essential to the rehabiHtation
program's succ.ess. The examiner must be able to re[er
back Lo previous evaluation records to determine the ath­
lete's progress and make the appropriate adjustments to
the rehabilitation plan.
SOAP Notes
The records of the evaluation process should be recorded
in SOAP (Su bjective. Objective. Assessmen t, Plan) note for­
ma t (Figure 3-7).
S (Subjective). This component of the SOAP note in­
cludes relevant information gathered during the sub­
jective phase of the evaluation when taking the
patient's history. This information might include the
athlete 's general impression, site of injury, mechanism
of injury, previous injuries, and symptoms. 16
o (Objective). The objective component of the SOAP
note includes relevant information gathered during
the objective phase of the evaluation. The athletic
trainer should record only the significant signs and
symptoms revealed during the objective evaluation.
An asterisk may be placed by information of particular
importance. This often helps the athletic trainer read­
ily rmd such information during subsequent reevalua­
tions to assess athlete progress. If,
A (AssesslI1ent). Assessment of the injury is the ath­
letic trainer's professional judgment with reg(]rd to
the impression and nature of injury. Although the
athletic trainer may be unable to determine the exact
nature of the injury, information pertaining to the
suspected site and pathological tissues involved is ap­
propriate. In addition, a judgment of injury severity
may be included. I6
P (Plan). The treatment plan should include the initial
first aid performed and the athletic trainer's intentions
relative to disposition.1 6 Disposition may include refer­
ral for more definitive evaluation or simply application
of splint, wrap. or crutches and a request Lo report for
reevaluation the follOWing day. Formulating the treat­
ment plan is the final step of the SOAP note. The plan
[or treatment should include short-Lerm and long­
term goals for the patien t. 1IJ · 14 Short- and long-term
goals should be objective and include timelines. This
will allow the athletiC trainer to judge the success of
the rehabilitation program and mal:;e any needed ad­
justments after determining whether the athlete was
able Lo meet Lhe goals.
The aLhletic traioer should attempt to make all infor­
mation recorded as quantitative as possible.1 4 This wiH al­
low the athletic Lrainer to better monitor the athlete's
progress during rehabilitation and make Lhe according ad­
justments and progressions to treatment as indicated by
reevaluation and comparison with previous evaluation
notes.
 CHAPTER 3 The Eva lmllion Process in Rehabilitatio n 67

Performance:

A Start Position B Stop Position C Side View

recorded

. th e ath­
What to look for:
Foot & Ankle
• Foot pronation: Y / N
• Externally rotation: Y / N
Knees
• Valgus collapse: Y / N
• Varus: Y / N
[he iniLia l
Lumbo-Pelvic-Hip Complex
in te nlions
• Asymmetrical weight shift: Y / N
dude refer­
• Lumbar lordosis: Y / N
_ applicatio n
• Hip adduction: Y / N
report for
• Hip internal rotation : Y / N
'e tb e treat­
'e . The plan What to do with findings:

an d long­ Foot pronation & external rotation

lo ng-te rm • Tightness: Soleus, lateral gastrocnemius, biceps femoris , peroneals , piriformis

elines. This Knee Valgus & Internal Rotation
uccess or
• Tightness: Gastrocnemius / soleus, adductors, IT band
needed ad­ • Weakness: Gluteus medius
aLh lete was
Lumbar Lordosis
'e a li in ror­ • Tightness: Erector Spinae & Psoas
This vvi ll al­ • Weakness: Transverse abdominis, internal obliques
e athlete's Hip Adduction
. d cording ud­ • Tightness: Hip adductors
ndicated by • Weakness: Gluteus medius
- eva lu ation
Hip Internal Rotation
• Weakness: Gluteus maxim us, hip external rotators

Figure 3- 5 Overhead squat test (Clark, 2001).

68 PART ONE The Basis of Injury Rehabilitation

Repeat procedures for Overhead Squat Test while performing a forward lunge. Pat
What to look for:
Foot & Ankle
• Foot pronation: Y / N
• Externally rotation: Y / N

Knees
• Valgus collapse: Y / N o
• Varus: Y / N
Lumbo-Pelvic-H.ip Complex
• Lumbar lordosis: Y / N
• Lateral trunk flexion: Y / N
• Trunk rotation : Y / N
• Hip adduction: Y / N
• Hip internal rotation: Y / N

What to do with findings:

Foot pronation &
external rotation A Start Position 8 Stop Position
• Tightness: Soleus, lateral gastrocnemius, biceps femoris, peroneals, piriformis

Knee Valgus & Internal Rotation

• Tightness: Gastrocnemius / soleus, adductors, IT band
• Weakness: Gluteus medius

Lumbar Lordosis
• Tightness: Erector spinae & psoas
• Weakness: Transverse abdominis, internal obliques
Lateral Trunk Flexion
• Weakness: Core musculature

Trunk Rotation
• Weakness: Core musculature

Hip Adduction
• Tightness: Hip adductors
• Weakness: Gluteus medius

Hip Internal Rotation

• Weakness: Gluteus maximus, hip external rotators

Figure 3-6 Lunge test (Clark, 2001).

velop a correspondin g goal. Typically. the duration of

Setting Rehabilitation Goals
Reh abilitation goa ls sh ould be included as part of th e treat­
ment plan in th e SOAP note. The rehabilitation goals
sh ould be based upon the information ga thered durin g the
evaluation an d should address signs an d sym ptoms
recorded in the SOA P note. 14 For every significan t sign a nd
sy mptom listed in the SOAP note. th e eX.aminer should de-
short-term goals is 2 weeks. lO14 FO]llowing th e evaluation
or reevaluation the examiner should consider what goals
could reasonably be ac hieved with in this time fra me. Long­
term goa'ls are the fin al goals the patient should ach ieve in
order to be ready to return to norma l activities . 14 The fol­
lowin g are examples of short- a nd long-term goals th at
may be inclllded for a grade 2 in version ank le sprain.
 CHAPTER 3 The Evaluation Process in Rehabilitation 69

Patient Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Date of Injury _ _ _ _ _ _ _ _ _ ___

Injury Site R L ___________________ Today's Date _ _ _ _ _ _ _ _ _ _ __

Subjective Findings (history):

Objective Findings (observation/inspection, palpation, range of motion, strength, & special tests):

Assessment (clinical impression):

Plan (treatment administered, disposition, rehabilitation goals, treatment plan):

Hgure 3-7 SOAP note.

Short-Term Goals
Decrease swelling by 3D percent within 4 days
Increase acrive range of motion by 50 percent within 1
You perform an injury evaluation on a soccer athlete. Af­
week ler completing the injury evaluation. you determine the
Progress to full weight bearing during walking gait fo llOWing information from the objective pha e:
within 1 week
• Active range of motion for knee extension limi ted by
Reduce acute pain by 50 percent within 4 days
10 degrees
Increase eversion ankle strength by 50 percent in 4
• Passive range of motion for knee flexion limited by

days
20 degrees

Increase plan tarl1exion ankle strength by .50 percent

• Presence of swelling and discoloration over anterior
in 4 days Lhigh
Long-Term Goals • Decreased quadricep strength compared La un injured
Return to limited practice using protective tape sup­
stde

port within 2 weeks

Based on these findings. how would you wrile up the

Return to fu'll practice using protective tape support

treatment goals for Lhis Inj u red athlete?

within 2. 5 weeks
Return to full competition using protective taping
within 3 weeks
affords the athletic trainer the luxury of being able to con­
du ration of tinuously adjust or adapt the treatment program based on
eval uation the progress made by the athlete on a day-to-day baSis.
wha t goals Progress Evaluations
The progress evaluation should be based on the ath­
ra me. Long­ The athletic trainer who is overseeing a rehabilitation pro­ letic trainer's knowledge of exactly what is occurring in
Id achieve in gram must constantly monitor the progress of the athlete the healing process at any given time. 'fhe timelines of in­
.H The 101­ toward full recovery throughout the reh abilitative process. jury healing dictate how the aLhletic trainer should
goals that In many instances the athletic trainer will be able to treat progress the rehabilitation program. The athletic trainer
prain . the injured athlete on a daily basis . This close supervision must understand that Iiu'le can be done in rehabilitation to
70 PART ONE The Basis of Injury Rehabilitation
speed lip the healing process and that progression will be
limited by the constraints of that process.
Progress evaluations will be more limited in scope than
the deta iled evaluation sequence previously described. The
off-field evaluation should be thorough and comprehen­
sive. taking time to systematically rule out information
that is not pertinent to the present injury. Once the extra­
neous information has been eliminated. the subsequent
progress evaluations can focus specificaHy on how the in­
jury appears today compared with yesterday. Is the athlete
better or worse as a result of the treatment program ren­
dered on the previous day?
To ensure that the progress evaluation wi.ll be com­
plete. it is still necessary to go through certain aspects of
history. observation. palpation, and special testing.
History
How is the pain today. compared to yesterday?
Are you able to move better and with less pain?
Do you th ink that the treatment done yesterday helped
or made you more sore?
Observation
How is the swelling today? More or less than yesterday ?
Is the athlete able to move better today?
Is the athlete still guarding and protecting the injury ?
How is the athlete's affect-upbeat and optimistic. or
depressed and negative?
Palpation
Does the swelling have a different consistency today.
and has the swelling pattern changed?
Summary
1. The components of the systematic differential evalua­
tion process are split into subjective and objective
phases. The subjective phase involves a detailed athlete
history. The objective phase includes observation/
inspection of the injured athlete, range-of-motion test­
ing. resistive strengt h testing . assessment of muscle
imbalances. performance of special tests based on pre­
vious findings. neurological testing. and functional
testing.
2. The syste matic injury evaluation process establishes
the foundation for deSigning an effective rehabilita tion
program. All significant fmdings from the systematic
differential evaluation will be used to identify the
pathological tissues as well as any related deficiencies
in the surroul1ding tissues. The rehabilitation plan
and treatment goals will then focu s on reestablishing
normal function to the tissues and structures revealed
to be pathological or delkient.
Is the inj ured structure sti.ll as tender to touch ?
Is there any deformity present today that was not as
obvious yesterday ?
Special Tests
Does ligamentous stress testing cause as much pain, or
has assessment of the gmde of instability changed ?
How does a manual muscle test compare with yester­
day ?
Has either active or passive range of motion changed?
Does accessory movement appear to be limited?
Can the athlete perform a speCific functional test better
today than yesterday?
Progress Notes. Progress notes should be routinely
written following progress evaluations done throughout
the course of the rehabilitation program. Progress notes
can follow the SOAP format outlined ea rlier in this chapter.
They can be generated in the form of an expanded treat­
ment note. or may be done as a weekly summary. Informa­
tion in the progress note should concentrate on the types
of treatment received and the athlete's response to that
treatment. progress made toward the short-term goals es­
tablished in the SOAP note. changes in the previous treat­
ment plan and goals. and the course of treatme nt over the
next several days.!
3. By applying knowledge of anatomy and the systema tic
differential evaluation process, the athletic trainer
should be able to determine what tissue is pathologi­
cal. This is accomplished by differentiating between
normal tissue (asymptomatic) and provoked tissue
(symptomatic).
4. Injury risk screenings may be performed to determine
whether the individual uses movemen t patterns dur­
ing functional activities that may place greater stress
on the surrounding tissues. By identifying such move­
ment patterns in the early stages. the athletic train er
may be able to incorporat e preventative training exer­
cises to reduce the risk of injury at a later time.
5. Short-term and long-term goals should be based on
th e significant l'indings from th e sys tematic differen­
ti al evaluation . All significant" findings should have a
cor responding rehabilitation goal. All goals should be
quantillable an d have a given lime period in which

they should be achieved. Typically, short-term goals
are those that can be achieved within a 2-week time
period. Long-terms goals are the final goals that the
References
1. Curaffa, A.. G. Cerulli.;\I1. Projett. G. Aisa, and A. Rizzo. 1996.
Prevention of anterior cruciate ligament injuries in saeGer: A
prospective controlled study of proprioceptive training. Kllee
Surgery Sport£ Traumatology Arthroscopy 4: 19- 21.
2. Clark, M, 2001. Muscle energy techniques in rehabilitation.
In Teclllliqucs ill I1lL1sculoskeletal I'elwbiliLation, edited by W.
Prentice and M. Voight. New York: McGraw-Hill.
3. ClarK, M., and A. Russell. 2001. Optimum peljormance trailling
Jor the perJormance enhancement specialist. Calabasas, CA: Na­
Lional Academy of Sports Medicine.
4. Corrigan, B., and G. Maitland. 1989. Practical orthopedic med­
icine. London: Butterworth.
5. Cyriax. J. 1982. Textbook oj orthopedic /Iledicine. 8th ed. Lon­
don: BailliereTindal.
6. Hewett, 1.. T Linden feld , J. Rlccobene, and F. Noyes. 1999.
The effect of neuromuscular training on the incidence of
knee injury in female athletes: A prospective study. American
Journal oj Sports Medicine 27(6):699-706,
7. Hislop, H. 1995. MOlltl/omery J. Daniels and Worthillgham's
Muscle Testing. 6th ed. Philadelphia: W. B. Saunders.
8. Hoppenfeld, S. 1977. Orthopaedic lIeurology: A diagnostic guide
10 neurologic levels. Philadelphia: Lippincott.
9. Hoppenfeld, S. 1976. PII,IIsical examination oj the spine and ex­
tremities, Norwalk, CT: Appleton & Lange.
10. Houglum, P. 2001. Therapeutic exercise for athletic injuries.
Champaign. IL: Human Kinetics.
11. Janda. V 1983. MuscleJlInction testing. London: Butterworth.
12. Kendall. F., E. McCreary, and P. Provance. 1993. Muscles. test­
illg alldJul1ction. 4th ed. Baltimore: Williams & Wilkins.
'c trainer
patbologi­
SOLUTIONS TO CLINICAL DECISION MAKING EXERCISE
g between
uJred tissue 3-1 The athletic trainer should perform special tests on
only those tissues they suspect to be pathological
determine based on the findings from the previous evaluation
phases. The special tests should be used to confirm
previous findings and eliminate other tissues from
being involved. Given the athlete's history, the ath­
letic trainer might sllspect meniscal or articular car­
tilage damage and perform special tests that focus on
these structures.
3-2 It is important to understand that altered postural
alignment can be caused by muscle force imbal­
ances. Muscles crossing the body segment may be
excessively tight or weak, causing an altered pos­
in which tural alignment. The athletic trainer should pay
CHAPTER 3 The Evaluation Process in Rehabilitation 71
athlete should achieve in order to be ready to return to
normal activities.
13. '''Iagee. D. 1997, Ortilopedic physical assessment. 3rd ed.
Philadelphia: W B. Saunders.
14. Moore, R., B. Mandelbaum. and D. Wantabe. 1997. Evalua­
tion of neuromusculoskelctal injuries. In Athletic training and
sports medicinc, edited by R. Schenck. 3rd ed. Rosemont, IL:
American Academy of Orthopaedic Surgeons.
15. Perrin, D. 1999. The evaluation process in rehabll.itation. [n
Rehabilitatiol1 techniqlles ill sports mcdicille. edited by W. Pren­
tice. 3rd ed. ~ew York: McGraw-HilI.
16. Prentice, W. 2003. Amhei/ll's principles of atilletic training.
11th ed. New York: McGraw-HilI.
17. Prentice, W. 1999. Mobilization and traction techniques in
rehabilitation. In RelwbiliLatioll techllil/llCS ill spons medicine,
edited by W. Prentice. 3rd ed.l\iewYork: McGraw-Hill.
18. Richardson, C.. G. Jull. P. Hodges, and J. Hides. 1999. T/lera­
Pelitic exercise Jor spimll se,qmrntal stabilization ill low back pain.
Edinburgh: Churchill Livingstone.
19. Riemann, B., K. Guskiewicz. and E. Shields. 1999. Relation­
ship between clinical and forceplate measures of postural sta­
bility. Jotlrnal oj Sport Rehabilitation 8(2): 1-7.
20 . Riemann, B., and K. Guskiewicz. 2000. Effects of mild head
injury on postural stability as measured through clinical bal­
ance testing. Journal oj Athletic Trail1ing 35(1): 19-25.
21. Shultz. S.. D. Perrin. and P. Houglum, 2000. Assessment oj
athletic injuries, Champaign. IL: Human Kinetics.
22. Starkey, C., and J. Ryan. 2002. Evaluation oj orthopedic and
atilletic injuries. 2nd ed. Philadelphia: F. A. Davis.
special attention to those muscles that may alter
postural alignment due to tightness or weakness
during range-of-motion and resistive strength test­
ing. For example, the athlete might demonstrate
tight/overactive hip Oexor and erector spinae mus­
cles Or weaklinhibited abdominal and gluteus max­
imus muscles.
3-3 Cyriax states that pain in the same direction of mo­
tion during active range of motion, combined with
pain in the opposite direction of motion during pas­
sive range of motion, is indicative of contracti.le tis­
sue injury. Based on these findings, the athletic
trainer may suspect injury to the hamstring muscle
group.
 72 PART ONE The Basis of Injury Rehabilitation
3-4 Always consider the potential causes for reduced
range of motion based upon your findings. Because
normal arthrokinematic motion was altered. the
athletic trainer will need to address this during reha­
bilitation. Joint mobilization techniques may be per­
formed in addition to traditional stretching exercises
to regain normal range oli motion. Failure to address
all possible causes (altered arthrokinematics) will re­
sult in an ,ineffective rehabilitation plan.
Long-term goals may include:
• Return to soccer practice in 2 weeks
• Return to full soccer participation in 2 )) weeks
3-5 The findings from midrange-of-motion muscle test­
ing should be used to help determine which muscles
to test during specific muscle testing. The athletic
trainer should perform specific muscle lestil1g for all
muscles that assisl with the symptomaUc movement
.:,'
pattern tested. Given that the athlete demonstrated
pain and weakness during hip extension. the athletic
trainer should perform specific muscle tests on the
gluteus maximus and hamstring muscles.
3-6 Rehabilitation goals should be based upon the evalu­
ation findings. Each significant finding should have
a corresponding rehabilitation goal. The athletic
trainer should include both short-term and long­
term goals.
Short-term goals may include:
• Decrease swelling by 25 percent in 3 days
• Increase knee extension active range of motion of
50 percent in 1 week
• Increase knee Ilexion passive range of motion by
50 percent in 1 week
• Increase quadriceps strength by 30 percent in 1
week
 CHAPTER 4
Psychological Considerations
for Rehabilitation of the
Injured Athlete
Elizabeth G. Hedgpeth
Joe Gieck
. motion by

Study Resources • Recognize irrational thinking and its

To become more familiar with the knowledge und skills resolution.
necessary to design. implemenl. and documen ttherapeu­
tic rehabilitation programs as identified in the NATII Ath­ • Explain the importance of athletes'
letic Trainillg Educatiollal Competencies lind Clillical taking responsibility for their actions in
l'rojiciwcies'Thempeutic Exercise content area. v,isit
regard to injury.
WWW.mbbe.co m/ prentice11e. Also, refer to th e lab exer­
cises in th e new Laboratory Manual and to eSims. which • Compare and contrast compliance and
simul ates the athletic training certification exam. at
adherence.
www.mhh e.eo m/esims. for more onlin e study resouroes.
visit our Health a nd Human Performance website at • Analyze the importance of rehabilita­
wwwmhhe.com/hbo.
tion compliance and its deviations.
After Completion of This
• Identify signs and symptoms of clinical
Chapter, the Student Should
depression and suicide intention.
Be Able to Do the Following:

• Discuss goal setting and rehabilitation

• Identify arious predictors of injury
and interventions.
• Recognize stressors in the athlete's life.
• Understand the concept of using
buffers for stress management.
• Explain the progressive reactions
to injury, dependent on length of
rehabilitation.
• Integrate interventions for the four
time periods of rehabilitation .
compliance.
• Revie,>\' the coping skills necessary for
successful rehabilitation.
• Recognize the importance of the rela­
tionship between the athletic trainer
and the athlete.
thletic injuries are considered to be one of the major
A health hazards of sport. ;s The ('ear of injury might
cause a negative view of participation in an activity
that has a positive impact on the heaHh and well-being of

73
74 PART ONE The Basis of Injury Rehabilitation
millions of participants: i ; Sports medicine and athletic
training are stUI inexact sciences. Nowhere is this more ev­
ident than in the psychological process of responding to
injury in a rational and productive manner and complet­
ing the rehabilitation process to the best of the ath lete's
ability. Early writings often mention th at one sho L!ld never
attempt to cure the body without curing the soul.
ACCULTURATION
An overlooked stressor for injured athletes is ac cultura­
tion, which refers to the moving of the injured athle tes
from the familiar sport culture to the unfamiliar rehabili­
tation culture (Figure 4-1 ). In the culture of sport, they
know haw the game is played, what the rules are, and who
is in charge. Once injured they move out of their comfort
zone of sport and into the world of rehabilitation where
th e rules are changed (lnd they arc on foreign territory.
'Without even dealing with the injury. the a th letes a rc
stressed. They are veteran players of their sport and now
they are in a new game. The coach has al'ways had tbe
power and now the athletic trainer and the sports medi­
ci ne team have the power. Pain is a fa ctor and the pain is
different from the normal pain of workin g out and playing.
The athletic trainer now tells them "Listen to your body"
where coaches have often said "Suck it up and play tough."
Coaches give ,instant feedback on the play; athletic train ers
say wait a nd see how your body reacts.
Loss of control is also a major factor. Athletes know
that if they work out a nd prilctice hard. they hilve n chance
to play- unlike renabllitillion , where they m ayor may not
get well even if t hey do all the treatments and exereises a
ordered. They call do aH that is asked in rehabilitation a nd
Uninjured athlete Injured athlete in rehab
Familiar activity Unfamiliar activity
Familiar rules Unfamiliar rules
Familiar field Unfamiliar area
Veteran player Rookie player
Familiar pain Unfamiliar pain
Coach in charge ATC's in charge
Instant feedback Feedback deferred
Control Loss of control
Measure success Different measure
Vigorous Loss of vigor
Figure 4-1 Acculturation: Injured ath letes moving
from the culture of sport to the culture of injury rehabili­
tation (Hedgpeth , 1997).
still not make progress due to factors out of th eir control.
The bone might not heal properly, or infection might set in,
or any number of other things could go wrong. Uninjured
illhletes measure success by amount of playing lime, num­
ber of LUns scored. or whatever clccomplishments arc spe­
cific to their spor t. In the athletic training room, the score
is measured in terms of how it feels. how strong it is, how
many reps can be done, and so on.
Loss of vigor is easily seen in athletes who feel that they
are not progressing fast enollgh or that the exercises are
boring. Vigor is regained when the athletes return to prac­
tice an d play. Loss of vigor might be masked as depression.
but it clears on its own over time. Therefore, though it
mi ght appear that injured athletes are stressed for no rea­
son, the acculturation from sport to rehabilitation is a
stressor in and of itself.
Most athle ies have the self-confidence to adapt to a
mild or moderate injury, and most have the support. un­
derstanding. and proper encouragement to adapt to more
severe injury, but even th e most self-confident athletes
have their doubts. One athlete put it this way. expressing
the positive aspects of return to competition but also some
of the doubts invo'lved: "The best competitors like to com­
pete, and to me this is just a game-an inner game. It's an
inner soul game. Can I beat my knee back?" But he also ex­
pressed doubts about the rCill test when a tackler "takes a
whack at the knee": "r haven 't thought about it, but I've
had nightmares about it. My buddy to'id me he broke his
ankle. He said once you gee th at real good bit and you pop
up and it pops up with you, then everything is going to fall
into place and you're going to be rollin g. You're going to go
out there like it's never been hmt and just play. ,.
With t he emergence of sport psychology. more atten­
tion is being paid to getling the mind ready to return to
competition to miltc h the adjustment of the body. Athletes
have begun to describe the nightmares. fe<:1rs. and anxiety
of returning to competition. Also. in the current (rend of
professional athletes receiving extremely high salaries.
some ath letes describe their injuries and surgery as the
most important things in th eir lives because th e <Jbility to
play will either make or break them. Surgery and subse­
quent reh abilitation Ciln determine whether athletes make
either millions of dollars in an athletic career o r only thou­
sands in a regula r job if the injury ends their career.
Athletes dOll't all dea l with injury in th e same manner.
Rotella 32 describes how one might view th e injury as disas­
trous, another might view it as an opportunity to show
courage, whereas another athlete might relish the injury as
a means to a\'o id embarrassment over poor perrormance, to
escape from a lOSing tea m. or to discou rage a domineering
pment. When injuries are career-threatening, athletes
 CHAPTER 4 Psychological Considerations for RehabiliLation of the Injured Athlete
Physical
Injury
/ ~
\: rcises are
urn lo prac­
d pression,
. though it
fo r no rea­
Figure 4 -2
Emotional ,
psychological
The physical and emolional aspecLs of return lo performance.
whose lives have revolved around a sport may have to
make major adjllstments in how they perceive lhem­
selves as well as how they are perceived within lheir soci­
ely. Olympic and olher lop-caliber athletes are o I'len
emotionally and socially years behind their chronologi­
cal peers because they have spent so much time in their
sport that their social inleractions have suffered. There­
fore many top or single-minded alhletes have difficullY
with emotional control when they sustain a serious in­
jury. Figure 4-2 demonstrates the physical and emotional
aspects of return to performance. The return to perfor­
mance is dther enhanced or negated by the physiological
results of both elements.
PREDICTORS OF INJURY
The Injury·Prone Athlete
Some alhletes seem to have a pattern of injury, whereas
others in exactly the same position with lhe same physical
:igh salaries. mal\eup are injury-free. Certain researchers suggest lhal
rgery as the some psycho,logica l trails might predispose the alhlete lo a
;.be ability to repealed injury cycle. ;0., 3.h;.7177 No one particular person­
a nd subse­ ality lype has been recognized as injury-prone. Howev r,
lhe individual who likes to take risks seems to represenllhe
injury-prone athlete.l~ Other factors lhat are seen as pre­
disposing an athlete to risk of injury are being reserved, de­
tached. tender-minded. 36 apprehensive, overprotective, or
easily distracted.'6 These individuals usuaJly also lack the
ability to cope with the stress associated with Lhe risks and
their consequences. Sanderson ;s suggests some other fac­
tors leading to a propensily for injury, such as altempls lo
reduce anxielY by being more aggressive, fear of failure, or
guill over unobtainable or unrealistic goals.
7S
• Physical fitness
goals
Return to
performance
• Acceptance ,
conflict
/
Stress and Risk of Injury
Much has been written about life Slress events and the IU<e­
lihood of illness ,1. 14.34.73 Stressors arc both positive (e.g. ,
making All-American) and negative (e,g.. not making the
slarting lineup. or failing a drug lest). Stressors that seem to
predispose an athlete to injury are the negative stressors. 73
Andersen and Williams 1 suggest that negative stres­
sors lead to a lack of allentional focus and to muscle ten­
sion, which in turn lead to the stress-injury connection,
Loss of aLLenlional fOCllS can cause the athlete lo miss cues
during a play, setting the stage for a possible injury, Muscle
lension (bracing or guarding) leads to reduced flexibility.
reduced motor coordination, and reduced muscle ef[1­
ciency. which set the athlete up for a variety of injuries
(e,g.. gelling hit by a golf ball or missing an obstacle dur­
ing a run ).
Allentional fOCUSing is perceived on two planes (width
and direcLional). A major component is the ability to
change focus when the siluation demands it. Width of fo­
cus ranges from broad (atlending lo a number of cues) to
narrow (allending to one cue), and direction of fOCllS is in­
terna l (attending lo feelings or thoughts) or external (at­
tending to events outside of the body), The trick is not only
to be able to change focus. bUl to know the optimal time to
make the change in order to minimize the possibility of in­
jury or reinjury, For instance. a football player ca n be
blindsided and lake an unanticipated hit. or the gymnast
can be distracled and miss a landing.
Life slress is a marc global assessment, taldng into ac­
counl events that cause stress over the past year to 18
months, The Life Events Survey for Co llegiale Athletes
(LESCA) asks collegiate-athlete-specific questions. eliciting
a negative o[ pOSitive response on a Likert-lype 8-point
76 PART ONE The Basis of Injury Rehabilitation

• TAB L E 4-1 Examples of Events in the

Lives of Athletes Most Likely
to Elicit a Stress Response.

Life Stress Events

Death of family member

Detention or jail
Injury
Death of close friend
Playing for a new coach
Playing on a new team
Personal achievements
Change in livLng habits
Social readjustments
Change to new school
Change in social activities

scale.;3 Typical events asked about are "major change in

playing status" and "pressure to gain or lose weight for
sport participation." Another life events assessment is the
Social and AthJetic Readjustment I{aling Scale! (SARRS).
The events most likely to elicit a negative stress response
are listed in Table 4-1.
Promes of Mood States 4h (POMS) is a more immediate
response inventory assessing moods within the last few days
or at the most the last few weeks. The POMS identiftes six
mood states. Five are negative, and one (vigor) is positive.
The six mood states are (1) tension-anxiety, (2) depression­
dejection, (3) anger-hostility, (4) vigor-activity, (5) faUgue­
inertia, and (6) confusion-bewilderment. When the POMS
results were compared using elite athletes and the general
population, a visual "iceberg profile" was noted for the elite
athletes by Morgan: 9 The elite athletes' Scores on the five
negative scales fall below the 50th percentile, and their
scores on the sixth , positive scale (vigor) peak considerably
above the 50th percentile, indeed resembling the silhouette
of an "iceberg."
'fhe POMS has been used to measure the mood states
of athletes at the lime of injury as well as at 2· week inter­
vals during the rehabilitation process. h4 When the P01\·[S
was used within 2 days of injury, tbe injured athletes
showed significant elevations in depression and anger, no
change in tension and vigor, but less fatigLle and confUSion
as compared to the college norms. When the athletes were
divided into groups according to severity of injury based
on length of rehabilitation, the data is more explicit con­
cerning reactions to injury and rehabilitation. Group 1
consists of athletes with less than 1 week of rehabilitation;
Figure 4-3 A close relationship between the athlete
and the athletic trainer is invaluable.
they had less tension, depression . fatigue, and confusion.
Group 2 consists of athletes in rehabilitation ror more than
2 weeks but less than 4 weeks; they had more anger but
less fatigue and confusion. Group 3 consists of athletes in
rehabilitation more than 4 weeks; they had more tension,
depression, and anger and less vigor. This fLnding is impor­
tant in that it sends a wake-up call to the sports medicine
team to be aware of the ramiricalions of severe injury that
entails a long rehabilitation period.
Interventions for Stress Reduction
Not all athletes need or want counseling, and the close re­
lationship between the athlete and the athletic traina is
invaluable in making this decision (Figure 4-3). Athletic
trainers arc now taking a more active role in the psycho­
logical aspects of injury and rehabilitation. They are the
closest to the athlete and often spend as much lime as the
athletes at practice and games. Athletic trainers are now
aware of the psychological, impact of injury and have a
workillg knowledge of counseling techniques for various
situations. ll .}!,. ;1 Few athletes react to stress events by
verbaliZing their feelings or Slress, yet 1110St handle them
 CHAPTER 4 Psychological Considerations for Rehabilitation of the Injured Athlete
very well by themselves. James Michener48 makes the [01­
iowing point:
For many athletes physical activity. rather than talking things
out. appears to offer a means of expressing feelings and ag­
gressions. Perhaps this substitution of actions for words con­
tributes to the seeming reluctance of athletes to come to a
service that requires that they articulate their feelings.
Unfortunately, many coaches do not have the interest
or ability to work with athletes who need help. Some sort
of screening device should be used to identify athletes who
are experiencing life situations that they are unprepared to
handle. Obviously the staff of a smal1er team is more fa­
miliar with the athletes and their problems and can more
effectively deal with them, 31 bu t larger teams' staffs should
attempt to deal with the athlete through the position
coach or other available support personnel (e.g., counsel­
ing centers, sport psychologists, grief support groups}.
Using Buffers. In many instances athletes feel that
their sport is the one positive thing in life that helps them
get through times of extreme stress. Areas outside of
sports are often stressful, and athletes tend to respond to
interventions that are within their framework of emo­
athlete tional comfort. The use of buffers might be all the athlete
needs to handle the stress of injury and rehabilitation.
Buffers are techniques that allay the symptom of stress but
do not address the problem that originally caused the
stressors. Several buffers that can be beneficial in reducing
d confusion. the stress of injury and rehabilitation are progressive re­
r morethan laxation with or without imagery, aerobic exercise, diet
e a nger but
modifications (e.g .. reduction of caffeine), treatment of
,r athletes il1 sleep disorders, and time management programs.
ore tension,
ng is lmpor­
rts medicine CLINICAL DECISION MAKING Exercise 4-1
in jmy that
Ju lie is a wornell's lacrosse player at a Division I school
playing in the starting lineup as a sophomore. She had
played her entire high school years without injury. so
having a severe ankle sprain at the end of this season was
uction a sbock. Julie is not accustomed to having the normal ac­
the close re­ tivities of daily living take so much time. and she feels she
never has lime to go to the athletic train1ng room for her
lic trainer is
rehabilitation. \Vhat can the athletic trainer do to help
~ 3 . Athletic
n the psycho­ Julie alter her scbedule to include time for rehabilltatlon?
They are the
h time as the
aine rs arc now
Abdominal Breathing. Deep abdominal breathing
ry and have a
for relaxation is a product of yoga and has been practiced
u fo r various
for more than 5,000 years. b9 The practice was brought to
events by
the West in the 19 60s. Deep abdominal breathing is Simple
. ha ndle them
77
to learn and is effective as a tool for relaxatLon and relief
from stress and pain. ~1 It is used in the Lamaze childbirth
method to relieve paln and stress during tbe birthing
process.69 Deep abdominal breathing 41 is simple and can
be mastered in a few days. Following is a simple way to
teach it to an athlete:
Lie on your back in a quiet place with one hand on chest and
one hand on your stomach. Inhale through your nose and
have the air 1111 up your belly without your chest moving. Now
breathe out through your mouth and fcel your belly go down.
Breathe slowly and pay attention to the air moving in and out
of your lungs. This can be used for pain and tension relief by
paying attention to the sore and tense muscle groups in the
body dur,ing the inhale phase. During the exhale phase feci
your pain and tension being 'blown out' of the body with the
exhaled breath.
Once the athlete has mastered the lying-down posi­
tion , move on to sitting and then standing positions. The
beauty of t'his practice is that it can be performed any­
where and anytime and emlbles athletes in rehabilitation
to control their pain and stress. 61
Relaxation Techniques. Progressive relaxation
techniques 37 are most effective for athletes who tend to be
stressed regarding an injury and who have problems sleep­
ing, tension headaches. or general muscle bracing or tight­
ness. Relaxation training, with or without imagery. allows
athletes to control their feelings of stress and anxiety with
a series of deep breathing, voluntary muscular contrac­
tion, and relaxation exercise. 4 Relaxation and imagery are
used by athletes to reduce the symptoms of anxiety associ­
ated with the reaction to injury and rehabilitation. Ath­
letes who are coping well on tibeir own should not be forced
to spend extra time on relaxation training.
Jacobsen's38 progressive relaxation technique ,is
thought to be effective because of the assumption that it ,is
impossible to be nervous or tense when the muscles are re­
laxed. The tenseness of the involuntary muscles and or­
gans c~n be reduced when the contiguous skeletal muscles
are relaxed. The muscles are tensed and relaxed in order
for the athlete to become familiar with how the muscle
feels in a relaxed state and in a tense state. The relaxation
method involves the tensing and relaxing of muscles in a
predetermined order. The arm and hand are done flrst be­
caLise the difference in tense and relaxed muscles ,is more
apparent in these muscle groups. The repetitions should
last approximately 10 to 15 seconds for the tension seg­
ment and 15 to 20 seconds for the relaxation segment,
with about three repetitions for each muscle group. After
the athlete is comfortable wHh tbe relaxation training,
then imagery can be introduced.
78 PART ONE The Basis or Injury Rehabilitation
CLINICAL DECISION MAKING Exercise 4-2
Tim Is a 17-yeac-old teunis player at a prep school kn own
for turning out exceptional tennis players ready 10 play al
the Division I level. He developed elbow tendinltls at the
elld of last season and has spent the summer doing reha­
billtallon. The medical slaff cleared him to play. but Tim
is unable to keep from tensing up when he knows he is
being observed by recr uiters. His whole body Is ~1iff i;llld
tight. and his usual warm-up stretching is not sunkient
to keep his muscles relaxed. How can the athletic trainer
help Tim manage this problem?
Imagery. Imagery is the use of one's senses to create
or recreate an experience in the mind. 6 Visual images used
in the l'ehabilitation process include visual rel1earsal, emo­
tive imagery rel1earsal, and body rel1earsal. J 5.66 Visual re­
hearsal uses both coping and mastery ,r ehearsal. Coping
rel1earsal has athletes visually rehearsing problems they
feel might stand in the way of a return to competition.
They then rehearse how they will overcome these prob­
lems. Mastery rel1earsal aids in gaining confidence and mo­
tivational skills. AthIetes visualize their successful return
to competition, beginning with early practice drills and
continuing on to the game situation.
In emotive rehearsal, the athlete gains confidence and
security by visualizing scenes relatin g to positive feelings of
enthusiasm, confidence, and pride-in other words, the
emotional rewards of praise and success [rom participat­
ing well in competition. Body rehearsal empiricaily helps
athletes in the healing process. It is suggested that athletes
visualize their bodies healing internally both during the
rehabilitation procedures as well as throughout their daily
activities.281'0 do this, the athletes have to have a good un­
derstanding of the injury and of the type of healing oc­
curring during the rehabilitation process. Ievleva and
Orlick 15 had athletes use imagery during physiotherapy by
imagining that the ultrasound was increasing blood flow
and thus promoting recovery.
Care should be taken to explain the healing and reha·
bilitative process clearly but not to overwhelm athletes
with so much information that they become intimidated
and fearful. This mistake is often made by the inexperi­
enced athle tic trainer who wants to impress the athletes .
Educate athletes only to the amount 01 knowledge re­
quired. By the same token, don't hold back information
athletes require for this imagery.
PROGRESSIVE REACTIONS
DEPEND ON LENGTH
OF REHABILITATION
The literature on reactions to injury has dispelled Lhe stage
theory of reaction to injury. according to an extensive lit­
erature review by Wortman and Silver. 79 However. lhere
are factors that are commonly seen among ath letes going
through adjustment to injury and rehabilitation in the
athletic training room. Severity of injury usually deter­
mines length of rehabilitation. Regardless of length of re­
habilitation. the injured athlete has to deal with three
reactive phases of the injury and rehabilitation process
(figure 4-4). These phases are reaction to injury. reaction
to rehabilitation, and reaction to return to competition or
career termination. These reactions can be cumulative in
nature depending on the length of rehabilitation. Other
factors that inf1uence reactions to injury and rehabilita­
tion are the athlete's coping skills. past history of injury,
socia.l support. and personality traits. These reactions fall
into four time frames: short·term (less than 4 weeks), long­
term (more than 4 weeks), chronic (recurring) , and termi­ jury befo~1
nation (career-ending). Reactions are primary and accept th
secondary, but athletes do not all have all reactions, nor do habilital
all reactions fa ll into the suggested sequence. Jeles em
\\'Itbout 11'
DEALING WITH, SHORT· TERM Jele's in/~
!.he athJe~_
INJURY
The
Short-term injuries are usually of less than 4 weeks but melhin",
may be a few days over depending on how the length is ounled
measured in terms of the end of rehabilitation. For practi­
cal purposes the rehabilitation is complete when the ath­
lete and the sports medicine team feel it is safe for the
athlete to return. when an appropriate level of competitive
fitness has been reached. and the athlete feels ready phys­
ically and psychologically to return to competition. Short­
term injuries can include, but are not limited to. first- or
second-degree sprains/strains. bruises, and Simple disloca­
tions. These are the type of injury that are fairly common
and are part of playing the game.
Reactions to Short· Term Injury
The primary reaction to these injuries is the shock of
surprise-the shock thallhe inJury cannot be just "walked
off" or "shaken off." At the time of the injury, the athlete
tries to walk it off or shake it off on the court or p'laying
field. Athletes have probably experien ced this type of in­
 CHAPTER 4 Psychological Considerations for Rehabilitation of the Injured Athlete 79

Length of Reaction to Reaction to Reaction to

rehabilitation injury rehabilitation return

Short Shock Impatience Eagerness

« 4 weeks) Relief Optimism Anticipation

Long Fear Loss of vigor Acknowledgment

(> 4 weeks) Anger Irrational thoughts
Alienation

Chronic Anger Dependence or Confident or

( recurring) independence skeptical
I

I
Frustration Apprehension

Termination Isolation Loss of athletic Closure and

(career-ending) identify renewal
Grief process

f'igure 4-4 Progressive reactions of injured athletes based on severity of

injury and Il ength of rehabilitation.

jury before with no residual complaint and need time to
ary and accept that, this time. it is not immediately going away. Re­
tions, nor do habilitation compliance is often compromised when ath­
letes envision themselves returnh1g in a couple of days
without treatment. The ath"etic trainer assesses the ath­
ERM lete's ,injury and explains the process of rehabilitation to
the athlete.
The secondary reaction is 'r eli.ef-relief that it is not
-l: weeks but something really major. given that it couldn't be dis­
the length is counted as just a "nick" or '·ding." The sense of relief is
n. For practi­ contingent on the athlete's trust of the athleNc trainer. At
'hen the ath­ this point the relationship between the athletic trainer and
afe for the the athlete is forged and trust is established. This sets the
f competitive tone for the success or failure of the rehabilitation process.
ready phys­
tition. Short­ Reactions to Rehabilitation
to, first-or
of Short~ Term Injury
1:imple disloca­
airly common Once short-term injury rehabilitation begins, the primary
reaction the athlete displays is impatience----an ,impa­
tience to get started, to do something. to get on with the
program as quickly as possible. During this time the athlete
is often experiencing peaks and valleys in the recovery
_ the shock of process. The athlete is accustomed to two speeds: no speed
be just "walked and full speed. Athletes often express the bellief that they
ury. the athlete should heal faster because they are in better shape, and
oort or playing they are not happy to spend time in the sequential phases
wi type of in- of rehabilitation. If it is a sprained ankle, the athlete does
not react with exhilaration to the crutch phase, then the
walking phase, then the walk-jog phase, then the jog-run
phase, then the run phase, and then finalily the full-speed
activity phase. The athletic trainer can reassure the athlete
that the phases are necessary and that to push it could set
back the rehabilitation time.
The secondary reaction is one of optimism. This opti­
mism is due to the confidence and trust established be­
tween the athletic trainer and the athlete. The athlete is
able to believe the athletic trainer's assessment that be­
cause tl1e injury turned out to be Iless serious than origli­
nally thought, it stands to reason that the rehabilitation
will work out as well. It is important that compliance be
consistent with the athletic trainer's treatment plan and
that the athlete does not try to return to practice or play
too soon. This level of injury has a good track record for ex­
cellent recovery.
Intervention for Short-Term Injury
Intervention should include allOWing the athlete to vent
frustrations and reiterating that there is a l,i ght at the end
of the tunnel. At the collegiate level. athletes have fre­
quently had this type of injury and consider it to be part
and parcel of playing the game. The athlete should be en­
couraged to remain involved with the team, attending
practices while performing rehabilitation , attending team
meetings, and interacting with teammates after hours, At
80 PART ONE The Basis of Injury Rehabilitation

this stage the athletic trainer and the athlete Vi/ill have to
conduct some reality checks to ascertain that the concerns 1. Change
that come up are in the realm of the athlete's control. Los­ ther mOl
ing their spot on the team, losing their speed, or losing 2. Difficult)
their best shot is not within the athletes' control. Doing ef­ 3. 'Lack of i
fective rehabilitation on a consistent basis is within their 4. lnapprop
control. Staying current with the team will keep them cur­ gression,
rent with plays and coaching changes. Effective rehabilita­ "I don't c
tion is the only way to return to their sport. Compliance is 5. F,l at aff~
not usua.lly a factor for short-term injuries. of facial
6. DecreasE
port suct
Reactions to Return to Competition 7. History a
after Short-Term Injury history 0
The primary reaction to returning to competition is ea­ Figure 4-5 The athlelic trainer assists the athlete to
gerness and the secondary reaction is anticipation, At Figure 4 -6 C
quell the fear aSSOCiated with long-term injuries.
depression.
the time of return to competition, the athletes with short­
term injuries are usually eager to begin to practice and
play. They anticipate that they will return to their preil1­ injury, as lo ng I
must allay the fear with pertinent information in terms clinical depres
jury competence the first day back. By the time the at hleti c that arc easy to understand. It is not helpful to overload the
trainer feels the athlete is ready to return, it is assu med In one stud:
athlete with all the latest information on that particular curs in only 4
that a level of trust has been established. The athlete and
the athletic trainer must agree on a realistic plan for return
i,njury. The rule of thumb is to present the truth in appro­ lion .s The po
priate doses thaI the athlete can handle. Again, establish­ depressed a thl
to activity so that the transition will be safe and satisfac­ ing a trusting relationship with the athletic truiner is a
tory for all concerned. medicine learn.
vital component of this long-term process. pelite, sleep disr
The secondary reaction to a long-term injury is thoughts of or
DEALING WITH LONG-TERM anger-anger thalthe injury happened, that it happened en!'. then th e
INJURY to them, that it happened at the time it did, and so on. dressed (Figu re
Anger cannot be reasoned with, and the sports medicine th e inciden c
Long-term injuries arc considered to have a rehabilitation team must understand and not react to the athlete's anger.
lime of more than 4 weeks and can be anywhere from 4 An angry, hostile, or surly attitude toward the personnel or
weeks to 6 months to a year. These injuries are the most se­ program should not offend the athletic trainer. Whoever
vere and tend to be the most difflcult for the athlete to han­ happens to be around the athlete often bears the brunt of
dle because of the length of inactivity and the lack of rapid the anger. This response is merely an emotional release.
progress during rehabilitation . Long-term injuries include, With anger the athlete is usually reacting to the situation
but are not limited to, fractures, orthopedic surgery, gen­ and not necessarily to the individual. t heir position
eral surgery, second- and third-degree sprains/strains. and menta l, and e
debilitating illness. Reaction to Long-Term Rehabilitation rehabilitative p
producing the
Reaction to Long-Term Injury The primary reaction to long-term rehabilitation is plus th e athl ete
twofold: loss of pigo/' and irratiollal OWl/alliS. At this pOint behind in th e ~
The primary reaction to long-term injury is fear-fe<lr the athletic trainer needs to be aware that a loss of vigor athlete if psych
that they will never get belter, fear that they can never play can be masked as depression, altho ugh depression can also since not all at
again, fear that they cannot handle a long rehabilitation be a possible reaction. The athlete appears to be lacking t he vcn li on.
period, fear of pain, and fear of the unknown (Figure 4-5). usu<ll vim. vigor, and vitality but docs not have the com­ The olher p
!'I,lost athletes have heard the horror stories of the <l thlete mon signs and symptoms of a true depression (Figure 4-6). is irrational
who had this sa me injury and never came back for a mul­ Understandl!1g this phenomenon wiII enable the athletic
titude of reasons. They hear stories of athletes who came trainer to understand the <lthlete's change in l'emperament
back but were never again as fast or as talented or as fear­ and disposition. The aU11ete should understa nd U1at it is psych ological i
less ... the list goes on. At this point the athletic trainer reasonable to feel somewhat discouraged concerning the q uen t1y ef'fccth',
 CHAPTER 4 Psychologica l Considerations for Rehabilit ation of the Injured Athlete
1. Change in eating and/or sleeping habits ei­
ther more or less than is usual
2. Difficulty in concentration
3. Lack of ,interest in activities previously enjoyed
4. Inappropriate reaction to stressful situations: ag­
gression, extreme agitation, rage or no lreaction:
"·1don't care," "Doesn't bother me," "Whatever"
5. Flat affect-a void of the normal fluctuation
of facia l expressions
6. Decreased involvement with normal social sup­
port such as teammates, friends, and family
7. History of depression in the past or family
history of depression
Figure 4-6 Common signs and symptoms of clinical
depression.
injury. as long there are no other presenting symptoms of
clinical deprcssion.
In one study, it was found that clinical depression oc­
that particular curs Ln only 4.8 percent of the injured athleHc popula­
th LO appro­ tion. 8 The possibility of attempted suicide by the clinically
. es tablish­ depressed athlete warrants the Vigilance of the sports
traioer is a medicine team. If signs of clinical depression (loss of ap­
pelite. sleep disruption, withdrawal. change in mood state.
though ts of or plans for attempting suicide, etc.) are pres­
ent, then the possibility of attempted suicide must be ad­
a nd so on. dressed (Figure 4-7). According to Smith and Mi lliner.h l
r medicine the in cidence of attempted suicide is high among the age
~Ie t e 's an ger. group of ] 5 to 24 years. In Smith and Milliner 's study of
pe rson nel or five athletes who had allempted suicide. the cornman fac­
er. Whocver tors were a serious injury that required surgical interven­
the brunt of tion, rehabilita tion of 6 weeks to a year whlle not
na l rclease. participati ng in sporl. diminished athletic skill upon re­
the situation turn after successful rehabilitation, and being replaced in
their pOSition on the team . Adaptation to the physical.
mental. and emotional fru stration is hard work during thc
ilitation rehabilitative process. The work the athlete is doing is not
prodUCing the same rewards CIS participation in the sport;
bilitation is plus the ath lete is becoming anxious abou t falling farther
-\[ this point behind in the sport. At this point it is prudent to ask thc
a loss of vigor athlete if psychological intervention is needed or desired,
ion can also since not all athletcs require or desire psycho'logical inter­
be lacking the vention.
ba\' the com­ The other primary reaction to long-term rehabililation
(Fig ure 4-6). is irrational thoughts (Figure 4-8). If irralionall
e the ath letic thoughts are persistent. interfere with the normal rouline
lemperament of daily life. and disrupt the rehabilitation process, then
tan d that it is psychologicaI intervention is recommended and is fre­
ncerning the quently effective. Irralionalthoughts can be negative per-
81
1. Has signs and symptoms of being clinically
depressed
2. Has feelings of helplessness and hopeless
such as seeing no way out of stressful
situation except suicide
3. Has thoughts of suicide or a previous at­
tempt, or has a close friend, family member,
or acquaintance who committed suicide
4. Has an ,i rreversible plan to commit suicide
(taking pills as opposed to jumping from the
top of a building)
5. Making plans to not be around, such as giv­
ing away possessions, writing letters, getting
affairs in order, saying good-bye to friends
6. Expresses intention to commit suicide (taking
demographics into account-women make
more attempts but men are more successful)
figure 4-7 Common signs of possible suicidal
in ten tions.
ceptions of pain, fear of reinju r y. lack of social support,
poor performance. Clnd so on. These ath letes might harbor
thoughts of not being to returning to play or not being able
to return to theLr previous level of play. Prcviously rationa l
and positive perceptions of situations now become nega­
tive and irrational as self-destructive emotions color the
thought process. Emotional reaction is exacerba ted when
the athlete fails to heal or rcturn faster than the nonath­
Jete. Frequently, athletes feclthat because Lhey arc in bet­
tcr shape at the time of injury,they should heal fasler than
non ath letes who are out of shape CIt the time of injury. The
athlete has often put in years of training and imposes pres­
sures to heal faster and return qukker. The athlete's com­
mon sense and judgmcnt become altered. This mood
change might occur daily or weckly, so continual interac­
tion bctween the athletic trainer and the athlete is neces­
sary to restore rationality and change negative thoughts.
The secondary reaction to long-term rehabilitation is
a feding of alienation. With ClIt injury that requires
weeks or months of rehabilitation before the athlete's re­
turn to competition. the athlete often feels that the
coaches have ceased to care, teammates hCl\ie no time ilo
spend with them. friends are no longer aroun d, and their
social life consists of tim e put into rehClbilitation. 'lfhe ath­
letes may have had lillie support from coaches and team­
mCltes. since the coaches Clrc concerned with the results of
the team. Injured athletes feel neglectcd if their daily ac­
tivities have revolved mound the sport and they are no
longer part of the sport.
82 PART ONE The Basis of I njury Rehabilita tion

successful r
Irrational Thinking toward Injury and Rehabilitation
be recogn ize
Exaggeration: Severity or mildness and significance or insignificance of injury- "I'm in
trolling in ne
process is o[
great shape, so my broken leg will heal faster than it would for someone who is out of shape."
men t ror ul tiJ
"How bad can a sprain be?" Negali \1~
Disregard.: Neglecting or overdoing rehabilitation treatment- "I'll wait a few weeks and see if it mental an d p
daily record (
gets better on its own." "If one repetition of five sets is good, then two of ten will be twice as good."
the correl ate(
Oversimplification: Thinking of rehabilitation as good or bad, right or wrong, necessary or stances in \\'t
unnecessary- "No one ever came back from ACL surgery." "I' don't see any reason to do rehab slop these De~
exercises if I am going to have surgery in two weeks." This step is fol
though t-stoPf
Generalization: Generalizing the outcome of one athlete's injury to all injuries, or one athlete's
ner, athletes b
outcome of rehabilitation to all rehabilitation- "All sprains heal in two weeks." "Rehab is necessary own positi\'e
only if youl plan to compete again." concentra tion
change inappr
Unwarranted Conclusions: Conclusions based on unsound thinking or false information- "I know
seeing physic;
an athlete who did everything they told him to do and his arm never got better." "They say that quickly to COlT'
once you break a bone you never can run as fast. " reinforcement
"'I'h i s too will
f'igure 4-8 Examples of thought patterns athletes might have concern ing injury and rehabilitation. thoughts. t\eg<
covery by iner
shou'id be eDC
The athlete must understand that the coach cares but Intervention for Long-Term ralher th a n into
has no expertise in injury management and must be con­ Rehabilitation create emotion
cerned with getting the rest of the team ready. The athletic be recognized ~
trainer has no expertise in coaching but is primarily inter­ Whenever possible, anger should not be challenged , be­ athlete sho uld j
ested in getting the athlete back to optimal fitness. Coaches cause no one can reason with anger. lnstead, the athletic should substil
work with players on playing their sport, athletic trainers trainer should wait until the individu.a l is in control of the The tecb ni
work with athletes on rehabilitating injuries: two different anger and then discuss the inappropriate behavior that athlete becom
fields , two different abilities, two different areas of expert­ cannot be tolerated in the rehabilitation setting. Then the behaviors. The
ise. Some coaches, unfortunately, might also want the in­ athletic trainer and the athlete can work out the cause of of "I can 't do il.
jured athlete kept away from other players to remove the the anger and together arrive at u solution . The athletic produces am.ie
reminder that injury is a possibility.20 trainer must act as an emotional blotter and, if possible, detrimental to
The inj ured athlete may feel unable to maintain or re­ not furt her aggravate the situation by attempting to exert might be iHogi
gain normal relationships with team mates. The injured power to calm down the athlete. It is as important to listen unrealistic deci
athlete is a reminder that injury ca n happen, and team­ to what the athlete is feeling in addition to what the ath lete placed th e old,
mates might pull away from that constant reminder. is sayin g. At this paint the ath lete has a need to ven t the helping the tea
Friendships based on athletic identil1cation are now com­ anger, and the athletic trainer must simply listen to the
promised, because the athletic identil1cation is gone, and athlete 's reaction.
they can be related to in athletic terms only by what they At this time active listening by the athletic trai ner is a
did yesterday or as injured teammates and not as individu­ move toward developing a su pportive and trusting rela­
als. Injured at hletes no longer have the camaraderie 01 the tionship with the athlete. Having a trusting relationship
dressing room. the practice bashing. the travel to away between the athlete and the athletic trainer can make all
even ts, and the other interactions mired in tradition th at the difference in getting the athlete into the proper frame
give athletes a sense of belonging, a sense of being impor­ of mind for successrul completion of the rehabilitation
tant. \l\lhen injured athletes can remain involved with the process.
team. however. they feel less isolated and less guilty for not One of the more difficult aspects of adjusting Lo injury
putting it on the line to help the team. is stopping negative thoughts, which are devastating to a
 CHi\PTER 4 Psychological Considerations for Rehabilitation of the Injured Athlete
successful rehabilitation process. These thoughts have to
be recognized by the athlete and then controlled. hO Con­
trolling inner thoughts determines future behavior. This
process is one of awareness. education. aod encourage­
ment for ultimate positive change.
Negative thoughts have a detrimental effect on both
mental and physical performance. , 7 It is helpful to keep a
daily record of when these thoughts lake place. as well as
the correlated physical progress and the time and circum­
stances in which they occur. 'Fhen athletes are helped to
stop these negative thoughts and instill a positive regimen.
This step is followed by an evaluation of the whole negative
thought-stopping program on a regular basis. In this man­
ner, athletes have the practice and feedback to begin their
own positive outluok in terms of constructive thoughts.
concentration. cues. images. and calming responses to
change inappropriate altitudes. This posWve outlook. plus
seeing physical progress. can help athletes return more
quickly to competition wit h better abilities to perform. The
reinforcement of sayings such as "You will get better" and
"This too will pass" aid in the blockage of the negative
. n. thoughts. Negative thoughts block the athlete's road to re­
covery by increasing pain. anxiety. and anger. i\thletes
should be encouraged to put their efforts into recovery
rath er than into the downward spiral of self-pity. Thoughts
create emotions. therefore tbese negative thoughts have to
be recognized and dealt with for a more rapid recovery, The
. Lhallenged. be­ athlete should never be allowed to say "I can't" but rather
'cad. the athletic should substitute ·'I'lItry."
co ntrol of the The technique of restructuring perceptions helps the
~ behavior that athlete become aware of these destructive. self-defeaUng
:tin g. Then the behaviors. The athlete, however, might fall into the mode
lIt the ca usc of of "r can't do it, I'll never get well." This irrational thinking
. The athletic produces anxiety. fear, and possibly depression. whieh are
detrimental, to progress in rehabilitation. The athlete
might be illogical. distort perceptions of events, or reach
unrealistic decisions and conclusions, The athlete has re­
placed the old set of worries about simply playing wel! aud
helping the team win with the set of "Woe is me," with its
resultant anxiety, ObvioLlsly. these thought patterns are
detrimental to the positive attitude necessary in tho reha­
trainer is a bilitation process.
trusting reI a­ The athletic trainer must recognize and challenge irra­
g relationship tional thinking. Examination of these thoughts with ath­
can make all letes reassures them that it is normal to feel unhappy.
frustrated. angry. or insecure. but that the injury is not
hopeless. they do not lack courage. and all is not lost and life
is not over. The athlete should be challenged to replace ir­
rational thoughts with positive and rational ones, In short.
the injury is aggravating and unfortunate, but it can be
83
handled and overcome, The injury is placed in perspective
and viewed in the same way as the athlete would consider
preparation for the next athletic contest. The athlete must
idcntify faulty thinking. gain understanding of it. and ac­
tively work for its change. Research/''·' indicates that the
self-thoughts. images. and attitudes during the recovery
period impact the length and quality of the rehabilitation.
CLINICAL DECISION MAKING Exercise 4-3
Dana is a DiviJ;ionl golfer who wan ts to play on the LPGA
tour next year after graduation. She has h ad chronic
neck and ' houlder spa 'ms for the pa t year. As a result of
her desire to play well at Qualifying School. coupled with
her a nxiety regarding her neck a nd shoulder pain. she
has fa lle n prey Lo negative Ulinking: "Whal tf my neck
nares up du ri ng Q-school. what if my neck blocks my
swing plane," How can the athletic trainer help Dana
manage this problem?
Lost social support can be replaced by organizing sup­
port groups or similar injury groups or mentoring by ath­
letes who have completed rehabilitaLion successfully.23
A supporting relationship between the athlete and Lhe
athletic trainer can be the mainstay in attainment of suc­
cessful rehabilitation (Figure 4-9), Establishing this rela­
tionship may be difficult for ath 'letes who have been
catered to when healthy and arc now in a reversed role. AL
this time athletes question many aspects of the rehabilita­
tion procedure. They question the doctor's diagnosis. the
athletic trainer for working them possibly too much , and
the coach for not paying attention to them. They question
whether they are thought of as malingerers. They ques­
tion whether the rehabilitation personnel know how im­
portant competition is Lo them.
Toward the end of rehabilitation. the ath lete should
begin sport-specific drills during practice time with the
team. The athlete then begins to re-enter the team culture
and is not isolated from the team environment. Thus more
effort is put into functional sport-speeiflc situations that
are generally less boring to the athlete. In so dOing. the ath­
lete gains a more realistic appreciation of the skills needed
to attain preinjury performance levels. The rehabilitation
routine is more easily tolerated by athletes if they can see
some carryover to thelr particular sport.
}\fter injury. athletes need the support of teammates.
To prevent possible feelings of negative self-worth and
problems of loss of identity for athletes, their support
84 PART ():\i!:: The Basis of Injury Rehabilit8tion

trust-tr ust
pared as pm
that everyth
healed-t h is
proven. Whe
everythin g b.
control. It is I
the plate an d
talion proce
m akes th e fir
race. Then . a
freedom an d (

DEALINC
Chronic in jur:
insidious on
of innamm at!
giving the iml
juries are USUE
tis. stress [ract

Reaction
T he prim M!
the atblet e h
gested as fa r
bilitation. an
desperateiv \\<j
Figure 4-9 The athlete and th e athl eti~ trainer develop a relationship of respec t and trust. bers tbat reha
ou t process . n
and over that
groups need to stress that they arc interested in the athlete lional criteria to be foll owed before return ing to play. The Such repeti tio
as a person as well as a team member. If the athletic trai ner athletic trainer and the athlete have discu ssed th e usc of selective heam
and spons medi cine tea m have established prior pe,r sonal additional padding. the wearing of a brn ce. or other equip­
contact with th e a lb!lete as a worthwhile perso n, this tran­ ment adjustments to minimize reinjury. The physici,lI1. the
sition ca n be easier. athletic trainer. the sport psych ologi st. and the coach have o\'e ruse inj
determined th,lt th e athlete is ready to play at 100 perce nt. trea tment or c:
the athlete fit s back into the chemistry of the current dllIing injun a
Reaction to Return to Competition lineup. th e athl ete is k n owled geabl e aboLlt recent changes playing, a ll th
in coaching strategy, and the alhlete feels psycholog'ically ning. throll'in
for Long-Term Injury
ready. T he athlete and the spo rts medIcin e te8m halle dis­ of th eir SPOrl
Th e primary rea ctio n to return to competition fr om a long­ cussed feelings of confiden ce about ret urning, Willingness chroni c inj llD
term injury is an acknowledgment that the rebab ilita­ to play with pain or soreness, and willingness to risk rein­ Ina cti\'it~
tion process is co mpl eted. This is a feeling of "r h ave don e jury or permanent dama ge. Th e athlete has gained the lion to chroni
my best and all that I can do in the area of rehabilitation," emotion a l self-control to think rati onally abo ut the injury are overuse in
The a thlete might go down a checklist of performance abil­ and cope successfully with th e return to competition. n is by a sen se of
ities. The team physician who ha s the final vote on med­ now LIp to the athlete to make th e decision to return to play. <Jt least done.
ically cleari ng a n athlete to return to competition has Mter going through the checklist of co ncerns Lhat the hacl'n 't run th
given the OK to return. The athletic trainer h as set func­ athlete feels are important, tbe seconda r y re<lction is set." If lhe al
 CHAPTER 4 Psychological Considerations for Rehabilitation of' the Injured Athlete
trust-trust that everything has been done to be as pre­
pared as possible to ret urn to play. Trust at this lime is trust
that everythiag has been done, not that the injury is
healed-this won't come until it has been tested and
proven. When the athlete has been cleared to return.
everything has been completed that is within the athlete's
control. It is now time to "put it to the test-to step up to
the plate and gh7e it a shol.'· Acceptance that the rehabili­
tation process is successful wiU not come until the athlete
makes the first move, takes the fITS! hit or runs the first
race. Then, and only then, will the athlete play with the
freedom and conildence she or he had prior to the injury.
DEALING WITH CHRONI'C INJURY
Chronic injury can be defined as an injury having a slow,
insidious onset, most often starting with pain and/or signs
of inflammation that might last for months or years and
giving the impression of recurring over time. I t hese in­
juries are usually overuse injuries and can include tendini­
tis, stress fractures (shin splints), compartment syndrome,
and other second- or third-degree injuries.
Reaction to Chronic Injury
The primary reaCtion to a chronic injury is anger. Often
the athlete has done everything the athletic trainer sug­
gested as far as rehabilitation and even maintenance reha­
bilitation, and still the injury recurred. The athlete
desperately wants to return La previous form and remem­
bers that rehabilitation is going to be another long. drawn­
out process. The athletic trainer often has to explain over
and over that setbacks occur even without provocation.
_ to play. The Such repetition is necessary because an angry athlete has
the usc of selective hearing and a short attention span. It might take
other equip­ several meetings for the athlete to cool down enough to
hy ic ian, the hear what is being said. Because many chronic injuries are
ecoach have overuse injuries, rest and inactivity are frequently the
100 percent. treatment of choice. Athlletes often describe this inactivity
the current during injury as being harder than playing. When they are
L'("cnt changes playing, all their energy is directed toward the goal of run­
._ hologica[Jy ning, throwing, jumping, or whatever oth er activity is part
_ am have di5­ of their sport. When they are dOing rehabilitation for a
J.. willingness chronic inj,ury, most physical activity screeches to a halt.
to risk rei n­ Inactivity leads to frustration, the secondary reac­
"ained the tion to chronic injury. The fact that many of these injuries
•ut the injury are Qveruse injuries increases the frustration brought on
peti tion. It is by a sense of somehow having caused the recurrence or
~ tur n to play. at least done something to increase the chance of it. "If I
'crus that the hadn't run the extra mile." "If I hadn't played the second
reaction is set." If the athlete has used sport as a buffer to control
85
stress, that outlet is gone for the time being. Stress then ac­
celerates. Often these athletes are useclto being very active
and the forced inactivity is frustrating. These athletes are
well acquainted with the rehabilitation process to come,
the emotiona') ups and downs, the time commitment, the
expense, and the hard work that goes into successful reha­
bilitation. The thoughts of going through the process
again with no real expectation of a permanent solullon is
indeed frustrating.
Reaction to Rehabilitation
of Chronic Injury
The primary reactions to rehabilitation of a chronic injury
are dependence and independence. These reactions
are manifested by athletes' reacting to the rehabilitalion
process as if they have no control or as if they have com­
plete control. The stance in either reactive or proacthre and
is seen in the athlete's either not taking control or respon­
sibility for getting betier or assuming total control over the
rehab ilitation process.
There is very little middle ground for these athletes in
the treatment protocol: they either try everything new or
they are unwilling to try anything new. They either ques­
tion every treatment the athletic trainer recommends or
accept every treatmenl the athletic trainer recommends.
Athletes might swing from one end of the spectrum to the
other, depending on factors such as how well the last re­
habilitation worked, how fast the last rehabilitation
moved, how well they liked the last athletic trainer, where
they are in their season, and any other situation they per­
ceived as warranting a change.
Dependent athletes don't take part in the decisions of
rehabilitation, they don't give their input concerning what
worked before or what didn't, and they often leave all deci­
sions up to the athletic trainer or team phYSician. Often
these athletes become dependent on the alhletic trainer
and relinquish all power regarding rehabilitation deci­
sions. These athletes want someone else to be responsible
for their welfare and to meet their every need at their whim
and command. They demand that more time be spent on
them. Failure of one athletic trainer to meet their demands
results in their selecting an athletic trainer who will meet
their demands. Athletic trainers with the greatest need to
help others wnt be easily taken advantage of, at the sacri­
fice of time needed for other athletes .
The independent reaction is just the opposite. These
athletes want to call all the shots and are up-to-date on
the latest fads. They are likely to change the treatment
plan-or the athletic trainer-if progress is not as fast or
86 PART 0"'1: The Basis of Injury Rehabilitation
as productive as they expect or want. They have a strong
urge to lind the perfect treatment by trying new tech­
niques. changing physicians and athletic trainers. or
shopping around for any solution that migbt work better
and faster. The atbletic trainer must not take this person­
ally. It is important to accept tbat shopping around is not
a rejection of the athletic trainer but a reaction to the
chronic injury rehabilitation.
The secondary reaction to chronic injury rehabilita­
tion is apprehension. At hletes with chronic injuries
know that although they might get through this f1areup.
there is a strong possibility that the injury will return. for
in fact it never completely heals. They approach rehabili­
tation with trepidation. not knowing what will work this
time and what williaslo They tend to fee l stress over every
sign and symptom that tbe rehabilitation is not going as
well or as rapidly as expected. Dependent athletes react to
this apprehension by being overcompliant. thinking that
they just need to work harder at what ~he athletic trajner
suggests. Independent athletes. reacting to apprehension .
tend to make more changes if rehabi'litation is not going
well-trying new and different things. looking for the per­
feet treatment
CLINICAL DECISION MAKING Exercise 4-4
Christine is a 1 5-year-old Junior Level diller who has
been competing since she was 9 years old. She has had
chronic back pain and muscle spasms for 3 months. For
se\rera l weeks she has been making irrational com­
plai nts: "No divers I know have ever been able to dive
once back pain starts." "Rehabilitation never works for
back pain." How can the ath letic trainer help Christine
change her opinion?
Interventions for Chronic Injury
If athletes become dependent and they no longer receive
the special attention they feel they deserve. they often lash
out in anger or frustration. '~'he athletic trainer needs to
head off this response by firmly explaining the restrictions
on time and wbat is required of the athlete in terms of re­
habilitation. This response should be pointed out to the
athlete as inappropriate. and it should be examined by the
athletic trainer and the athlete if it becomes a continual
problem . because it is only a detriment to recovery. At this
time the athlete is encouraged to transfer the time and en­
ergy formerly given to the sport into the rehabilitation
process. The athlete has to become an active. not a passive,
participan t. The injury is now the competitor. ratber than have an uny
next week's opponent. Care should be taken to prevent the experiences
athlete from becoming a dependent patient. confidence i
Tn order to be more proactive rath er than reactive. the essarUy an in
dependent athlete is encouraged to take part in the reha­ ality lrai t 81
biHtation. This does not mean that the athlete assumes the partiCipation
role of the athletic trainer. but it does mean th at they work contingent u
as a team. This is where the trust and respect between the do not care. b
athletic trainer and the athlete is of paramount impor­ sign and man
tance. It is a two-way street where the athletic trainer pro­ the ir life.
Vides the expertise concerning the injury and the athlete It is une
has the expertise concerning his or her body. other. It can !
The independent athlete is encouraged to develop a re­ one or the ot;
lationship with the athletic trainer that is one of respect The mi Ugalio
and trust. At this point the ath'tetic trainer can facilitate be maturily.
this trust by being current with the latest literature on the playing a SIlO
athlete's particu'iar injury. Knowledge of the il1jury. its meanin g of I'
healing mechanism. a nd the rehabilitation progression
gives athletes an orderly timetable within which to pro­
ceed. It will help if the athletic trainer and the athlete have DEALlN4
a plan that is mutually acceptable. The athletic trainer can ENDING
make an effort to be particularly flexible when working
with these athletes; thus wUI go a long way in strengthen­ One of the hz
ing tbe relationship of trust and respect so necessary to a when to end
smooth rehabiHtation . ter U' this L
All athletes are participants in the rehabilitation team )or one'
process. but they must be active participants and become a b ilit y) . ~n FOl"
there is a ree.
engaged in the process. Athletes have to be encouraged
unexpected t
and believe in future success. All efforts should point to­
reers voluma
ward a positive result. with the athletes working with what
played th
is available and not with wishfu'l thinking.
Reaction to Chronic Injury Recovery
Recovery from chronic injury is in some ways a misnomer.
beca use the very nature of the injury assumes it will recur
if the athlete continues to play. The single level reaction is
twofold---either skeptical or confident.
The skeptical reaction is not necessarily a negative Isolation is I
reaction but one born of multiple experiences with reha­ a nd is dcpen
bilitation. Skeptical athletes arc realistic in their options port ance of
and have usually made peace with the nature of a chronic as par t of 8 l~
injury. This is not to say defeat is accepted but that reality in gful acth-ii_
is acknowledged. They have not given up hope. but the boundaries r
hope is tempered with acceptance of factors that lhey have
no power to control. These athletes rehabilitate to the best nncd roles \\
of their ability but accept that some things are not within iogs. ro les \\
their control. termination .
The confident reaction to recovery from chronic in­ fi liation. cou
jury is not necessarily an unrealistic or unenlightened re­ pansion of
action regarding the course of this injury. These athletes debililalinll: e,
 CHAPTER 4 Psychological Considerations for Rehabilitation of the Injured Athlete
rat her than Ihave an unyielding failh that is untarnished. by repeated
experiences with recurrence of a chronic injury. Often
confidence is more global for these athletes and is not nec­
essarily an injury-specific reaction. This may be a person­
ality trait and is not tied into the injury or lack of
participation in their sport. Identity for these athletes is not
contingent upon sport. Th is does not mean these athletes
do not care, but just that they do not allow the injury to de­
un t impor­ sign and mandate their di position or to define and oulline
their life.
It is unclear whether one reaction comes before the
other. It can be assumed that athletes are not relegated to
one or the other reaction but can move between the two.
The mitigating factors for moving between the two could
be maturity, experience with rehabilitation, length of time
playing a sport, the particular time in the season, or the
e injury. its meaning of the sport to the athlete.
progression
. h ic h to pro­
athlete have DEALI NG WITH A CAREER·
. trainer can ENDING INJURY
en working
n stre ngthen­ One of the hardest adjustments an athlete has to make is
:cessary to a when to end parlicipation in a sport.lt does appear to mat­
ler if this is an abrupt en ding (injury. illness, cut from
habilitation team) orone with some advance warning (retirement. age,
and become ability). 20 For the athlete whose career ends unexpectedly,
encouraged there is a feeling of not being able to complete goals due to
I point to­ unexpected termination. 7 ; The athletes who ended ca­
rt" with what reers voluntarily. who chose the time to kave, and who had.
played the sport longer had a smoother transition.
Injuries that fall into this category include spinal cord
injuries, extensive hardware implants (screws, plates,
Recovery etc.), multiple surgeries with declining benefits, and per­
a misnomer. sistent debi'litating or incapacitating illness.
it will recur
,\el reaction is
Reaction to a Caree....Ending I'njury
- ri[_ a negative isofation is the primary reaction to termination of sport
with reha­ and is dependent upon the athlete's perception of the im­
their options portance of participation. :\,fany athletes have spent year~
re of a chronic as part 01' a team that has offered a well-defined and mean­
_ ut lhat reality ingful activity. The very nature of sport is one of exact
hope, but the boundaries (rules of play, precise beginnings and endings,
..bat they have codes of conduct, etc.), and the athletes in turn have de­
ate to the best fined roles within these boundaries (position played. rank­
_ are not within ings. roles within the team structure. etc.). Attbe lime of
termination. the disruption of a signU'icant attachment af­
rom chronic in­ filiation , coupled with a large time commitment and ex­
nlightened re­ pansion 01' injury. all set these athletes up for the
Th se athletes debilitating effects 0[' depression. 2o
87
The secondary reaction is that these athletes must go
through a process of grief-grieving for a loss of not only
a career, but an identity, an extended family. a place in so­
ciety where they know the rules and can play the game.
Sport for the athlete is a community. where they are pro­
ductive members, where they excel, where they feel ac­
cepted. and where they feel they belong. These athletes
grieve for what they no longer have: their place in the
group, their place in society. their identity as an athlete.
their job or career, their place of comfort. their sense of
belonging.
The grief process is an adjustment period, and the form
it takes and how long it lasts depend on the individual's
personality and the importance the sport had in forming
that personality. There are many theories of the process of
grief. A good review can be found in Baillie and Danish lor
Evans and HardyY The grief process is a sequential pro­
gress ion: The grief process must take place before accept­
ance, the acceptance process must take place before career
change, the career change attempts to fill the void created
after the end of the dream of competition.
Reaction to Rehabilitation
for a Career.Ending Injury
Loss of athletic identity is Lhe primary reaction Lo reha­
bilitation of an injury that terminates participation in a
sport. It is a feeling of "Who am I? Where do [ belong?
What is my purpose, my reason for being ?" The rehabilita­
tion involves the psychological adjustment to the loss of
self. Baillie and Danish 3 suggest that athletes have taken
anywhere from 2 to 10 years to adjust Lo termination [rom
sport.
The athlete enters physical rehabilitation halfheart­
edly. if at all. The athlete often says. "Who cares?" "What
does it matter?" "Who will know?" in response to setting a
rehabilitation plan. These athletes might go through the
motions of rehabilitation , but the inner spark to get back
to competition is missing. At this point the athletic trainer
must decide whether the athlete needs to be referred to a
counselor or sport psychologist. The criterion for referral is
usually an established protocol and consists of a determi­
nation of whether the athlete is able to maintain a sense of
control and an engagement in activities while emotionally
working through the grief process.
Intervention in a Caree ....Ending Injury
Interventions for career-ending injuries are decided on
an individual basis. Intervention can have the nature of
88 PART 01\£ The Basis of Injury Rehabilitation

psychological counseling (stress management, alcohol or the level of perfon11ance present prior to injury. The pri­
roughly 50 pt
drug counseling, etc.), career counseling (school enroll­ mary treatment is exercise to retrain the mu.scles that have
one-third ah\
ment, job placement etc.), financial planning (invest­ been damaged due to injury. The psychological ramifica­
and one-lhird
ments, tax shelters, etc.), or whatever the athlete needs. tion of unsuccessful rehabilitation is that the ath lete Lends
(high intraocu
Adjustment to termination is better for athlet-es who had to focus on the injury. resulting in guarding or muscle ten­
they didn',[ usc
participated longer, were aware of chronic injuries, knew sion and /or luck of attentional focus , setting up the sce­
Only 42 perce
of the possibility of being cut. or had planned on retiring nario for reinjury. In what follows, we d,iscuss. tlrst.,
by the physkil:
from the team. Poor adjustment is associated with sudden definitions of compliance and adherence; second, inci­
told they were
unexpected injury that occurs in the prime of the career dents of compliance in other fields; third, measures of
did not campi.
and results in a forced retirement. I compliance: fourth, deterrents to compliance: and tlfth, in­
by 16 percent.
centives to increase compliance.
58 percen t Wei
Reaction to Recovery from noncomplia nt
a Caree....Ending Injury Compliance and Adherence Defined The exerci
is a 30 to 70 PI
The primary reaction to recovery from a terminating in­ According to !vleichenbaum and Turk,'u compliance is a
exercise proglCl
jury is to see it as hoth an ending and beginning. Closure term from the medical profession and means obedience of
exercise on a T'
the patient to the physician's or health caregiver's instruc­
and renewal are intertwined, with closure being neces­ all. ls Self-im pfi
sary to give full energy to renewal. Once they reach the ac­ tion. The concept of compliance is more passive than ac­
The dropout ra
ceptance stage. these athletes can put closure on a career tive, and carries the connotation that if patients are
ment program!
that has ended and focus their other talents, long over­ noncompliant. they arc at fault. This assigns an authorita­
of people wear
shadowed by athletic prowess, toward a new career. This tive position to the caregiver. The implication is: "I tel-I you
compliance ra l
might be either in the field! of athletics (coaching. an­ what to do. and you do it." The concept of compliance
should be u nde
nouncer, sponsor. etc.) or in a totally unreJiated field. Bail­ mainly applies to immediate short-term treatment that
is not necessarJ
lie and Danish 3 found that Olympic athl'etes and college has been prescribed for a patient. Adherence is a term from
.it was found It­
athletes were better prepared and made a beller adjust­ the exercise discipline and carries the meaning of active
adequate to bril
ment to new careers than did older professional athletes. voluntary choice. a mutuality in treatment planning. Ad­
keep in mind t.J
The reason for this might be betier education, more herence iJlVolves long-term change on a more voluntary
solute. fs the a
choices of careers. more assistance in career planning-in basis and suggests a behavioral change sought by the par­
without doing
other words. more options. Many athletes make a satisfac­ ticipant. Usually when adherence is the term used , it carries
They are onl)
tory adjustment to termination from sport wh en it is in the implication that the service was sought out as opposed
be the gold stal'1
their time frame and of their choosing, but termin ation to being prescribed-for instance, when people seek an ex­
forced by an un expected even t such as inj,ury is received ercise program or a weight-loss program, instead of being
with less than enthusiasm. ordered by the physiCian to enroll in one. These are usually Measurem
long-term commitments.
For th e purpose of this discussion about rehabilitation, How complian
CLINICAL DECISION MAKING Exercise 4-5 the term compliance will be used, but either is acceptable. problem. In lUI
The term compliance has been chosen because there are measured in 0
Joe is a 20-year-old juntor at a Division I schoollVhere he certain guidelines for treatments that produce the desired and therapeutic
had played footbaU for 3 years. He had dreamed of play­ result of reh abilitation of an injury. 'l'he athlete needs to ing whether ill
ing In the NFL unlil a severe concussion put an end to comply w'i lh a certain regimen for the short term to facili­ ther a stru el
those dreams. How call tbe athletic trainer help Joe deal tate healing. then adhere to a program of exercise to de­ record keepi n
with this realizalion? crease the risk of reinjury. In rehabilitation. a comply track). These m
now-adhere later approach is the best descriptor for suc­ ory, trying to ph
cessful return to the previous level of fitness, havior to pl e~
attendance is t~
The problem w
COMPLIANCE AND ADHERENCE Incidences of Compliance was done. It ju
TO REHABILITATION in Other Disciplines athletes could q
to sign in. or siIi
Compliance to athletic injury rehabilitation programs is In the field of athletic injury, compliance is the biggest de­
do only a portioi
abysmal, considering the purpose of rehabilitationY·lo.1Y terrent to successful rehabilitation. ;9 The fields of medi­
Therapeutic ou
The goal of athletic rehabilitation is to return the athlete to cine and exercise fare no better. In medi cine. compliance is
confounded by ~
 CHAPTER 4 Psychological Considerations for Rehabilitation of the Injured Athlete
roughly 50 percent, with the rule of thumb being that
one-third always comply, one-third sometimes comply,
and one-third never eomply.47 In a study of glaucoma
(high intraocular fluid pressure). patients were told that if
they didn't use drops 3 times a day, they would go blind.
Only 42 percent complied with treatment recommended
by the physician. Several weeks later at revisit. they were
ond, inci­ told they were in danger of losing sight in one eye if they
dLd not comply with treatment. Compliance only increased
by 16 percent. according to Vincent. 71 In other words, only
58 percent were compliant when the likely result of being
noncompliant was to go blind in one eye!
~fined The exercise Iiterature lS shows similar findings: There
is a 30 to 70 percent dropout rate in the first 3 months of
exercise programs. Sixty-six percent of Americans do not
exercise on a regular basis: 44 percent do not exercise at
alL IS Self-improvement programs do not fare any better.
The dropout rate for obesity, smoking. and stress manage­
ment programs is 20 to 80 percent. Only ]1 6 to 59 percent
of people wear scat belts. There is limited literature on the
compliance rate for athletes. Before all hope is lost, it
compliance shou,ld be understood that maybe 100 percent compliance
realIDent that is not necessary to achieve total rehabilitation. [n medicine
it was found that less than) 00 percent compliance was
g of active adequate to bring about desired resultsY It is important to
an ning. Ad­ keep in mind that 'love are looking at a range, not an ab­
e voluntary solute. Is the athlete who gets back to preinjury standards
_ l by the par­
without doing 100 percent of treatments noncompliant?
d. it carries They are only if 100 percent compliance is considered to
Ul as opposed
be the gold standard.
eseek an ex­
ead of being
Measurements of Compliance
are usually
How compliance is measured might be an indicator of the
reh abilitation.
problem. In medicine and exercise, compliance is usually
. acceptable.
measured in one of three ways: self-report. attendance,
u 'e there are
and therapeutic outcome. 47 Self-report consists of just ask­
ce the desired
ing whether the person has becn compliant, through ei­
lete needs to
ther a structured questionnaire, sclf-monitoring with
Lerm to facili­
record kceping, or corroboration (someone else keeps
exercise to de­
track). These methods can be inaccurate due to poor mem­
·on. a comply
ory, trying to please the investigator, or channeling the be­
' ptor for suc­
havior to please the investigator. Keeping track of
attendance is the most common and most direct method.
The problem with attendance is that it doesn 't say what
was done, it just indicates that the athlctes showed up. The
athletes could be doing exercises somewhere else, or forget
to sign in, or sign in and then leave without exercising, or
. lh biggest de­
do only a portion of the prescribed rehabilitation excrcises.
fiel ds of medi­ Therapeutic outcome is not completely reliabl.e, as it can be
e. compliance is confounded by other factors. In a weight-loss program the
89
athlete could be gall1l11g muscle weight but losing fal
weight. could lose weight due to exercising but not due to
recommendcd changes in eating habits, or could lose
weight because of iHness without exercising or change in
eating habits.
In order to start at the beginn,ing of measuring c.olTI­
pliance, the Hedgpeth/Gansneder Athletic Rehabilitation
Indicators )2 were designed to determine whilt treatments
were used. and what percentage of the time were they
used. in a Division [University. The basic areas assessed are
aerobic conditioning, strength conditioning. balance.
modalities, and long-term strategies (bracing. taping, pro­
tective equipment). Athletes are asked what percentage of
the time the treatment was done. A range of compliance is
measured. with 0-10 percent being the lowest compli­
ance, and 91-100 percent being the highest compliance.
A category of NI A was included to indicate that the ath­
letic trainer had not suggested the treatment. At the same
time, athletic trainers were asked to complete the indica­
tor. Preliminary reports suggest a 87 percent rdiability
rate for the indicator. Until such a time as what is being
done in the athletic training room setting is determined, it
is premature to discuss why it is or is not being done.
Factors Influencing Compliance
Shank 62 found that athletes who are committed to the re­
habilitation program work harder and thus return to com­
petition more quickly with better results than those who
are nonadherents. Their pain tolerance is greater and of
less concern, and they are more self-motivated, as opposed
to the apathy of the nonadherents.
Also, support from peers, coaches. and rehabilitation
staff is important in influenCing compliance.' Athletes
with support show a greater effort to fit the rehabilitation
effort into their schedules. They are more likely to keep
commitments to those who support them. Athletes who
arc nonadherents respond better to support and motiva­
tion from their support group than do the adherents. Thus
extra encouragement from this support group for the non­
adherent athletes can really pay dividends in getting them
motivated to successfully complete their rehabilitation .
Attitude is another important consideration when
dealing with injured athletes. If the athletic trainer expects
the athlete to be nonaciherent. this can create the self­
fulfilling prophecy. 74 If the athletic trainer feels the athlete
is going to be nonadherent, then it is less likely that the ath­
letic trainer will work to motivate the athlete to comply
with the treatment program. Webborn et al. 74 suggest that
if instructions are written down--even in the face of the
athlete's denial of the need [or written instruction-the
90 PART O:-';E The Basis of Injury Rehabilitation
Figure 4-10 A supportivc cnvironmcnt and a belief in
the cffectiveness of th e treatment improvcs compliance.
more likely it is that thc athlcte will follow through with
the treatmenl plan. Athletic lrail1ers have an impact on
compliance through enhancing lhe athlete's belief in the
efficacy of th e trcatment as well as providing a supporlive
environmentl 'J (Fig ure 4- 10).
Athletes are expected to report for rehabilitation. but
the coach is the disciplinarian. not the athlelic lrainer. and
the coach insUlu tes punishmen t for lack of participation
in the rehabilitation process. Thc coach must supporllhe
rehabilitation conccpt. Athletes soon know if rehabilita­
tion is nol a priority with thc coach and begin to lose in­
teresl if Lhey are nol high.!y molivaled to return to
compeiiLion.
The real challenge of rehabilitation is how to motivate
athlc1.cs lo do their besl in the rehabilitalion process. Ath­
Ictes who are not reporUng for rehabilitation have a rea­
son. Everything is don e for some nced. The rehabilitation
program must bc established within lhcse Ileeds. If ath­
letes arc not reporting for rehabilitati on. either something
is more impor tant to lhem th a n a hastened recovery. or
UJ(~y have nol had the imporlance of lhe process adc­
quately expLained to lhcm. Reexamine th e program and
the athlcle's goals. If lhe program has not been well ex­
plained and lhe alhlelc is not committed to the program.
the program cither is doomed to failure or will be less than
successful. IvloLivalion must come from within. but lhe
athlelic trainer can provide lh e encouragement and posi­
tive reinforcement necessary for the alhlcle to make a
commitment..
Lack of commilm cnt might indicate fruslraUon, bore­
dom. or feelings of a lack of progress. In this case. further
explanations or changes in routine are necessary. The ath­
lete might need the op portunity to comment on the Rehabilitalion
program and make a rommitment to the rehabi'litation be­ tbe aspecLS l
fore being structured into a strict regimen of rehabilitative Pain i
procedures. [hal lhe pain
The athlelic trainer should keep in mind that athletes is. Altbough •
may have many acti\7iUes in lheir daily schedules. and fit­ ure compliar
ting the rehabilitation to their schedul es rather than the ge nera l. it is n
reverse can also enco urage co mpliance. The more the a th­ [c Uc trainer l
lete is allowed input and llexibiJity. the more successful the the sy mptoJ1l>
eomp'liance will bc. wellin g is lbe
Another aspect of compliance has to do with a thletes ' the swelli ng b
perception of their ability. ALhleles who perceive them­ pain a nd disrfj
selves as continuing on to a more adva nced level of com­ the pain. Pain
petition tend to shirk rehabilitation. They usually are the justmen ts in
better alhletes. They do not have to work as hard as. but the amo unt of
perform better than. th eir peers. so th ey assume the same etitions ) shoul
attitude about rehabiJitalion. With this attitude. these team physiciar
good athletes never become truly great athletes becau se of Alhletes of:'
their lack of commitment to their sport. Oncc they have jured." But th
risen to the lop level where most athleles have the same lete. There is tb
skills. the work habit is nol lherc to put them in lhe top of the pain of reh
the elile alhlclic group. chronic pain ,
Other factors of compliance for athletes arc lhe length sity (O = n onel
of time at a particular school. semesler grade-poinl aver­
age. perception of class load . career goals. am ou nt of par­
ticipation time in contests . perception of time aVililable for
treatments. and previous experience with rehabilitation
programs. The more formal education a person has. the
higher the level of compliance to trealments; lhe higher
the semesler grade-point average. the higher thc treat­
ment compliance. Interesti ngly enough. an inverse rela­
tionship exists betwcen athletcs' perception of difficully of
their class load and compliance. orten athletes do bel.ler
academically durlng the scason than at other times. possi­
bly because they budget their time with better discipline
during the season. and this approach carries over in to th e
rehabilitation selling. Athleles wh o have beller-defined
career goals and those who have th e grealesl amount of
partiCipation time have high er levels of compliance. as do
those who perceive they have a greater a mount of time
available for lreatmcnts and those who have prcvious ex­ green. playi ng
pericnce wilh rehabilitati on programs. whist..le. or pia)
off unUllh e b
PAIN AS A DETERRENT
TO COMPLIANCE GoalSettil
to Complia
Almosl all rehabililation sho uld be pain-free. and what is
no t is usually detr im ental to the return to competition. Goal selling in
Painful exercise. therefore. is not only h ar mful bUl also re­ fccUve motlvatl
duces compliance. especially in the non adh erent alhleteY 8th/cUe injury
 CHAPTER 4 Psychological Considemtions for Rehabilitation of the Injured Athlete
Rehabilitation programs should be examined to determine
the aspects that may bc painful.
Pain is subjective, and the caregivers must assume
that the pain is as severe or persistent as the athlete says it
is. Although the symptoms of pain must be treated to en­
sure compliance, the ca use needs to be addressed. h8 [n
ge neral. -it is more productive in the long run for the ath­
letic trainer to determine the ca LIse of pain than to treat
the symptoms and disregard the ca use. For instance, if
swelling is the cause of th e pain, then treatment to reduce
the swelling is of a more lastin g bene!lt than treating the
pain and disregarding or masking the underlying cause of
the pain. Pain that persists and does not respond to ad­
ju stments in the rehabilitation process (e.g., decreases in
the amount of weights. number of sets, or number of rep­
etitions) should be reevaluated by th e athletic trainer or
team physician.
Athletes often say "You can play hurt, you can't play in­
jured." But the difference is in what pain means to the ath­
lete. There is the pain of performance. the pain of training,
the pain of rehabilitation, the pain of acute injury, and the
chronic pain of overuse. Pain can be assessed across inten­
arc the length sity (0 = none to 10 = worst) and quality (burning. aching,
e-poin t aver­ stabbing. stinging. etc.), but pain is subjective. Factors
o un t of par­ affectir1g pain can be culturc.'x type (contact verses non­
av ailable for conlac t) of sport,39 a nd indivicluall'ersus team sport. 44
rehabilita tion One technique for pain management that is frequ e ntly
r - n has. the used and easy to apply is disassociation. 11.7U Disassocia­
: the higher tion involves thinking about something other than the
", ber the treat- pain. such as a favorite location, a mountain cabin with
inverse rela­ the smell of fresh crisp a ir and the magnil1cent view of
of difficulty of mountains, or a beach collage with the feel and smell of
etes do better the salty breeze an d the calming rhythmic sound of the
r limes, possi­ surf. Another tactic is one :\orman Cousins ll used to dis­
Her c\bcipline tract his thoughts fr om intractable pain from cancer as
over in to the well as to prolong th e action of pain medication. He
better-de!lned watched funny. vintage. slapstick movies such as Laurel
'c t amount of and Hardy, the Three Stooges. an d Abbott and Costello.
plia nce. as do l\ny activity that engages th e mind can be used. 25 The
• iffi un t of time a thlete could visualize playing a round of golf from tee to
\e previous ex­ green. playing a footb all game from kickoff to the !lna!
whistle, or playing a finat ~CAA basketball game from tip­
off until the buzzer.
Goa~ Setting as a Motivator
to Compliance
_- ree. and what is
. LO competition. Goal setting ill and of itsel f h as been shown to be an ef­
...ruu l but also re­ fective motivator for compliance to rehabilitation of an
heren t athlete.
22 athletic inj ury lh.27 as well as reaching goals in a general
91
spo rt setting. 1<J .4.l Athletes have been setting goals since
lt hey started competing. usually from an early age. T hey
set goa ls to run faster. jump higher, shoot straighter,
throw longer. hit harder. and so on. T hese goals have a ll
had one thing in common, a nd that is that they were not
achieved with one burst of effort but ca me as the result of
m any s hort-term goals havin g been met prior to the
ac h ievement of the lon g-term goa l. For a comprehensive
expla nation on goal setLing in general. see Locke, 41 or for
goal setting speciflcally in sport, see Locke and Lath­
man. 43 Heil ll sugges ts nine gU ides for goal setting: It
should be specific and meas urable: use posilive rather
than negative language: be challenging but realistic: have
a timetable: integrate short-. medium-, and long-term
goals: li nk outcome to process: invo lve internalized goals;
involve monitoring and eva luating goals and sport goals
linked to life goals.
In athletic rehabilitation. a thl etes need to kn ow ex­
actly what th e goal is and have a sense that it ca n be met.
This could be accomplished by. for instance. telling a n a th­
letc that by a certain day the athlete should be partial
weight bearing with crutches. However, this is n either
speCific or measurable. It is more effective to say th a t by
achieving a certain range of motton and strength leve l,
the foot can be placed on Lhe ground with weight bearing.
The measurement of success is that the partial weight
bearin g is to be without pain . T he goal must be a chal­
lenge, but one th at th e athlete can reach with reasonable
rehabilitation effor t. Goa ls that are easily reached h a e no
reward in success. Goals must be personal and internally
satisfying, not imposed on the athlete by the coach or ath­
letic trainer. 'The setting of goals needs to be a joint ven­
ture between the athlete and the athletic trainer to be
suecessful. l ? The athlete has to take responsibility for th e
prog ress of the ,i njury and be responsible for doing the
necessary rehabilitati on .
Goal setUng incorporates a multitude of other motivat­
ing factors that intuitively a ppear to up the odds of compli­
ance by reducing the stress associated with injury
rehabilitation. These buffers incorporated within the goal­
setting paradigm include: positive reinforcement when
goa'ls are met, time management for incorporating goals
into a lifestyle. a feeling of soc ial support when goals are
set with the athletic trainer, the feelings of increased self­
effIcacy when goals arc achieved, etc. Goals should be easily
understood by athletes. be concrete, be active eve nts. and be
a natural part of their sport that requires no additional time
commitment. 9 Goals can be daily for a sensc of accomplish­
ment, weekly for a sense of progress. and monthly or yearly
for long-term achievement (Figu re 4- 1 1).
92 PART ONE The Basis of Injury Rehabilitation

Weeks 1-3 Set a goal to use relaxation techniques or abdominal breathing before and after treat­ player. AthIe!
ments. This will lessen the fear that can make pain more intense or more evident when to injury, espc
going from knee extension to weight bearing to balance exercises. Neglecti
Weeks 4-7 This block of time can be monotonous and frustrating. Athletes should set goals to use tion that th c~
imagery to see themselves using these movements in their sport. The imagery will be an and reinjury.
effective motivator to continue rehabilitation. the players 11
Weeks 8-11 The goal for this block of time is to use disassociation to handle the pain that accompa­ Some coacbt"
nies the increased use of muscles when jogging, rope jumping, and stair running. jured players
Weeks 12-15 Goals at this level should be more reality checks, such as "I am closer to returning to them in fro nl
play" or "I can see the light at the end of the tunnel." the athlete 1\"
Week 15 to Goals here are to remain positive and to use positive affirmations, such as "I am almost tactic might \
return to play there-each day I am getting stronger and more ready to play." but it only cal
who suffer SC1
Figure 4-11 Process goals for rehabilitation. Some coa
tell others the
isn't tough CD
trainer is easily intimidated by the coach and not backed
CLINICAL DECISION MAKING Exercise 4-6 ing frustra tio i
up by the athletic director and sports medicine physician.
this situation
Either situation results in poor medical care and leaves the
George is a second-year Division I goalie on the soccer be helpful. Co
managemen t vulnerable to legal action as a result of neg­
tea Ill. lie tore hi s ACL in the first game of the season. had nority. Durin g
ligence. Courts expect competent medical care to be pro­
surgery. and is now starting rehabilita lion . He is frus­ shows its can
vided to the athletes. That care can be provided only by a
trated with the projected length of reh abilitation and is athlete's loyal
qualil'ied athletic trainer or a sports medicine physician.
oven\'helmed lViUlthoughts of n ot being able to return to dermine the a
Flint and VVeiss 2i found that coaches returned players
his previous le\'e1 of play. What should the a thlete trainer be let down \\
on the basis of status and game situation, whereas athletic
do to help George establish attainable goals for his reha­ trolling the Of
trafners' decisions were determined by the player's injury.
bilitat ion program? derperform 0
Players who feel that a missed practice or a game will rele­
The athletic Q
gate them to the bench for the year, or those who have been
athlete to re<l
encouraged to play no matter what, are candidates for in­
same token t.q
RETURN TO COMPETITION jury and reinjury. Usually what happens, however. is that
broker and in
they are performing poorly because they are not at full
Showing the
The saying "YOll have to play with pain" has been inter­ strength, thus they only reinforce the coach·s decision to
speed can pr'
preted more literally to mean that the athlete has to play play someone else. The role of the athletic trainer is to de­
that the atb l
through an injury. The difference is that some injuries may termine when the player is Uunctionin g at optimal physical
be mild and only somewhat painful. resulting in no rein­ fitness without risk of injury or reinjury and to keep the
sary to get rea
jury in competition. whereas a more severe injury is made coach abreast of the player's status. It is important that the
worse by continuing to compete. The competitive athlete athlete have a clear perception of the injury and its Iimita"
might be more "body aware" than the general public and tions,u An important role of the athletic trainer is to in­ INTERPI I
therefore more apt to respond to injury with the us e of pro­ form the athlete of the difference between pain and injury.
tection, rest, ice. compression, and elevation (PR1CE) in or­ The at hlete who continues to play with all unhealed or
BETWEEj
der to promote healing. The general public, on the other poorly rehabilitated inj.ury is constantly reducing h er or ATHLETI
hand, is more likely to respond to the pain of injury rather his chances for a heah.hy life of physical activity. The ath­
The athleUc ti
than the healing process. i2 Therefore the athlete might lete has to live past the few years of competition. Most ath­
act with after
want to return to cOlUpetition in spite of pain, whereas the letes, however. have difficulty seeing past the present
ery. As a res
nona[jllete wants the pain to be treated before engaging in season, or at best have the goal of participating in their
athlete as a p
any activity. The importance of an athleli.c trainer for mak­ sport until they can no longer compete, regardless of the
enter the trea
ing the decision of when it is safe to compete and when consequences. The rewards of competition and the admi­
that the ath !
reinjury is a possibility is obvious. ration of others take sports out of perspective and retard a
and not just a
Unfo rtun ately, untrained personnel, such as fellow healthy attitude toward sports. 'J'he athlete's attitude is
letic train er I
teammates, parents, and coaches. assume this responsibil­ "Give it up for the sport" and ''['m invincible." Lack of this
and effort. Fi
ity when no athletic trainer is present or vvhen t'he athletic attitude is viewed by some as weakness or not being a team
a person befon
 CHAPTER 4 Psychological Considerations for Rehabilitation or the Injured Athlete
player. Athletes with this attitude have difficulty adjusting
to injury, especially a career-ending one.
Neglecting injured athletes or giving them the percep­
tion that they are "outcasts" also can contribute to injury
and reinjury. Coaches who foster this attitude are saying to
the players that they have no worth if they are injured.
Some coaches go so far as to prevent team contact with in­
jured players until they are ready to return, or to belittle
them in front of their peers. believing that this will make
the athlete want to get back to competition quicker. This
tactic might work with some players with minor injuries.
but it only causes major adjustment difficulties for athletes
who suffer severe injury.
Some coaches refuse to talk to the injured athlete, or
tell others that the athlete really doesn't want to play or
isn't tough enough. The coach and athlete are experienc­
ing frustration with the injury. Counseling the coach in
this situation to point out the effects of such attitudes may
be helpful. Unfortunately, these coaches are not in the tni­
nority. During this period, either the sports medicine team
..:are to be pro­ shows its concern for the athlete and in return wins the
ded only by a athlete's loya:lty and dedication down the road. or they un­
e physician. dermine the athlete 's trust and set up a futurc situation to
ur ned players be let down when the athlete gets in the pOSition of con­
ereas athletic trolling the outcome of a contest- the athlete might un­
layer's injury. derperform out of spite. Commitment is a two-way street.
T<lllle will rele­
The athletic trainer has to show their commitment to the
'ho have been athlete to receive commitment from the athlete. By the
didates for in­ same token the athletic trainer must not become thc power
wever, is that broker and in essence say" He can't play beca use I say so."
are not at full Showing the coach that the athlete who usually has 4 .5
~. decision to
speed can presently run only a '5.0 illustrates to the coach
L ;.:rainer is to de­
that the athlete is not ready for competition. It will also il­
'?limal physical lustrate to the athlete that more time and effort are neces­
d to keep the sary to get ready to return.
rtantthatthe
_. a nd its limita-
L rrain er is to in­ IIN TERPERSONAL RIE LATIONSH I P
in and injury. BETWEEN ATHLETE AND
an unhealed or
reducing her or ATHLETI,C TRAINER
uvily. The ath­ The athletic trainer is often the first person athletes inter­
li n. Most ath­ act with after injury and the one who will direct the recov­
l the present
ery. As a result. the athletic trainer has to deal with the
lpating in their athlete as a person and not as just an injury. When athletes
~ega rdless of the
enter the treatment setting. they should get the perception
and the admi­ that the athletic trainer cares for the athlete as a person
and not just as part of the job. Their perception of the ath­
·tc· · attitude is letic trainer makes a difference in terms of recovery time
." Lack of this
and effort. First they have to respect the ath lelic trainer as
"n l bclngateam a person before they can trust the athletic trainer in the re­
93
habilitative setling. Successful communication between
the athletic trainer and the athlete is essential for effective
rehabilitation. Taking an interest in athletes before injuries
have occurred enables the athletic trainer to know the ath­
letes' personalities and be able to work with them in help­
ing to build their confidence.
Active listening is one of the athletic trainer's most im­
portant skills. One must learn to listen to the athlete be­
yond the complaining. The athletic trainer should listen
for fear, anger. depression, or anxiety in the athlete and his
or her voice. With fear. the athlete might be wondering
what the pain means in terms of function and whether she
or he will be accepted by peers. Anger is often a feeling of
being victimized by the injury and the unfairness of it. A
depressed athlete will have an overwhelming feeling of
hopelessness or loneliness. Athletes who feel anxiety won­
der how they can survive the injury and what will happen
if they cannot return Lo full competition. 04
Body language is important as well. The athletic
trainer who continues to work on paperwork while talking
to the athlete is sending a message of noncaring. The ath­
letic trainer needs to be concerned, and look athletes in the
eye with a genuine interest in their problems. This will go
a long way toward gaining confidence and respect.
It is important for the athletic trainer to consider the
athlete as an individual instead of the "sprained ankle." If
the injury is the onbr consideration, the athlete becomes
just an injury and not a person. As a result t he attitude
projected to the athlete is just that, thus the athletic trainer
is perceived as caring for the athlete only superfiCially (Fig­
ure4-12).
The relationship between the athletic trainer and the
athlete should be one of person to person and not of a
coach to a player or one of a judgmental nature. When the
athlete is treated as an equal. the relationship is improved,
and it helps the athlete accept responsibility for his or her
own rehabilitation. With injury a,thletes lose control over
their physical eflorls. They have gone from 4 or .5 hours a
day of practice or competition to no activity. They are in a
temporary lifestyle change. Their feelings are going to af­
[ect the success or failure of the rehabilitation process. The
athletic trainer must establish rapport and a sense of gen­
u,ine concern and caring for the athlete, who is not fooled
by superfkiality.
During an injury evaluation, the athletic trainer
should allow the athlete to provide as much input about
her or his injury as possible. Paraphrasing or restaling the
information to the athlete will be invaluable to the athletic
trainer who is unsure of the mechanism of injury or its re­
sults. Statements such as "I see" or "Go ahead" or Simple
silence to allow athletes to fully express themselves are of
94 PART ONE The Basis of Injury Rehabilitation

Ie or un
Type of athletic trainer Knowledgeable Convincing Sincerely concerned Frequentll
pon pla)'ed. ,
.Un> can be.a
Great athletic trainer X X X
_-ulture and 11
Good athletic trainer X X 0 urc. Ton
frustrntir. =­
Fair athletic trainer X 0 0 The ty,
Quack 0 X 0
h-esmorl

Bad athletic trainer 0 0 0 Summa

Figure 4-12 The effectiveness of an athletic trainer is based on three factors.

value. One of the most important bits of information can
be the question posed at the end of gathering subjective in­
formation: "vVhat else have [ not asked you or do [ need to
know about this injury?" Then give the athlete input into
the decision of where to go from here.
The athletic trainer is often the person who effectively
explains th e injury to the athlete. Care should be taken to
explain the situation to the athlete in understandable
terms. In most cases the simplest explanation acceptable to
the athlete is the best. With mild and moderate injuries,
the use of the term sprain, strain, or bruise su fllees. The ex­
ample of a sprained knee and torn ligaments of the knee
can be descriptions of the same grade II injury, but the ath­
lete might interpret the two terms altogether differently
and react in a totally different way to the explanation.
Athletes must have injuries explained to them to their
satisfaction. Disseminating injury information appropri­
ate to athlete's emotional and intellectual level can be a
real challenge. The rate and degree of acceptance is not the
same with all athletes. Severity of injury is certainly im­
portant, but the athlete's perception of that severity is
what matters in the rehabilitation process.' J Thus the
physiological must be interrelated with the psychological.
In working with athletes, the athletic trainer should be not
only empathetic but also nonjudgmental.
The addition of a sport psychologist to the rehabilita­
lion team can facilitate the athlete's transition from the
sport culture into the rehabilitation culture. Each culture
has specinc rules as well as denned roles that the members
of that culture must follow. An understanding of the dif­
ferent rules and roles can assist the athlete's transition af­
ter the injury from the sport culture to the rehabilitation
culture. The role of the sport psychologist is to understand
the impact this transition has on the athlete who is injured
and has to assimilate into a totally new environment. fol­
low new rules, and aSSllme a new role. For example, the
concept of pain in the football culture is entirely differellt
from the concept of pain in the reh abilitation culture. rn
the football culture, "Suck it up" and "Play through the
pain" are the norm. In the rehabilitation culture. pain can
be an indication that needs to be evaluated. The athlete
and athletic trainer need to reevaluate the rehabilitation
exercises or activity level, decrease the amount of repeti­
tions, change the type of exercise. or to consult with the
team physician. If tbe pain is something the athlete must
assimilate into his or her lifestyle, then the sport psycholo­
gist can teach the athlete how to deal Vlri th it. This can be
done through pain management (dissociation) or pain
perceptions (pain versus soreness).
The amount of stress associated with playing a sport, References
and the meaning the sport has to the athlete, can impact
the athlete's compliance with rehabilitation. 2 The athlete
has a more successful rehabi'litation when engaged fully in
the activity of rehabilitation, much as the athlete will have ,
a more successful sport career when more interested and
involved! in the sport. Stress can be a deterrent to engaging
in rehabilitation. Several techniques the sport psychologist 3.
can use (relaxation, imagery, cognitive restructuring.
thought stopping) can lessen the stressful reaclion to in­
jury. Oft.cn a change in Ihe athlete's perception of the in­
jury and rehabilitation can affect outcome. Systematic
rationali~ationh7 can facilitate changing the athleLc 's rcac­ fl.
tion to injury and rehabilitation through changing how
the athlete perceives events.
Returning to competition is another area where the
sport psychologist can help the athlete. Often athletes per­
ceive themselves as rcady to return but not being a'llowed
to. or as being forced to rcturn before ready. The sport psy­
chologist can assist thc athlete to make a decision based on
'J.
the facts and not clouded by emotions.
The addition of a sport psychologist to th e sports med­
icine team can be an effective link when athletes are un-
 CHAPTER 4 Psychological Considerations for Rehabilitation of tbe Injured Athlete
able or unwilling to continue to participate in their sport.
erned Frequently an athlete's identify is intertwined with the
sport played. The transition into a completely different cul­
ture can be a traumatic experieI1ce. it is stressful to enter a
culture and not know one's place or identity in that cul­
ture. To not know what the game is and what the rules are
is frustrating for the injured athlete.
The treatment of athletic injury and rehabilitation in­
volves more than the physical, emotional, and psychologi­
Summary
1. There are no absolutes when it comes to how an ath­
lete will react to an injury. However, there are some
rely different
guidelines for progressive reactions to injury based on
n c ulture. In
length of rehabilitation. These guidelines allow the
th rough the
athletic trainer to conceptualize individual stress reac­
ure, pain can
tions to injury and to implement psychological inter­
~u. he athlete
ventions to facilitate successful rehabilitation.
rehabilitation
2. The athlete must take responsibility for rehabilitating
unt of repeti­
his or her injury, but the inLerpersonal relationship be­
u lt with the
tween the athlete and the sports medicine team can
athlete must
promote a positive adjustment to the rehabilitation
rt psycholo­
process .
. Th is can be
don or pain
~ ing a sport. References
e. can impact 1. American Academy of Orthopaedic Surgeons. 1991. Ath­
~ The athlete leLir training and sports medicirle. 2d ed. Park Ridge. 11: Amer­
.ga ged fully in ican Academy of Orthopaedic Surgeons .
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- l {Q engaging
Sport alld Exercise Psychology 10:294-306.
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psychologist
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. being allowed
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-h lctes arc uo- 8:176-88 .
9S
cal[ aspects of the individual. The impact of the environ­
ment. the support of the athletic community. and the cul­
ture in which the athlete resides at the time of injury
combine to influence the course the athlete takes from in­
jury, through rehabilitation, to return to competition.
Treating the athlete's physical injury and attending to the
extraneous factors ,i nfluencing the injured athlete are t he
chaUenges faCing the sports medicine team.
3. The use of psychological techniques such as di sassoci­
ation for pain management. the use of buffers for
stress reduction , and goal setting for motivation can
assist the athlete in taking control of and managing
her or his successful rehabilitation .
4. The key to successful rehabilitation is compliance. Ad­
vances in the l1eld of medicine have allowed injuries
that 10 years ago would have ended an athlete's ca reer
to now be successfully repaired. Without compliance
to the rehabilit a tion process, these medical advances
are moot.
10. Carron. A. V. 1984. Motivation: ImplicationsJor coachillg and
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13. Crossman . J.. and J. Jamieson. 1985. Differences in percep­
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23:.52-58.
IS. Cupal. D., and B. Brewer. 2001. Effects of relaxation and
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96 PART ONE The Basis of [njury Rehabilitation

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delete
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4-2 The al~
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 CHAPTER 4 Psychological Considerations for Rehabililation of the Injured Alhlete
'iH. Sanderson. l'. 11. 1992. Psychology ilnd injury prone ath­
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contracting
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165-72.
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York : Random
SOLUTIONS TO CLINICAL DECISIONI MAKING EXERCISES
ceberg profile.
-bologica l char­ 4-1 Julie and the athletic trainer sat down and mapped
,Ials o} the New out a plan to fit what she needed to get accom­
plished into a reasonable amount of time. Julie first
erapists' per­ made a list of her priorities. She decided just what
mi ury rehabili­ activities she l1eecled lo get done and whieh ones she
91-206 .
delete or postpone. After 'he had the list of neces­
illjur!l: Diag­
sary activities, she block.ed out several 30-minute
ndoo: Butler-
stretches of Lime fOT "catch-up" or "thinking lime."
of athletic in­
These 30-minute periods allow Julie to not be 4-3 The athletic trainer and Dana will work on chang­
r t on women
rushed throughout the enlire day. Juli e and th e ath ­ ing the negatives to positive in two ways. The first is
.'11 7- 38. letic trainer were able to combine activities to save
-:.eptember. time and to come to the athletic training room on
.1 993. Injuries orr-hours when it was less crowded. Julie came to
'am JOllmal oj realize that, with a bit of creativity and some orga­
nizational skills, she could use time management as
Il/mUO/lal stress
a buffer for stress. play the video in her mind of the correct result.
rdl Lhesis. Poly­
4-2 The athletic trainer helped Tim realize that his whole
body and mind n eed to be rela xed by using the pro­
Injured atb lete.
-uland. Philadel­ gressive relaxation technique. By tightening and re­
laxing all his muscle groups in progression, Tim was
97
68. Taylor, I.. und S. Taylor. 1998. Pain education and manage­
ment in the rehabili tation from sports injury. Sport PSijChol­
69. Tomlinson. C. 2000. Siillple !!oya. Edison. f) : Castle.
70. Turk , [). C.. D. Meichcnbaum. and M. Genest. 1983. Pain and
York: Guilford Press.
71. Valiant, P. M. 1981. Personality and injury in competitive
rUntlers. Perccptual and Motor Skills 53:251- 53.
72. Vincent, P. ] 971. Factors influencing patient 'ompl,iance: i\
Lheoretical approach. N ursillg Rcsenrclz 20:509 - 16.
73. Vinokur, A., and M. L. Selzer. 1975. Desirable vers ns unde­
sirable life events: Their relationship to stress and distrcss.
]ollmaloJ PerSOllulity alld Social Psycho lOllY 32: 3 29- 37.
74. Wcbborn, A. D. j .. R. J. Carbon, and B. P. Miller. 1997. Injury
rehabilitation programs: "I-\'hat are we talking about?"
JoumaloJ Sport Relzabilitatioll 6:54-61.
75. Werthner, P.. ondT. Orlick. 1'186. Retirement experiences of
successful athletes. Ifltematiollal Journal oj Sport Psychology
17:337-63.
76. Wiese, D. M., and M. 'R. Weiss. 1987. Psychological rehabil­
itation and physicul injury: Implicaiions for the sports med­
icine team. Sport Psychologist 1:3 18-30 .
77. Williams,J. M.. T. D. Hogan . and M. B. Andersen.l993. Pos­
itive states of mind and injury risk. Psychosolllntic Medicine
55:468-72.
78. Wolff. B. B. 1985. Ethnocultural factors inl1uencing pain
and illness behavior. Clinical Journal oj Pain 1:23- )0.
79. Wortman. C. B.. and R. C. SUver.1989. The myth of coplng with
loss. ]oumal oj Consultillg and Clinical PSYc/lOlaa!J 57: 349-57.
able to have a low-intensity workout for the high­
intens ity motion s to be performed during the match.
Tim also did some yoga abdominal breathing, which
cleared his mind and a llowed him to become more
centered. This amounts to a mind and body dress re­
hearsal for the performance match. Tim w as then
able to go out and play in a more relaxed state with
less pain and a more Iluid motion.
by changing the words such as can't to enn, won't to
positive terms like will. Por example: "I enn swing my
club freely" or "My turn is smooth." The second
change can be in the mental picture she has of her­
self hitting the shot. This works best if Dana can re­
much as one retapes over an existing video. She can
see herself swinging the club without pain in a very
Iluid and effortless manner. In her mind she can
project that image on her mind-tape. Dana will
98 PART ONE The Basis of Injury Rehabilitation
become very imaginative at creating the tapes she
chooses to have in her mind's recorder.
4-4 The athletic trainer will need to continually remind
Christine that rehabilitation will help her back. Offer
examples of athletes who have returned from back
problems. Allow Christine to vent her irrational
thoughts, but counter them with reality checks such
as "Just last year one of your teammates came back
from back problems and is diving now." The athletic
trainer can work with Christine to keep her assess­
ment of her condition based on the medical facts, not
her irrational fears.
4-5 Joe and the athletiC trainer need to discuss what
Joe's options are for the future. Joe first must decide
if he wants to stay in sports. or rethink his career
goals. He can use imagery to daydream what it
would look like and feel like to be in another field. Joe
can "see" himself as a color commentator for the
NFL and get some idea of what that experience
would involve. A different field entirely may suit his
personality and he can explore his options . It is ,im­
portant that he see the career change as a challenge
to be overcome, not a defeat. This will be long and
rocky process, and one he has been forced to take.
What he does have control over is choosing how he
sees himself in a new role. Imaging allows him time
to get used to his new identity.
4-6 The athletic tra'i ner and George start with short­
term goals to make the process more manageable
and allow George to aCQieve satisfaction with short­
term accomplishments. George and the athletic
trainer set goals that are realistic, positive, and meas­
urable. These process goals can be monitored and
measured. George is now able to see that the plan is
in place and the end is in sight. Process goals act as
stepping stones to the end result. George under­
stands that he is moving forward toward the long­
term goal of returning to play.
•
~
may suit his PART TWO

. II is im­
a ch allen ge

Achieving the Hoals

of Rehabilitation

fge nnder­
rd t he lon g-

5 Reestablishing Neuromuscular Control

6 Restoring Range of Motion and Improving ,Flexibility

7 Regaining Muscular Strength, Endurance, and Power

8 Regaining Postural Stability and Balance

9 Maintaining Cardiorespiratory Fitness during Rehabilitation

 CHAPTER 5
Reestablishing Neuromuscular
Control
Scott Lephart
C. BllZ Swanik

Freddie Fu

Kellie Huxel

~
.----­
which encoml
lion . restorali
Study Resources • Recognize the importance of feed­ well as psycho
To become more familiar with the knowledge and skills forward and feedback neuromuscular In the dOlI
necess ary to design . impicment. and document therapeu ­ basic science l'
tic rehabilitation programs as identified in the ;\lATA Ath­
control.
and /or mOlor
letic Training rllumlional COlllpetelicies and Clinical romuscul ar c~
• Identify the various techniques for
Prujicifllcies' Therapc.ulic ExcTcise content aTea , visit articular an d i
ww w.mhhe.com/prenticcll e. Also. refer to the Jab exer­ reestablishing neuromuscular control
cular control
cises ill the new Laboratory Manual and to eSims, which in both the upper and the lower to the individ~
simuJ8tcs the athletic training certifi cat ion exa m, at extremities. such as th e
www.mhhe.com/csirn.:;. For more onlin e study reso w-ces, stabilize an d Ii
visit our llcalth and Human Performance website at chanical res
11'\\'w.mhhe.com/hbJ2.

After Completion of This

Chapter, the Student Should

sition sensati
Be Able to Do the Following:
been implic,
ness. 3. 50. ; 1.8~ I
• Explain \'",hy neuromuscular control is WHY IS NEUROMUSCULAR ing, is one of j
essential in the rehabilitation process. dynamic reSL
CONTROL CRITICAL TO THE tween joint ~
• Define proprioception, kinesthesia, and REHABILITATION PROCESS? appreciation fl
tern prior to a
neuromuscular control Reestablishing neuromuscular co ntrol is a criUcal compo­ Injury to
nent in the rehabilitation of pathological joints. The objec­ chanical dist ul
• Explain the physiology of articular and tive of neuromuscular control activities is to refocus the addition to Ii g~
tenomuscular mechanoreceptors. athlete's awareness of peripheral sensations and process ripheral mec ~
these signals into more coordinated motor strategies. This is referred to
• Describe the afferent and efferent muscle activity serves to protect joint structures from ex­ ferentation d~
neural pathways. cessive strain and provides a prophylactic mechanism to joint stabilizatl
recurrent injury. Neuromuscular conirol activities are in­ is substan tiaJ
te nded to complement traditional rehabilitation protocols. muscle activi
100

 CHAPTER S Reestablishing Neuromuscular Control 101

r
r
Repetitive injury
Ligamentous injury

I LI___ln_s_ta_b_i_lit_y_ _-, Proprioceptive

deficits

L,- - - - - -, 1
Functional· instability
Deceased neuromuscular
control

Figure 5-1 Functional stability paradigm depicting the influence of me­

chanical instability and proprioceptive dellcits on neuromuscular control
and functional stability, which predisposes Lhe knee to repetitive injury,

which encompass the modulation of pain and inflamma­ rupted neural pathways.lLiJ.52.69,90.I01./07 Therefore, joint
tion. restoration of f1exibility, strength. and endurance, as pathology not onIy reduces mechanical stability. it often di­
well as psychological considerations. minishes the capability of the dynamic restraint system.
In the domain of joint motion and position awareness, rendering the joint functionally unstable (Figure 5-1),
basic science research has provided insight into the sensory The goal of reconstructive surgery is to restore me­
and / or motor characteristics of structures regulating neu­ chanica'! stability, but recent evidence strongly supports
romuscular controL Peripheral mechanorecepLors within the reinnervation of graft tissue by peripheral receptors,S7
articular and tenomuscular structures mediate neuromus­ Therefore surgery. combined with rehabilitation, pro­
cular control by conveying joint motion and position sense motes several neuromuscular characteristic associated
Lo the individual. The primary roles of articular structures' with the dynamic restraint system. 72.74 Clinical research
such as the capsule. ligaments, menisci, and labrum are to has reveaJed a number of act'ivities that enhance these
stabilize and gUide skeletal segments while providing me­ characteristics and are benencial to developing neuro­
chanica'i restraint to abnormal joint movements, J 10 How­ muscular control.]7,44.]OI '1'0 accomplish thi's, clinicians
ever. capsuloLigamentous tissue also has a sensory role must identify the peripheral and central neuromuscular
essential for detecl,i ng joint motion and position,l9.5b.94 characteristics that compensate for mechanical insuffi­
Tenomuscular receptors contribute to joint motion and po­ ciencies and encourage these adaptations to restore func­
sition sensation via changes in muscle length, and have tional stability,
been implicated in the regulation of muscle sliff­ Rehabilitation of t.he pathological joint should address
ness,3.50.51.86 Increased muscle stiffness, prior to joint road· the preparatory (feed-forward) and reactive (feedback)
ing, is one of the most important mechanisms utilized for neuromuscular control mechanisms required for joint
.AR dynamic restraint of jOints,95 Recently, the interaction be­ stability, Four elements crucial for reestablishing neuro­
THE tween joint and muscle receptors has received even greater muscular control al1d functional stability, The four ele­
S? appreciation for contributing to the dynamic restraint sys­ ments are joint sensation (position. motion, and force).
tem prior to and succeeding joint pathology,lo.29.S] dynamic stability. preparatory and reactive muscle char­
criti cal compo­
Injur~' to articular structures results not only in a me­ acteristics, and conscious and unconscious functional
iot . The objec­
chanical disturbance. but also in a loss of joint sensation, In motor patterns,7J
. LO refocus the
addition to ligamentous tears, microscopic nerves from pe­ The follOWing sections will denne the sensory recep­
ns and process
ripheral mechano receptors may also be damaged; this tors and neural pathways that contribute to normal joint
stra tegies, This
is referred to as deafferentation,52.92.97 This partial deaf­ stabilization, The theoretical framework for reestablishing
-LLITeS from ex­ ferentation disrupts sensory feedback necessary for reflexive neuromuscular control will be presented, followed by spe­
- mechanism to
joint stabilization and neuromuscular coordination, There c!ftc activities designed to encourage the peripheral,
activities are in­
is substantial evidence suggesting that the aberrations in spinal. and cortical adaptations crucial for improving
ation protocols.
muscle activity subsequent to jOint injury are a result of dis­ functional stability.
102 PART TWO Achieving the Goals of Rehabilitation

WHAT IS NEUROMUSCULAR THE PHYSIOLOGY OF the stretch se

mechanism (
CONTROL? MECHANORECEPTORS the capaci!)' l(
Proprioception refers specillcaJly to conscious and un­ Golgi tend
conscious appreciation of joint position, whereas kines­
Articular Mechanoreceptors ing muscle a,
thesia is the sensation of joint motion or acceleration.~i muscle ten siO!
The dynamic restraint system is mediated by speCialized
The perception of force is an ability to estimate joint loads. nerve endings ca'iled mec hanoreceptors. 38 A mechanore­ tenomuscular
These signals are transmitted to the spinal cord via affer­ to protect the
ceptor functions by transdUCing mechanical deformation
ent (sensory) pathways. Conscious awareness of jOint mo­ of tissue (e.g., stretching, compression) into frequency­ muscle act h'a
tion. position, and force is essential for proper joint modulated neural signals. lS Increased tissue deformation damage. Then
function in sport and activities of daily living, while un­ spindles by pre
is coded by an increased afferent discharge rate or a rise in
conscious proprioception modulates muscle function and muscle being I
the quantity of mechal1oreceptors activated. lo .41 These
initiates reflex stabilization. The efferent (motor) response signals provide sensory information concerning internal
to sensory information is termed neuromuscular con­ and external forces acting on the joint. Three morphologi­
trol. i4 Two motor control mechanisms are involved with cal types of mechanoreceptors havc been idenlifled in the NEURAL
interpreting afferent information and coordinating el'fer­ knee: Pacinicll1 corpuscles, Meissner corpuscles, and free PERIPHE
ent responses 24 .'i\ Feed-forward nelirOilluscular collLml in­ nerve endings.29.3H.ss These mechanoreceptors are classi­
volves planning movements based on sensory information lIed as either quick adapting (QA), because they cease dis­ Understandin!
from past experiences.24.6i Tbe feedhack process continu­ charging shortly after the onset of a stlmulus, or slow muscular sen
ously regulates muscle activity through reflex pathways. adapting (SA). because they continue to dischClrge as long of the rellex il'f
feed-forward mechanisms are responsible for preparatory as the stimulus is presenl. I9.Z9.18.of>.93 In healthy joints, QA eral afreren lS.
muscle activity: feedback processes are associated with re­ mechanoreceptors are believed to provide conscious and an.d position al
active muscle activity. Because of skeletal muscle's orien­ unconscious kinesthetic sensations in response to joint afferent path
tation and activatiol1 characterisl.ics, a diverse array of (CNS).l(1.29 \\1
movement or acceleration while SA mechClnoreceptors
movement capabilHies can be coordinated involving con­ proVide continuous feedback and thus proprioceptive in­ numerous con
centric. eccentric. and isometric contractions. while exces­ formation relative to jOint position. 19 .I1.3 H.% Debate exists maLion may t
sive joint motion is restricted. Therefore dynamic restraint over the relative contribution of artieular afferents in the pathways. ASII
is achieved thr ough prep<lratory and reflexive neuromus­ dynamic restraint system , because mechanoreceptors in cortex provid
cu 'ar control. 23 .t·1.lS.39.47 articular structures appear to be stimulated only when un­ and hl1esthes'
The level of muscle activa tion, whether it is prepara­ der considerable loads. 99 Sensory organs in the musculo­
tory or reactive, greatly modifies its stiffness proper­ tendinous unit largely provide continuous feedback
ties.8 6 .92 From a mechanical perspective, muscle stiffness during submaximalloading.
is the rutio in the change of force to the change in
length. l .n 2' In essence. muscles that are more sUff resist
stretching episodes more effectively and provide more ef­ forward ne
Tenomuscular Mechanoreceptors
fective dynamic restraint to joint displacement. 3 .8o postuwl con t
Electromechanical deJay (EMD) is a period of time that Changes in joint position are accompanied by simultane­ Balance is in
elapses between the arrival of a neural impulse (electri­ ous alterations in muscle length and tension. ;\i!uscJe spin­ mechanism t
cal) initiating muscle contraction and the development o ~ dles. embedded within skeletal muscle, detect length <lnd tially depen d
force (mechanical). rate of length changes, transmitting these signals by way of joint pOSition 1
Clinical studies have recently established the impor­ afferent nervcs.'UIl.4J Muscle spindles are also innervated with neuroml!
tance of muscle stiffness in the dynamic restraint sys­ by small motor nbers called gamma efferents. 4.4 1.68 This in­ qucntly used
Item.Hdl.IflO In the knee, for example, increases in dependent arrangement of sensory and motor fibers per­ defici ts can r
hamstring muscle activation also signillcantly increased mits the muscle spindle to accommodate for muscle length loop of tRe lov
hamstring sUffness. and there is a moderate correlation and rat,e of length changes while continuously transmit­ Synapses
between the degree 01' muscle stiffness in ACL-deflcienr ting afferent signals. M1 Muscle spindle afferents project di­ ticular and tel
athletes and their functional ability.oo.lou Therefore, effi­ rectly on skeleta l motoneurons through very fast nerves. cOllsli
cient regulation of muscle stillness- aught embody all of monosynaptic reflexes. 109 When muscle spindles arc stim­ formation an d
the ~omponents in tile dynamiC restraint system, .and thus ulated, tbey elicit a ref1lex contraction in the agonist muscle. link contribm
be vital for restoring functional stability. Increased signals from the gamma motor nerves heighten back process
 CHAPTER 5 Reesta blishing Ne uromuscular Control 103

the stretch sensitivity of muscle spindles. 5o . 5 ! This is the terneurons within the spinal column also connect articu­
mechanism (stretch reflex) whereby muscle spindles have lar receptors and GTOs with large motor nerves innervat­
the capacity to mediate muscle activity. )0.82.109 ing muscles and small gamma motor nerves innervating
Golgi tendon organs (GTO) are also capable of regulat­ muscle spindles. Johansson; ! contends that articu,l ar af­
ing muscle activity and are responsible for monitoring ferent pathways do not exert as much influence directly on
musclc tension or load. 27.~R Located within the tendon and skeletal motoneurons as ,prcviously reported, but rather
_ b~ specialized they have more freq L1ent and potent effects on muscle spin­
tenomuscular junction, GTOs are force detectors and serve
-\ m cchanore­ dles. Muscle spindles, in turn, regulate muscle activation
to protect the tenomuscular unit by reflexively inhibiting
:-al deformation through the monosynaptic stretch reflex. Articular affer­
muscle activalion when excessive tension might cause
o frequency­ ents therefore have some influence on the large skeletal
damage. Therefore GTOs have the opposite effect of muscle
deformation motor nerves as well as the tenomuscular receptors, via
spindles by producing a reflex inhibition (relaxation) in the
rate r a rise in gamma motor nerves. 30.i 1.51
muscle being loaded. ) 8.48
ed. J 041 These This sophisticated articular-tenomuscular link has
rr)in g internal been described as (he "final common input."l.5l The final
morphologi­ common input suggests that muscle spindles li ntegrate
mi fied in the
NElJRAL PATHWAYS OF
peripheral afferent information and transmit a final mod­
les. and free PERIPHERAL AFFERENTS ified signal to the (CNS).l .;l This feedback loop is respon­
r are classi­ sible for continuously modifying muscle activity during
Understanding the extent to which articular and tcno­
• hey cease dis­ locomotion via the muscle spindle's stretch reflex
muscular sensory information is utilized requires analysis
ulus. or slow arc. 4 ;.R6 By coordinating reflexive and desce nding motor
of the renexive and cortical pathways employed by periph­
h arge as long commands. muscle stiffness is modified and dynamic sta­
eral afferents. Encoded signals concerning joint motion
y joints, QA bility is maintained. 51.6 1
and position are transmitted from peripheral receptors , via
nscious and
afferent pathways, to the central nervous system
nse to joint
an oreceptors
(CNS).21;.29 Within the spinal cord, interneurons proVide FEED·FORWARD AIN D FEEDBAC'K
numcrous connections (synapses) so that the same infor­ NEUROMUSCULAR CONT,ROL
. ceptive in­
mation may be transmitted along a variety of different
De bate exists
pathways. Ascending pathways (tracts) to the cerebral The elTerent response of muscles transforming neural in­
~ eren ts in the
cortex provide conscious appreciation of proprioception formation into physical energy is termed neuromuscular
receptors in
and kinesthesia. Two reflexive pathways couple articular control. 34 Traditional beliefs about the proczessing of affer­
nJy when un­
receptors with motor nerves and tenomuscular receptors ent signals into efferent responses for dynamic stabiliza­
ilie musculo­
in the spinal column. A third monosynaptic reflex path­ tion were based on reactive or feedback neuromuscular
us feedback
way links the musclc spindles directly with motor nerves. control pathways.hR1"[ore contemporary theories empha­
Sensory information from the periphery is utilized size the significance of preactivated muscle tension in an­
by cerebral cortex for somatosensory awareness and f'eed­ ticipation of movements and joint loads. The
forward neuromuscular controL whereas balance and preactivation theory suggests that prior sensory feedback
ptors postural control are processed at the brain stem.20.JI.41.55 (experience) concerning the task is utilized to prepro­
b} imultane­ Balance is influenced by the same peripherall afferent gram muscle activation patterns. This process is de­
\ luscle spin­ mechanism that mediates joint proprioception and is par­ scribed as feed-forward neuromuscular conlrol."l.25.l7.h5
length and tially dependent upon the inherent ability to integrate Feed-forward motor control utilizes advance information
a ls byway f joint position scnse. vision. and the vestibular apparatus about a task. usually from experience, to preprogram
I- innervated with neuromuscufa r control. Balance, therefore, is fre­ muscle activity. 24.hi These centrally generated motor
,. -11. 68 This in­ quently used to measure functional joint stability, and commands are responsible for preparatory muscle activ­
lOr fibers per­ deficits can result from aberrations in the afferent feedback ity and high-velocity movements. 55
m uscle length Iloop of the lower extremity. Preparatory muscle activity serves several functions
usl transmit­ Synapses at the spinal level link afferent fibers from ar­ that contribute to the dynamic restraint system. By in­
nts project di­ ticular and tenomuscular receptors with efferent motor creasing muscle activation levels. the stiffness properties of
gh very fast nerves, constituting the reflex loops between sensory in­ the entire tenomuscular unit arc increased. s 1 This in­
dles are slim­ formation and motor responses. This reflexive neuromotor creased muscle aclivation and stiffncss can drastically im­
ago nist muscle. link contributes to dynamic stability by utilizing the feed­ prove the stretch sensitivity uf the muscle spindle system
"ler\'es heighten back process for reaclive muscular activat-ion.! l.90.99 fn- while redUCing the electromechanical delay required to
104 PART TWO Achieving the Goals of Rehabilitation

r 1'00""" m"~" "iff",~ I 1 proprioceplior

ical joints. 8. 5~
with congen it
ished capabili
lion. 30.33.98
Decreased Increased spindle characteristi c~
electromechanical delay stretch sensitivity to functional i i

LI
Developin~
sia, and neurOI
Eeff",'" ""Ii" I..-JI
muscle characteristics
minimize the I
sioning and rC(
bilitation. is (

~ kinesthetic al\"
involved lim bs.
Increased dynamic restraint capability Theobj ecu
velop or reesu
Figure 5-2 Diagram depicting the influence of muscle stiff­ tbat enhance I
ness on electromechanical delay and muscle spindle sensitiv­ to in vivo load
ity, which enhances the reactive characteristics of muscle for lishing neuroll
dynamic joint restraint. 11) propriocepl
joint stabil izat
develop muscle tension.21.2 J.39.47.52.HO,63.92 Clinical re­ passes through a sequence of synapses, the synapses be­ and (4) fun cti.
search has also shown that the stretch reflex can increase come more capable of transmitting the same signal. 4 1. 46 joint thes e drru
muscle sLiffness one to three limes. 42 ,7> Heightened stretch When these pathways are ;ofacilitated" regularly, memory lack of statiC'
sensitivity and stiffness could improve the reacLive capabil­ of that signal is created and can be recalled to program fu­
ities of muscle by proViding additional sensory feedback ture movements. 41 Frequent facilitation therefore en­
and superimposing stretch reflexes onto descending motor hances both the memory about tasks for preprogrammed
commands.2l. ll,8J motor control and reflex pathways for reactive neuromus­ lenance of [lo
Whether muscle stiffness increases stretch sensitivity cular control. Therefore, rehabilitation exercise must be indude the
or decreases electromechanical delay, it appears to be cru­ executed with technical precision, repetition, and con­ , ion of affer
cial for dynamic restraint and functional stability (Figure trolled progression for these physiological adaptations to
5-2). Preactivated muscles therefore can provide quick occur and enhance neuromuscular control.
compensation for external loads and are criUcal for dy­
namic joint stabili ty2U 'J Sensory information about the
task is then used to evaluate the results <:Ind help armnge REESTABLISHING ing dynamic
future muscle activation strategies. Althougb
NEUROMUSCULAR CONTROL lechniques sh
The feedback mechanism of motor control is charac­
teri2ed by numerous reflex pathways conLinuously adjust­ Ati1letes who have sustained damage to the articular lions to theSt'
ing ongoing muscle activity. J4,24,6H,I>l Information from structures in the upper or lower extremities exhibit distinc­ neuromuscul ,
joint and musclc receptors refleXively coordinates muscle Live proprioceptive. kinesthetic, and neuromuscular rehabilitatio n j
activity toward thc completion of a task, This feedback deficits. 5. 11.1 1.67M.74.76,9>,9(,,98.107 Although identifying de activity. 11 ~
process, however. can result in long conducLion delays and these abnormalities might be difficult in a clinical setting, a closed-kinetic
is best equipped for maintaining posture and regulating thorough appreciation of the pathoetiology of these condi­ and high-repej
slow movements. " The ef'lleacy of reflex-mediated dy­ tions is necessary to guide clinicians who are attempting to through rea CI
namic stabili b.a tion is therefore related to the speed and reestablish neuromuscu lar control and functional stability. and biofeed b
magnitude of joint perturbations. It is unclear what rela­ • Most researchers believe that disruption of the articu­ companied by
tive contribution feedback mediated muscle reflexes pro­ lar structures results in some level of deafferentation to eial adaptatj
vide when in vivo Loads are placed on joints. ligamentous and probably capsular mechanorec.ep­ responsible fOl
Both feed-forward and feedback neuromuscul.ar con­ tors.27 ,2 8.n 7M .70,7~,'J(, . 98 Tn the acute phase of healing. joiot their efficien
trol can enhance dynamic stability if the sensory and mo­ inflammation and pain can compound sensory deficits; Tn order t
tor pathways are frequently stimulated. Each time a signal however, this can not account for the chronic defiCits in sary for fune

proprioception and kinesthesia associated with patholog­
ical joints.8 . 58 Research has demonstrated that athletes
with congenital or pathologica l joint laxity have dimin­
ished capability for detecting joint motion and posi­
tion. ' I)·ll.98 These proprioceptive and kinesthetic
characteristics. coupled with mechanicctl instability, lead
to functional instability. hs.72
Developing or reestablishing proprioception. kinesthe­
sia, and neuromuscular control in the injured athletes wH,1
minimizc the risk 0[' reinjury. Capsuloligamentous rcten­
sioning and reconstruction . coupled with traditIonal reha­
bilitation, is onc optio(J that appears to restore some
kinesthetic awareness. although not equal to that of non­
involved limbs.21. 72.87
The objective of neuromuscular rehabilitation is to de­
velop or reestablish afferent and efferent characteristics
that enhance dynamic restraint capabilities with respect
to in vivo ,loads. Four basic elements are crucial to reestab­
lishing neuromuscular control and functional stability:
(1) proprioceptive and kinesthetic sensation. (2) dynamic
joint stabilization. (3) reactive neuromuscular control.
and (4) functional motor patterns .h~ fn the pathological
ynapses be­
roe ignal. 4 1.46 joint these dynamic mechanisms are compensatory for the
lack of static restrannts. and can result in a functionally
-'= arly. memory
stable joint.
program fu­
Several afferent and efferent characteristics contribute
m erel'ore en­
to the efficient regulation of these elements and the main­
programmed
tenance of neuromuscular control. These characteristics
:e neuromus­
include the sensitivity of peripheral receptors and facilita­
.ise must be
tion of afferent pathways. muscle stiffness. the onset rate
on. and con­
and magnitude of muscle activity. agonist/antagonist
ada ptations to
coaclivation. renex muscle activation . and discriminatory
muscle activation. Specific rehabilitation techniques allow
these characteristics to be modil1ed. signitkantly impact­
ing dynamic stability and function. 12 . 17.4<.49.r,7.101.108
Although clinical research continues, several exercise
TROL techniques show promise for inducing beneficial adapta­
tions to these characteristics while the plasticity of the
the articular
neuromuscular system permits rapid modifications during
exhibit distinc­
rehabilitation that enhance preparatory and reactive mus­
neu romuscular
cle acti\rity. 12 .46.48.4~.I3. 108 The techniques include open and
identifying
c1osed-kinetic-chain activities. balance train,ing. eccentric
dini al setting. a
and high-repetition/low-Ioad exercises, renex facilitation
of these condi­
through reactive training. stretch-shortening activities,
are attempting to
and biofeedback training. Traditional rehabilitation. ac­
.'1clional stability.
companied by these specific techniques. results in benefi­
n of the articu­
cial adaptations to the neuromuscular characteristics
afferentation to
responsible for dynamic restraint. ultimately enhancing
me 'hanorecep­
their efficiency for providing a fun ctionally stable joint.
eof healing. joint
fn order to restore dynamic muscle activation neces­
nsory deftci ts;
sary for functional stability. one must employ simulated
:hr nic deficits in
CHAPTER 5 Reestablishing i'ieuromuscular Control lOS
posit,ions of vulnerability that necessitate reactive muscle
stabilization. Although there are inherent risks in placing
the joint in positions 0[' vulnerability, if this is done in a
controlled and progressive fashion. neuromusc ular adap­
tations will occur and subsequently permit the athlete to
return to competitive situations with confidence that the
dynamic mechanisms will protect the joint from subluxa­
tion and reinjury.
CLINICAL DECISION MAKING Exercise 5-1
Following a grade 2 ankle sprain and a rehabilitalion pro­
gram to regain strength in the lateral lower leg mu ·cles.
your soccer athlete continues to sustain repeated inver­
sion ankle injuries durl ng culting maneuvers. What com­
ponents of neuromusc ular control might be deficient ill
this athlete" What type of rehabilitation exercises should
you implement to en hance neuromuscular control?
Neuromuscular Characteristics
Peripheral Afferent Receptors. The foundation for
feedback and feed-forward neuromuscular control ,is based
on reliable molion, position. and force information. Altered
peripheral afferent information can disrupt motor control
and functional stability. Closed-kinetic-chain exercises cre­
ate axial loads that maximally stimulate articular receptors
while tenomuscular receptors are excitcd by changes in
length and tension. 19 . 38 ;2.!05.l06.lll Open-chain activities
may require more conscious awareness of limb position be­
cause of the freely moving distal segment. Performing open­
or closed-chain exercises under weighted conditions in­
creases the Ievel of di(ficulty and may be used as a training
stimulus. 66 Chronic athletic participation can also enhance
proprioceptive and kinesthetic acuity by repealedly facilitat­
ing afferent pathways from peripheral receptors. Highly
conditioned athletes demonstrate greater appreciation of
joint kinesthesia and more accurately reproduce limb posi­
tion than sedentary controls. 6.7o.7 5 \<\'hether this is a con­
genital anomaly or a training adaptation, greater
awareness of joint motion and position can improve feed­
forward and feedback neuromuscular control. 70
Muscle Stiffness. [t is evident that mu scle stiffness
has a SignifIcant role in preparatory and reactive dynamiC
rest"raint 'by reSisting and absorbing joint loads. 77. 7 9.~O
Therefore exercise modes that increase muscle stiffness
should be encouraged during rehabilitatIon. Research by
Bulbulian and Pousson l ;.9 '1 has established that eccentric
loading increases muscle tone and stiffness. Chronic
106 PAI{TTWO Achieving the Gauls of Rdwbilital iol1
overloading of the musculotendinous unit cLin result in
connective tissue proliferation, desensitizing GTOs and in­
creasing muscle spindle activity.48 Such evolu tions impact
both the neuromuscular and the tend inoll s components
of stiffness.! ,.35.83.9 1
Training techniques that emphasize low loads and
high repetitions cause connective tiss ue adaptations simi­
lar to those found with eccentric training. However, in­
creased muscle stiffness re:;ulticng from this reh,l bLlitatio n
technique can be att ribut ed to fiber type lransi­
tion. 1 '.4 N.63 .b4 Slow-twitch fibers have longer crossbridge
cycle times and can maintain th e prolon ged. low-intens ity
co ntracUo ns necessary fo r postural control. 64 Gou bel])
found, in the animal model. th'lt 10w-load/ hi gh-repetiLion
training resulted in high er muscle stiiTn ess, compared to
strength training. However, Kyrolaninen's 64 analysis of
powcr- and endurance-trained athletes inferred th at mus­
cle sti ffn ess was greater in the power-trained ind ividllals,
because the onset of muscle preactivation (E1VIG) was
faster and higher prior to joint loading. It appears tbat en­
dura nce training might enhance stiffness by in creasing
the baseline motor tone an d crossbrid ge form a tion time.
whereas power training alLers lhe rate and magn itude of
musrle lension during preactivation. Both of these ad ap­
tations readily adhere to existing principles of progressi\7e
rehabilitation , where early slrength ening exercises focus
on low loads with high rcpetitions, progressing to shorter.
more explosive, spo rl-specific activities. Resea rch assess­
ing the efficacy of low-Ioad/ hig h-repeti ti on trai n ing ver­
sus high-load / low-repetiUon train in g wouJd be ben eficial
for optimizing muscle stiffness an d functional progression
in th e injured athlete.
Reflex Muscle Activa tion. Various trainin g modes
also cause neuromllscular ada ptations th at might ac­
count for discrep a ncies in the reflex latency times between
power- and endurance-trained athletes. Sprint- and/or
power-trained individuals h ave more \"igorou ~ rc!'lex re­
sponses (tendon-tap) relative to sedent ary and cn durancc­
trained samples. i~.I,IlI01 McComas 7Rsuggests th at strengt h
training inc.reases desce ndin g (corUcal) drive to the large
motor nerves of skeletal muscle and th e small efferent
fibers to muscle spindles, referred to as a lph a-gamma
coaclivation. Increasing both muscle tension and efferent
drive to muscle spi ndl es resul ts in a heightened sensitivity
to stretch , consequently reduci ng refl ex latencies." s
Melvill-Jones K I suggests that the stretch reflexes are super­
imposed on preprogram med muscle acti vity fro m higher
centers. illustrating the concomitant use of feed- fo rwa rd
and feed back neuromu scular cont1'ol for regulati ng
preparatory and reactive muscle stiffness. The refore.
preparatory and reactive mu.sclc actiV(ltion might improve
dynamic stability and function if muscle stiffness is en­
banced in a mechanically insllfficient or reconstructed
jOint.
A limited number of clinical training studies have been
directed at improving reaction times. J2 ·N108 Ihara4~ sig­
nificantly reduced the laWncy of muscle reactions over a
3-week period by inducing perturbations to ath leles on
unstable platforms. Several ot her research ers later con­
finned this finding with rehabilitation programs designed A
to improve reflex muscle activation. 12.I 08 Beard 12 and Wo­
jlyes lOR suggest that ag ility-type train 'ing, in the lower ex­
tremity, produces more-desirable muscle reaction times
when compared to strength training. This research has
Significant impliculion s for reestablishing the reactive ca­
pability of the dynamic restraint system. Reducing the
elccl"romechanical delay between protective muscle acti­
vation a nd joint loading can increase dynamic stability
Figure 5-3
and fllnction . moting func tio
Discriminative Muscle Activation. In addition to
reactive muscle firing, unconscious control of muscle ac­
tivity is critical for coordination and balancing joint forces. ch a in exercises
This is most eVident relative to the force couples described Early joint-repc
for the shoulder complex. Restoring th e force couples of ceptive and kin
agonist and an tagonis ts might initially require conscious, conscious ap
discriminative muscle activation before unconscious con­ Applying a n
trol is reacquired. Biofeedback training provides instanta­ additional p
neous sensory feedback concerning specific muscle stimulating cui
contractions and ca n help uthletes correct erro rs by con ­ cises that simul
sciously altering or redistributing muscle activity.IO. l1 The help reestablis~
objective of biofeedback training is to re(lcquire voluntary tion. and load ij
muscle control and promote functionally specific motor of difficulty. th
patterns, eventually converting these patterns from co n­ ate loads. 66
scious to unconscious control lO (Figure 5-3 ). Using Dynamic '
biofeedback for discriminative muscle control can help jOint stubilizali
eliminate muscle imbulclllces while reestublishing onistla ntagoo'
preparatory und reactive muscle activity for dyn amic joint stores t he fore.
stability.24.3 2 and increase j
imparted to III
from muscles
Elements for Neuromuscular Control
loads. This inc
Proprioception and Kinesthesia, The obj ective of
kinesthetic a nd propriocep tive training is to restore the
neurosensory properties of injured capsuloligamentous ercises both r
stru ctures and enhunce the sensitivity of uninvolved pe­ tivity through
ripheral afferents 71 To what degree this occurs in conser­ sys tems, while
vatively managed athletes is unknown; however.ligamenl for indU Ci ng
retensioning and recons truction coupled with extensi \le Chimura 17 an
reh abilitation docs appear to normalize joint moti on and shortening exe
position sen se.Y.7 2." 7 hance coordino
joint compression is belie\7ed to maximally stimulate ar­ Reactive 1
ticu lar receptors and can be accomplished with closed- romuscular tn
 CHAPTER 5 Reest.ablishing euromuscl1lar Control 107

ltl ness is en­ EMG Biofeedback

reconstructed
Scale. Matte... Zoom :iupcrpotilfon ()ycfl .y S1atf..Uca ertnt Qtt tic",

die havc been

l hara-l~ sig­

A B

Figure 5-3 Biofeedback training reestablishes discriminative musclt! control. ciiminating muscle imbalance and pro­
moting functionally spccific muscle act ivation patterns.

r muscle ac­
~ joint forces. chain exercises throughout the available ROM.1 9.1H.51.1tl>. lllh
"c described Early joint-reposLtioning tasks enhance consciOllS proprio­
"I! couples of ceptive and kinesthetic awareness. eventually leading to un­
conscious appreciation of joint motion and pOSition.
Applying a neoprene sleeve or elastic bandage Gill provide
additional proprioceptive and kLneslhelic information by
stimulating cutaneOllS receptors ~ .71.HY (figure 5-4). exer­
cises that simultaneously involve the noninjureu limb may
help reestablish consciOllS awareness of joint position. mo­
tion. and load in the injured extremity. To increase the level
'cific motor of difllculty. these exercises can be performed under moder­
Cram con­ ate loads .6 ('
--3). Using Dynamic Stabilization. The objective of dynamic
rol can help joint stabilization exercises is Lo encourage preparatory ag­
reestablishing onist/antagonist coactivalion. Efficient coactivation re­
stores the force couples necessary to balance joint forces
and increase joint congruency. thereby reducing the loads
imparted to the static structures. Dynamic stabilLzaLion
from muscles requires anticipating and reacting to jOinL
Control
loaus. This includes placing the joint in positions of vu l­
he objective of nerability where dynamic support is established under
.0 restore the controlled conditions. Balance and stretch -shortening ex­
oligamentous ercises both require preparatory and reactive muscle ac­
uninvolved pe- tivity through feed-forward and feedback motor control
systems. while closed-kinetic-chain exercises are excellent
for inducing coacLivation and compression . RecenLiy.
himura l 7 and Hewett44 have confirmed that slretch­
hortening exercises increase muscle coactivation and en­
hance coordination. Figure 5-4 eoprene sleeves stimulate cutaneous re­
Reactive Neuromuscular Control. Reactive nClI­ ceptors. providing additional se nsory feedback for jo int
ro musc ular training focuses on stim ulating the reflex motion and position awareness.
108 PART TWO Achieving the Goals of Rehabilitation

pathways from articular and tenomuscular receptors to ferents, muscle coactivation, and reflex and prepro­ Lower-Ex,
skeletal muscle. Although preprogrammed muscle stiff­ grammed motor control. EmphasiS should be placed on
~Ia ny acti\'itie
ness can el1hance the reactive capabHity of muscles by re­ sport-specific techniques, including positions and maneu­
lower extremit
ducing rellex latency time. tJle objective,js to generate joint vers where the joint is vulnerable. \l\l ith repetition and con­
Early kinesth
perturbations that are not anticipated, stimulating rellex trolled intensity, muscle activity (preparatory and
begintor~
stabilization. The efOcacy of reactive neuromuscular exer­ reactive) gradually progresses from conscious to uncon­
LO skeletal moL.
cises was demonstrated nearly a decade ago. 1 9 Persistent scious motor controL 55 Implementing these activities will
Lical motor
use of these rellex pathways can decrease the response help athletes develop functionally specific movement
ness increa
time and develop reactive strategies to unexpected joint repertoires, within a controlled setting, decreaSing the risk
receptors. To iI
loads. 4 ] Furthermore, Caraffa]() significantly redu ced the of inj.ury upon completion of rehabiUtation.
cises should bt
incidence of knee injuries in soccer players who performed Understanding the afferent and efferent characteris­
in tervals, focus
reactive type training. All reactive exercises should induce tics that contribute to joint sensation, dynamic stabiliza­
stiffness and ..
ul1Cmticipated jOint perturbations if they are expected to tion, rel1ex activity, and functiona:) motor pattern is
lenomuscuJar r
facilitate reflex muscle activation. Reflex-mediated muscle necessary for reestablishing neuromuscular control and
mation concer
activity is a crucial element in the dynamic restraint mech­ functional stability n'able 5-1).
These teeh
anism and should complement preprogrammed muscle
groups thal req
activity to achieve a functionally stable joint.
to weight assi!
Functional Activities, The objective of functional CLINICAL DECISION MAKING Exercise 5-2
couraged been.
rehabilitation is to return the athlete to preinjury activity
to the lower-e)
level while minimizing the risk of reinjury.7l This may re­ There was an increase In ACL inluries last year on the
women's soccer leam. You decide LO develop a prevention pools or with u
quire video analysis and consultation with the coaching
program in an effort to minimize injuries in the upcom­ closed-chain
staff to identify and correct faulty mechanics or movement
ing season. What are the main goals of the prevention knee, or hip to
techniques. The goals include restoring functional stability
and sport-specil1c movement patterns or skills. then utiliz­ program with respect to neuromuscularconlrol? What
ing functional tests to assess the athlete's readiness to re­ do you feel Is the most effective method of training to
turn to full participation. Fun ctional activities incorporate achieve your goals?
all of the available resources for stimulating peripheral af­

• TABLE S-l The Elements, Rehabilitation Techniques, and Afferent/Efferent Characteristics

Necessary for Restoring Proprioception and Neuromuscular Control.

Elements Rehabilitation Techniques Afferent/Efferent Characteristics

Proprioception Joint repositioning Peripheral receptor sensitivity

and Kinesthesia Functional range of motioo Facilitate afferent pathways
Axial loading
Closed-kinetic-chain exercises
Dynamic Stabilit)' Closed-kinetic-chain exercises and Agonist! antagonist coactivation
translatory forces Muscle acth'ation rate and amplitUde
H igh-repeti tion / low -resista nce Peripheral receptor sensitivity
Eccentric loading Muscle stiffness
Stretch-shortening exercises
Balance training
Reactil'e Neuromuscular Reaction to joint perturbation Reflex facilitation
Control Stretch shortening. plyometrics Muscle activation rate and amplitude
Balance reacquisition
Functional Motor Biofeedback Discriminatory muscle activation
Patterns Sport-specinc drills /\rthrokinematics
Control-progressive participation Coordinated locomotion
 CH;\I'TER
Lower-Extremity Techniques
.vlany activities that promote neuromuscular control in the
lower extremity exist in traditional rchabilitation schemes.
Early kinesthetic training and joint repositioning tasks can
begin to reestablish reflex pathways from articu lar afferents
to skeletal motor nerves, the muscle spindle syste m, and cor­
tical motor control centers, whUe enhancing muscle stiff­
ness increases the stretch sensitivity of tenomuscular
receptors. To induce udaptations in muscle stiffness, exer­
cises should be perrormed w it h high repetitions and low rest
intervals, focusing on the eccentric phase. Increased muscle
stiffness and tone will heighten the stretch sensitivity of
tcnomuscular receptors, providing additional sensory infor­
mation concerning joint motion and position.
These techniques shou ld focus on individual muscle
groups that req uire ullenlion and progress from no weight
to weight assisted. The use of closed-chain activ ities is en­
couraged because they replica tc the environment speCific
to the lower-extremity function. Partial wcig ht bearing. in
pools or with unloading deviccs, simulatcs the open- and
closed-chain environments without subjecting the ank le.
knee, or hip to excessive joint loads. 57 The closed-chain n(l-
-ation
amplitude
ampli tude
at ion
igure 5-5 "Kickers" use an elastic band fixed to the dista l aspect of the involved or uninvolved limb. The athlete at­
,empts to balance while executing short kicks with either knee ex tensio n or hip Ilexion. This exercise is most dirl1cult
\-hen performed on unstable surfaces.
~ RL'l'SlUblishing "ieuromuscular Control 109
ture of Lhese exe rcises creatcs joint compression . thus en­
hanCing jOint congruency and neurosensory feedback.
w hile minimizing shearing forces on the joints. SR
Early dynamic joint stabilization exercises begin wi th
bala nce training and partial weight bearing on stable sur­
faces. progressing to partial weight bearing on un stable
surfaces. Ba lanCing o n un stabl e surfa ces is initiated once
fu ll weigh t bearing is achieved. Exercises such as "kickers"
also require balance and can begin on stable surfaces. pro­
greSSing to unstable platforms (Figure 'i-'l).
Slide board training and basic strength exercises can
be instituted to st imulate coactivation while increasing
muscular force and endurancc. Strength exercises foclls
on eccentric and endurance-type activities in a closed ki­
netic orientation, further enhanCing dynamic stability
through increases in preparatory muscle stiffness and re­
active characteristics. Eccentri c loading is accompl ished
by activities suc h as forward and backward stairciimbing
or backward downhill walking. Strength and bal.ancc ex­
ercises can be combined and executed w ith light external
forces to increase the level of difficulty (Fig ure 5-6).
Biofeedback can also help alhletes trying to develop
agon,ist/antagon ist coactivation during strength exercises.
110 PART TWO Achieving the Goals of Rehabilitation

Figu re 5-7
hopping.

linstable pi
ear and angul
Figure 5-6 Balance and stre ngth exercises arc co mbined by incorporating light external forces and increasing the athlete's ce nt
level of difficulty for balancing while strengthening the muscles required for dynamic stabilization. balance (Fig url
tions to reflex ~
resulting in re
Biofeedback provides additional information concerning trolled by manipulating the load or number of repetitions. incorporated i
muscle activation and encourages voluntary muscle activa­ Stretch-shortening movements require both prepClrCltory purpose of di
tion by facilitating efferent pathways. Reedu cating injured and rea ctive muscle activities along with the related scious. rea ct h'e
athletes through selective muscle activation is necessary for changes in muscle stiffness. This preparatory musc le acti­ also require si
dynamic stabilization and neuromuscular control. vation prior to eccentric loading is considered to be pre­ hance reflexi\'e
programmed. while activation after ground contact is During the
considered reactive. Plyometric activities such as lo\\,­ romuscul"u' ac
CLINICAL DECISION MAKING Exercise 5-3 impact hopping may commence once weight beClring is athlete begins'
achieved (Figure 5-7). Double-leg bounding is an effective gressing to ho
A fem ale cross-country runner complains of chronic an­ intermediate exercise. because the uninvolved limb can be tion. The most
terior knee pain. Your assessment reveals thaI she has used for assistance. Stretch-shortening activilies arc catching a ball.
patellofemoral pain with nssociated hypertrophy of her made more diff'icull with alternate-leg bounding. then landing surface
vastus lalere lis fmd atrophy in the vaslt.ls medialis Single-leg hopping. Subsequent activities such as hopping Pu nCLion al
oblique. What modalities would you utilize to correct this with rotation. lateral hopping. and hopping onto various Clinicians can
muscular imbalance? [)iscuss the ralionale for c,lch surf<Ices arc instituted as tolerated. Plyometric training he lp athletes i,
modali ty and how iI relates to neuromuscular control. requires preparatory muscle <Iclivation and facilitates re­ stance and swl
flexive pathways for reactive neuromuscular control. waLking. whi cl
Rhythmic stabilization exercises should be included string acti vati
Stretch-shortening C'xerciscs arc a necessary compo­ during early rehabi litation lo enhance lower-exlremity vice is availabl,
nent for conditioning the neuromuscular apparatus to re­ neuromuscular coordination Clnd reaction to unexpected begin. progre!
spond more quickly and forcefully. permitting eccentric joint perturbations. The intensity of rhythmic stabilization Functional ac
deceleration then developing explosive concentric con­ is increased by applying greater joint loads and displace­ restore motor
tractions. 1 Stretch-shortening exercises need not be with­ menls. Foot pass drills are also effective for developing co­ straints. Weig ~
held until the late stages of rehabilitation. There is a ordinated preparatory and reactive muscle activity: begin with th e in cor
variety of plyometric activities, and intensity Gill be con­ with large balls and progress to smaller balls. and pivot ma:1:
 CHAPTER') Reestablishing Neuromuscular Control 111

Figure 5-7 Plyomelrics begin with low-impact hopping, progressing to double-leg bounding, and fina lly single-leg
hopping.

Unstab le platforms are uUlized to manually induce lin­

ear and angular perturbalions to the joint. altering the
athlete' ce nter or gravity while the athlete allempts to
balance (Figure 5-8). These exercises can racililale adapta­
tions to reflex pathways medi<!ted by periphera l affcrellts,
resulting in ·r eactive muscle aclivaUon. Ball tossing can be
incorporated in conjunction with balance exercises ror the
purpose or disrupting concentwtion and inducing uncon­
scious, reactive adaptations. vValking and running in sand
atso require similar reactive muscle activity and can en­
hance reflex.ive joint stabilization.
During Lhe later stages or rehabilitation, rea ctive neu­
romuscular activity incorporales trampoline hopping. The
athlele begins by hopping and landing on both reeL. pro­
gressing to hopping on one foot, and hopping with rota­
tion. The mosl dHt1cult reaclive tasks include hopping while
catching a ball. or hopping orr or it trampoline onto various
landing surfaces such as artil'iciallurf. grass, or dirt.
Functional activities begin with restoring normal gait.
Clinicians can give verbal inslruction or use a mirror to
help athletes internaliz(' normal kinematics during the
tance and swing phases. This includes backward (retro)
lValking. which has been show n to rurther facilitate ham­
string ac tivation and baiance. 84 rr a pool or unloading de­
vice is available, c rossover walking and figure eights can
begin, progressing to jogging and hopping as tolerated.
Functional activilies during partial weight bearing help
~estore motor patterns without compromising static re­
straints. Weight-bearing activities are continued on la nd Figure 5-8 An unstable platform promotes reactive
with the incorporation of acceleration and deceleration musc le activity when an athlete nuempts to ba lance and
and pivot maneu vcrs. Drills such as jogging, cutting, and a clinician manually perturbs the platrorm.
112 PART TWO Achieving the Goals of Rehabilitation
carriocas are initiated, gradually increasing the speed of
maneuvers ,
The most dirt1cult functional activities are designed to
simulate the demands of individual sports and positions
and may require input from the coaching staff. Activities
such as shuttle runs, carrioca crossovers, retro sprinting
and forward sprinting are implemented with sport-specific
drills such as fielding a ball, receiving a pass, and dribbling
a soccer ball.
CLINICAL DECISION MAKING Exercise 5-4
A volleyball player Is recovering from an Achilles­
gastrocnemius strain , Develop plyometric exercises that
can be Implemented In each stage of rehabiutation.
What would your rationale be for integrating these ac­
tivlLies into the athlete's rehabilitation? Describe the
neuromuscu lar adaptations that you expect to occur.
Upper Extremity
Contrary to the lower extremity, the glenohumeral joint
lacks inherent stability from capsuloligamentous struc­
tures; therefore dynamic mechanisms are even more cru­
cia l for maintaining functional stability.4o.104 The dirt1culty
of working with a diverse array of shoulder positions and
velocities is compounded by shearing forces associated
with manipu lating the upper extremity in an open-kinetic­
chain environment. 1114 Maintaining joint congruency and
functional stability requires coordiQated muscle activation
for dynamic restraint while complex movement reper­
toires are executed. 7l
Two distinct types of muscle have been identified in th e
shoulder girdle and are primarily responsible for either sta­
bilization or initiating movement. The orientation and size
of the stabiliZing muscles, referred to as the rotator cuff,
are not suited for creating joint motion but are more capa­
ble of steering th e humeral head in the glenOid fossa. 71
Larger muscles (primary movers) with insertion sites fur­
ther from the glenohumeral jOint have greater mechanical
advantage for Loitiating joillt motion. 7 1. 74 .7> Maintaining
proper joint killematics requires balanCing the external
forces and internal moments while limiting excessive
translation of the humeral head on the glenoid fossa.
Injury to the static structures can result in diminished
sensory feedback and altered kinematics of the scapulotho­
racic and glenohomeral joints. Moreover. failure of the dy­
namic restraint system exposes the static structures to
excessive or repetitive loads, jeopardizing joiot integrity and
predisposing the at hlete to rcinjury. Developing or restoring
neuromuscular control in the upper extremity is an impor­
tant component to rehabilitation and the eventual return
to functional activities. Exercise tcchniques originaUy de­
signed to promote neuromuscular control in the lower ex­
tremity can be adapted for the upper extremity as well.
Activities to enhance proprioceptive and kinesthetic
awareness in the upper extremity emulate techniques dis­
cussed for the lower extremity. Stretch-shortening (plyo­
mctric) exercises in the overhead athlete have been shown
to improve proprioception. Multiplanar joint repositioning
tasks are performed actively and passively to maximize the
increased range of motion available in the shoulder. Func­
tional positions, such as overhead throwing, should be in­
corporated and are more sport-specitlc (Figure 5-9).
Closed-kinetic-chain activities can be performed in the up­
per extremity, although the objectivc is slightly different.
The glenohumeral articulation is not contlgured to
function in closed-chain environments such as weight
bearing. However, with signitlcant axial loads and muscle
coactiv ation, thc resultant joint approximation stimu'lates
capsuloligamentous mechanoreceptors, similar to lower­
cxtremity activities. H 105 Therefore, closed-chain activities
should be used to promote afferent feedback and coactiva­
tion in the upper extremity.
Muscle stiffness can be enhanced by using elastic re­
sistance tubing, concentrating on the eccentric phase, and
performFng high repetitions with low resistance. These ex­
ercises are well established for strengthening and recondi­ Figure 5-9 :\
tioning the rotator cuff muscles in functiona l patterns. To ual sports.
complement elastic tubing exercises, c]jnicians can utilize
commercially available upper-extremity ergometers for
endurance training.
Like similar exercises for the lower extremity, dy­
namic stabilization exercises for the shoulder use unsta­
ble platforms to create linear and angular joint
displacement, maximally stimulating coactivation. The
intensity is controlled by manipulating the degree of
joint displacement and loading. Four closed-chain exer­
cises have been described to stimulate coactivation in the
shoulder: push-ups, horizontal abduction on a slide
board, and tracing circular motions on a slide board with
the dominant and nondominant arms 71 (Figure 5-10). A
These exercises accommodate for th e individual's toler­
ance to joint loads by progressing from a quadrupcd to a
push-up position. Multidirectional slide board exercises
also require dynamic stabilization while concomitantly
using feed-forward and feedback neuromuscular con trol.
Plyometric exercises with a heavy ball are also excellent
for conditioning preparatory and reactive muscle coacti­
Figure 5-10
va tion (Figure 5-11). board.
 CHAPTER:5 Reestablishing Neurom uscular Control 113

ng or restoring
t~ i an impor­
n tual return
originally de­
the lower ex­
~ a well.
d k inesthetic

repositioning
ma :imlze the
ulde r. Func­
h uld be in­
Figure 5-9).
ed in the up­
lly different.
nfig ured to
h as weight
.i nd muscle

Figure 5-9 Active a nd passive repositioning activities shoulci be performed in functional positions spccilk to inclivicl­
llat sports.

er use u nsta­
ang ular joint
tivation. The
th e degree of

A B

Figure 5- 10 Dynamic stabilization exercises for the upper extremity. A, Push-ups. B, li.orizontal obduction on a slide
boa rd.
114 PART TWO Achieving the Goals of RehQbilit<ltion

c D

Figure 5-13
Figure 5-10 (continued) C, Tracing a circle with the dominant arm on a slide bO<lrd. D, TracLng a circle with the inclu de sim ula
nondominant arm on a slide board. neurom uscular

Figure 5-11 tJpper-extremity plyometric exercises

with a heavy ball require preparatory and reactive
Figure 5-12 Elastic bands are used during rhythmic
muscle activation.
stabilization exercises to create joint loads and facilitate
muscle activation.

Reactive l1euromusculilr characteristics are facilitated

by manually perturbing the upper extremity while lhe ath­
lete attempts to maintain a permanent position. During
the cady phases of rehabilitation. light loads arc used with
rhythmic stabilization exercises. A~ the atb lete progresses.
resistance is added to maximize muscle activation (Figure
5-12). Positions where the joint is illherently unstable
must be incorporated. but under controlled intensity (Flg­
ure 5-13). Increased jOint loads during rhythmic stabiliza­
tion exercises mimic closed-cha.in environments and
cooditions the athlete for more diJficult reactive drilLs un­
der weighted conditions on stable sw-faces and unstable
platforms (Figure 5-14).
CLINICAL DECISION MAKING Exercise 5-5
During preparLicipation physicals. you note that one of
the tenn is players has a history of inferior glenohumeral
dislocation and. as a result. excessive laxity. The sur­ Summary
rounding masculaturr appears strong. but the athlete
continues to hal'r sensations of instability. What is the
nature of this athlete's problem. and what exercises
would you use to improve dynamic stability of the rotator
cuff musdes? Justify your decision to incorporate these
exercises.
ni sllls of joil
 CHAPTEl.R 5 Reestablishing leuromuscular Co ntrol 115

Punctionaltraining for the LIpper extremity most of­

ten involves de veloping motor pattern s in the overhead po­
SitiOll, whet her it be sho()ling a ba sketball. throwing, or

••
hitting as in volleyball and te nnis. However, special co n­
siderations a re n ecessary fo r other spo rts, like row ing,
wrestling. and swimming, th a t rely h eavily on th e upper
extremity. Fun ctional ac tivities need to reproduce the de­
mands of specifl c eve nts. beginning with slower velocitiL~ s
D a nd conscious con trol and eve ntU<llly progreSSing to fun c­
tional speed' and unconscio us con trol. Technique, rather
th a n speed , should be emphaSized to promote the appro­
priate muscle activation patterns and avo id fa ulty kine­
matics. Reeducating fun ctional motor pa tterns involves
all of the cle ments for dynamic restra int and neuromus­
cular control an d w ill minimize the risk of rei11jury upon
Figure 5·13 Rhythm ic sta biJiza tion exerc ises should
t' w il h the include sim u lated positio ns of vul nerab ility, promoting returning to full participation.
neuro m uscula r adaptatio ns to dyna m ic stabil izatio n.
CLINICAL DECISION MAKING Exercise 5-6

A wrestler is performing rehabi lltiltion for a grade 2 me­

dial collateral ligament (MeL) sprain. His rehabilitation is
in the final stage and you would like to incorporate func­
tional exercises into the protocol. Considering the specific
demands related to thi, sport. develop a progression of
fLlI1ctional exercises for this athlete's return to full
participation.

The speed and complcxity of movements in athletic

competition requires rapid integ ration of sensory infor­
mation by feed-forward and feedback neuromuscular con­
trol syste ms. Although many peripheral. spinal. and
1'- rhyt hmic cortical clements con tribute [0 the neuromusc ular control
and facilitate systcm, dynamiC joint sUlbilizalion is contingent upon
both cortical ly programmeu prci:lctivi:ltion and renex-me­
diaLed muscle activation. Disrupteu joint kinealics, muscle
figure 5-14 Li nea r di placement ' produced by a clini­ activation patterns, and conditioning can contribuLe to
Exercise 5-5 cian facilit-a te reflex patin ay ' lor dynamic stabilizationrn disruption of the dynami c restraint sys tem and must bc
the upper extremity. rccsWblished for fun cti on al stability.

Summary

1. The efferent response to peripheral affere nt informa­
lion i termed neuromuscu lar con trol.
2. [nj ury to caps ul oli ga mentous st ru ctures co mpromise
both the static a nd the dynam ic res training mec ha­
n isms of joillts.
3. The primary role of a rticular structures is to guide
skeletal segmen ts providing static restraint. but they
a lso co ntain mecha noreceptors that mediate the dy­
namic restraint-mechani ' DJ .
116 PART TWO Achieving the Goals of Rehabilitation

4. A rticular sensations are coupled with information 9. Rehabilitative techniques produce adaptations in the 17. Chimu rd
from tenomuscular mechanoreceptors, via cortical sensitivity of peripheral receptors and facilitation of 2002. EI'
stral"egi
and reflex pathways, providing cQnscious and uncon­ afferent pathways. agonist/,lIltagonist coactivalion.
Ilth/rUr T
scious appreciation of joint motion and position. muscle stiffness, the onset rale and magnitude of mus­
18. CiecollU
5. Muscle spindles have received special consideration for cle activity. reflex muscle activation. and' discrimina­ tromyogr
their capacity to integrate perip.heral afferent informa­ tory muscle activation. Hies: D. T
tion and reflexively modify muscle activity. 10. AITerent and efferent characteristics regulate the four recon stru
6. Feed-forward and feedback neuromuscular controls elements critical to neuromuscular control and func­ 22(5 ): 6 5
ulilize sensory information for preparatory and reac­ tional stability: proprioception and kinesthesia, dy­ 19. Clark . F. I.
tive muscle activity. namic stabilization. reflex muscle activation. and tors in ca
7. The degree of muscle activation largely determines a functional motor patterns. :Veuropily·
muscle's resistance to stretching or stiffness. Muscles J 1 . Each phase of traditional rehabi\jtation can incorpo­ 20. Clark. F. ,.
198 5. R
with increased stiffness can assist the dynamic restraint rate the appropriate activities. emphasizing each of
limb po
mechanism by resisting excessive joint translation . the four elements. according to tbe individual's toler­
21. Col ebatch
8. To reestablish neuromuscular control and functional ance and functional progression . By integrating these constant i
stability, clinicians may utilize specifIc rehabilitation elements into the rehabilitation of injured athletes. di­ ponen ls iT
techniques- including, closed-kinetic-chain activi­ nicians can maxim~e the contributions of the dy­ 22. Corrigan
ties. balance training. eccentric and high-repetition / namic restraint mechanisms to functional stability. prioccpti,
low-load exercises, reflex facilitation through reactive JOillt SII
train ing. stretch-shortening activities. and biofeed­ 23. Dietz. \ .J.
back training. between p
brachii d
olo!!!! 3 1 :
24.
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'Klli· iduals. Clinical
CHAPTER 5 Reestablishing Neuromuscular Control 119
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120 PART TWO Achieving the Goals of Rehabilitation
SOLUTIONS TO CLlN,ICAL DECISION MAKING EXERCISES
5-1 In addition to strength restoration, rehabilitation
should focus on reestablishing neurosensory proper­
ties of the injured ligament. Balance. perturbation ,
and agility exercises should be used to restore propri­
oception and kinesthesia elements, as well as to
enhance reflexive- pathways. Closed-kinetic-chain
exercises increase joint congruency and neurosen­
sory feedback necessary for reestablishing dynamic
stability. Taping or braCing the ankle will provide sta­
biHty during rehabilitation and practice but also will
facilitate additional, efferent feedback from cuta­
neous receptors.
5-2 Prevention programs should be concentrate on
prep8ratory and reactive muscle con tractions to en­
hance motor coordination and muscle stiffness of the
lower extremity. To achieve these g081s. balance,
agiJity. and sports-spe.cilk activities should be incorpo­
rated into prevention progrClms. BenefIts of bal8nce
8nd 8gility training are enhanced proprioception,
kinesthesi8 , and reactive muscle activation. Func­
tional activities integrate these neuromuscular ele­
ments and should be performed in controlled. isolated
movements and progressed to mu'ilidirectional com­
plex activities (example: b811 dribbling around cones to
ball dribbling and cutting 8gainst a defender).
5-3 The athletic trainer should recognize that strength
and voluntary muscle control of the vastus medialis
oblique must be reestablished to achieve balanced
coactivation bet ween the vastus latera lis and vastus
medialis oblique. Biofeedback training provides sen­
sory feedback, as well as visual Hod/or 8uditory en­
couragement. for selective voluntary muscle control
of the vastus medialis oblique.
5-4 Literature supports the use of plyometric training to
increase strength and perfonnHnce. Theories regard­
ing neuromuscular bencJits include restoration of
functional motor programs. heightened reUexes, and
increased proprioceptive Hwareness. Incorporation
of plyometric exercises in the early stages of rehabil­
itation when the athlete ,is not bearing weight should
use elastic tubing for resislance in sitting, supine.
Hnd prone positions. A.s the athlete is able to bear
more weight. exercises should be progressed from
two-legged to one-legged exercises. The range of ex­
Ct
ereises should be taken into consideration and grad­
ually increased according to the athlete's strength
and level of pain. Activities that can be easily modi­
fied in this mHnner include forward-to-backward R
and lateral hopping and jumping maneuvers. Exer­
cises should not be performed at too great a speed­
faster movements can harm the healing tissues.
al
5- 5 The rotator cuff muscles arc not functioning prop­ Wi lli
erly to fulfill their stabilizing role at the gleno­
humeral joint. Rotator cuff strength should be
assessed and imbalances remedied through
strengthening and closed-kinetic"chain exercise.
~
Benefits of closed-kine tic-chain exercises are in­
creased joint congruency and enhanced force­
couple conctjvation . Strength-shortening, or plyo­
metric, exercises promote preparatory and reactive
muscle activity, encourage muscle coactivation. and To become Ilk
improve proprioception . The importance of proper necessary to d
technique in rehabilitation exercises and sport move­ lic rehabil.itaL
ments must be addressed. Verbal feedback from the Zelie Trail/i llg E
athletic trainer and visuHI feedback using a mirror Proficj(,llci('~
can be used to develop proper motor patterns. In this
stage of rehabilitation. a coach's critique and infor­
mation obtained from motion analysis are advanta­
geous and allow lhe athletic trainer to tailor the
athlete's protocol to speCific needs.
5-6 Functional activities incorporate a variety of stim­
uli. so that the body must simultaneously integrate
and efficiently use mu'ltiple elements of neuromus­
cular control to maintain function and stability. For
the wrestler. factors that should be modified to
progress from easy to difficult. as well as from iso­
lated to combined. movements Hre (1) changing lev­
els (e.g .. high vs. low body position). (2) lateral
movements (i.e.. side shuffles), and (3) rational
movements (e.g., carioca . pivot). Surface and axial
load can be modified to progress the level of diffi­
culty of exercises. A hard. fiat surface can be
changed to a softer. unstable surface (e.g., foam and
mat). Weight vests or belts can be used to increase
the axial load. thus enhancing stimulation of artic­
ular and l.cnomuseular receptors. Tt is also beneflcial
to receive feedback concerning technique and style
from the coaching staff during this stage.
 CHA PTER 6
ration and grad­
th lete's strength
'1 be easHy modi­
ani-to-backward
Restoring Range of Motion
aneuvers. Exer­
great a speed­ and Improving Flex'ibility
ing tissues.
clioning prop­ William E. Prentice
at the gleno­
gth should be
jed through

Study Resources • Analyze the neurophysiological princi­

To become more familiar with the knowledge and skills ples of str tch ing.
neceSSiJry to design. implem('nt. iJnd document therapeu­
tic rehiJbilita!ion programs as identified in the ,'JA T!\ ilt/J­ • Examine the effects of stretching on
lelic Trainillg Educati0/1{/ 1CO/JJPetencies 1lI111 Clinical the physical and mechanical properties
u ing a mirror l'rojicietlcits' Thera peutic Exercise co ntc nt area. visit
paHerns. In this \\'IVw.mhhe,co m/ prenl icc L1 e. ;\\so. refer to the lab cxer­
of muscle.
'qu e and infor­ cises in the new Laboratory Manual and to cSims. which • Assess the effects of stretching on the
a rc advan ta­ simulates the athlet ic training certification exam. at
_ to tailor the www.mhhe.cQm/csims. For morc on lin c study rCSOUl"CCS.
kinetic chain.
visit our l!ca lth and lluman Performance \\'c bsile at
• Demonstrate stretching exercises that
www.mhhe.com/hha·
may be used to improve l1exibility at
After Completion of This
speciflc jOints throughout the body.
Chapter, the Student Should

Be Able to the Following:

• Define l1eJl.;bility. and describe its
importance in injury rehabilitation.
• Identify factors that limit l1exibilily.
• Differentiate between active and pas­
sive range of motion.
• Explain the differences between ballis­
tic. static. and PNF stretching.
• Discuss techniques for stretching tight
neural structures.
• Apply myofascial release stretching
techniques.
THE IMPORTANCE OF
FLEXIBILITY TO THE ATHLETE
For the athletic trainer, the restoration of. or improvement
in . normal prci njury range or motion is an importa nt goal
of any rehabilitation program."" Wh en injury occurs,
there is a lmost always some associated loss of the ability to
move normally. Loss of motion may by due to pain.
swelling. muscle guarding or s pasm. inactivity res ulting in
shortening of connective tissue and muscle; or some com­
bination of th ese factors. Restoring normal range of mo­
tion loJlowin g injury is one or th e primary goals in any
rehabilitation program. i1 Thus the athleti c trainer must
routinely include stretch ing exercises designed to restore
normal range of motion to regain normal function.
Flexibility has been defined as the ability of the neuro­
muscular system to allow for effiCient movement of a joint

121
122 PART TWO Achieving the Goals of Rehabilitation

or series of joints through a full, nonrestricted, pain-free

range of mNiol1. 2.2(),3f,, 56.68
Flexibility can be discussed in relation to movement in­
volving ooly one joint, such as the knees. or movement in­
volving a whole series of joints . such as the spinal vertebral
joints. which must all move together to allow smooth
bending or rotation of the trunk. Lack of flexibility in one
joint or movement can affect the entire kinetic chain. A
person might have good range of molion in the ankles,
knees, hips. back. and one shoulder joint but lack normal
movement in the other shoulder joint; this is a problem
that needs to be corrected berore the person can runction
normally.j()
iv!ost sport activilies require relatively "normal" Figure 6-2 E
amounts of flexibility. However. some activities. such as extended elbo\\
gymnastics. baBet. diving. and lemate. require increased
flexibility for superior perrormance (Figure 6-1) . For an
athl'ele who has a restricted range of motion . perrormaoce gical repair of a
capabilities wiJJ probably decrease. 12 For example. a long perlocls of .
sprinter with tight. inel'aslic hamstring muscles probably It is also po
loses some speed because the hamstring muscles restrict ligaments a nd
the ability to flex the hip joint and thus shorten stride referred to as b
length. Lack or tlexibility can also create uncoordinated or would be an elb
awkward movement palterns resulting [rom lost neuro­ degrees (Figure
muscular control. cia ted ·with 100'
;vfost athletic trainers would agree that good ncxibility problem in m ll
is essential to successful physical performance. although tractures.
their ideas are based prim[lrily on observation rather than Figure 6-1 Sport activities require superior levels of Bony strul
scientific research. tikewise. they also believe thaI main­ flexibility. range. An c1bo~
taining good nexibility is important in prevention of injury might lay do \\'
to the musculotendinous unit, and they will generally in­ the joint to lose i
sist that stretching exercises be included as part of the ANATOMIC FACTORS THAT instances we re
warm-up before engaging in strenuous uclivity.17.50,60 al­ at normal en d 11
LIMIT FLEXIBILITY
though little or no research evidence is available to support Fat. can a l
this practice. A number 01 anatomic factor~ can limit the ability of a range or mOlio
In this chapter we will concentrate primarily on reha­ joint to move through a full. unrestricted range or motion. on the alxlom e;
bilitative stretching techniques used to increase the length Muscles and their tendons. along with theit- surrounding
of the musculoten dinous unit and its associated fascia. as fasci a l sheaths. arc most often responsible ror limi tin g can ael us a \\!
well as restricted neural tissue. Joint mobilization and trac­ range of motion. When performing stretcbiog exercises to movemcnt w h t:
tion techniques used La address tightness in the joint cap­ improve t1cxibiliLy about a particular join t. you are at­ Skin mi gh t
sule and surrounding ligaments will be discussed in tempting to take advantage of th e highly clastic properties For exampl e. a
Chapler- 14. of i:ll11usclc. Over time it is possible to increase the elastic­ surgery inl'ol\' j
ity. or the length that a givelJ muscle can be st retdled. Per­ skin. particular
sons who have a good deal of movement at a particular formed at tha t ~
CLINICAL DECISION MAKING Exercise 6-1 joint tend to have highly elastic and flexible muscles. ing with joint
Connective tissue surrounding the joint. such as lig­ Over time. 51
A gynm8s1 is oUl of practice for 2 weeks bec<Jl1Se of a aments on th e joint capsule. can be subject to contrac­ aments. joint cl
stress fracture in her tibia. Why is it essential to incorpo­ tures. Ligaments and joiot capsules h ave some elasticity; capable of im prl
rate tlexibililY into the rehabilitation program for this in­ however. if a jOint is inmlobilized for a period of time. these stretching. Wil
jury? structures tend to lose some elasti city and actually gender. all the
shorten. This condition is most commonly seen after sur-
 CHAPTER il
Figure 6-2 Excessive joint motion , s uch as the hyper­
extended elbow, can predispose a joint to injury.
gical repair of an unstabl e joint, but it ca n also result from
lon g periods of inactivit y.
It is also possible for a person to have re latively slack
ligame nts and jOint ca psules. These people a re generally
referred to a s bein g loose-jointl:d. Examp l(~5 of this trait
would be a n e lbow or kn ee that hy perex tends beyond 180
degrees (Figure 6-2). Frequently there is instabillty asso­
ciated wi th 100se-jointeLiness that can present as great a
problem in move men t as ligamentous or capsu lar COll­
tract ures.
'or levels of Bony structure ca n restrict the eI1d point in the
range. An elbow that has been fructured through th e jOint
m ight lay down excess calcium in the joint space, causing
the jOint to lose its ability to fuUy x tend. However, in many
HAT instances we rely on bony pro minences to sto p movements
at normal end pOints in the range.
Fat can also limit the ability to move through a fuU
the ability of a ra nge of motion. i\ person who has a large a mo Llnt of fat
on th e abdo men might have sl:vercly r t rieted trunk fl ex­
ion when asked to bcnc.l forward a nd touch the lacs. rhefat
c an act as a wedge bet ween tll'O lever arm s, restricting
moveme nt wherever it is found.
Skin might also be responsible fo r limi tin g 11l0vemL'nt.
For example, a person w ho has had some type of injury or
surge ry involving a tea ring incision or lace ratio n of the
skin, particularly over a joint. will have inelastic scar ti ssue
fo rmed a t that site. This scar tissue is inca pable of stretch­
ing with join t movem en t.
Over time, skin con tractu res caused by scarring of lig­
aments , joint caps ules, and muscul otendin ous uni t.s arc
capa ble or improving elastici ty to varying degrees through
tretching. With th e exception or bone slructure, age. and
ge nder. a li the other factors that limit flexibility ca n be al­
tered to increase range of join t motion.
Restoring Range of Motion and Impwving Flexibility 123
.\ 'eural tissue tightness resulting from acute compres­
sion, chron ic repeWive microtraum a, muscle imbalances,
joint dysfun c ti on , or poor postu re can create morph olog­
ica l changes in neural tissues, These c hanges might in­
clude illtraneural edema, ti ss ue hypox ia. chemical
irritation, or microvasc ular stas is- aLi of which could
stimulate nocice ptors, creating pain. Pain ca uses muscle
guarding and spasm to protect th e infl amed neural struc­
tures, and this a lters normal movement patterns. Event u­
ally neural I1brosis resuits, whi ch decreases the elasLicity
of neural lissue and prevents normal moveB1en t within
surrounding tissues .! I
CLINICAL DECISION MAKING Exercise 6-2
Two days alter an intense weight-lifting workout. a loot­
ball player is complaining of quad pain . The athletic
trainer determines that the athlete has delayed onset
muscle soreness. The soreness is prel'enting the athlete
from getti ng a sufficient stretch. What can be done to op­
timize hiSstretching?
ACTIVE AND PASSIVE RANGE
OF MOTION
L\ ctive range of motion, also called dynamic j7exiWity.
refers to th e deg ree eo which a joint can be moved by a
muscle con traction, usually t hrou gh th e midran ge of
movemen t. Dynamic flexibility is not necessarily a good in­
di cator of the stiffness or looseness of a joint, because it ap­
plies to the ability to move a joint effiCiently, with little
resista nce Lo motion. ~ 1
Passive range of motion , sometimes called static jlexi­
bility, refers to th e degree to which a join t can be passively
moved to the e nd points in the rau ge of motion . . 0 muscle
contraction is involved to move a joi nt throu gh a passive
range.
When a muscle actively co ntracts, it produces a joint
movement through a speci'llc ra nge of motion. , 6.65 How­
ever. if passive pressure is applied to a n extremi ty, it is ca­
pable of mov in g farther in the ra nge of motio n . It is
essential in sport ac tivities that an ex tremity be capable of
moving through a nonrestricted range of motion. 5,\ For ex­
ample, a hurdler who ca nn ot fully e. lend th e knee joint in
a n ormal stride is at co nsiderable disadvantage, because
strid e length and thus , peed will be redu ced significantly
(Figure 6-3),
Passiv range of motion is importan t for injury pre­
vention. Ther are many situations in sports in which a
 124 PART TWO Achieving the Goals of [{ehabilitCltion

• TABL IE

Joint

Shoulder F
E
}
~
L
Elbow F
Forea rm P
S
Figure 6 -4 Measurement of active knee joint nexion Wrist F
using a goniometer. E
J\
.~

Table 6-1 provides a list of what wnuld be considered nor­ Hip F

mal active ran ges ror movements at various joints. [
The goniometer has an important place in a rehabili­ A
tation selling, where it is essential to assess improvement
in joiut IllexibiJily to modify injury rehabilitation pro­
."
Figure 6-3 Flexibility is an essential component or grams.
many spor t-related activi ties. Knee

Ankle

Clinical Decision Making Exercise 6-3

muscle is rorced Lo stret ch beyond its normal active limits. Foot
following a n ACL surgery. one of the llrs! goals of reba­
If the muscle docs not have enough clasUcity to compen­
bili!ation is to regain full ROM. How ca n improvements
sa te for this additional stretch. it is likely that the musculo­
in knee exten sion be quantified for day-to-day record
tendinous unit will be injured.
keeping?
ing is called hal
Assessment of Active and Passive tive bouncing
Range of Motion static stretchin
STRETCH ING TECHNIQUES discomfort a n
Accurate measurement or active and passive ran ge or joint
tended time. T
motion is difficull. 17 Various devices have been designed to Flexibilit~, has been defined as th e range of motion possi­
Another grou
accommodate variations in the size or the joints. as well as ble about a single joint or throu gh a series of articulations.
tively as prop.
the complexity or movements in articulalions that invol've The maintenance of a full, nonrestricted range or motion
techniques, il
more than one joint. H.l9 Of these device s, the simplest and has lon g been recognized as an essential component or
stretches, has ~
most widely used is the goniometer (Figure 6-4 ). athletic i1tness. 13.1 4 . 15 Flexibili ty is impor tant not on ly for
emphasis h as
A goniometer is a large protractor with measurements su ccessful physical performance but also for the preven­
tion or injury.l.i.lL5 I.b9 The goal of a ny effective [1exibility
oIaSciai tissue
in degrees. By aligning the individual arms of the go­
hancing the \
niom eter parallel to th e longitudinal axis or the two seg­ program should be to improve the range of motion at a
eflkienUy co n
ments involved in motion about a specific joint. it is given articulation by a ltering the extensibility of the mus­
tion. Research (
possible to obtain reasonably acc urClle measurement or culotendinous units that produce movement at that jOint.
which of these
range of movement. '1'0 enhance reliability. standardiza­ It is well documcnted that exercises th at stretch these mus­
range of moli oi
tion of me.asuremeni techniques and methods of record­ culotendinous units and their fascia over time will increase istS. 2 I.2R .4 1.5 3."
ing active and passive ranges of moti on are critic al in the range of movement possible abo ut a given join1. 2s . i l
Agonist \'I
indiv idual clinics where successive measurement s might Stretclling techniqu es ror improving flexibility h ave
cussing the difl
be taken by different athletic trainers to assess progress . evol ved over the years: w Th e oldest tech niq ue for stretch­
to define the t
 CHI\PTER 6 Restoring Range of :vIotion and Improving Flexibility 125

!. TABtE 6·1 Active Ranges ofJoint

Motions.
Most joints in the body arc capable of more than one move­
ment. The knee joint, for example, is capable of flexion and
extension. Contraction of the quadriceps group 0[' muscles
Joint Action Degrees of Motion on the front of the thigh causes knee extension, whereas
contraction of the hamstring muscles on the back 0[' the
Shoulder Flexion 0-180 degrees thigh produces knee flexion.
Extension 0-50 degrees '}'o achieve k nee extension, the quadriceps group con­
Abduction 0-] 80 degrees tracts while the hamstring muscles relax and stretch. !VI us­
Medical rotation 0-90 degrees cles that work in concert with one another in this manner
Lateral rotation 0-90 degrees arc called synergistic muscle groups. h The muscle that
Elbow Flex:ion 0-] 60 degrees contracts to produce a movement, in this case the quadri­
Forearm Pronation 0-90 degrees ceps, is referred to as the agonist muscle. The muscle being
Supination 0-90 degrees stretched in response to contraction of the agonist muscle
io t flexion Wrist Flexion 0-90 degrees is called the antagonist muscle.27 In this example 0[' knee
Extension 0- 70 degrees extension, the antagonist muscle would be the hamstring
Abduction 0-25 degrees group. Some degree of balance ,in strength must exist be­
!\dduction 0-65 degrees tween agonist and antagonist muscle groups. This balance
n ide red nor­ Hip Flexion 0-] 2 :; degrees is necessary for normal. smooth. coordinated movement,
Extension 0-15 deg rees as well as for redUCing the likelihood of muscle strain
i in ts.
e i n a rehabili­ Abductio n 0-45 degrees caused by muscular imbalance. Comprehension of this
improvement Adduction 0-15 degrees synergistic muscle action is essential to understanding the
iLiLation pro- Media'l rotation 0-45 degrees various techniques of stretching.
Lateral rotation 0-45 degrees
Knee Flexion 0-1 40 degrees
Ankle Plantarl1exion 0-45 degrees Clinical Decision Making Exercise 6-4
Dorsiflexion 0-20 degrees
Foot Inversion 0- 30 degrees During a preseason screening. you observe that a rower
Eversion 0-10 degrees has only 120 degrees of knee tlexion. Wh at arc some of
the things that might be limlting this motion?

ing is called ballistic stretching, which makes use of repeti­

tive bouncing motions. t\ second technique, known as
static stretching, involves stretching a muscle to the point of
IES discomfort and lhen holding it at that point for an ex­
tended time. This tech nique has been used for many years.
motion possi­ Another group of stretching techniques known collec­
ar ti culations. tively as proprioceptive neuromuscular Iacilitation (P.\ 'F)
range of motion techniques, involving alternating contractions and
compoll.ent of stretches, has also been rccommended. 4170 Most recentry,
l n ot only for
emphasis h as been on the contribution of stretcllillg my­
lo r the preven­ oJascial tissue as ,',Tell as stretclling tight neural tissue in en­
' tive flexibility hancing the ability of the neuromuscular system to
.... of motion at a efi1cienLiy control movement through a full range of mo­
:..ity of the mus­ tion. Researchers have had considerable discussion about
t a t that joint. which of t hese techniques is most effective for improving
retc h these mus­ range of motion, and no clear-cut consensus currently ex­
wne will increase ists. 2 1.28,44.:; 3.:;7
~I\en joint. 2H . i1
Agonist versus Antagonist Muscles. Before dis­
~ fle xibility have
cussing the different stretching techniques, it is essential
q ue for stretch­ to define the terms agonist muscle and antagonist muscle.
Ballistic (Dynamic) Stretching
If you were to walk oulto the track on any spring or fall af­
ternoon anc! watch people who arc warming up with
stretching exercises before they run. you would probably
see them use bouncing movements to stretch a particular
muscle. Th is bouncing technique is more appropriately
known as ballistic stretching, in which repetitive COrl.trac­
tions of the agonist muscle are used to produce quick
stretches of the an tagonist muscle.
Over the years, many fitness experts have questioned
the safety of the ballistic stretching technique. l2 .4h Their
concerns have been primarily based on the idea that bal­
listic stretching creates somewhat uncontrolled ['orces
wilhin the muscle that can exceed the extensibility limits
of the muscle fiber, thus producing small microtears
within the musculotendinous unil.22.2l.2h.49.7l Certainly
this might be true in sedentary icndividuals or perhaps in
athletes who have sustained muscle injuries.
126 PARTTWO Achieving the Goals o[ Rehabilitation
Most sport activities are dynamic and require ballistic­
type movements. For example. forcefully kickil1g a soccer
ball SO ti mes involves a repeated dynamic contraction of
the agonist quadriceps muscle. The antagonist ham­
strings are contracting eccentrically to decelerate the
lower leg. Ballistic stretching o[ the hamstring muscle be­
fore engaging in this type o[ activity should allow the
muscle to gradually adapt to the imposed demands and re­
duce the likelihood o[ injury. Because ballistic stretching
is more fun ctional, it should be integrated into a recondi­
tioning program during the later stages of heaHng when
appropriate.
Static Stretching
The static stretching technique is another extremely effec­
tive and widely used technique of stre tching. » This tech­
nique involves passively stretching a given antagonist
muscle by placing it in a maximal position o[ stretch and
holding it there for an extended time. Recommendations
for the optimal time for holding this stretched position
vary. ranging from as little as 3 seconds to as much as 60
seconds. lJ Several studies have indicated that holding a
stretch [or 15 to 30 seconds is the most effective for in­
creasing muscle l1exibilily.4.42.40 Stretches lasting for
longer than 30 seconds seem to be uncomfortable for the
athlete. A staUcstretcb of each muscle should be repeated
3 or 4 times. A static stretch can be accompHshed by using
a contraction of the agonist muscle to place the antagonist
muscle in a pOSition o[ stretch. A passive static stretch re­
qulres the use of body weight. assistance [rom the athletic
trainer or partner. or use of aT-bar. primarUy for stretch­
ing the upper extremity.
]'I'luch research has been done comparing ballistic and
static stretching techniques [or the improvement of l1exi­
bility. Static and ballistic stretching appear to be equally ef­
fective in increasing flexibility. and there is no significant
difference between the two. 23 However. much of the litera­
ture states that with static stretching there is less danger of
exceeding the extensibility limits of the involved joints be­
cause the stretch is more controlled. Most of the literature
indicates that ballistic stretching is apt to cause muscular
soreness. especially in sedentary individuals. whereas
static stretching generally does not ca use soreness and is
commonly used in injury rehabilitation of sore or strained
muscles. 1UI Static stretching is likely a much safer
stretching technique. especially [or sedentary or ul1trained
individua]s. Ho·wever. because many physical activities in­
volve dynamic movement. stretching in a warm-up should
begin with static stretching followed by ballistic stretching.
which more closely resembles the dynamic activity.
A progressive veloCity (}exibility program (PVPP) has one side of a jl
been proposed that takes the athlete through a series of or the antagol
stretching exercises where the velocity of the stretch and Slow re\'
the range o[ lengthening are progr essively controlled, 73 ally referred
The stretching exercises progress from slow static stretch­ f(RAe). teetu
ing; to slow. short. end-range stretching; to slow. fuLl-range the agonist. \\
stretching; to fast. short. end-range stretching; to fast. full­ onist pattern .
range stretching. This program allows the athlete to con­ antagonist Illl
trol both the range and the speed with no assistance from push pbase. 0
an athletic trainer. relaxed whilt
movement in
thus stretc hin
Clinical Decision Making Exercise 6-5
con tract-rela
rim ge of mati
A freshman high school cross-countTy runner needs to
antagonistic "
know how to best stretch on his own. What sbould he
PNF s(retci
know about how far to go in his stretch and how long he
muscle in the
should hold it?
tec hniques are
though th ey fT1
PNF Stretching Techniques
PNF techniques were first used by physical therapists for
treating athletes who had various neuromuscular disor­
ders.41 More recently. PNF stretching exercises have in­
creaSingly been used as a stretchLng Lechnique for
improving flexibility.I n.4 i,52,>l
There are tbree different PN'F techniques currently be­
ing used for stretching: slow-reversal-hold-relax. contract­
relax. and hold-relax techniques."7 All three techniques
involve some combination of alternating isometric or iso­
tonic contractions and relaxation o[ both agonist and an­
tagonist muscles (a lO-second pushing phase followed by
a 10-second relaxing phase) .
Contract-relax (CR) is a stretching technique that
moves the body part passively into the agonist pattern. The
athlete is instructed to push by contracting the antagonist
(the muscle that will be stretched) isotonically against the comparing s t~
resistance of the athletic trainer. The a thlete then relaxes stretching is cei
the antagonist while the athletic trainer moves the part in fleXibility 0\
passively through as much range as possible to the point major disad \'an
where limitatioo is again felt. This contract-relax tech­ usually requirj
nique is beneficial when range of motion is limited by mus­ stretchin g w ith
cle tightness.
Hold-relax (HR) is very similar to the contract-relax
technique. It begins with an isometric contraction of the improving fl
antagonist (the muscle that will be stretched) against re­ How long
sistance. [ollowed by a concentric contraction of the ago­ tained once
nist muscle combined with light pressure [rom the athletic indicated th ata
trainer to produce maximal stretch of the antagonist. This ter only 2 week
technique is appropriate when there .is muscle tension on be maintain ed f
 CHAPTER 6
a m (PVPP) has one side of a joint and may be used with either the agonist
~
u gh a series of or the antagonist.
the stretch and Slow reversal-hold-relax (SRHR) also occasion­
I controlled. 73 ally referred to as the contract-relax-agonist-corztractioll
, static stretch- (CRAe). technique begins with an isotonic contraction 01'
o low. full-range the agonist. which often limits range of motion in the ag­
io g: to fast. full­ onist pattern. followed by an isometric contraction of the
e athlete to con­ antagonist (the muscle that will be stretched) during the
) assistance from push phase. During the relax phase. the antagonists are
relaxed while the agonists are contracting. causing
movement in the direction of the agonist pattern and
thus stretching the anLagonisl. 'l"his technique, like the
Exercise 6-5 contract-relax and hold-relax. is useful for increasing
rcltlge of motion when the primary limiting factor is the
antagonistic muscle group.
PNF stretching techniques can be used to stretch any
muscle in the body. 9. I H. I Y.i 2 . i>.4 7. ~Y . i '. b 7 PNF stretching
techniques are perhaps best performed with a partner. al­
though they may also be done using a wall as resistance.
Comparing Stretching Techniques
therapists for A'i tholigh all three stretching techniques discussed to this
u c ular disor­ point have been demonsLrated to effectively improve l1exi­
",rci es have in­ bility. there is still considerable debate as to which tech­
=- 'echnique for nique produces the greatest increases in range of
movement. ; The ballistic technique is recommended for
" currently be­ any athlete who is involved in dynamic activity. despite its
cla.'\:. contract­ potential for causing muscle soreness in the sedentary or
ret' techniques untrained individual. In highly trained individuals, it is un­
- metric or iso­ likely that ballistic stretching wHI result in muscle Soreness.
ago nist and an­ Static stretching is perhaps the most widely used tech­
ase followed by nique. It is a simple technique and does not require a part­
ner. A fully nonrestricted range of motion can be attained
: tec l nique that through static stretching over time. PNF stretching tech­
i pattern. The niques are capable of producing dramatic increases ,in
the antagonist range of motion during one stretching session. Studies
ally against the comparing static and PNF stretching suggest that PNF
ete then relaxes stretching is capable of prodUCing greater improvement
moves the part in l1exibility over an extended training period. 3o .3 I. i i The
"ble to the point major disadvantage of PNF stretching is that a partner is
ct-relax tech­ usually required to assist with the stretch. although
" " ited by mus- stretching with a partner can have some motivational ad­
vantages. More and more athletic teams seem to be adopt­
It' co ntract-relax ing the PNF technique as the method of choice for
traction of the improv ing l1exibility.
-hed) against re­ How long increases in muscle flexibility can be sus­
itClion of the ago­ tained once stretching stops is debatable.">·b2.!! One study
_from the athletic indicated that a significant loss of flexibility was evident af­
anlagonist. This te r only 2 weeks. 74 It was recommended that l1exibility can
IlllStle tension on be maintained by engaging in stretching activiLies at least
Restoring Range of Motion and Improving Plexibility 127
once a week. However. to see improvement in flexibility,
stretching must be done 3 to 5 times per week. 2 '
SPECIFIC STRETCHING
EXERCISES
Chapters 18 through 25 will include examples of variolls
stretching exercises that may be used to improve rIexibilily
at specific jOints or in specific muscle groups throughout
the body. The stretching exercises shown in Figure 6-5 may
be done statically: they may also be done with a partner us­
ing a PNF technique. There are many possible variations to
each of these exerciscs. l8 The athlete may also perfc)rm
staLic stretching exercises using a stability ball (Figure 6-6).
The exercises selected are those that seem to be the most ef­
fective for stretching of variolls muscle groups.
Stretching Neural Structures
The athletic trainer should be abJe to differentiate between
tightness in the musculotendinous unit and abnormal
neural tension. The athlete should perform both active and
passive multiplanar movements that create tension in the
neural structures that are exacerbating pain, limiting
range of motion. and increasing neural symptoms. includ­
ing numbness and tingling. I I For example. the straight leg
raising test not only applies pressure to the sacroiliac joint
but also may indicate a problem in the sciatic nerve (r.igure
6-7C). Internally rotating and adducling the h ip increases
the tension on the neural structures in both the greater
sciatic notch a.nd the intervertebral foramen. An exacer­
bation of pain from 30 to 60 degrees indicates some sciatic
nerve involvement. If dorsil1exing the ankllc with maxi­
mum straight leg raising increases the pain. then the pain
is likely due to some nerve root (L3-4. S 1-3) or sciatic nerve
irrit ation. Figure 6-7 shows the assessment and stretching
positions for neural tension in the median. radial, and sci­
atic nerves as well as the vertebral nerve roots in the spine.
Myofascial Release Stretching
Myo/ascial release is a term that refers to a group of tech­
niques used for the purpose of relieving soft tissue Crom the
abnormal grip of tight fascia. It is essentially a form of
stretching that has been reported to have significant im­
pact in treating a variety of conditions. Some specialized
training is necessary for the athletic trainer to understand
specific techniques of myofascial release. It is also essential
to have an in-depth understanding of the fascial system .
128 P1\RT nvo Achiel'i ng tb e Guals of Rehabilitation

A
A B

c D

c
Figure 6- 5 Examples of stretching exercises that may be done sLatically or using a PNF tec hniqu e. A, hamstrings.

B, /\nkle plantar fl exors. C, Qua driceps. V, Glenohumeral joint extensors.

fascia is a type of connective tissue that surrounds
muscles, tendons, nerves , bones, and organs. It is essen­
tially continuous from bead to toe and is interconnected in
various sheaths or pl(lnes. Fascia is composed primarily of
collagen a long with some olastic nbcrs. During movement
the fascia mu st stretch and move ['reely. If there is damage
l.o the fascia owing to inj llry. disease, or inflam mati on, it
will not only a ffect loca l adjacent structures but may also
affect areas far removed from the site of the injury. Thus it
may be necessary to re lease lightness both in the (lrea of
injury and in distant areas. It will l.end to soften and 1'e­
le(lse in response to gentle pressure over a relatively long
period of lime.
\lyofascial release has also been referred to as soft­
tissue l1lobilizalion. Soft-tissue mobilization should not be
confused \vith joint mobilization. although it must be em­
ph <lsized th(lt the two an; riosely rl'IClted. Joint mobilization Figure 6 -6
is u sed to restore normal joint arthrokinetnatics, and spe­ V , Piriform '
cific rules exist regarding direction of movemcn t and join t
pOSition based on tbe shapt: of the articulating surfa ces (see
Chapter 14). Myofa scial restrictions are conSiderably more
unpredictable and may occur in many different planes and sllperGcial ra ~
directions. Myofascial treatment is based on loca liZi ng (he more superfici;
reBtricti on and moving inlo the directio n of the restriction, Lions Cil n be II
regnrdl ess of whether that follows the nrthrokincmalics of damage to su pi
a nearby jOin!. Thus. myo1ascialmaI1ipuiation is considt:r­ low myofasciaI
ably more su bjective and relies he av ily on the experience of soft-tissut: res
the athletic trainer. Ms'ofasciai m an ipulation focuses on
large treatmt:nt areas, wh ereas joint mobilization focuses lion nnd strd
on a specillc joint. Relea Sing myofascial restrictions Clver a be incorpora t
large tre atment area ca n have a significant impact on joint recommend ed
mo biLity, The progression of the technique is to work from which helps p.
 CHAPTER 6 Restoring Range of MoLion und Improving Flexibility 129

A D

D
E

c
tru lrings.

"ll mobilization Figure 6-6 Static stretching using a stability ball. A, Back extension. B, Side stretch. C, Latissimus dorsi stretch.
• alies. and spe­ D, Piriformis stretch. E, Quadriceps stretch.
cnt and joint
'12 . urfaces (see
-iderab ly more
superficial fascial restrictions to deeper restrictions. Once terns. As freedo m of movement ilnproves, postural reedu­
en t planes and
1110re superficial restrictions are released, the deep restric­ cation may help ens ure the maintenance of the less re­
n loca lizing the
tions can be locmed and released without causing any stricted movement patterns.
the restriction ,
damage to supcrficiallissues. Joint mobHization should fol­ Generally, acute cases tend to resolve in just a few
.okinemalics of
low myofascial release and will likely be more effective once treatments. The longer a condition has been present, the
n is consider­
soft-tissue re.strictions ure eliminated. longer it will take to resolve. OccaSionally, dramatic results
e experience of
As extensibility is improved in tbe myofascia , elonga­ will occur immediately after treatment. It is usually rec­
ion focuses on
tion and stretching of the musculotendinous unit should ommended that treatment be done at least three times per
"Iization focuses
be incorporated. In addition. strengthening exercises are week.
r ietions over a
recommended to enhunce neuromuscular reeducation, Myufascial release can be done manually by an athletic
im pact on joint
which helps promote new. more efficient movement pat­ trainer or it can be done by the athlete stretching using a
i to work from
 130 PAHTTWQ Achieving the Gauls of RchClbili(ution

A B

c o c

Figure 6-8
D, Piriformis.

Figure 6-7 Neuraitension stretches. A, \'[edian nerve. B, Radial nerve. C, Sciatic nerve. D, Slump position.

bioform foam roller. Figure (i-H shows examples of stretch­ the stretch reJ1ex: lhe mllscle spindle an d th c (;o lOi lendon or­
nervous system
ing using the foam roller. gan. Both types of receptors are se nsitive to changes in
pulses return 10
muscle length. The Golgi tendon organs arc also arfected
the mu scle to
by changes in muscle tension.
NEUROPHYSIOLOGICAL BASIS stretch. 46 The G
OF STRETCHING in length and Ih
CLINICAL DECISION MAKING Exercise 6-6 impulses of th c~
'!'he stretching tec hniq ues nre bnsed on a neurophysi olog­ the muscle cont!
ical phenomenon involving the stretch reflex (see Figure r\ conch asks th e athlet ic trainer for recolllmendations for least 6 secondsl
15-] . p. 3(4).54 Every muscl e ill the body contains various stretching to help improve the llexibility of his players. begin to overrid
types or
Illech anoreceptors that. when stimulated. inform What three types of stretc hes could be recommended . from the Golgi t
the central nervous system of what is happening with that and ",hat are th e advantages and disadvan tages of cachO muscle spindle.
muscle. Two of th ese mech,]!1 oreceptors are important in muscle. This ren
 CHAPTER 6 Restorin g l{ange of \'I:lotion <llld [mprovi ug· lexibility 131

A D

B E

D
c F

Figure 6-8 Myofaseial release stretching usin g a foam roller. A, Tensor fascia lalae. B, Quadriceps. C. Adductors.
D, Piriformis. E, Teres minor. F, Thoracic spi ne.

don .
When a muscle is stretched , both the muscle spindles
a nd th e Golgi tendon organs inullediaLely begin sending a
volley of sensory impulses to the spinal cord. Initially im­
pulses coming from the muscLe spindles inform the central
;,,)/gi /elldon or­
nervous system thilt th e muscle is being stretched. Im­
O c hanges in
pulses return to the muscle from Lhe spina l cord. causing
fi also affe cted
the muscle Lo re['!exillely contract. thelS resisting the
stretch. 4b The Golgi tendon orga ns respond to the change
in length and the incre<lse in tension by firing off sensory
imp ulses of their own to the spinal cord. If the stretch of
the muscle continu es for an extended period of time (at
least 6 seconds). impul ses [rom the Golgi tendon organs
begin to O\'crride muscle spindle impulses. The impulses
from the Goigi tendon orga ns. unlike the signals from the
muscle spindle. cause a reOex rela xatio n of the antagonist
muscle. This reDex relaxation serves as a protective mech­
anism Lhat will a llow the muscle to stretch through relax­
ation witho ut exceeding the extensibility limits, which
could damage the muscle t1bcrs. ~
\,\'itb th e jerking. boun ci ng m otion of ballisllc stretch­
ing. the muscle spindles are being repeti tive ly stretc hed;
thus there is continuous resista nce by the muscle to fur­
ther stretch. 1 11e ba llistic stretch is no t con tinued long
enough to allow the C;olgi tendon organs to have a relax­
ing effect.
Tile static stretch involves a co ntinuous susta ined
streLch lasting anywhere from h to 60 seconds, which is
sufficien t time for th e Golgi tendon organs to begin re­
sponding to tbe in crease in tension. The impu lses from the
Colgi tendon orgilns ca n override the impulses coming
from the mu scle spindles. allowing the muscle to reflex­
ively relax a fter th e initio I reflex resista nce to the change in
132 PAR1' TWO Achieving the Goals of Rehabilitation

le ngth. Thus lengthening the muscle and allowing it to re­ Both the contractile and the noncontractiJe compo­ and a specitlc
main in a stretched position lor an extended period of time nents appear to resist deformation when a muscle is be slow to aCL
,is unlikely to produce any injury to the muscle. stretched or lengthened. The percen tage of their individ­ traIizers su bst
The effectiveness of the PNF techniques can be attrib­ ual contribution to resisting deformation depends on the the ca se. new
uted in part to these same neurophysiological principles. degree to which the muscle is stretched or deformed and ample. if the p
The slow-reversal-hold-relax tecbniq ue discussed previ­ on the velocity of deformation. The noncontractile ele­ maximus will
ously takes advantage of two additional neurophysiologi­ ments a re prhnarily resistant to the degree of lengthening, maximus (prL
cal phenomena.>2 while the contractile elements limit high-velocity defor­ creased neura
The maximal isometric contraction of the muscle that mation. The greater the stretch. the more the noncontrac­ lizers (erectOI
will be stretched during the lO-second "push" phase again tile componenls contribute. substitute and
causes an increase in tension that stimulates the Golgi ten­ i' - Lengthening of a muscle via stretching. which is This creates ~
don organs to effect a reflex relaxation of the antagonist maintained for a period long enough to allow for autogenic muscular co nt
even before the muscle is placed in a position of stretch. inhibition to reflexively relax the muscle. allows lor vis­ Muscle ti g]
This relaxation of the antagonist muscle during contrac­ coelastic and plastic changes to Docur in th e collagen and creased muse!
tions is referred to as autoaenic inhibitioll. elastin tlb ers. The viscoelastic changes that allow slow de­ cause decreast
During the relaxing phase the antagonist is relaxed formation with imperfect recovery are not permanent. antagonist. Tt:
and passively stretched while there is a maximal isotonic However. plastic changes, although dimcult to achieve. re­ which ill turn
contraction of the agonist muscle pulling the extremity sult in residua l or permanent change in length du e to de­ involved segIDI
further into the agonist pattern. Tn any synergistic mus.cle formation creat.ed by long periods of stretching. or hypertonici1
group. a contraction of the agonist causes a rellex relax­ The greater the velocity of deforrnation. th e greater nist (gluteus m
ation in the antagonist muscle, allowing it to stretch and the chance for exceeding tha t tissue's capability to un­ drive). causing
protecting it from injury. This phenomenon is referred to dergo viscoelastIc and plastic change. 73 turn leads to
as reciprocal inhibition (,! (see rigure 1.5-2 on p. 303).
phenomenon l
Thus, with the PNV techniques the additive effects of a weak and /or
autogenic and reciprocal inhibition should theoretically THE EFfECTS OF STRETCHING
tion capabili li
allow the muscle to be stretched to a greater degree than I.S
possible with static or ballistic stretching. >4
ON THE KINETIC CHAIN
couple relali
reaction.
Joint hypomobilily is one of the mosi. frequently treated
THE EFFECTS OF STRETCHING causes of pain. However. th e etiology can usually be traced
to faulty posture. mu scular imbalances. and abnormal THE 1M
ON THE PHYSICAL AND neuromuscular conlrol. Once a particular joinl has ,lost its
MECHANICAL PROPERTI,ES normal arthrokinematics, the muscles around that jOint P,RIOR TI
OF MUSCLE attempt to minimize the stress at that involved segment. To most effecq
Certain muscles become tight and hypertonic to prevent rehabilitation.
The neurophysiological mechanisms of both autogenic additional jOint translation. rr one muscle becomes tight or creased prior ~
and reciprocal inhibi~ion result in reflex relaxation with changes its degree of activation, then synergists. stabiliz­ has a positive
subsequent lengthening of a muscle. Thus the mechanical ers. and neutralizers have to compensate. leading to the elastin compol
properties of that muscle that physically allow lengthen­ formation of complex neurornusc uloskeletal dysfunctions. deform. Also.
ing to occur arc di ctated via neural input. Muscle tightness and hypertonicily have a Significant reOexively reI",
Both muscle and tendon are composed largely of non­ impact on neuromu scular control. Muscle lightness af­ is enhanced wi
contractile collagen and elastin fibers. (The physical and feels the normal len gth-tension relationships. "Vhen one optimal temiX;
mechanical properties 01 collagen and elastin were dis­ muscle in a force-couple beco mes tight or hypertonic. it al­ effects is 39°
cussed in Chapter 2.) Collagen enables a tissue to resist me­ ters the normal arthrokinematics of the involved joint. temperature Co
chanical forces and deformation, whereas elastin This affects th e synergistic function of the en tire kinetic warm-up type
composes highly elastic tissues that assist in recovery from chain. leading to abnorma'l joint stress. soft-tissue dys­ apeutic mod al ~
deformation. function, neural compromise. and vascular/lymphatic sta­ used as the pri
Unlike tendon , muscle also has active contractile com­ sis. Alterations in recruitment strategies and slabiJi:mtion temperature.
ponents which a re the actin and myosin myofilaments. strength result. Such compensations and adaptations af­ The use of
Collectively the contractile and noncontractile elements fect neuromusc ular e[,ficiency throughout the kinetic ommended. C
determine the muscle's capability of deforming and recov­ chain. Decreased neuromuscular control alters the activa­ some musde g
ering fr om deformation. 71 tion sequence or firing order of different muscles involved de soreness. ;>
 CHAPTER 6 Restoring Range of Mot.ion and Improving Flexibility 133

lractile compo­ and a speCific movement is disturbed. Prime movers may

en a muscle is be slow to activate. while synergists. stabilizers. and neu­
of their individ­ tralizers substitute and become overactive. When this is
depends on the the case. new joint stresses will be encountered. l l For ex­
r deformed and ample. if the psoas ,is tight or hyperactive. then the glutcus
contractile ele­ maximus will have decreased neural drive. If the gluteus
of lengthening. maximus (prime mover during hip extension) has de­
. -\'elocity defor­ creased neural drive. than synergists (hamstrings). stabi­
lizers (erector spinae). and neutralizers (piriformis)
substitute and become overactive (synergistic dominance).
This creates abnormal joint stress and decreased neuro­
muscular control during functional movements.
Muscle tightness also causes reciprocal inhibition. In­
e collagen and creased muscle spindle activity in a specific muscle wlll
allow slow de­ cause decreased neural drive to that muscle's functional
l permanent. antagonist. This alters the normal force-couple activity.
t to achicve. rc­ whicb in turn affects the normal arthrokinematics of the
gt h due to de­ involved segment. For example. if an athlete has tightness
in g. or hypertoniCity in the psoas. than the functional antago­
n. the grcater nist (gluteus maximus) can be inhibited (decreased neural
iJDilbUity to un- drive). causing decreased neuromuscular contro!' This in
Figure 6-9 Strength training through a full range of
turn leads to sYl1ergistic dominance-the neuromuscular
motion will not impair. and might improve. t1exibility.
phenomenon that occurs when synergists compensate for
a weak and/ or inhibited muscle to maintain force produc­
rCHIN.G tion capabilities.]] This process alters the normal force­
couple relationships. which in turn creates a chain THE RIELATIONSHIP BETWEEN
reaction.
uen tly treated STRENGTH AND FLEXIBILITY
-ua lly be traced We often hear about the negative effects that strength
an d abnormal THE IMPORTANCE OF WARM-UP training has on flexibility. For example, someone who de­
int has lost its velops large bulk through strength training is often re­
un d that joint PRIOR TO STRETCHING
ferred to as "muscle-bound." The expression muscle-bound
"'ed segment. To most effectively stretch a muscle during a program of has negative connotations in terms of the person's ability
onic to prevcn t rehabilitation . intramuscular temperaturc should be in­ to move. We tend to think of people who have highly de­
. becomes tigh tor creased prior to stretching. 50 Increasing the temperature veloped muscles as having lost much of their ability to
ergists. stabUiz­ has a positive effect on the ability of the collagen and move freely through a full range of motion. 4 3
. leading to the elastin components within the musculotendinous unit to Occasionally a person develops so much 'bulk that th e
"'al dysfunctions. deform. Also. the capability of the Go'lgi tendon organs to physical size of the muscle prevents a normal range of mo­
~ ve a Significant reflexively relax the muscle through autogenic inhibition tion. Strength training that is not properly done can im­
'Ie Llghtness af­ is enhanced when the muscle is heated. It appears that the pair movement. However. there is no reason to believe that
hIp . Whcn one optimal temperature of muscle to achieve these beneficial weight training. if done properly through a full range of
, ypertonic. it al­ effects is 39°C. or 103°F. This increase in ,i ntramuscular motion. will impair flexibility. 59 Therefore. during a reha­
involved joint. temperature can be achieved either through low-intensity bilitation program the athlete must be encouraged to
e entirc kinetic warm-up type exercise or through the use of var,ious ther­ strength-train througJh a full , pain-free range of motion
oft -tissue dys­ apeutic modalities, 29.60 It is recommended that exercise be progreSSing as rapidly as pain decreases will allow. Proper
r lymphatic sta­ used as the primary means for increasing intramuscular strength training probably improves dynamic flexibility
and stabilization temperature. and. if combined with a rigorous stretching program. can
J adaptations af­ The use of cold prior to stretching has also been rec­ greatly enhance powerful and coordinated movements
lU I the kinetic ommended. Cold appears to be most useful when there is that are essential for success in many athletic activities. In
alters thc activa­ some muscle guarding associated with delayed-onset mus­ all cases a heavy weight-training program should be ac­
mu cles involved cle soreness. 5; companied by a strong flexibility program (Figure 6-9).
134 PART TWO Achieving the Goals of Rehabilitation

GUIDELINES A'ND PRECAUTIONS Exercise caution when stretching the low back and

neck. Exercises that compress the vertebrae and their

References
FOR STRETCHING discs can cause damage.

1. Allerheilig,
The following guidelines and precautions should be incor­ Stretching from a seated rather than a standing posi­

strength trai
porated into a sound stretching program: 5 J. 6lM tion takes stress off the low back and decreases the
paign. IL: H
Warm up using a slow jog or fast walk before stretch­ chances of back injury.
2. Alter. M. 19
ing vigorously. Be sure to continue normal breathing during a stretch.
man KineUc
To increase flexibility. the muscle mus~ be overloaded Do not hold your breath.
3. Armiger. P.
or stretched beyond its normal range but not to the Static and Pl\TF techniques are most often recom­
focus on flt']
point of pain. mended for individuals who want to improve their
4. Bandy. W D.
range of motion .
stretch on l
Stretch only to the point where tightness or resistance
Ballistic stretching should be done only by those who
Therapy 74:1
to stretch. or perhaps some discomfort. ,is felt. Stretch­ 5. Bandy. W D
ing should not be painful.! are already flexible or accustomed to stretching. and

static stretd
should be done only after static stretching.

Increases in range of motion will be specific to what­

Stretching should be done at least 3 times per week to

flexibility or
ever muscle or joint is being stretched. Sports Pilysi
Exercise caution when stretching muscles that sur­ see minimal improvement. It is recommended to
6. Basmujian .
round painful joints. PHin is an indication that some­ stretch between 5 and 6 times per week to see maxi­
lNilliams & ,
thing is wrong and should not be ignored . mum results.
7. Blanke. D. 1
Avoid overstretching the ligaments and capsules that by II'I. MelUo
surround joints. 8. Burke. D. Goo
ical basis or
nal of St reng:
Summary 9. Carter. A. M
Propriocepti
activity dur;
muscles. J014
1. Flexibility is the ability of the neuromuscular system 7. Ballistic. static. and proprioceptive neuromusc ular fa­
10. Chapman. ~
to allow for efficient movement of a jOint or a series of cilitation (PNF) techniques have all been used as
sti ffness: EIll
jOints smoothly through a full range of motion. stretching techniques for improving flexibility. Gerontology
2. Flexibility is specific to a given joint. and the term good 8. Stretching of tight n eural structures and myofascial 11 . Clark . M. 1
flexibility implies that there are no joint abnormalities rcleHse stretching are also used to reestablish a full Calabasas.
restricting movement. range of motion . 12. Condon. S.
3. Flexibility can be limited by muscles and tendons and 9. Each of these stretching techniques is based on the activity and
their fascia. joint capsules or ligaments. fat. bone neurophysiological phenomena involving the muscle ingprocedw
structure. skin. or neural tissue. spindles and Golgi tendon organs. PNF techniques ap­ 13. Corbin. c..
4. Passive range oj motion refers to the degree to which a pear to be the most effective in producing increases in fitness. lO ll
joint can be passively moved to the end points in the 14. Corbin. c..
flexibility.
Education. ~
range of motion. Active range oj motion refers to move­ 10. Stretching should be included as part of the warm-up
15. Corbin. c.. Ii
ment through the midrange of motion resulting from period to prepare the muscles for what they are going nent of ph~
active contractiol). to be asked to do and to prevent injury. as well as in the ercise prognn
5. Measurement of jOint flexibility is accomp1ished cool-down period to help reduce injury. Stretching af­ Alliance for'
through the use of a goniometer. ter an activity can prevent muscle soreness and will Dance.
6. An agonist muscle is one that contracts to produce help increase l1exibility by stretching a loose. warm ed­ 16. Cornelius. \
joint motion; the antagonist muscle is stretched with up muscle. apy and p~
contraction of the agonist. 11. Strength training. if done correctly through full range Training 19: '
of motion. will likely improve flexibility.
 CHAPTER 6
" low back and
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35. Hubley. C. L.. j. W. Kozey, and W, D. Stanish, 19 84.1 he effects tions for athletic rehabHitation and performance. Forum
therapy, edit
of stil tic stretching exercises and station ary cycling on range Medicwn (51): 1-13 .
of motion at the hip jolnt. jOlll'l1al of Orthopaedic and Sports 55. Prcntice, W, E. 1982 . An electromyogmphic analysis of h eat SOLUTION
Physical Therapy 6:104-09. or cold and stretching for inducing muscular relaxation. jour­
36. Humphrey, L. 0 . 1981. Flexibility. JOIIl'lwl of Physical EduclI­ nalof Orthopaedic and Spans Physical Tllerapy 3: 13 3-40.
tion, Recreation and Dance 52:41. 56. Rasch, P 1989. Kinesiolo!!y anri IIpplied anatomy. Philadelphia: 6-1 Flexibilit)
37. Hutin ger, E 1974. How Ilexible are you? ;\ljLwlic World Maga­ Lea & Febiger. During tl
zine, January. 57. Sady, S. p" M. Wortman , and D. Blanke. 1982. Flexibility maintain
38. Ishii. D. K. 19 76, Flexibility strexercises for co-cd groups. training: Ballistic, static, or proprioceptive neuromuscular fa­ does not I
ScilOlasUc COllch 45: 31. cilitation? Archives of Physical Medicine and Relwbilitlltion ening of
39 . Jackson , A. w., an d A. A. Baker. I '186. There'lat ionship of the 63:261-63. risk for m
sil-and-rcilch tcst to crilerion measures of hamstring and 58. Sapega. A. A" T, Qllcdenfcld, R. Moyer, et al. 1981. Biophysi­
malac m~
back llexibility in young fema ]cs. ll.esCllrch Quarterly jlll' Exer­ ca l fa clors in range-or-motion exercise. Physiciilll lind Sports
6-2 Applying
cise 1II1d Sport 57( 3): 183 . :vledicinc 9(12): )7.
40, Knortz, K .. and C. Rin gel. ] YS5. Flexibility techniques. NII­ 59. Schilling, H. K. and' M. H. Stone. 2000 . Stretching: Acute ef­ and/or eL
timwl Strrngth and COlldiUollin[1 flssociaUon jOllrlLaI7(2 ): 50. fects on st rength and power performance. Strength and Condi­ pain and
41. Knotl, M .. iJnd P Voss. 19S). Proprioceptive lIet/ramusclllar fa­ tioning jOlll'llal 22( 1): 44. ROM, Del;
cilitlltioll. 3d ed, NelV York: Harper & Row. 60. Shellock, F" and W. E. Prentice. 1985, Warm-up and stretch­ gin to sub
42 . Lentell. G., T. Hetherington, J. Eagiln. et al. 1992. The usc of ing for improved physical pcrformance and prevention of 6-3 A goniom
thermal agents to influence the effectiveness of a low-load sport reliIled injury. Sports Medicine 2:267-78. tween the
prolonged stretch. journal of OrtllOpardic IJrld Sports l'ilysical 61. Shindo, M" H. Harayama , K. Kondo, et al. 1984. Changes in Oexion aJi
Therapy 5:200-07. reciprocalla inhibition during voluntary contraction in man.
meas ureD
43. Liemohn, W. 1 '1~S. Flexibi lily and muscu lar strength. journal Experimental Brain Resmrch 53:400-08.
sequen tia
of I'llysiCill Edllmtion, Recreatioll and Dallce 59(7): 37. 62. Spcrnoga, S. G., T. L. Uhl. B, L. Arnold, and B. M. Cansneder.
44. Louden, K. j,.. C, E. Bolier. K. A. Allison. cl ai, 1985. Effects of 2()()1. Duration of main/sined hamstring flexibility after a
6-4 The mo ti
two stretching method s on the fl exibility ,1I1d retention of one-time, modified hold-relax stretching protocol. jou rnal of nistic) ill
flexibilily a t the ankle joint in runners. Physical Therapy f1tl1letic Training 36(1): 44-48. sule. pa
65:698 . 63 . St. George, F. 1994 , The stretching handbook: Ten steps to mus­ prevent in
4). I\I\adding, S. W.. J. G. Wong, and A. Hallum. 1987. Effects of clefitness. Rosevillc,!L: Simon & Schuster.
duration of passive stretching on hip abduction range of mo­ 64. Stamford, B. 1994. A st retching primer. Pilysicilln lind Sports
tion . jotlrnal of Orrhopaedic a/1d Sports Ph!lsical Thcl'llpy ;v/criicinc 22(9): ~5-86.
8:409-16. 65. Surburg, P. 199'1. Fl exibility/ range of motion. Th e Brockport
46. Mann, 0 .. and C. Whedon. 2001. FuncLional stretching: Im­ physiCilI jltness traininll gllide, edited by J. P. Winnick. Cham­
plemCl1ting a dynamic stretc hing program. II/hletic Therapy paign, 11: Human Kinetics.
Today 6(3 ): 10-13. 66. Surburg, E 1 '195. Flexibility training program design. In Fit­
47. (v!arkos , P. D. 1979. [psilateml and contmlateral errects of ness prnqrammirl[1 lind physiCilI disability, edited by P. Miller.
proprioceptive neuromuscular facilitation tcchniques on hip Champaig n, IL: Human Kinetics.
mot ion and clcctromyographic activily. Physical Therapy 67. Tanigawa, M. C, 1972. Comparison of the hold relax proce­
59:1 .~66-73, dure and passive mobilization on increaS ing mu scle length.
48. ~IcAtee . R. 1993 . Fllcilitated st retdlill[j. Champaign, IL: Hu­ Physiml Th erapy 52:725.
man Kin etics. 68. Tobias, M., and J. P Sullivan. 1992. Complete stretching. New
49. Moore, M.. and R. Hutl'on. 1980. Electromyugraphic investi­ York: Knopf.
gation of muscle stretching techniques. ;V1edicin e awl Science 69. va n Mechcl en, P 1993. Prevention of running injuries by
ill Sports and Exercise 12 :322- 29. warm-up, cool-down, and stretching. American Journal of
SO. Murphy, P. 1986, Warming up before stretching advised. Sports Medicine 2 1(5): 711-19.
PhYSician and Sports J1edicinc] 4(3): 45. 70, Voss, D. E.. M. K. Lonta, and G. J. Myer s. 1985. Proprioceptive
51. Norris, C. ] 994. Flexibilit!J principles lind practices. London: neurollluscular facili tation: PaU erns and techniques. 3d ed.
A&CBlack. Phil ad elphia: Lippincott.
 CHAPTER 6 Restoring Range of Motion and Improving Flexibility 137

71. Wessel, J.. and A. I;Van. 1984. Effect of stretching on intensity 74. Zebas, C. J.. and M. L. Rivera. 1985. Retention of fiexibility in
use of PNF tech­
of delayed-onset muscle soreness. Journal of Sports Nledicine selected joints after cessation of a stretching exercise pro­
ry. ."thletic Train­
2:83-87. gram. In Exercise physiology: Current selected resea.rch topics.
72. WorreU, T.. T. Smith. and J. Winegardner. 1994. Effect of ham­ edited by C. O. Dotson and J. H. Humphrey. New York: AMS
string stretching on hamstring muscle performance. Journal of Press.
Orthopaedic and Sports Pilysical Therapy 200): 154-59.
73. Zachewski. J. 1990. Flexibility for sports. In Sports physical
tlzerapy. edited by B. Sanders. Norwalk. CT: Appleton & Lange.

- analysis of heat SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES

- relaxation. Jour­
3: 13 3-40.
Philadelphia: 6-1 Flexibility is crucial to a gymnast's performance. tibia and femur or between the patella and femur,
During the time while she is not training, she must fat/muscle causing tissue approximation, or scar tis­
9 1. Flexibility maintain movement at all of her joints so that she sue in the anterior portion of the joint.
muscular fa­ does not lose f1exibility. Inactivity can cause a short­ 6-5 A static stretch should be held for about 30 seconds.
ReiIabilitation ening of elastic components. This would put her at This allows time for the golgi tendon organs to over­
risk for muscular injury when she resumes her nor­ ride the muscle spindles and produce a ref1ex muscle
-9 1. Biophysi­ mal activity. relaxation. The athlete should stretch to the point
iWI a/lll Sports
6-2 App.lying certain therapeutic modalities. such as ice where tightness or resistance to stretch is felt but it
and/ or electricaJ stimulating currents, can decrease should not be painful. The stretch should be repeated
bing: Acute ef­
'19th alld Condi­ pain and discourage muscle guarding to increase 3 to 5 times.
ROM. Delayed-onset muscle soreness will usually be­ 6-6 Ballistic stretching is dynamic stretching that is use­
-up and stretch­ gin to subside at abollt 48 hours following a workout. ful prior to activity because -it is a functional stretch.
prevention of 6-3 A goniometer can be used to measure the angle be­ It mimics activity that will be performed during com­
tween the femur and the fibula . giving you degrees of petition. However, there is some speculation that be~
9 -1-. Changes in flIexion and extension. To maximize consistency in cause it is an uncontrolled stretch, it may lead to
!merion in man. measurement, it is helpful if the same person takes injury, especially in sedentary individuals. Static
sequential goniometric measurement. stretching is convenient because it can be done on
8,~!, Cansneder.
6-4 The motion might be limited by quadriceps (antago­ any muscle and it doesn't require a partner. It is not
exibility after a
nistic) muscle tightness, tightness of the joint cap­ very functional. PNF stretching will most likely pro­
oeol. Journal of
sule, pathological or damaged bony structure vide the greatest increase in ROM. but it is a little
Ttll steps to /1lUS­ preventing normal accessory motions between the more time consuming and ("equires a partner.

icil1ll and Sports

. Tile Brockport
p. \\1nnick. Cham-

design. In Fit­
l '"Led by P. Miller.

I) ld relax proce­
g muscle length.

·t slrelcllill[j. New

'llIllling injuries by
rntric{/Il Journal of

. 9 -. Proprioccptive
. hniques. 3d ed.
 CHAPTER 7
at least a normal
group is import.
ness or imbalaOI
and can impa ir
Regaining Muscular Strength, musele streng!J,
Muscular st

Endurance, and Power endurance. l\1u'

repetHive musel
for an extended
William E. Prentice cular strength i.J
the average per
endurance i.s Uk
cular stren gth I
probably more c
tics of living."11
Most moven
elude clements (
Study Resources • Differen tiate between muscle strength effective. 2 If a Iii
Ta become more familiar with the knowledge and skill s and muscle endurance. tbe movemelll C
necessary to design. implement. and document therapeu­ Without the abi
tic rehabilitation programs as identil1ed in th e _\ / II4 Atll­ • Compare differences beu'Veen males and limited in his or
letic Training Educational Co mpetencies and Clinical females in terms of strength development. training plays
Projlcienries ' Therapeutic Exercise content area, visit ness levels an d
www.mhhc.com/ prenlice11 e. Also. refer to the lab exer­ • Compare established strengthening
cises in the new Laboratory Manual and Lo cSims. which regimes relative to their recommendations
simulates the athletic training certi.l1calion exam, at
www.mh he.com/csims. far more on line study resources.
for sets, repetitions, etc.
visit our Health and Human Performance website 81
wlvw.mhhe.com/hhp.

After Completion of This

WHY IS REGAINING STRENGTH,
Chapter, the Student Should
ENDURANCE, AND POWER
Be Able to Do the Following:
TYIPES 0
ESSENTIAL TO THE MUSCLE i
• Differentiate between muscular REHABILITATION PROCESS?
Skeletal muscle
strength, endurance, and power and
Developing muscular strengtJl, endurance, and power is traction: (1) i ~
discuss their importance in a program an essential element in any training and conditioning pro­ contraction. ~
of rehabilitation following injury. gram for the athlete. From the perspective of the athletic metric contrac'
trainer supervising a rehabilitation program. regaining­ produce tension
• Recognize the anatomy and physiology and in many instances improving-levels of strength. en­ Considerable fo
of skeletal muscle. durance, and power is critical not only for achieving a able resistance
competitive fitness level but also for returning the athlete concentric con
• Analyze the physiology of strength de­ to a competitive functional level follOWing injury. It is im­ while tension i
velopment and identify factors that de­ portant to understand that functional movements involve ance. In an ecct:J
acceleration, deceleration, and stabilization in all three than the muse
termine strength.
planes of motion (sagittal, transverse, and frontal). all of lengthens while
• Examine specific methods for improv­ which are controlled by neuromuscular mechanorecep­ tric contraction
tors within the kinetic chain I 5 Recenlly. a
ing muscular strength. By defmition, muscular strength is the ability of a mus­ bines both a cor~
cle to generate force against some resistance. Maintenance of tric contractior~
138

 CHAPTER 7
atleast a nonnal ,level of strength in a given muscle or muscle
group is important lor normal healthy living, NIuscle weal<­
ness or imbalance can result in abnormal movement or galt
,
and can impair normal functional movement. Developing
muscle strength is crilicalto aLhlelic performance,
Muscular strength is closely associated with muscular
endurance. Muscular endurance is the ability to perform
repetitive muscular contractions against some resistance
for an extended period of time. As we will see later. as mus­
cular strength increases, endurance tends to increase. For
the average person in the population. developing muscular
endurance is IU.;.ely more important than developing mus­
cular strength or power, because muscular endurance is
probably more critical in carrying out the everyday activi­
ties of living. hJ This becomes in creasingly true with age.
.\10st movements in sport are explosive aod must in­
clude elements of both strellgth and speed if they are to be
effective. 2 If a large amount of force is generated quickly,
the movement can be referred to as a power movemen1. 60
Without the ability to generate power, an athlete will be
Ihuiled in his or her performance capabilities. 41 Resistance
training plays a critical role in achieving competitive fit­
pment.
ness levels and also in injury rehabilitation.
CLINICAL DECISION MAKING Exercise 7-1
A softball pitcher was out for a whole season ror rehabili­
tation rollO\~ing shoulder surgery. Why is it important
Ihal she regain all three aspects of muscular fitness?
ENGTH,
ER TYPES OF SKELETAL
MUSCLE CONTRACTION
ESS?
Skeletal muscle is capable of three different types of con­
traction: (1) isometric contraction, (2) concentric
contraction, and (3) eccentric contraction. An iso­
metric contraction occurs when the muscle contracts to
produce tension but there is no change in muscle length.
Considerable force can be generated againsl some immov­
able resistance even though no movement occurs. In a
concentric contraction the muscle shortens in length
'" in jury. It is im­ while tension increases to overcome or move some resist­
ements involve ance. In an eccentric contraction, the resistance is greater
on in all three than the muscular force being produced, and the muscle
d fr ontal), all of lengthens while producing tension. Concentric and eccen­
tric contractions are considered dynamiC movements. 56
Recently, an econcentric contraction which com­
bines both a controlled concentric and a concurrenteccell­
tric contraction of the same muscle over two separate
Regaining ;v luscular Strength, Endurance, and Power 139
joints, has been introduccd. 19 . 3!l An econcentric contrac­
tion is possible only in muscles that cross at least two joints.
An example of an econcentric contraction would be a
prone, open-kinetic-chain hamstring curl. The hamstrings
contract concentrically to flex the knee, while the hip tends
to flex eccentrically, lengthening the hamstring. Rehabili­
tation exewises have traditionally concentrated on
strengthening isolated Single-joint motions. despite the fact
that the same muscle is functioning at a' second ioint si­
multaneously. Therefore it has been recommended that the
strengthening program included exercises that strengthen
the muscl e in the mann er in which it contracts function­
ally. Traditional strength-training programs have been de­
signed to develop strength in individual mu scles, in a single
plane of motion. However. because all muscles function
con centrically, eccentrically, and isometricall)1 in three
planes of motion. a strengthening program should be mul­
Lip'l anar. concentrating on all three types of contractionY
FACTORS THAT DETERMINE
LEVELS OF MUSCULAR
STRENGTH,ENDURANCE,
AND POWER
Size of the Muscle
Muscu1lar strength is proporLional to lhe cross-sectional
diame ter of the muscle fibers. The greater the cross·
sectional diameter or the bigger a particular muscle, the
stronger it is, and thus the more force it is capable of gen­
erating. l 'he size of a muscle tends to increase ,i n cross­
sectional diameter w,i th resistance train-ing, This increase
in muscle size is referred to as hypertrophyY A decrease in
the size of a muscle is referred to as atrophy.
INumber of Muscle Fibers
Strength is a function of the number and diameter of mus­
cle \lbers composing a given muscle. The number of fibers
is an inherited characteristic; thus a person with a large
number of muscle fibers to begin with has the potential to
hypertrophy to a much greater degree than does someone
with relatively few fibers. 30
Neuromuscular Efficiency
Strength is also directly related to the efficiency of the neu­
romuscular system and the function of the motor unit in
140 PARTTWO Achieving the Goals of Rehabilitation

limits. Overtrai
B down (stalcn e~
involve muscuk
Lng in proper a
proper diet, and
I:
o
.;;; the potential n~
I:
24 cm ~
Effort arm Effort arm
A c
Figure 7-1 The position of attachment of the muscle
tendon on the lever arm can affect the ability of that A gymnast fe
muscle to generate force. B should be able to generate colles' fraClurt
greater force than A because the tendon attachment on Sarcomere length should isomcu
the lever arm is closer to the resistance. into her reh®
Figure 7-2 The length-tension relation of the muscle.
Greatest tension is developed at point B, with less tension
producing muscular force. 4 (' As will be indicated later in developed at points A and C.
this chapter, initial increases in strength during the fIrst 8 Fast- Tw,itc~
to 10 weeks of a resistance (raini'ng program can be attrib­
All fibers in a
uted primarily to increased neuromuscular efficiency. 59 Re­ the interaction between the actin and myosin myoJ1la­
sistance training will increase neuromuscular efficiency in
twitch fibers 0
ments through the crossbridges is greatly reduced, thus
tinctive metaboli
three ways: there is an increase in the l1umber of motor the muscle is not capable of generating significant tension.
units being recruited, in the flring rate of each motor unit,
Slow-Twite
ferred to as type
and in the synchronization of motor unit firing. 7
Age more resistant k
the time requirec
Biomechanical Considerations The ability to generate muscular force is also related to
twitch fjbers. ~ ~ I
age.· Both men and women seem to be able to increase
ant, slow-twit
Strength in a given muscle is determined not only by the strength throughout puberty and adolescence. reaching a
long-duration. a
physical properties of the muscle but also by biomechani­ peak around 20 to 25 years of age, at which time this abil­
Fast-T\Vite~
cal factors that dictate how much force can be generated ity begins to level off and in some cases decline. After about
of producing q
through a system of levers to an external object. 3 1.3B.63 age 25 a person generally loses an average of 1 percent of
dency to fatig u
Position of Tendon Attachment. If we think of his or her maximal remaining strength each year. Thus at
Past-twitch fibe
the elbow joint as ol1e Qf these lever systems, we would age 65 a person would have only about 60 percent of the
have the biceps muscle producing flexion of this joint (Fig­ strength he or she had at age 25. 45 This loss in muscle
ure 7-1). The position of attachment of the biceps muscle strength is definitely related to individual levels of physica'l
tractions, when
on the forearm will largely determine how much force this activity. People who are more active. or perhaps continue
endurance force
muscle is capable of generating. If there are two athletes, to strength-train, conSiderably decrease this tendency to­
Ilbers. Although
A and B. and A has a biceps attachment that is closer to the ward declining muscle strength. In addition to retarding
ble of rapid conci
fulcrum (the elbow jOint) than B's, then A must produce a this decrease in muscular strength, exercise can also have
greater effort with the biceps muscle to hold the weight at
colytic (FOG) Ii
an effect in slowing the decrease in cardiorespiratory en­
while type IIb fi b
a right angle because, the length of the erfort arm will be durance and flexibility, as well as slOWing increases in body
idly and are coD!
greater than for B. fat. Thus strength maintenance is important for all ath­
cently, a third gr~
Length-Tension Relationship. The length of a letes regardless of age or the level of competition for
iden tified in aniIJ
muscle determines the tension that can be generated. By achieving total wellness and good health and in rehabilita­
sistant and are t ~
varying the length of a muscle, different tensions can be tion after injury.62
ity less than th a
produced. J ! This length-tension relationship is illustrated
IIa fibersY
in Figure 7-2. At position B in the curve. the interaction oC
Overtraining Ratio in Ml
the crossbridges between the actin and myosin myoflla­
both types of .fib
ments within the sarcomere is at maximum. Setting a Overtraining can have a negative effect on the develop­
dividual muscle
muscle at this particular length will produce the greatest ment of muscular strength. Overtraining is an imbalance
primary function
amount of tension. At position A the muscle is shortened, between exercise and recovery in which the training pro­
quire more end
and at position C the muscle is lengthened. In either case gram exceeds the body's physiological and psychological
 CHAPTER 7 Regaining ivfuscular Strength. Endurance. and Power 141

limits. Overtraining can result in psychological break­
down (staleness) or physiological breakdown, which can
involve musculoskeletal inj ury. fatigue, or sickness. Engag­
ing in proper and efficient resistance training. eating a
proper diet. and getting appropriate rest can all minimize
the potential negative effects of overtraining.
c fibers . II> Conversely. marathon runners generally have a
CLINICAL DECISION MAKING Exercise 7-2
A gymnast fell from the balance beam and sustained a
colles' fraclure. he will be casted for several weeks. How
should isometric and isotonic exercise be in orporated
into her rehabilitation program?
of the muscle.
Uh less tension
slow-twitch fibers. Muscles that produce powerful, rapid,
explosive strength movements tend to have a much higher
percentage of fast-twitch fibers.
Because this ratio is genetically determined. it can play
a large role in determining ability for a given sport activity.
Sprinters and weight lifters. for example. have a large per­
centage of fast-twitch fibers in relation to slow-twitch
higher percentage of slow-twitch fibers. The queslion 0['
whether fiber types can change as a result of training has
to date not been conclUSively resoh'ed. lo However, both
types or l'lbers can improve their metabolic capabilities
through specific strength and endurance training. 7
CLINICAL DECISION MAKING Exercise 7-3

Fast-Twitch versus Slow-Twitch Fibers A new high school track coach wants to train his best dis­
tance runner to compele in hurdling events. Based on
All fibers in a particular motor unit are either slow­
myosin myofila­ what you know about muscle physiology. why might this
twitch fibers or fast-twitch fibers. Each kind has dis­
_. r duced, thus be a diJIkult task?
tinctive metabolic and contractile capabilities.
Slow-Twitch Fibers. Slow-twitch fibers are also re­
ferred to as t!lpe I or slow-oxidative (SO) f·ibers. They are
more resistant to fatigue than fast-twitch fibers; however.
CLINICAL DECISION MAKING Exercise 7-4
the time required to generate force is much greater in slow­
a Iso rela ted to
twitch fibers. 29 Because they are relatively fatigue resist­ Two football players of the same age have been following
Ie to increase
ant. slow-twitch fibers are associated primarily with the exact same training plan . One is consistently able to
long-duration. aerobic-type activities. perform a hamstring curl using more weight than the
Fast-Twitch fibers. Fast-twitch fibers are capable olber. Whal could possibly be making him stronger al
Ll1 • After about
of producing quick. forceful contractions but have a ten­ this task?
~ of 1 percent of
dency to fatigue more rapidly than slow-twitch fibers.
h year. Thus at
Fast-twitch fibers are useful in short-term, high-intensity
percent of the
activities, which mainly involve the anaerobic system.
loss in muscle
Fast-twitch fibers are capable of producing powerful con­
eITls of physical
tractions, whereas slow-twitch fibers produce a long­ THE PHYSIOLOGY OF STRENGTH
endurance for ce. There are two subdivisions of fast-twitch ID EVEtOPMIENT
fibers. Although both types of fast-twitch fibers are capa­
ble of rapid contraction. type IIafibcrs or fast-oxidative gly­ Muscle Hypertrophy
colytic (FOG) fibers are moderately resistant to fatigue,
while type IIb fibers or fast-glycolytic (FG) fibers fatigue rap­ There is no question that resistance training to improve
ieUy and are considered the "true" fast-twitch fibers. Re­ muscular strength results in an increased size, or hyper­
cently, a third group of fast-twitch fibers, type IIx, has been trophy, of a muscle. V/hat. causes a muscle to hypertrophy?
competition for
identilled in anima;l models. Type llx Ilbers are fatigue re­ A number of theories have been proposed to explain this
an in rehabilita­
sistant and are thought to have a maximum power capac­ increase in muscle size.22
ity less than that of type JIb but greater than that of type Some evidence exists that there is an increase in the
IIa fibers. 4 ) number of muscle fibers (huperpJasia) due to Hbers splitting
Ratio in Muscle. Within a particular muscle are in response to training. 39 However. this research has been
both types of fibers , and the ratio of the two types in an in­ conducted in animals and should notbe generalized to hu­
dividual muscle varies with each person, 32 Muscles whose mans. It is generally accepted that the numbe r of fibers is
. an imbalance
primary fun ction is to maintain posture against gravity re­ genetically determined and does not seem to increase with
uire more endurance and have a higher percentage of training.
142 PART TWO Achieving the Goals of Rehabilitation

Sarcomere Sarcomere muscle to impn

a higher level II
muscle must Ix
will be able to IT
tinued against
!<.
tomed. but. no

s;
Crossbridges
-+
Thick myosin
t·
Thin actin ~
This mainlenar
may be more iI
phasize museul
Crossbridges Many individuc
filaments filaments
health by con
Figure 7-3 Muscles contract when an electrical impulse from the central nervous durance. HOWl:
system causes the myonIaments in a muscle fiber to move closer together. strength. resisla
ing effort agaim
Resistive ex~
Second. it has been hypothesized that because the Other Physiological Adaptations overload and PI
muscle is working harder in resistance training. more all of the followi
to Resistance Exercise ducc improve!]]«
blood is required to supply that muscle with oxygen and
other nutrients. Thus it is thought that tile number of capil­ In addition to muscle hypertrophy. there are a number of In a rehabili
laries is increased. This hypothesis is only partially correct; other physiological adaptations to resistance training. 4o itcd to some de,
no new capillaries are formed during resistance training; The strength of noncontractile structures. including ten­ athletic trainer t
however. a number of dormant capillaries might well be­ dons and Ligaments. is increased. The mineral content of lion. the rate of
come filled with blood to meet this increased demand for bone is increased. thus making the bone stronger and more the injured at hlt
blood supply.45 resistant to fracture. Maximal oxygen uptake is improved bation of pain 01
A third theory to explain this increase in muscle size when resistance training is of sufficient intensity to elicit letic trainer th a
seems the most crediblc. Muscle fibers are composed pri­ heart rates at or above training levels. However. it must be
marily of small protein nIaments. called myonIaments . emphasized that these increases are minimal and that. if Isometric I
which are contractile elements in muscle. Myofilaments increased maximal oxygen uptake is the goal. aerobic exer­
are small contractile elements of protein within the sar­ cise rather than resistance training is recommended. There An isometric e
comere. There are two distinct types of l11yofllal11ents: thin is also an increase in several enzymes important in aerobic which the Icn guj
actin myoftlal11ents and thicker myosin myonIaments. and anaerobic metabolism. 3.25.26 All of these adaptations sion develops I
Fingerlike projections. or crossbridges. connect the actin contribute to strength and endurance. able resistance
and myosin myofllaments. When a muscle is stimulated to provides stabUi21
contract. the crossbridges pull the myoftlament~ closer to­ length-tenSion
gether. thus shortening the muscle and producing move­ TECHNIQUES OF RESISTANCE critical for norl11
ment at the joint that the muscle crosses; (Figure 7-3). cises are capabl
TRAINING
These myofilaments increase in size and number as a re­ ever. strength g.
sult of resistance training. causing the individual muscle There are a number of different techniques of resistance a 20 percent 0\"
fibers to increase in cross-sectional diameter. 5s This in­ training for strength improvement. including isometric ex­ performed. At
crease is particularly present in men . although women will ercise. progressive resistive exercise. isokinetic training. dramatically b
also see some increase in muscle size. More research is circuit training. and plyometric exercise. Regardless of the gle. Thus. stren
needed to further clarify and determine the specific rea­ specific strength-training technique used. the athletic tion. but there i
sons for muscle hypertrophy. trainer should integrate functional strengthening activi­ ot her posittons i.
Reversibility. If resistance training is discontinued ties that involve multiplanar, eccentric. concentric. and Another m
or interrupted. the muscle will atrophy. decreasing in both isometric contractions.
strength and mass. Adaptations in skeletal muscle that oc­ pressure tha t
cur in response to resistance training can begin to reverse The Overload Principle cardiovascu:l ar ~
in as little as 48 hours. It does appear that consistent exer­ blood pressure
cise of a muscle is essential to prevent reversal of the hy­ Regardless of which of these techniques is used. one baSic increases intrat
pertrophy that occurs due to strength training. principle of reconditioning is extremely important. For a this effect. it is r~
 CHAPTER 7 Regaining Muscular Strength, Endurance. and Power
muscle to improve ,in strength. it must be forced to work at
a higher level than it is accustomed to. In other words, the
muscle must be overloaded. Without overload the muscle
will be able to maintain strength as Ilong as training is con­
tinued against a resistance to which the muscle is accus­
tomed, but. no additional strength gains will be realized.
This maintenance of existing levels of' muscular strength
may be more important in resistance programs that em­
phasize muscular endurance rather than strength gains.
Many individuals can beneflt more in terms of overall
health by concentrating on improving muscular en­
durance. However. to most effectively build muscular
strength, resistance training requires a consistent, increas­
ing effort agail1st progressively increasing resistance. 38.56
Resistive exercise is based primarily on the prinCiples of
overload and progression. If these prinCiples are applied,
all of t'he following resistance training techniques will pro­
ducc improvement of muscular strength over time.
In a rehabilitation setoting, progressive overload is lim­
ited to some degree by the healing process. Because the
athl.etic trainer takes an aggressive approach to rehabilita­
tion, the rate of progression is perhaps best determined by
gerand more the injured athlete's response to a spec ilk exercise. Exacer­
is improved bation of pain or increased swelling should signal the ath­
Lensity to elicit letic trainer that their rate of progression is too aggressive.
'er. it must be
, and that. If Iisometric Exercise
;\n isometric exercise involves a muscle contractiun in
which the I.cngth of the muscle remains constant while ten­
Siun develops toward a maximal force against an immov­
able resistance" (Figure 7-4). An isometric contraction
provides stabilization strength that helps maintain normal
length-tension and force-couple relationships, which are
critical. for normal joint arthrokinematics. Isometric exer­
ises are capable of increasing muscular strength . 54 How­
ever, strength gains are relatively specific, with as much as
. of resistance a 20 percent overflow to the joint angle at which training is
perfurmed. At other angles, the strength curve drops off
dramatically because of a lack of motor activity at that an­
gie. Thus, strength is increased at the specific angle of exer­
ion, but there is no corresponding increase in strength at
·)ther positiuns in the range of mution.
Another major disadvantage of these isometric exer­
'ises is that they tend to produce a spike ,in systolic blood
pressure that can result in potentially life-threatening
cardiovascular accidents. 29 This sharp increase in systolic
blood pressure results from a Valsalva maneuver, which
. used, one basic increases intrathoracic pressure. To avoid or minimize
important. For a th is effect. it is recommended that breathing be done dur-
143
Figure 7-4 Isometric exercises involve contraction
against some immovable resistance.
ing the maximal contraction to prevent this increase in
pressure.
The use of isometric exercises in injury rehabilitation
or reconditioning is widely practiced. There are a number
of conditions or ailments resulting [rom trauma or overuse
that must be treated with strengthening exercises. Unfor­
tunately, these problems can be exacerbated with full
range-of-motion resistance exercises. It. might be more de­
sirable to make use of positional or runctiunal isometric ex­
ercises that involve the application of isumetric force at
multiple angles throughollt the range of motiun. Func­
tional isometrics should be used until the healing process
has progressed to the point that full-range activities can be
performed.
During rehabilitation, it is often recommended that a
muscle be contracted isometrically fur 1 () seconds at a time
at a frequency of 10 or more contractions per hour. Isu­
metric exercises can also offer significant benefit in a
strengthening program. 64
There are certain instances in which an isometric
contraction can greatly enhance a particular movement.
For example, one of the exercises in power weight lif'ting
is a squat. A squat is an exercise in which the weight is
supported on the shoulders in a standing positiun. The
knees are then flexed. and the weight is lowered tu a
three-quarter squat positiun, from which the lifter must
stand completely straight once again.
It is not uncommon for there to be one particular an­
gle in the range of motion at which smooth movement is
difllcliit because of insufficient strength. This joint angle is
referred to as a sticking point. A power lifter will typically
use an isometric contraction against some immovable
144 PART TWO Achieving th e Goals of Rehabilitation
resista nce to increase strength at this sticking point. If
strength can be improved at this joint angle. then a
smooth. coordinated power lift can be performed through
a full range of movement.
CLINICAL DECISION MAKING Exercise 7-5
A weight lifter bas been progrcssing his maxinlUm beuch­
press weight. However. he sLilI requ ires a spottcr to gel
him through the full ROM . He gets "stuck" at about 90
degrees of elbow extension. What can he do to progress
through this llrnitatlon?
Progressive Resistive Exercise
A second technique of resistance training is perhaps the
most commonly used and most popular technique among
athletic trainers for improving muscular strength in a re­
habilitation program. Progressive resistance exercise
training uses exercises that strengthen muscles through a
contraction t hat overcomes some fixed resistance such as
with dumbbells. barbeJls. various exercise machines, or re­
sistive elastic tubing. Progressive resistive exercise uses iso­
tonic, or isociYl1amic, contractions in which force is
generated while the muscle is changing in length.
Concentric versus Eccentric Contractions. Iso­
tonic contractions can be concentric or eccentric. In per­
forming a bicep curl. to lift the weight from the starling
position the biceps muscle must contract and shorten in
length. This shortening contraction is referred to as a con­
oentric or positive contraction. If th e biceps muscle does
not remain contracted when the weight is being lowered.
gravity would cause this weight to simply fall back to the
starting position. Thus, to control the weight as it is being
I'owered. the biceps muscle must continue to contract
while at the same Lime gradually lengthening. A contrac­
tion in which the muscle is lengthening while stU! applying
force is called an eccentric or negative contraction.
It is possible to generate greater amou_nts of force
against resistance with an eccentric contraction than with
a concenlric contraction, because eccentric contractions
require a much lower level of motor unit activity to
achieve a certain force than do concentric contractions.
Because fewer motor units are firing to produce a specilk
force. additional motor units can be recruited to generate
increased force. In addii.ion. oxygen use is much lower dur­
ing eccentric exercise than in comparable concentric exer­
cise. Thus eccentric contractions are less resistant to
fatigue than are concentric contractions. The mechanical
erlkiency of eccentric exercise can be several times higher
than that of concentric exercise. >6
Traditionally, progressive resistive exercise has con­
centrated primarily on the concentric component without
paying much attention to the importance of the eccentric
component. ;o The use of eccentric contractions, particu­
larly in rehabilitation of various sport-related injuries. has
received considerable emphasis in recent years. Eccentric
contractions am critical for deceleration of limb motion.
especially during high-velocity dynamic activities. 3 ; For
example, a baseball pitcher relies on an eccentric contrac­ A
tion of the external rotators of the glenohumeral joint to
decelerate the humerus. which might be internally rotat­
ing at speeds as high as 8.000 degrees per second. Cer­ Figure 7-5
tainly, strength deficits or an in ability of a muscle to by changint:
tolerate these eccentric forces can predispose an injury.
Thus. in a rehabilitation program the athletic trainer
should incorporate eccentric strengthening exercises. Ec­ tack of weigh t
centric contra_ctions are possible with alJ free weights. with restrict the mon
the majority of isotonic exercise machines. and with most increased or deer
isokinetic devices, Eccentric contractions are used with a weight key (Fig
plyometric exercise discussed in Chapter 11 and can also There are il
be incorporated with functional PNF strengthening pat­ weights and rna,
terns discussed in Chapter 15. rively safe to uSt'
In progressive resistive exercise it is essential to incor­ ampl e, a bench
porate both concentric and eccentric contractions 33 Re­ to help lift th e \~
search has dearly demonstrated that the muscle should be Lifter does no! h
overloaded and fatigued both concentrically and eccentri­ otherwise th e w
cally for the greatest strength improvement to occur4 .22.4> the machin es th
When training specifically for the development of muscu­ without fear of i
lar strength, the concentric portion of the exercise should His aJso a si
require 1 to 2 seconds, while the eccentric portion of the weight by mav in
lift should require 2 to 4 seconds. The ratio of the concen­ chines. alt ho ugh
tric component to the eccentric component should be ap­ crementsof 10
proximately 1 to 2. Physiologically the muscle will fatigue must be added 0
much more rapidly concentrically than eccentricalJy. 'f'he biggest d
Free Weight.s versus Exercise Machines. Vari­ tba t with few ex,
ous types of exercise equipment can be used with pro­
gressive resistive exercise. including free weights (barbeJis ling more fun c!
and dumbbeJls) or exercise machines such as Cybex, Uni­ planes simulta n
versal, Paramount, Tough Stuff. Icarian Fitness. King Fit­ !\lhletes wh
ness. Body Solid, Pro-Elite. Life Fitness, Nautilus, il nd exercise ma
BodyCraft. Yukon , Flex. Cam-Bar. GymPros. N ugym, of weight thal
BodyWorks. DP, Soloflex. and Body Master. Dumbbells weights have no
and barbells require the use of iron plates of varying many different d:'
weights that can be easily changed by adding or subtract­ With free weigh!
ing equal amounts of weight to both sides of the bar. The on the part of t h~
exercise machines for the most part have stacks of weights iL Ji,Otn moving I
that are lifted through a series of levers or pulleys. The usually decrease '
 CHAPTER 7 Regaining Muscular Strength. Enduran ce. and Power 145

The mechanical

nl ric contrac­ A B
u meral joint to
mlemally rotat­
r second. Cer­ Figure 7-5 Isotonic equipment. A. ivlost exercise machines are isotonic. B. Resistance can be easily changed
by changing the key in the stack of weights.

stack of weights slides up and down on a pair of bars that

restdct the movement to only one plane. Weight can be
increased or decreased simply by changing the position of
a weight key (Figure 7-5).
There are advantages an d disadvantages to fre e
weights and machines. The exercise machines are rela­
tively safe to use in comparison with free weights. For ex­
ample. a bench press \\lith free lVeights requires a partner
to help lift Lhe weight bac'\.;: onto the support racks if the
lifter does not have enough strength to complete the lift:
~ a nd eccentri­ otherwise Lhe weight might be dropped on the chest. With
t LO occll r. 4 . l2 .4; the machines the weight can be easily and safdy dropped.
e nt of mllSCU­ without fear of injury.
ex rcise should It is also a simple process to increase or decrease the
- po rtion of the weight by moving a single weight key with the exercise ma­ Figure 7-6 Strengthening exercises using surgicall tLl b­
of the concen­ chines. although changes can generally be made only in in­ ing are widely used in sport injury rehabilitation.
t should be ap­ rements of J () or I ') pounds. With free weigh ts. iron plates
.I Ie wi'll fatigue must be added or removed from eac h side of the barbe ll.
e ntrically. The biggest dlsadvan tage in usi ng exercise ma ch ines is
Vari- that with few exceplions the design constraints of the ma­ CLINICAL DECISION MAKING Exercise 7-6
chine allows only single-plane motion . limiting or control­
li ng more functional movcments that occur in multiple The head athletic trainer wants to buy new equipment
planes Simu lta neo usly. for the weight room. What are the advantages and disad­
Athletes who have strength-trained using free weights vantages to investing in exercise machines rather than
a nd exercise machines rea lize th e difference in th e amount free weightsi
f weight that can be lifted. Unlike the machines. Iree
\\-eights have no restricted motion and can thus move in
many different directions. depending on the forces applied. Surgical Tubing or Theraband. Surgical tubillg or
With free \Veights. an element of neuromuscular control Theraband. as a means of providing resistance. has been
n the part of the lifter to stabilize th e weight and prevent wide'!y used in sports medicine (Figure 7-6). The advantage
l from moving in any other direction than vertical will of exercising with surgical tubing or Theraband is that
sually decrease the amount of weight that can be li fted 66 movement can occur in multiple planes s.imultaneously.
146 PART TWO Achieving the Couls of Rclwbililulion

Set: A pari
IntellSit!J: 11
R('covcry p
frequenc!J:
a week':

Recommel,
ing. SpeCific
proving mu
athletic tmin e
been done in
(1) tbe amount
etitions, (3) th
training.
A varieLy of
recommend tb.
A B
maximal gain .
gardless of the
dictate the s
Certainly, to i
gressivelyoverl
number of repe
cle work at hi g
factor is the 111
gram. The resj
Figure 7-7 Exercise rnachines. A, Bench-press machine. B, The cam is designed to equalize resistance
throughout the full range of motion. Signed to ultim
the atbleLe.
Resistance
Thus exercise can be done against resistance in more func­ motioo has been Labe led accom m odating resistance or by power Iil'ter
tional movement planes. The u se of surgical tubing exer­ variable resistance. commonly used
cise in plyometrics and PNF strengthening techniques will A number of exercise machine manufacturers have at­ following:
be discussed in Chapters 11 and IS. Surgical tubing can be tempLed La alleviate this problem of changing force capa­
used to provide resistance with the majority of the bilities by using a cam in its pulley sysLem (figure 7-7). The Sil1gle set. On
strengthenin g exercises show n in Chapters 18 through 25. cam is individually designed for each piece oj' equipment so exercise ~
Regardless of which type of equipmen t is used. the same that the resistan ce is variable tllroughouL thc movement. Tri-sets. 1\ g r~
principles of progressive resistive exercise may be Clpplied. The com is intended to Cl .lter resistance so that the muscle cle gro up
Variable Resistance. One problem often men­ can handle a greater load. but at the points wh ere the joint crcise \.\Tiq
tioned in reluUo n to progressive resistive exercise recondi­ angle or muscle length is m echCl ni cally disadvantClgcous. i'vIliItiplc sets. ;
tioning is that the amount of force necessmy to move a it reduces the resi stance to muscle movement. Whether sively inq
weight through a range of motion cbanges according to this design does what it claims is debatable. sets at th~
the angle of pull of the contracting muscle. It is greatest Progressive Resistive Exercise Techniques. Per­ Supcrsets. Eit~
wben th e a ngle of pull is approximately 90 degrees. In ad­ haps the single most confusing aspect of progressive resis­ era I exerc!
dition. once tbe inertia of the weigbt hils been overcome tive exercise is the terminology used to describe specific formed Oil
and momentum bClS been estublished, the force required to programs. 12 Tbe follOWing list of te rms witb tbeir opera­ repetilionj
move lbe resistance varies according to th e for ce the mus­ tionol deilnitions may help clarify tbe confusion: group wi ll
cle can produce tbrough the range of molion. Tbus it has Pyramids. Om
been argued lhat a disadvantage of any type of isoton ic ex­ Repetitions: The number of Umcs you repeat a specific sisLance. ~
ercise is that the force required to move the resistol1ce is movement sets until c
consta ntly cha nging throughout the range of movement. Repetition maximwl1 (RM): The maximum number of Tbe pyran;
'fhis change in resistClnce at different points in tbe range of repetitions at a given weigbt beavy to Ii
 CHAPTER 7 Regaining Nluscular Strength, Endurance, and Power
Set: A particular number of repetitions
Intensity: The amount of weight or resistance lifted
Recovery period: The rest interval between sets
Frequency: The number of times an exercise is done in
a week's period
Recommended Techniques of Resistance Train­
ing. SpeCific recommendatiuns fur techniques of im­
proving muscular strength are controversial among
athletic trainers. ;\ considerable amount of research has
been done in the area of resistance training relative to
(1) the amount of weight to be used, (2) the number of rep­
etitions, (3) the number of sets, and (4) the frequency of
training.
A variety of speci.fic programs have been proposed that
recommend the optimal amount of weight, number of
B sets. number of repetitions, and frequency for producing
maxima'! gains in levels of muscular strength. However, re­
gardless of the techniques used. the healing process must
dictate the specifics of any strength-training program.
Certainly. to improve strength, the muscle must be pro­
gressively overloaded. The amount of weight used and the
number of repetitions must be suff1cient to make the mus­
cle work at. higher intensity than it is accustomed to. This
factor is the most critical in any resistance training pro­
gram. The resistance training program must also be de­
lance
signed to ultimately meet the specific competitive needs of
the athlete.
Resistance tra,i ning programs were initially designed
g resistance or by power lifters and body builders. Programs or routines
commonly used in training and conditioning include the
lurers have at­ following:
Single sct. One set of 8 to .12 repetitions of a particular
exercise performed at a slow speed.
Tri-sets. A group of three exercises for the same mus­
cle group performed using 2 to 4 sets of each ex­
ercise with no rest in between.
Multiple sets. 1'wo or 3 warm-up sets with progres­
sively increasing resistance followed by several
sets at the same resistance.
Supersets. Either one set of 8 to 10 repetitions of sev­
eral exercises (or the same muscle group per­
formed one after another, or several sets of 8 to 10
repetitions of two exercises for the same muscle
group with no rest in between.
Pyramids. One set of 8 to 12 repetitions with light re­
sistance. then an Lncrease in resistance over 4 to 6
sets until only 1 or 2 repetitions can be performed.
um number of The pyramid can also be reversed going from
heavy to light resistance.
147
Split routine. Workouts exercise different muscle
groups on successive days. For example. Monda~7.
vVednesday, and Friday might be used for upper­
body muscles, and Tuesday, Thursday. and Satur­
day would be used for lower body muscles.
Circuit traillillg. This technique may be useful to the
athletic trainer for maintaining or perhaps im­
proving levels of muscular strength or endurance
in other parts of the body while the athlete allows
for healing and reconditioning of an injured budy
part. Circuit training uses a series of exercise sta­
tions, each of which involves weight training,
flexibility, calisthenics. or brief aerobic exercises.
Circuits can be designed to accomplish many dif­
ferent training goals. With circuit training the
athlete moves rapidlly from one station to the next.
performing whatever exercise is to be done at that
station within a speCified time period. A typical
circuit would consist of 8 to ] 2 stations. and the
entire circuit would be repeated three limes.
Circuit training is most definitely an effective tech­
nique for improving strength and flexibility. Certainly if
the pace or time interval between stations is rapid and if
workload is maintained at a high level of intensity with
heart rates at or above target tmining levels, the cardiores­
piratory system may benellt from this circuit. However,
there is little research evidence t hat circuit training is very
effective in improving cardiorespiratory endurance. It
should be, and is most often , used as a technique for devel­
oping and improving muscular strength and endurance. l7
Techniques of Resistance Training 'Used in Reha­
bilitation. One of the first widely accepted strength­
development programs to be used in a rehabilitation pro­
gram was developed by DeLorme and was based on a repe­
tition maximum of 10 (10 RM).IS The amount of weight
used is what can be lifted exactly 10 times Cfable 7-1).
Zinovieff proposed the Oxford technique, which, like De­
Lorme's program, was designed to be used in beginning, in­
termediate, and ad\!anced levels of rehabilitation.o s The
only difference is that the percentage of maximum was re­
versed in the three sets (,fable 7-2). McQueen's technique 48
• TABLE 7-1 DeLorme's Program.
Set Amount of Weight Repetitions
1 50%01' ]ORM 10
2 75%of 10RM 10
3 100% of]O RM 10
148 PART TWO Achieving the Goals of Rehabilitation

differentiates bet"veen beginning to intermediate and ad­
vanced levels, as is shown in Table 7-3.
Sanders' program (,rable 7-4) was designed to be used
in th e advanced stages of rehabilitation and was based on
a formula that used a percentage of body wei,ght to deter­
mine starling weig hts. 56 The percentages below represent
median starting points for different exercises:
Barbell squat-45% of body weight
Knight applied th e concept of progressive resistive ex­ sets of 8 RAJ.
ercise in rehabilitation. His DAPHE (daily adjusted pro­ creased. 8 PrOl1
gressive resistive exercise) program (Tables 7-5 and 7-6) mined by th c ;
allows for individual differences in the rates at which pa­ three sets. Wh
tients progress in their rehabilit<ltion programs. l 7 10 percent of L
Berger has proposed a technique that is adjustable low at least 6 fl
within individuallimitalions (Table 7-7) . For (lny given ex­ For reh abi
ercise. the a mount of weight selected should be s ufficient should be pen

to allow 6 to 8 RfvI in each of the three sets. with a recov­ amount of wei
Barbell bench press-30°.I.) of body weight

ery period of 60 to 90 seconds between sets. Initial selec­ lions governed

Leg extension-20°;', of body weight

tion of a starting weight might require some trial aD d error ercise. As the
Universal bench press-30% of body weight

to achieve this 6 to 8 R/v! r ange. If at least three sets of 6 swelling is no I

Universal leg extension-20u"{' of body weight

Ri\il cannot be completed. the weight is too he(lvy and ele group sha u l
Uni\7ersalleg curl-lO to 15 % of body weight

shoul.d be reduced. If it is possible to do more than three At that point lh

niversalleg press-50°/r) of body weig ht

'least 3 limes pe
Upright rowing-20'X) of body weight

It is common I
• TABLE 7-5 Knight's DAPRE Program. however. they f
• TABLE 7-2 The Oxford Technique. sive days.
Set Amount of Weight Repetitions It has been
Set Amount of Weight Repetitions using both COD
1 SO% of RM 10 ance training is
SO%oflORM 10 2 75% of EM 6 this schedule hi
2 75% of]o RM 10 3 100% of RM Maximum
3 100% of ] 0 R.\tl 10 4 Adjusted working weight* Maximum Isokinetic
' See Table 7-6. An isokinetic
which th e leng
• TABLE 7-3 McQueen's Technique. traction is pe
• TAB L E 7-6 DAPRE Adj usted Working maximal resiSl
Amount of Weight. motion by the
Sets Weight Repetitions machine will
Number of Adjusted the torque app
3 (Beginning/ 100% of 10 RM 10 Repetitions Working Weight N'e xt isokinelic exe"
intermediate) Performed DUring During Fourth Exercise which resis ta n ~
4-S (Advanced) 100% of 2-3 RM 2-3 Third Set Set Session Several iso
Cybex and Biodi
0-2 - 5-1 0 Ib - S- 10 lb (Figure 7-8) . [~
3-4 -Q-Slb Same weight malic, and rne<J
• TABLE 7-4 Sanders' Program. 5-6 Same weight + S- 10Ib constant veloci
7-]0 + 5-10 Ib + 5- 1S Ib pable of resisti
Amount of
11 + LO-] Sib +10-20Ib a fixed speed to
Sets Weight Repetitions
Isokinetic!
I'ices are deSign!
'Total of 4 sets applied again st
(.3 times per week) 100% of 5 RM S • TA.B LE 7-7 Berger's Adjustment tain speed. Tha
Day 1-4 sets ]00% of 5 RM S Technique. force or only
Day 2-4 sets 100%o f 3 RM 5 quently. in isok~
Day 3-1 set ]00% of 5 RM S Sets Amount of Weight Repetitions exert as much
2 sets 100% of 3 Ri\1 S (ma xim(ll effor
2 sets 100% of 2 Rivl S 3 100% of 10 RM 6-8 !'vlaxim<ll effort I
netic strel1gth-~
 CHAPTER 7
. resistive ex­
i n~ sets of 8 RM. the weight is too light and should be in­
ly adj usted pro­ creased. 8 Progression to heavier weights is then deter­
les 7-5 and 7-6) mined by the ability to perform at least 8 RM in each of
lies at which pa­ three sets. When progressing weight, an increase of about
[rams. 17 1() percent of the current weight being lifted should still al­
1 t is adj ustable low at least 6 RM in each of three setsY
o r any given ex­ For rehabilitation purposes. strengthening exercises
ld be sufficient should be performed on a daily basis initially. with the
~ . with a recov· amount of weight. number of sets, and number of repeti­
~. initial selec­ tions governed by the injured athlete's response to the ex­
e tr ial and error ercise. As the healing process progresses and pain or
. three sets of 6 swelling is no longer an issue. a particular muscle or mus­
l 0 heavy and de group should be exercised conSistently every other day.
ore than three At that point the frequency of weight training should be at
least 3 times per week but no more than 4 times per week .
It is common for serious weight lifters to lift every day;
lE Program. however. they exercise different muscle groups on succes­
sive days.
Repetitions It has been suggested that if training is done properly.
using both concentric and eccentric contractions. resist­
10 ance training is necessary only twice each week. However.
6 this schedule has not been sufnciently documented.
\laximum
la ximum Isokinetic Exercise
An isokinetic exercise involves a muscle contraction in
which the length of the muscle is changing while the con­
traction is performed at a constant velocity. II In theory,
ed Working maximal resistance is provided throughout the range of
motion by the machine. The resistance provided by the
machine will move only at some preset speed. regardless of
the torque applied to it by the individual. Thus the key to
Uit Next isokinetic exercise is not the resistance but the speed at
th Exercise which resistance can be moved.
Session Several isokinetic devices are available commercially.
Cybex and Biodex are the more common isokinetic devices
- 5-1OIb
(Figure 7-8). In general, they rely on hydraul,jc. pneu­ of muscular strength and thus becoming useful as a diag­
ame weight
matic, and mechanical pressure systems to produce this nostic tool. 49
+ 5- 10 Ib
constant velocity of motion. Most isokinetic devices are ca­ Becanse the capability exists for training at specific
+ S-lS1b
pable of resisting concentric and eccentric con tractions at speeds, comparisons have been made regarding the rela­
+ 10- 201b
a fixed speed to exercise a muscle. tive advantages of training at fast or slow speeds in a reha­
[sokinetics as a Conditioning Tool. Isokinetic de­
vices are designed so that regardless of the amount of force
applied against a resistance. it can only be moved at a cer­
stment tain speed. That speed will be the same whether maximal
I'o rcc or only half the maximal force is applied. Conse­
quently, in isokinetic training. it is absolutely necessary to
Repetitions exert as much force against the resistance as possible
'maximal effort) for maximal strength gains to occur.lI
6-8 Maximal effort is one of the major problems with an isoki­
netic strength-training program.
Regaining i'vluscular Strength. Endurance. and Power 149
Anyone who has been involved in a resistance training
program knows that on some days it is diff1cult to find the
motivation to work out. Because isokinetic training re­
quires a maxima l effort. it is very easy to "cheat" and not
go through the workout at a high level of intensity. In a
progressive resistive exercise program. the athlete knows
'how much weight has 10 be lU'ted for how many repeti­
tions. Thus isokinetic training is often more elTeclive if a
partner system is used. primarily as a means of motivation
toward a maximal dfort. When isokinetic training is done
properly with a maximal effort. it is theoretically possible
that maximal strength gains are best achieved through the
isokinetic training method in wh,jch the velocity and force
of the resistance are equal throughout the range of mo­
tion. However, there is no conclusive research to support
this theory.
Whether this changing force capability is a deterrent
to improving the ability to generate force against some re­
sistance is debatab'le. In real life it does not maller
whether the resistance is changing; what is important is
that an individual develops enough strength to move ob­
jects from one place to another. The amount of strength
necessary for athletes is largely dependent on their level
of competition.
Another major disadvantage of using isokinetic de­
vices as a conditioning tool is their cost. With initial pur­
chase costs ranging between $SO,OOO and $80.000 and
the necessity of regular maintenance and software up­
grades. the use of an isokinetic device for general condi­
tioning or resistance training is for the most part
unrealistic. Thus isokinetic exercises are primarily used as
a diagnostic and rehabilitative tool.
Isokinetics in Rehabilitation. Isokinetic strength
testing gained a great deal of popularity throughout the
1980s in rehabilitation settings. This trend stems [rom its
providing an objective means of quantifying existing levels
bilitation program. The research literature seems to
indicate that strength increases from slow-speed training
are relatively specific to the velocity used in training. Con­
versely. training at faster speeds seems to produce a more
generalized increase in torque values at all velociLies. Min­
imal hypertrophy was observed only while train'i ng at rast
speeds. affecting only type If or rast-twitch fibersYi2 An
increase in neuromuscular eff1cicncy caused by more ef­
fective motor unit firing patterns has been demonstrated
with slow-speed training. 45
150 PART TWO Achieving the Go als of Rehabilitation

pelvic-hip cOl11pl
functional stJ"Cn
eiency t hro ugh o l
tors can lri bu te tI
dynamic stabillzi
functional mO\'e'
proxima l stabilit}
Grealer neuromu
will offer a more
en tire kinetic ch
muscular efficien
roac h facilita te
entire kinetic ch a
Many athlete:

Figure 7-8 The Biodex is an isokinetic device th a t provides resista nce at a co nstant velocity.

During the ea rly 1 99 0s, th e val ue of isokinetic devices balls and other types of weighted equipment for the upper
fo r qua ntifying torque values at fun ctional speeds was extremity. 12.]; Depth jumping is an exa mpl e of a plyomet­
questi oned'. This issue, in additi on to th e th eory and use of ric exercise in which an individual jumps to th e gro und OPEN· VE~
isokinetic exercise in a rehabilitCl[ion sellin g, will be dis­ I'r01l1 a specil1ed h eight and th en quickly jumps aga in as
cussed in deta il in Cha pter 13. soon as ground con ta ct is made.5 3 CHAIN EXI
Plyometrics tend to place a great deal of stress on the
Plyometric Exercise musculoskeletal system . The lea rning and perfection of
specitk jumping skills and other plyometric exercises must _ " remilies. In
Plyometric exercise has also been referred to in the liter­ be technically correct a nd specific to one's age, ac tivity, ~1.Te rnity kin eti~
ature as rcacti\7 e neuromuscula r training. [t is a techniqu e physical. and skill development. Plyomelric exercise w ill be :llIlon g t he fool.
that is being increasingly incorporated into later stages of discussed in deteJil in Ch apte r 11. he upper extre
the rehabilitation progra m by the athletic trainer. Plyo­ .~t' i ghl-bearin g
metric training includes specific exercises that encom pass orearm, elbo\\'. u
() rapid stretch of a muscle eccentricaUJ'. followed immedi­ CORE STABILIZATION An open kinf
ately by a rapid concentric co ntraction of that mus.c le to STRENGTHENING is n ot in co nta ct
facilitate and develop a forceful ex plosive movement over a In a closed kim
short period of time. 13. 20The greater the stretch put on the A dynamic core stabilization training program shou ld be a bearing. Moveme
muscle from its resti ng len gth immediately before the con­ fun da mental component of a ll comprehensive stren gth­ segments are am
ce ntric con tra ction, th e greater the resistance th e muscle ening as well as injury rehabili tation programs. H . 3" The ne tic-cha.in positi
can overcom e. 1'Iyomelrics emphasi~e the speed of the ec­ core is defined as th e lumbo-pel vic-hip complex. The co re ponents of th e a
centric phase. The rate of st retch is Il1nre criiicalthan the is where the center of gravity is loca ted an d where all when changin g rr
magnitude of th e stretc h. An advantage to using plyomet­ movement begins. The re a rc 29 mu scles that h ave their at­ ity. In a closed ,
ric exercises is tha t they can help to develop eccentric con­ tachment to tbe lumbo-pelvic-hip com plex . g round an d work
trol in dynamic moveme nts! I A core stabilization strengt hening program can h el p to in a closed kineU,
PlyomeLric exercises involve bops. bounds. and depth improve dynami C postural control. ensu re appropriate iDUS tissues and ;j
jumping for the lower extremity a nd the usc of medicine muscul ar balance and joint movement around the IUl11 bo­ ply dissipating as
 CHAPTER 7
pelvic-hip complex. allow for the expression of dynamic
functional strength. and improve neuromuscular efll­
ciency throughout the entire body. Collectively these fac­
tors contribute to optim<ll acceleration, deceleration, and
dynamic stabilization of the entire kinetic chain during
functional movements. Core stabiHzalion also provides
proximal stabilitJFfor efficient lower extremity movements.
Greater neuromuscular control and stabilization strength
will offer a more biomechanically efficient position for the
entire kinetic chain, therefore allowing optimal neuro­
muscular efficiency throughout the kinetic chain . This ap­
proach facilitates a balanced muscular functioning of the
cn tire kinetic chain.l i
Many athletes develop the functional strength, power,
neuromuscular control, and muscular endurance in spe­
cilk muscles to perform functional activities. However, rel­
tively few athletes have developed the muscles required
for stabilization. The body's stabilization system has to be
functioning optimally to effectively utilize the strength,
power. neuromuscular control. and muscular endurance
lhat they have developed in their prime movers. If the ex­
£remity muscles are strong and the core is weak, then there
will not be enough force created to produce efficient move­
ments. A weak core is a fundamental problem of inefll­
ient movements that leads to injury. l i
fo r the upper
of <1 plyomet­
o the ground OPEN· VERSUS CLOSED·KIINETIC·
LImps again as
CHAIN EXERCISES
I str ess on lh e The concept of the kinetic chain deals with the anatomical
perfection of .u nctional relationships that exist in the upper and lower
exercises mllst _'tremities. In a weight-bearing position . the lower­
'. age. activity. ex tTemity kinetic chain involves the transmission of forces
exercise will be among the foot, ankle. lower leg. knee. thigh, and hip. In
;.he upper extremity. when the hand is in contact with a
-eight-bearing surface, forces are transmitted to the wrist.
rearm, elbow. upper arm, and shoulder girdle.
An open kinetic chain exists when the foot or hand
...; not in contact with the ground or some other surfjlce.
n a closed kinetic chain. the foot or hand is weight
aring. Movements of the more proximal anatomical
gments are affected by these open- versus closed-ki­
llc-chain positions. For example, the rotational eom­
nents of the ankle. knee. <lnd hip reverse direction
be!J. changing from opcn- to closed-kinetic-chain activ­
'. ' In a closed kinetic chain the forces 'begin at the
~ro und and work their way up through each joint. Also,
a closed kinetic chain. forces must be absorbed by var­
u tissues and anatomical structures rather than sim­
~ r dissipating as would occur in an open chain.
Regaining Muscular Strength, Endurance, and Power 151
In rehabilitation. the use of closed-chain strengthen­
ing techniques has become a treatment of choice for many
athletic trainers. Most sport activities involve some aspect
of weight bearing with th e foot in contact with the ground
or the hand in a weight-bearing pOSition. so closed-kinetic­
chain strengthening activities are more functional than
open-chain activities. Therefore reh<lbilitative exercises
should be incorporated that emphasize strengthening of
the entire kinetic chain rather than an isolated body seg­
ment. Chapter 12 will discuss closed-kinetic-chain activi­
ties in detail.
"rRAINING FOR MUSCULAR
S"rRENGTH VERSUS MUSCULAR
ENDURANCE
Muscular endurance was defined as the ability to perform
repeated muscle contractions against resistance for an ex­
tended period of time. Most resistance training experts be­
lieve that muscular strength and muscular endurance are
closely related.nio.i7 As one improves, there is a tendency
for the other to improve also.
It is generally accepted that when resistance training
for strength. heavier weights with a lower number of rep­
etitions should be used. 65 Conversely, endurance training
uses relatively lighter weights with a greater number of
repetitions.
It has been suggested that endurance training should
consist of three sets of 10 to 15 repetitions. 9 using the same
criteria for weight selection progression and frequency as
recommended for progressive resistive exercise. Thus. sug­
gested training regimens for muscular strength and en­
durance are similar in terms of sets and numbers of
repetitions. ii Persons who possess great levels of strength
tend to also exhibit greater muscular endurance when
asked to perform repeated contractions against resistance.4R
RESISTANCE TRAINING
DIFFERENCES BETWEEN
MALES AND FEMALES
Resistance training is absolutely essential for an athlete.
The approach to strength training is no different for female
than for male athletes. However. some obvious physiologi­
cal differences exist between the sexes.
The average female will not build significant muscle
bulk through resistance training. Significant muscle hy­
pertrophy is dependent on the presence of the steroidal
hormone testosterone. Testosterone is considered a male
152 PARTTvVO Achievin g the Goa ls of Rehabilitation

hormone. although all females possess some level of RES,ISTANCE TRAINING 3. 'Ivluscular em
testosterone in their systems. Women with higher testos­
terone levels tend to have more mascu'line characteristics. IN THE YOUNG ATHLETE strength. th u
ponents ar c .
such as increased facial and body hair. a deeper voice. and The principles 0[' resistan ce training discussed previously 4. Muscula r sire
the potential to develop a little more muscle bulk. 21·iu For may be applied to the yo un g athlete. There are cerlainly a ponen ts of ar
the average female athlete. developing large, bulky mus­ number ()f sociological questions regarding the advantages 5. Muscular pm
cles through strength tra inin g is unlikely, although muscle and disadvantages of younger, in particul'ar prepubescent, ful muscle COl
tone can be improved. Muscle tOile basically refers to the athletes engaging in rigorous strength-training programs, 6. The ability to
firmness of tension of the muscle during a resting state. From a physiological perspective. experts have for years de­ ical properli
The initial stages of a resistance training program arc bated the value of strength training in young athletes. Re­ ciency, as we
likely to rapidly produce dramatic increases in levels of cently. a number of studies have indicated that if properly how mucb rc
strength. l For a muscle to contract. an impulse must be supervised. young athletes can improve strength. power, system to an I
transmitted from the nervous system to the muscle. Each endurance. balance. ,rud proprioception; develop a positive 7. Hypertrophy
muscle fiber is innervated by a specific motor unit. By over­ body im age; improve sport performance; and prevent in­ size and perh,
loading a particular muscle. as in weight training, the mus­ juries.4 1 A prepubescent child can experience gains in lev­ tein myol1l arr
cle is forced to work more eflkiently. Ef'ficiency is achieved els of muscle strength without muscle hypertrophy. 51 sectional dial
by getting more motor units to lire. thus causing more mus­ An athletic trainer supervising a rehabilitation pro­ 8. The key to i
cle IIbers to contract, which results in a stronger contrac­ gram for an injured young athlete should certainly incor­ training is U"
tion of the muscle. Consequent~y, both women and men porate resistive exercise into the program. However. close cons train ts
often see extremely rapid gains in stTength when a weight­ supervision. proper instruction, and appropriate modil1ca­ 9. Five resist al1l
training program is first begun. l , In the female. these initia l lion of progression and intensit.y based on the extent of muscular Sir,
strength gains, which can be attributed to improved neuro­ physical maturation of the individual is critical to the ef­ resistive exen
muscular effiCiency, tend to plateau. and minimal improve­ fectiveness of the resistive exercises. 41 and plyomclr
ment in muscular strength is realized during a continuing
resistance training program. These initial neuromuscular
strength gains are also seen in males. although their SPEC,I FIC RESISTIVE EXERCISES
strength continues to increase with appropriate training] USED ,I N REHABILITATION
Again, females who possess higher testosterone levels have
the potential to increase their strength Iurther because Because muscle contractions resuJ t in joint movement. the
they are ab le to develop greater muscle bulk. goal of resistance training in a rehabilitation program References
Differences in strength levels between males and fe­ should be to either regain and perhaps in crease the
1. Ak.im a. II .. II.
males are best illustrated when strength is expressed in re­ strength of a specific muscle that has been injured or to in­
lation to body weight minus fal. The reduced strength/ body crease the cr!1cieney 01 movement about a given joint.~i
weigl1t ratio in women is the result of their percentage of The exercises included throughout Chapters 18 to 25 2.
body fal. The strength/ body weight ratio can be signifi­ show exercises for all motlions about a parficular joint rather
cantly improved through resistance training by decreasing than for each speCific muscle. These exercises are demon­
the body fat percentage while increasing lean weigh1. 4i strated using free weights (dumbbells or bar weights) and 3.
The absolute strength differences are considerably re­ some exercise machines. Other strengthening techniques und strucL
duced when body size and composition are considered. Leg widely used for injury rehabilitation involving isokinetic ex­ letes. jOllmal
slrength can actually be stronger in the female than in the ercise, pJyometrics. core stability training, closed-kinetic­ 4. Astrand. P. O.
male. although upper-extremity strength is much greater chain exercises, and PNF strengthening techniques will be ogy. New York
) . Baechle. T.. ed,
in the male.45 discussed in greater detail In subsequent chapters.
6.
speciflcity :
Summary of strength 3.Ii
Pilysi%(Jy 6S ~
- Bundy, W.. \. !J
tation or skel
]. l'duscula r strength may be defined as the maxima'l 2. Muscular endurance is the a bility to perform repeated t/lOpaedic alld.'l
fo rce that can be generated against resistance by a isoton,ic or isokinetic muscle contractions or to susLain -;. Berger. R. 1 9
muscle during a single maximal contraction. an isometric contraction without undue fatigue. 9 . Berger. R. 19
strength. ReStI
 CHAPTER 7 Regaining Muscular Strengt.h. Endurance. and Power 153

~
3. Muscular endurance tends to improve with muscular 10. Improvements in strength with isometric exercise oc­
'E strength. thus training techniques lor these two com­ cur at specific joint angles.

~
~sed previously
re are certainly a
ponents are similar.
4. Muscular strength and endurance arc essential com­
11. Progressive resistive exercise is the most common
strengthening technique used by the athlJctic trainer
ponents of any rehabilitation program. for rehabiHtation after injury.
. g the advantages 5. Muscular power involves the speed with which a force­ 12. Circuit training involves a series of exercise stations
war prepubescent. ful muscle contraction is performed. consisting of resistance training. flexibility. and cal­
lnlin ing programs. 6. The ability to generate force is dependent on the phys­ isthenk exercises that can be deSigned to maintain
have for years de­ ical properties of the muscle. neuromuscular efl1­ fitness while recondHioning an injured body part.
~ un g alh'letes. Re­ ciency. as well as the mechanical factors that dictate 13. Isokinetic training provides resistance to a muscle at a
ed that if properly how much force can be generated through the lever fixed speed.
trength. power. system to an external object. 14. Plyometric exercise uses a quick eccentric stretch to fa­
develop a positive 7. Hypertrophy of a muscle is caused by increases in the cilitate a concentr,ic contraction.
nd prevent in­ size and perhaps the number of actin and myosin pro­ 15. Closed-kineUc-chClin exercises might provide a more
~ 0 e gaills in lev­ lein myof1laments. which result in an increased cross­ functional technique for strengthening of injured
pertrophy. il sectional diameter of the muscle. muscles and joints in the athletic population.
_habilitation pro­ S. The key to improving strength through resistance 16. Females can significantily increase their strength levels
certainly incor­ training is using the principle of overload within the but gen em lly wilil not build muscle bulk as a result of
. However. close constraints of the healing process. strength training because of their relative lack of the
priale modi fiea­ 9. P·ive resistance training techniques that can improve hormone testosterone.
n the extent of muscular strength are isomctric exercise. progressive
resistive exercise. isokinetic training. circuit training.
and plyomelric training.

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Skeletal muscle adaptations during early phase or heavy re­
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iolog!l 7h:1247-5 S.
60 . Stone. J. 1998. Rchabilitation-$pecd of movement/museu­
l<Ir power. Athletic Thera p!I Today 3(5): 10.
61. Stone. J. 1998. Rehabi litatioo-;'v1 uscular endurance. Ath­
3. Changes in fOW­ letic Therapy Today 3( 4): 21.
p a nd isokinctic h2. Stone. M.. S. Fleck. and 2'.1'riplctt. 1991. Health and perfor­
tandard plus plyo­ mance related potential 0(" resistance training. Sports Medi­
"Iml oj Sports Med­ cille 11:21 0- 31.
power theory for
y 65:41S-20.
Exercise physiol­ SOLUTION TO CLINICAL DECISION MAKING EXERCISES
·e. Philadelphia:
7-1 She must regain strength to maximize whole-body
mechanics for technique and injury prevention. She
must regain endurance so that she is sure to make it
metric training. through a whole game without fatiguing and risking
12:258. reinjury. l\nd she must restore power so that she can
the tec hniques of generate speed in her throwing technique.
nal ll:] 1993. 7-2 Isometric exercise can bc performed right away.
un " nonathletic While in the cast. the athlete can perform muscle
Pilysicill :vlcilicine
contractions that will stimulate blood flow and pro­
et aI. 1988. ;"'lus-
vide for some maintenance of strength. As soon as
the cast is removed, she should perform active con­
centric and eccentric isotonic contractions until she
is strong enough to perform resisted concentric and
eccentric exercise with weights or surgical tubing.
When planning an isotonic exercise, you should al­
ways encourage the athlete to perform the eccentric
movement more slowly as it is the stronger move­
ment and will not have a chance to fatigue bcl'ore the
concentric movement does. fn athletics it is impor­
tant to have a strong eccentric component to ensure
controlled and balanced movements for good tech­
1 9 89. Force. en­ nique and injury prevention.
in voluntary iso­ / -3 fndividuals have a particular ratio of fast-twitch to
_rQ ups. Biomedical slow-twitch muscle flbers. Those who have a higher
conditioning. In
_. :-Ionvalk, CT: Ap­
RegClining Muscular Strength. Endurance. and Power 155
63. Strauss. R. H.. cd. 1991. Sportsllledidllc. Philadelphia: W. B.
Saunders.
64. Imer. H.. W. Knierman. 1. \Varlow. ct ill. 1989. Interindivid­
ual variability of isometric endurance with regard to the en­
durance performance limit for static work. Biomedical
13iociIClllistry Acta 48(5- 6): S504.
65. Van Ellen. L.. E. Verstappen. and K. V,lcstertcrp. 1994. Effect
of body building on weight training induced adaptations in
body composition and muscular strength. JVIe,Udllc ami Sd­
m cr ill Sports mId Exercise 26: 515- 21.
66. Weltman. A.. and B. Stamford. 1982. Strength training: Free
weights vs. machines. PI'!Jsiciwlalld Sports .l;Ie,lieil!e 10:197.
67. Yates. J. W. 1987. Recovery of dynamic muscular endurance.
European JOlinIal oj Llpplied Physiology 56(6): 662.
68. ~inoviefr. A. 1951. [[cavy resistance exercise: The Oxford
technique. British Joumal oj P/lysi%gicnl ,VIedicine 14: 129.
ratio of slow-twitch to fast-twitch are better at en­
durance activities. Because this ratio is genetically
determined. it would be surprising if someone who is
good at endurance activity could also be good at
sprint-type activities.
7-4 The athlete who is able to move more weight proba­
bly has a mechanical advantage. rr the tendinous in­
sertion of the hamstrings is more distal. a longer
lever arm is created and thus less force is required to
move the same resistance.
7-5 Doing isomc!ric exercise at that point will help him
gain strength for that specific tension point.
'7-6 Exercise machines typically are safer and more com­
fortable. It is easier to change the resistance. and the
weight increments are small for easy progressions.
Many of the machines utilize some type of cam for ac­
commodating resistance. However, they are expensive
and can be used only lor one specific joint movement.
Dumbbells or free weights are more versatile as well as
cheaper. They also implement an additional aspect of
training. as it requires neuromuscular control to bal­
ance the weight throughout the full range of motion.
 CHAPTER 8 Despi te beill ~
goals associa ted
of balance is a

Regaining Postural Stability joint injuries th a

orthopedic reb at
la ted joint mecha
and Balla nce ity, and increasin
tha n on afferent
proces.sed by tht
Kevin M. Guskiewicz
search in th e a re
emph aSized th e n
JOint pOSition ser
"ital to all athle
rent rehabilitatio
combination of 0
Ibc n ecessity [0'
kinetic-chain exe.
Study Resources • Evaluate the effect tha t injury to the
ru nnin g). as the
To become more ramiliar with the knowledge and skills ankle. knee. and head has on balance (open chain) an d I
necessary to design , implem ent. and document therapeu­
and postural equilibrium. midstance and tOl
lie rehabilitation programs as identified in th e .i\ ',1TA Ath­
on tbe postural c
leLic Trainil1g Educatiol1al Competel1cies alld Clil1ical • Identify the goals of each phase of bal­ techniques, an d l.
Proficiel1 cies'Therapeutic Exercise content area, visit
ance training, and how to progress the abling sports med
IVww,mhhe,com/prentice ll e. Also, refer to the lab exer­
athlete through each phase. balance del1cits in
cises in the new Laboratory Manual and to eSims, which
simulates the athJetjc training certification exam, at
www.mhhe.com/esims. For more online st udy resources,
• State the differences among static,
THE POST'
visit our Health and Human Performance website at semidynamic and dynamic balance­
SYSTEM
www.mhhe.com/hhp. training exercises.

The athlctic tra i

lhe postural con
After Completion of This

The postural ca n
Chapter, the Student Should
lthough maintaining balance while standing may ap­
Be Able to Do the Following:

• Define and explain the roles of the

A pear to be a rath er simple motor skill for able-bodied
athletes, this fe a t Cannot be tuken for granted in an
athlete with musculoskeletal dysfunction. Mu scu lar weak­
\'olving both se1

three sensory modalities responsible ness, pro prioceptive defi cits, and range-of-motion (ROM)
deficits may challenge a person's ability to ma,i ntai n their
for maintaining balance. center o[ gravity (COG) with in the body's base of support.
• Explain how movement strategies or in other words. cause them to lose their balance. Bal­

along the closed kinetic chain help

ance is the si ngle most important element dictating move­
ment strategies within the closed kinetic chain. ~
maintain the center of gravity in a safe Acquisition of effective strat egies [or maintaining balan ce
and stable area. is therefore essential [or athletic performance. Although

• Differentiate between subjective and

balance is often thought of as a static process, it's actually
a highly integrative dynamic process involving multiple
~
objective balance assessment. neurological pathways. Though balance is the more com­

~
monly used term. postural equilibrium is a broader
• Differentiate between static and dy­ term that involves the alignment of joint segments in ajl ef­
namic balance assessment. fort to maintain the COG wWlin an optima l range of the
figu
maximum limits of stability (LOS), which will be discussed
Con
later. ]99
156
 CHAPTER 8
Despite being classified at the end of the continuum of
goals associated with therapeutic exercise,47 maintenance
of balance is a vital component in the rehabilitation of
joint injuries that should not be overlooked. Traditionally,
orthopedic rehabilitation has placed the emphasis on iso­
lated join t mechanics such as improving ROM and f1exibil­
ity, and increasing muscle strength and endurance, rather
than on afferent information obtained by the joint(s) to be
processed by the postural control system. However. re­
search in the area of proprioception and kinesthesia has
emphasized the need to train the joint's neural system,S-;l
Joint position sense, proprioception, and kinesthesia are
vital to all athletic performance requiring balance. Cur­
rent rehabilitation protocols should therefore focus on a
combination of open- and closed-kinetic-chain exercises.
The necessity for a combination of open- and closed­
kinetic-chain exercises can be seen during gait (walking or
running), as the foot and ankle prepare for heel strike
(open chain) and prepare to control the body's COG during
rn idstance and toe-off (closed chain). This chapter focuses
on the postural control system, various balance training
t chniques. and technological advanccments that are en­
a bling sports medicine athletic traincTS to assess and treat
alance deficits in physically active people.
THE POSTURAL CONTROL
SYSTEM
The athletic trainer must first have an understanding of
the postural control system and its various components.
The postural control system utilizes complex processes in­
-, olving both sensory and molor components. Mainte-
r gran ted in an
. \[uscular weak­
.... f-molion (ROM) Determination of body position
Compare, select and combine senses
t t t
I Vision I Somatosensation
t t t
gments in an ef­
! Environmental interaction I I
'm al range of the Figure 8-1 Dynamic equilibrium. (Adapted from Allison, L.. Fullcr, R. Hedenberg, et al.
h will be discussed Contemporary Management of Balance Dejicit.,I', Clackamas. OR: NeuroCorn International.
1994; with permission)
Regaining Postural Stability and Balance 157
nance of postural equilibrium includes sensory detection
of body motions, integration of sensorimotor information
within the central nervous system (CNS), and execution of
appropriate musculoskeletal responses. Most daily activi­
ties, such as walking, climbing stairs, reaching, or throw­
ing a ball. require static foot placement with controlled
balance shifts. especially if a favorable outcome is to be at­
tained. So, balance should be considered both a dynamic
and a static process. The successful accomplishment of
static and dynamic balance is based on the interaction be­
tween body and environment 46 The complexity of this dy­
namic process can be seen in Figure 8-1. From a clinical
perspective, separating the sensory and motor processes of
balance means that a person may have impaired balance
for one or both of the follOWing two reasons: (1) the posi­
tion of the center of gravity (COG) relative to the base of
support is not accurately sensed, and (2) the automatic
movements required to bring the COG to a balanced posi­
tion are not limely or effectively coordinated. 64
The position of the body in relation to gravity and its
surroundings is sensed by combining visual, vestibular.
and somatosensory inputs. Balance movements also in­
volve motions of the ankle. knee. and hip joints, which are
controlled by thc coordinated actions along the kinetic
chain (figure 8-2). These processes are all vital for pro­
ducing fluid sport-related movements.
CONTROL OF BALANCE
The human body is a very tall structure balanced on a
relatively small base. and its COG is quite high, being just
above the pelviS. HO Many factors enter into the task of
Choice of body movement
Select and adjust muscle contractile pattern
Generation of body movement
158 PART TWO Achieving the Goals of Rehabilitation

anee is sign ific

rather th an opt
Somatosel
cerning th e ori
to the su ppaft
lion of th e eye
jecLs. and pl aY'
balance. On a ..
only minimal i
jects. However.
ligame ntou s in
~igni/'icantly. 1

G plies in fOrma li(

angular acce!
space. Tt do es n
lion in relatior
onlly a minor ro
v'isual an d som;

Posterior muscle J 1 Anterior muscle

informalion. H

SOMATO!
RELATES
Figure 8-2 Paired relationships between major postural musculatu.res that execute
coordinated actions along the kinetic chain to control the center of gravity. The terms som~
balance are ortc :
the more glo
controlling balance within the base of support. Balance The second component, muscle coordination, is the mechanisms r
control involves a complex network of neural connec­ collection of processes that determine the temporal se­ rately be used
tions and centers that are related by peripheral and cen­ quencing and distribution of contraclile activity among matosensalion
tral feedback mechanisms. 1 6 the muscles of the legs and trunk that generate supportive variaLion of 1
The postural control system operates as a feedback reactions for maintaining balance. Research suggests that passes the sen
control circuit between the brain and the musculoske'letal balance deficiencies in people with neurological problems joint position I
system. The sources of afferen t information supplied to the can result from inappropriate interaction among the three cussed. balance
postural control system collectively come from visual, sensory inputs that provide orientation information to the COG within lh
vestibular. and somatosensory inputs. The involvement of postural control system. A patient may be inappropriately mCltosensalion
the central nervous system (CNS) in maintaining uprigh~ dependent on one sense for situations presenting intersen­ control syste
posture can be divided into two components. The first sory connict. bO.7l movement and
component, sensory organization, involves those From a clinical perspective. stabilization of upright (e.g.. muscle s~
processes that determine the timing, direction, and ampli­ posture requires the integrati on of afferent information ci..!ptors). So lhl
tude of corrective postural actions based upon informa­ from the three senses, which work in combination and are tion il111 uence
tion obtained from the vestibular. visual. and all critical to the execution of coordinated postural correc­
somatosensory (proprioceptive) inputs. nO Despite the tions. Impairment of one component is usually compen­ tors, but it is u
availability of multiple sensory inputs, the central nervous sated for by the remaining two. Often, one of the systems cle spindles .
system generally relies on only one sense at a time for ori­ provides faulty or inadequate information about different controlling b
entation information. For healthy adults, the preferred surfaces and/or changes in visual acuity and /or peripheral electromyograp'
sense for balance control comes from somatosensory in­ vision. In this case it is crucial that one of Lhe other senses perturbations.
formation (I.e., feet in contact with the support surface, provide accurate and adequate information so that bal­ the responses j
and detection of joint movement). 39,60 In considering or­ ance can be maintain ed. For examp'le, when somatosen­ longer tb an th
thopedic injuries, the somatosensory system is of most im­ sory connict is present, as when the individual is standing otatic renex, T
portance and wiD be the focus of this chapter. on a moving platform or a compliant foam surface, bal- anism j()r in cr
 CHAPTER. 8
ance is significantly decreased when the eyes are closed
rather than open.
Somatosensory inpuLs provide information con­
cerning the orientation of body parts to one another and
to thl! support surface. 11 b4 Vision measurl!S the orienta­
tion of the eyes and head in relation to surrounding ob­
jects, and plays an important role in the maintenance of
balance. On a stable surface. closing the eyes should cause
only minimal increases in postural sway in hea lthy sub­
jects. Howevcr. if somatosensory input is disrupted due to
ligamentous injmy. closing the eyes will increase sway
significantly. ll.1 7.19.4tl.h4 Th e vestibular apparatus sup­
plies information that measures gravitational, linear. and
angular accelerations of the head in relation to inertial
space. II dlles not, however, provide orientation informa­
tion in relution to external objects. and therefore plays
only a minor role in (he maintenance of balance when the
visual and somatosensory systems are providing accurate
information. i>4
SOMATOSENSATION AS IT
RELATES TO BALANCE
The terms somntosensiltion. proprioception. kincslhcsill. and
/Jailll'lcc are often used interchangeably. Somillosensiltioll is
the more global term used to denote the proprioceptive
rw nation, is the mechanisms related to postura l control and can accu­
the temporal se­ rately be used synonymously with the other terms. So­
activity among matosensation is therefore is best deFined as a specialized
~ era te supportive variation of the sensory modality of touch that encom­
b suggests that passes th e. sensation of joint movement (kinesthesia) and
logical problems joint [Josition (joint position sense).4 .52 As previously dis­
among the three cussed. bllinn ce refers to the ability to maintain the body's
nfo rmation to the COG within the base of support provided by the feet. So­
inappropriately matosensation and balance work closely, as the postural
eLlting intersen­ control system utilizes sensory information related to
movement and posture from peripheral sensoq' receptors
tion of upright (e.g.. muscle spindles. GTO. joint afferents, cutaneous re­
erent information ceptors). So the qnestion remain s, how does propriocep­
bination and are tion inl1uenre postural eqU ilib rium and balance?
postural correc­ Somatosensory input is recdved from mechanorecep­
usually compeLl­ tors. but it is unclear whether the tactile senses. the mus­
one of the systems cle spindles. or the GTOs are more responsible for
n about different controlling balance. ashner ,9 concluded, after using
._ and/or peripheral electromyography (EMG) responses following platform
~ of l he other senses perturbation s. that other pathways had to be involved in
"Dati on so that bal­ the responses they recorded because the latencies were
~ when somatosen­ longer than those nornwlly associated with a classic my­
kiiddual is standing otatic reflex. The stretch -related rerIex is the earliest mech­
, foa m surface, bal­ anism for increasing the activation level of muscles about
Regaining Postural Stubility and Balance 159
a joint follOWing an externally imposed rotation of the
Joint. Rotation of the ankles is the most probable stimulus
·o f the myotutic reflex that occurs ,in many persons. It ap­
pears to be the first useful phase of activity in the leg mus­
cles after a change in erect posture. i9 The myotatic reflex
can be seen when perturbations of gait or posture au to­
matically evoke functionally directed responses in the leg
muscles to compensate for imbalance or increased pos­
tural sway. I ;.i~ Muscle spindles sense a stretching of the
agonist. thus sending information along its afferent fibers
to the spin al cord. There the information is transferred to
alpha and gamma motor neurons that ca rry information
back to the muscle fibers and muscle spind le, respectively.
and contract the muscle to prevent or control additional
postural sway. I i
Postural sway was assessed on a platform moving into
a "toes-up" and "toes-down" position. and a stretch reflex
was fGLlnd in Lhe triceps surae after a sudden ramp dis­
p'lacement into the "toes-up" position. ]c' j\ medium latency
response (103-118 ms) was observed ,in the stretched mus­
cle, followed by a delayed response of the antagonistic an­
terior tibialis muscle (108-124 ms). The investigators also
blocked afferent proprioceptive information in an attempt
to study the role of proprioceptive information from the legs
for the maintenance of upright post.ure. These results sug­
gested that proprioceptive information from pressure
and / or joint receptors of the foot (ischemia applied at an­
kle) plays an important role in postural sLabili:wtion during
low frequencies of movement, but is of minor importance
for the compensation of rapid displacements. The experi­
ment also included a "visual" component, as sllbjects were
!tested with eyes closed and then with eyes open. Results
suggested that when subjects were tested with eyes open.
visual information compensaLed for the loss of propriocep­
tive input.
Another studyl, used compensatory EJ\ilG responses
during impulsive disturbance of the limbs during stance
on a treadmill to describe the myotatic reflex. Results re­
vealed that during backward movement of the treadmill.
a nkl e dorsiOexion caused the COG to be shifted ankriorly.
thus evoking a stretch reflex in the gastrocnemius muscle.
followed by weak anterior tibialis activation. In anolber
trial. the movement was reversed (plant ar flexion) . thus
shifling the COG posteriorly and evoking a stretch reflex of
the anterior tibialis muscle. Both of these studies suggest
that stretch reflex responses help control the body's COG.
and that the vestibular system is unlikely to be directly in­
volved in the generation of the l1ecessars' responses.
Elimination of all sensGry inform ation from the feet
and ankles revealed that proprioceptors in the leg mus­
cles (gastrocnemius and tibialis anterior) were capab le of
160 PART TWO Achieving the Goals of Rehabilitation
providing sufficient sensory information for stable stand­
ing. 2 ] Resea rchers specul ated that group I or group rr
muscle spindle a fferents. and group Ib afferents from
GTOs were the probable sources of this proprioceptive in­
form atio n. The study demonstrated that normal subjects
can stand in a stable manner when receptors in the leg
muscles are the only source of information about pos­
tural sway.
Other studies 5.40 have examined the role of somatosen­
sory information by altering or limiting somatosensory in­
put through the use of platform-sway referencing or foam
platforms. These studies reported that subjects still re­
sponded with well-coordinated movements but the move­
ments were often either ineffective or inefficient for the
environmental context in which they were used.
BALANCE AS IT RELATES TO
THE CLOSED KINETIC CHAIN
Balance is the process of maintaining the center of gravity
(COG) within the body's base of support. The human body
is a very tall structure balanced on a relatively small base.
and its center of gravity is quite high. being just above the
pelvis. Ho Many factors enter into the task of controlling
balan ce within this designated area. One component often
overlooked is the role balance plays within the kinetic chain.
Ongoing debates as to how the kinetic chain should be de­
fined and whether open- or closed-kinetic-chain exercises
are best has caused many athletic trainers to lose sight of
what is most important. An understanding of the postural
control system and the theory of the kinetic (segmental)
chain about the lower extremity helps conccptualize the
role of the chain in maintaining balance. Within the ki­
netic chain. each moving segment transmits forces to
every other segment along the chain. and its motions are
inOuenced by forces transmitted from other segments]]
(see Chapter 12). The act of maintaining equilibrium or
balance is associated with the closed kinetic chain. as the
distal segment (foot) is l'ixed beneath the base of support.
The coordination of automatic postural movements
during the act of balancing is not determined solely by the
muscles acting directly about the joint. Leg and trunk
muscles exert indirect forces on neighboring joints
through the inertial interaction forces among body seg­
ments. 6 1. 6 2 A combination of one or more strategies (an­
kle. knee. hip) is used to coordinate movement of the COG
back to a stable or balanced position when a person's bal­
ance is disrupted by an external perturbation. Injury to
anyone of the joints or corresponding muscles along the
kinetic chain can result in a loss of appropriate feedback
for maintaining balance.
BALANCE DISRUPTION iaJis anterior.
should not be L
Let's say. for example. that a basketball player goes up for a itaLion progran
rebound and collides with another player. causing her to ecuting relali n
land in an unexpected position. therefore compromiSing support is fir m
her normal balance. To prevent itself from falling. the body ter. The ankle
must correct itself by returning the COG to a position maintaining a
within safer limits of stability (LOS). Afferent mechanore­ center. The lhi:
ceptor inputs from the hip. knee. and ankle joints is respon­ thereby resist l
sible for initiating automatic postural responses through due to the indin
the use of one of three possible movement strategies. imal joints (Tat
activation of ill
lected to mai n L
Selection of Movement Strategies differences a
with vestibul ar
Three principle jOint systems (ankles. knees. a nd hips ) are
strategies. PefS(
located between the base of support and the COG. This al­
on their hip mu
lows for a wide variety of postures that can be assumed
cncing forward
while the COG is still positioned above the base of support.
support surface
As described by Nashner. 64 motions about a given joint are
If the ankle
controlled by the combined actions of at least one pair of
cessive sway. l.b
muscles working in opposition. When for ces exerted by
motion of the I
pairs of opposing muscle about a joint (e.g .. anterior tib­
rapid motions a
ialis and gastrocnemius/soleus) are combined. the effect is
the ankles. Thi5
to resist rotation of the joint relative to a resting position.
near the LOS pc:
The degree to which the joint resists rotation is called joint
contracted by a
stiffness. The resting position and the stiffness of the joint
the COG is disp
are altered independently by changing the activation lev­
(stepping stml l'y!
els of one or both muscle groups.41.64 Joint resting position
prevent a fall. L .
and jOint stLffness a re by themselves an inadeq uate basis
It is propo~
for controlling postural movemen ts. and it is th eorized that
in individuals
the myotatic stretch renex is the earliest mechanism for in­
creasing the activation level of the muscles of a joint fol­
lowing an externaUy imposed rotation of the joint. 64
When a person's balance is disrupted by an external • TABLE
perturbation . movement strategies involving jOints of the
lower extremity coordinate movement of the COG back to
a balanced position . Three strategies (an kle. hip. stepping)
have been identified along a continuum. l9 In general. the Joint
relative effectiveness of ankle. hip. and stepping strategies
Ln repositioning the COG over the base of support depends Hip
on the configuration of the base of support. the COG align­
ment in relation to the LOS. and the speed of the postural
movement. J9.40 Knee
The ankle strategy shifts the COG while maintaining
the placement of the feet by rotating the body as a rigid
mass about the ankle joints. This is achieved by contract­ Ankle
ing either the gastrocnemius or the anterior tibialis mus­
cles to generate torque about the ankle joints. Anterior
sway of tbe body is counteracted by gastrocnemius activ­
ity. which puns the body posterioriy. Conversely. posterior Adapted from I\a~ ,
sway of the body is counteracted by contraction of the tib­ man. and J. Kart
 CHAPTER 8 Regaining Postural Stability and Balance 161

ialis anterior. T hus. the importan ce of these muscles such as an ankle or knee sprain. For example. weakness of
should not be undereslimated when designing the rehabil­ ligaments following acute or chronic sprain about these
~r goes lip for a italian program. The ankle strategy is most effective in ex­ joints is likely to reduce range of motion. therefore shrink­
ca using her to ecuting relatively slow COG movements when the base of ing the LOS and placing the person at greater risk for a fall
~ compromising support is Hrm and the COG is well within the LOS perime­ with a relatively smaller sway envelope.62 PintS(I(lr et al. 71
ling. the body ter. The ankle str(ltegy is also believed to be effective in revealed lhat impaired function is related to a change from
- to a position maintaining a stalic posture with the COG offset from the ankle synergy toward hip synergy for postural adjust­
t mechanore­ center. The thigh and lower trunk muscles contract and ments among athletes with functional anlde instability.
thereby res ist the destabilization of these proxim(ll joints This finding. which is consistent with ,previous results re­
due to the indirect effects of the ankle muscles on the prox­ ported by Tropp et al .. 7X suggests that sensory propriocep­
a tegies. imal joints Cfable 8-1). Under normal sensory conditions. tive function for the 'i njured athletes is affected.
activation of ankle musculature is almost exclUSively se­
lected to maintain equi'librium. However, there are subtle ASSESSMENT OF BALANCE
tegies differences associated with loss of somatosensation and
with vestibular dysfunction in terms of postural control Several methods of balance assessment have been pro­
. and hips) are
strategies. Persons with somatosensory loss appear to rely posed for clinical use. Many oj' tbe technliques have been
e COG. This al­ on their hip l11usculature to retain their COG while experi­ criticized for offering only a subjective ("qualitative")
II be assumed
encing forward or backward perturbalion or with different measurement of balance rather than an objective ("quan­
e of support.
support surface lengths 21 titative") measure.
given joint are
If the ankle sLrategy is not capable of controlling ex­
ast one pair of
cessive sway, the hip strategy is avaiJable to help control Subjective Assessment
es exerted by
motion of the COG through the initiation of large and
.. a nterior tib­
rapid motions at the hip joints with antiphase rotation of Prior to the mid 19805. there were very few methods for
med. the effect is the ankles. This is most effective when the COG is located systematic and controlled assessment of balance. The as­
ling position.
near the LOS perimeter. and when the LOS boundaries are sessment of static balance in athletes has traditionally
n is called joint
contracted by a narrowed base of support. Finally. when been performed through the use of the standing Romberg
of the joint
the COG is displaced beyond the LOS. a step or stumble test. This test is performed standing with feet together.
activation lev­
(stepping strategy) is the only strategy that can be used to arms at the side. and eyes closed. Normally a person can
.. ling pOSition preven t a fall. 61 .1>4 stand motiordess in this position. but the tendency to sway
adequate basis
It is proposed that LOS and COG alignment are altered or fall to one side is considered a positive Romberg 's sign
lheorized that
in individuals exhibiting a musculoskeletal abnormality indicating a loss of proprioception. R The Rombcrg test has.
-hanism for in­
of a join t 1'01­
e joint. 64
_ by an external • TABLE 8·1 Function Anatomy of Muscles Involved in Balance Movements.
join ts of the
e COG back to Extension Flexion
h ip. stepping)
In general. the Joint Anatomic Function Anatomic Function
iog strategies
pportdepends Hip Paraspinals Paraspillals Abdominal Abdomin als
the COG align­ Hamstrings Hamstrings Quadriceps Quadriceps
of the postural Tibia'iis Gastrocnemius
Knee Quadriceps Paraspinals Hamstrings Abdomina ls
ile maintainjng Quadriceps Castrocnem ius Hamstrings
dy as a rigid Gastrocnemius Tibialis
ed by contract­ Ankle Gastrocnemius Abdominals Tibialis Paraspinals
'or tibialis mus­ Quadriceps Hamstrings
Joints . Anterior Gastrocnemius Tibialis
roc nemius activ­
ref ely. posterior Adapted from Nashner. L. M. 1991 . Physiology of Balance. In Handbook oj Balance Function and Testing. edited by G. Jacobson. C. New­
'act ion of the lib­ l11«n. and J. KarlLlsh. pp. 261 - 7'3. Sl. Louis: l\;losbyYcarbook.
162 PARTTI'VO Achieving the Goals of Rehabilitallon
however, been criticized for its lack of sensitivity and ob­
jectivity. It is considered to be a rather qualitative assess­
ment of static balance because a considerable amount of
stress is required to make the subject sway enough for an
observer to characterize the sway.H
The use of a quantifiable clinical test battery called the
Balance Error Scoring System (BESS) is recommended
over the standard Romberg test. Three different stances
(double, single, and tandem) arc completed twice, once
while on a firm surface and once while on a piece of
medium-density foam (balance pad by Airex is recom­
mended) for a total of six trials (Figure 8-3) . Athletes are
asked to assume the required stance b)1 placing their hands
on the iliac crests, and upon eye closure the 20-second test
begins. During the Single-leg stances, subjects are asked to
maintain the contralaterallirnb in 20 to 30 degrees of hip
flexion and 40 to 50 degrees of knee flexion. Adclitionally,
the athlete is asked to stand quietly and as motionless as
possible in the stance position, keeping their hands on the
iliac crests and eyes closed. The single-limb stance tests are
performed on the non dominant foot. This same foot is
placed toward the rear on the tandem stances. Subjects are
told that upon losing their balance, they are to make any
necessary adjustments and return to the testing position
as quickly as possible. Performance is scored by adding one
error point for each error committed in Table 8-2 . Trials
are considered to be incomplete if the athlete is unable to
sustain the stance position for longer than 5 seconds dur­
ing the entire 20-second testing period. These trials are as­
signed a standard maximum error score of 10. Balance
test results during injury recovery are best utilized when
compared to baseline measurements, and dinicians work­
ing with athletes or patients on a regular basis should at­
tempt to obtain baseline measurements when possible.
CLINICAL DECISION MAKING Exercise 8-1
How can the Balance Error Scoring System (BESS) or any
other quantifiable measure of balance be effectively used
in developing a sound rehabilitation program?
Semidynamic and dynamic balance assessment can be
performed through functional reach tests, timed agility
tests such as the figure-eight test, I h.2tl.S2 carioca or hop
test,42.H2 Bass Test for Dynamic Balance. 79 limed "T-Band
kicks," and limed balance-beam walking with the eyes
open or closed. The objective in most of these tests is to de­
crease the size of the base of support. in an attempt to de­
termine an athlete's ability to control upright posture
while moving. Many of these tests have been criticized for
failing to quantify balance adequately, as they merely re­
port how long a particular posture is maintained, angular
displacement. or the distance covered after \valk­
ing.o.22.4.~.64 At any rate, the)1 can often provide the athletic
trainer with valuable information about an athlete's func­
tion and/or ability to return to play.
Objective Assessment
Advancements in technology have provided the medical
community with commercially available balance systems
(Table 8-3) ror quantitatively assessing and training static
and dynamic balance. These systems provide easy, practi­
cal, and cost-effective methods of quantitatively assessing
and training functional balance through analysiS of pos­
tural stability. Thus, the potential exists to assess injured
athletes and (1) identify possible abnormalities that might
be associated with injury, (2) isolate various systems that
are affected, (3) develop recovery curves based on quanti­
tative measures for determining readiness to return to ac­
tivity, and (4) train the injured athlete.
Most manufacturers use computer-interfaced force­
plate technology consisting of a Oat, rigid surface sup­
ported on three or more points by independent
rorce-measuring devices. As the athlete stands on the force
plate surface, the position of the center of vertical forces
exerted on the forceplate over time is calculated (Figure
8-4). Movements of the center of vertical force provide an
indirect measure of postural sway acUvity. 63 The Kistler,
and more recently, Berlec forceplates, arc used for much of
the work in the area of postural stability and bal­
ance.A.1R.2R,4.5 7Manufacturers such as Chattecx Corpora­
tion (Hixson. Tenn.) and NeuroCom International. Inc.
(Clackamas, Ore.) have also developed systems with ex­
panded diagnostic and training capabilities that make in­
terpretation of results easier for athletic trainers. Athletic
trainers must be aware that the manufacturers often use
conllicting terminology to describe various balance pa­
rameters; trainers should consult frequently with the
manufacturer to ensure that there is a clear understand­
ing of the measure being taken . These inconsistencies
have created confusion in the literature, because what
some manufacturers claSSify as dynamic balance, others
claim is really static balance. Our classification system (see
the section "Balance Training") will. we hope, clear up
some of the confusion and allow for a more consistent la­
beling of the numerous balance-related exercises.
Force platforms ideally evaluate three aspects of pos­
tural control: steadiness, symmetry, and dynamic stability.
Steadiness is the ability to keep the body as motionless as
 CHAI TER H Rega inin g Postural Stability and Balance 163

_ n cri ticized fo r

th e medical

rrainin g slatic
de easy. practi­
th'ely assessing
ana lysis of pos­
asse's injured
lies that mighl

A B c

urers often use

u balance pa­
eOlly with the
<-oar und crsland­

D E F
Figure 8-3 Stance posilions for l3alance Error Scoring System (BESS) .
1\, Double-leg. finn surface. 8, Single-leg, firm surface. C, TUlldcm. firm
surface. D. Double-leg. foam surface. E, Single-leg. foam surface. F, Tandem,
foam surface.

as molionlcs ~ as
164 PART TWO Achieving the Goals of Rehabilitation

• TABLE 8·2 Balance Error Scoring

System.

Errors

Hands lifted off iliac crests

Opening eyes
Step. stumble, or fall
Moving hip into more than 30 degrees of flexion or
abduction
Lifting forefoot or heel
Remaining out of testing position for more than
5 seconds
The BESS score is calculated by adding one error
point for each error or any combination of errors
occurring during one movement. Error scores from
each of the six trials are added for a total BESS
score, and higher scores represent poor balance.
figure 8·5 Eq

as the relative \\ t
• TABLE 8·3 High·Technology Balance
as measured 0
Assessment Systems.
force (COF). on
Figure 8-4 Athlete training on the Balance Master.
Static Systems Dynamic Systems
face. In any case
to the force pLaU
Chattecx Balance System Biodex Stability System lean or reach as far as possible without losing one's bal­ body weight and
EquiTest Chattecx Balance System ance. Some manufacturers measw-e dynamic stability by ment of the bod_
Forceplate EquiTesL assessing a person's postural response to external pet'tUf­ and motionl ess,
Pro Balance Master EquiTest with EMG bations from a moving platform in one of four directions: erence points i
Smart Balance Master Forceplate tilting tocs up. tilting toes down . shifting medial-lateral ment of the bod!
Kinesthetic Abilt.iy Trainer (M-t). and shifting ,mterior-posLerior (A-P). Platform per­ forces req uired l
(KAT) turbation on some systems is unpredictable and deter­ ould ma intain
Pro Balance Master mined by the positioning and sway movement of the m idJines.
Smart Balance Master subject. In such cases, a person's reacti on response can be Once the COij
delennined (Figure 8-5). Other systems have a more pre­ alance pm-arne
dictable sinusoidal waveform, wh ich remains constant re­ point in any clire.
gardless of subject positionin g (Pigure 8-fi). Postural sway em
possible. This is a measure of postural sway. Symmetry is 1Vlal1Y of these force platform systems measure the ng on whi ch sy
the ability to distribute weight evenly between the two feet vertical ground reaction force and provide a means of eo gth of sway pi
in an upright stance. This is a measure of center of pres­ computing the center of pressure (COP). The COP rcpn:­ queney, and dir
sure (COP). center of balance (COB). or center of force sents the center of the distribution of the total forc e up­ :u lated on most
(COF), depend~ng which testing system you are using. Al­ plied to the supporting surface. The COP is calculuted th e angular diffe
though inco nsistent with our classification system. dy­ from horizontul movement and vertical force data gener­ anterior to postel
namic stability is often defined as the ability to transfer ated by triaxial force platforms. Center of balance (COB), maximum displa.
the vertical prOjection of the COG around a stationary sup­ in the case of the Chattecx Balance Syste m. is the point ional's Equi Tesl.
porting base. 28 This is often referred to as a measure of between the feel where tJle ball and heel of each root each r scatt.er of da ta
one's perception of "safe" limits of stability. as the goal is to has 25 percent of the body weight. This point is referr ed to Balance System.
 CHAPTER 8 Regaining Postunu Stability and Balance 165

Figure 8·5 EquiTesL

as the relative weight positioning over Lhe four load cells

a meas ured only by vertica l force s. The ce nter of vertical
r. rce (COF), on I eu roCom 's EquiTest. is Lhe center of the
dllce Mas ter. \'ertieal force exer ted by tbe fe et. agai nst the support sur­
face. In any case (COP. COB, COF) . the total force applied
to the force platform Ouctu ates because it in cludes both
ing one's bal­ body weight and the inertia l effects of the slighlest move­
amic stability by m ent of tIle body that occur eve n when one atlempts to
eJo.iernal pertur­ land motionless. The movement o f these force-based ref­
fo ur directions: erence points is theorized to vary acco rding to the move­
g medial-latera l ment of the body's COG and the distribution of Ul.L1s c\e
-PI. Platform per­ orces required to control posture. Ideally. healthy athletes
tab le and deler­ hould maintain their COP very near the l\-P and M-L
\'ement of the midlines.
re ponse can be Once the COP. COB. or COP is calc ulaLed, several other
a\'e a more prc­ a lance pClfameLers can be alluined. Deviation from this
mains constant re­ point in any direction represents a person 's postural sway.
- -fil. Postural sway can be measu:red in various ways. depend­
measure the ng on which system is being used. Mean displ acement,
~ \ ide a means of ellgth of sway path, length of sway mea, amplitude. fre­
T be COP reprc­ ue ney, and direction with respect to the COl' CCltl be cal­
c total force ap­ :ulated on most systems. An eq uilibrium score. comparing
'OP is calculal d the angular difference between the ca'lculated maximum
fo rce data gener­ ..nterior to posterior COG displacement.s to a theoretica l
f balance (COB) . mao,itl1utl1 displacement, is unique to euroCom Interna­
tem. is the poin t .ional's EquiTest. Sway index (ST) . represen ting the degree
of ach foot each )f scatter of data about tbe COB. is unique to the ChaLtecx
point is referred to &lance Systelll.
Figure 8·6 Chattecx Balance System.
Forceplate technology allows for quantita tive analysis
and understanding of a subject 's postural instability.
These systems are fully lntegrated with hardware/
softWClre systems for quickly and quantitatively assessing
an d rehabilitating balance disorders. Most manufacturers
alluw for both static and dynamic balance assessmenL in
ei ther double- or single-leg stances. with eyes open or eyes
closed. euroCom's Equi est System is equipped with a
moving visual surround (wa ll ) that allows for the most so­
phisticated tec hnology available for isolating and assess­
ing sensory modality interac tion .
Long forccplates have been developed by some ma nu ­
facturers in an attempt to combat criticism that balance
assessmen t is no t func\ional. Inclusion of the long force
plate (Figure 8-7) adds a vast array of dynamic balance ex­
ercises for training. such as walking, step-up-and-over,
sid e and crossover steps. hopping. leaping, and lunging.
These ill1portan t return-to-sport activities can be prac­
ti ced and perfected through the use of the computer's vi­
sual feedback.
166 PART TWO Achieving the Goals of Rehabilitation

mpting propri(
the first to repOi
instability foll o1
ercises were pel
articular deaJfer
mechanism (he
stability of th e
balan ce traini n
Since 1965
juries cause paJ
bility. a person'
proprioception
ported FreemaI
usin g high-tec"
etc.) have re\'{',
acute sprains-'
bilities. 1fl ,21.2 ,.: 1
Differences '
jured ankles in
erized strain g;
postura l sway pc
center of pressu
Figure 8-8 Biodex Stability System. age speeu, and
Figure 8-7 Balance tvlasLe.r wilh accessory 5-1'00t force­ (mel 10 mm ) Lal
pl a te.
stance position
live mechanisms necessary for mainten ance of proper bal­ jured and nonil
Biodex Meuical Systems (Shirley. N.Y.) malJufactures a ance. Research has reveuled tb ese impairments in individ­ the application
dynamic mul tiaxial Lilting platform that offers computer­ uals with ~U1kle injur;1l2.72 and anterior e ruciate ences bet wee n i1
generated data similar to that of a forceplate system. l he ligament (ACL) injury.'u,/ The lack of proprioceptive feed­ ler. th erefore I
Biodex Stabillty System (Figure 8-8) ulillzes a dynami c back resulting from such injuries might allow excessive or importantly th i
mu ltiaxiul platform that allows up to 20 degrees of deflec­ inappropriate loading of a joi nt. Furtherm ore, although n iq uc of seleCli ~
tion in any direction. It is theorh:ed that this degree of de­ the presence of a capsular lesion might interfe.re with the tbe frontal plan
flection is sufficient to stress the joint mechanoreceptors transmission of afferent impulses from the joint. a rnore area is smallesy
that provide proprioceptive feedback (at end ranges of mo­ important errect might be altera tion of the afferent neural culties of mai n
tion) necessary for balance control. Athletic tminers can coele that is conveyed to th e CNS.84 Decreased reOex exci­ \'01 ves the subt
therefore assess dell cits in dynamic muscular control of tation of motor neurons can result from either or both of movements of
posture rel a tive to joint pathology. The patient's ability to the following events: (a ) a decrease in propriocepti\'c input primarily ,in the
control th e platform 's angle of tilt is quantiJied as a vari­ to the eNS, und (b) an increase in the activation of in­ this could expla
ance from center, as well as degrees of deflec tion over time, hibitory interneurons within tbe spinal cord. All of these bilometry stud i
at va rious stability levels. A large variance is indicative of factors may lead to progressivc degeneration of the joint Orthotic in t
poor m uscle response. Ex-ercises performed on a mulLiaxial and continued dellcits in joint dynamics. bulancc. und in 1'3 subj ects \,
unstable system such as the Biodex arc similnr to those of coordination. uninjured subjf1
tbe Bi omechnnical Ankle PLatform System (BAPS board) lhoUc. nonor t h ~
and are especially effec ti ve for regaining proprioception inve rsion/ evers'
Ankle Injuries lateral pcrLur b~
a nd b,ltance following injury to the cmkle joint.
Joint proprioceptors are believed to be damaged during in­ injured subj ectS
jury to the lateral ligaments of the ankle because joint ,re­ when assessed j
INJURY AND BALANCE vealed that cm
ceptor fibers possess less tensile streng tl1 l.ban the ligament
]t has long been theorized that failu.re of stretched or dam­ fibers. Damage to the join t receptors is believed to cause motion at th e
aged :J,igaments to provide adequate neural feedback in an joint deafferenta tion, which diminishes the supply of mes­ mechanorecept~
injured extremity may co ntribute to decreased propriocep- sages from the inju red joint up the ufferent puthway, dis­ slructu rul supp
 CHAPTER 8
rupting proprioceptive function,25 Freeman el al. 25 were
the I1rsl to report a decrease in the frequency of functional
instability following ankle sprains when coordination ex­
ercises were performed as part of rehabilitation . The term
articular deafferentatioll was 'i ntroduced to designate the
mechanism they believed to be the cause of functional in­
stability of the ankle, This I1nding led to the inclusion of
balance training in ankle rehabilitation programs,
Since 1963, Freeman 24 has theorized that if ankle in­
juries cause partial deafferentation and functional insta­
bility, a person's postural sway would be altered due to a
proprioception del1cit Some studies 76 .77 have not sup­
ported Freeman's theory, but other, more recent studies
using high-tech equipment (forceplate, kinesthesiometer,
etc,) have revealed balance del1cits in ank'les following
acute sprains26.n.7o and/or in ankles with chronic insta­
bilities.IIl.2 U7.7 1
Differences were identified between injured and unin­
jured ankles in ] 4 ankle-injured subjects using a comput­
erized strain gauge forceplate. 2h Four of llve possible
postural sway parameters (standard deviation of the mean
center of pressure dispersion, mean sway amplitude, aver­
age speed, and number of sway amplitudes exceeding 5
and 10 mm) taken in the frontal plane from a Single-leg
stance position were reported to discriminate between in­
ance of proper bal­ jured and noninjured ankles. The authors ,r eported that
-rments in individ­ th e application of an ankle brace eliminated the differ­
an terior cruciate ences between injury status when tested on each parame­
oprioceptivc feed­ ter, therefore improv,ing balance performance, More
allow excessive or importantly this study suggests that the stabilometry tech­
ermore, although nique of selectively analyzing postural sway movements in
inted cre with the the frontal plane, where the diameter of the supporting
the joinl. a more area is smallest. leads to higher sensitivity, Because diffi­
he afferent neural culties of maintaining balance after a 'ligament lesion in­
reased reflex exci­ volves the subtalar axis, it is proposed that increased sway
either or both of movements of the different body segments would be found
prioceptive input primarily in the frontal plane. The authors speculated that
e aclivation or in­ this could explain nonsignLficant fmdings of earlier sta­
al cord, All of the~e bilometry studies 76 .77 involVing injured ankles.
alion of the joint Orthotic intervention and postural sway was studied
lillie , balance, and in 13 subjects with acute inversion ankle sprains and 12
uninjured subjects under two treatment conditions (or­
thotic, nonorthotic) and four platform movemen,ts (stable,
inversion/ eversion, plantarflexion/dorsiflexion, medial!
lateral perturbations). 31 Results revealed that ankle­
damaged during in­ injured subjects swayed more than uninjured subjects
. e because joint re­ when assessed in a Single-leg test. The analysis also re­
h t ha n the ligament n~aled that custom-fit orthotics can restrict undesirable
believed to causc motion at the foot and ankle, and enhance joint
the supply of mes­ mechanorcceptors to detect perturbations and provide
ffere nt pathway, dis­ structural support for detecting and controlling postural
Regaining Postural Stability and Balance 167
sway in ankle-injured subjects , J\ similar stud y 70 reported
improvements in static balance for injured 'subjects while
wearing custom-made orthotics,
Studies involving subjects with chronic ankle inst:abil­
ities JlJ.21.17.71 indicate that individuals with a history of in­
version ankle sprain arc less stable in a Single-limb stance
on the involved leg as compared to the uninvolved leg
and/or noninjured subjects, Significant differences be­
tween injured and uninjured subjects for sway amplitude
but not sway frequency using a standard forceplate were
revealed. III The effect of stance perturbation on frontal
plane postural control was tested in three groups of sub­
jects: (1) a control group (no previous ankle injury): (2) a
functional ankle instability and 8-week training program
group; and (3) a mechanical instability without functional
instability group (w,i thout shoe. with shoe, with brace and
shoe),71 The authors reported a relative change from ankle
to hip synergy at medially directed translations of the sup­
port surface on the NeuroCom EquiTest. The impairment
was restored after 8 weeks of ankle disk training, The effect
of a shoe and brace did not exceed the effect of the shoe
alone. Impaired ankle function was shown to be related to
coordination, as subjects changed from ankle toward hip
strategies for postural adjustments,
Similarly, researchers 3 ~ reported that lateral ankle
joint anesthesia did not alter postural sway or passive joint
position sense, but did affect the COB position (Similar to
COP) during both static and dynamic testing. This suggests
the presence of an adaptive mechanism to compensate for
the loss of afferent stimuli from the region of the lateral
ankle ligaments, 38 Subjects tended to shift their COB medi­
ally during dynamic balance testing and slightly laterally
during static balance testing. The authors speculated that
COB shifting may provide additional proprioceptive input
from cutaneous receptors in the sole of the foot or stretch
receptors in the peroneal muscle tendon unit, which there­
fore prevents increased postural sway.
Increased postural sway frequency and Ilatencies are
parameters thought to be indicative of impaired ankle
joint proprioception,14. 72 Cornwall et al.lO and Pintsaar
et a!., 71 however, found no differences between chronically
injured subjects and control subjects on these measures,
This raises the question whether postural sway is in fact
caused by a proprioceptive deficit. Increased postural sway
amplitudes in the absence of sway frequencies might sug­
gest that chronically injured subjects recover their ankle
joint proprioception over time. Thus, more research is war­
ranted for investigating loss of joint proprioception and
postural sway frequency,10
In summary, results of studjes involving both chronic
and acute ankle sprains suggest that increased postural
168 PART TWO Achi eving the Goals of Rehabilitation

lower-extremil~
sway and/or balance instability might be due not to a sin­ that joint mechanoreccptors play. Neurophysiological
gle factor but to disruption of both neurological and bio­ studies29.30A ;.48 have revealed that joint mechanorecep­ a quadriceps s l
mech,mical factors at the ankle joint. toss of balance tors provide enhanced kinesthetic awareness in the near­ caused a disru p
could result from abnormal or altered biomechanical terminal range of motion or extremes of motion. and base of su p
aligI1ment of the body. thus affecting the transmission of Therefore , it could be speculuted that if the ma.ximum LOS sa tory weight ,
somatosensory information from the ankle joint. [t is pos­ are never reached during a static balance test, damaged chain that 113\1'
sible that observed postural sway amplitudes folloWing in­ mechanoreceptors (muscle or joint) might not even be­ may be detect ed
jury result from joint instability along the kinetic chain, come a factor. Dynamic balance tests or functional hop tests and / or ra l
rather than from deafferentation. 1·hus. t.he orthoLic inter­ tests that involve dynamic balance could challenge balance. Havill
vention n .lii.h6 may have provided more optimal joint the postural control system (ankle strategies are taken quantify balanc
aLignment. over by hip and/or stepping strategies). requiring more Imagination an
mechanoreceptor inpul. These tests would most likely dis­ able to athletic t1
criminate between functionally unstable ACL-deficient ing to design bal
Knee Injuries Beca u.se Vinl
knees and normal knees.
Ligamentous injury to the knee has been proven to impair lower-extremil}
subjects' ability to accurately detect position.n.Ms.')]') 2 be performed in
CLINICAL DECISION MAKING Exercise 8-2 movement spet':
The general consensus among numerous investigators
performing proprioceptive testing is that a clinical propri­ easily controlled
A gymnasl recovering from a grade 1 MeL sprain to her quate, safe fun cti
oception deficit occurs in most patients after an ACL rup­
rlght knee is ready to begin ber rebabllitation. What fac­ the reh abilitatiOi
ture who have functional instability and that this deficit
tors must ftrst be considered prior to designing her bal­ rehabiHtation pi
seems to persist to some degree after an ACL reconstruc­
ance exercise program and progression? should attempt t
tion. 2 Because of the relationships between proprioception
(somatosensation) and balance. it has been suggested that chain exercises <;
the patient's ability to balance on the ACL-injured leg may injury, this could
also be decreased. 4 .69 Because tIl(
Head Injury matosensaLio n .
Studies have evaluated the effects of ACL ruptures on
standing balance using forceplate technology; although Neurological status following mild head injury has been
some studies have revealed balance def'icits .2 (";6 others assessed using balance as a criterion variable. Athletic
have not. J9.37 Thus. there appear to be conflicting results trainers and team physiciuns have long evaluated head in­ have been pro
from these studies. depending on which parameters are juries with the Romberg tests of sensory modality function the most curre
meusured. Mizuta et al. ih found significant differences in to test "bulance." This is an easy and effective sideli ne lest; and knee injur}
postural sway when measuring center of pressure and however. the literature suggests there is more to posture A v<Jriety of
sway dislance area between 1] functionally stable andi 15 control than just bala nce and sensory modality, 59.W.6S.69.74 but the athletic
functionally unstable subjects who had unilateral ACL­ especially when assessing people with head injury.31.34.35 before beginnin!
deficient knees. Faculjak et al., 19 however. found no differ­ The postural control system. which is responsible for link­ The exercise
ences in postural stability bet ween 8 ACL-deficient sub­ ing brain-to-body communication. is often affected as a re­
jects and 10 normal subjects when measuring average sult of mild head injury. Several studies have identilled Incorporat
laLency U11d response strength on an EquiTest System. postural stability deficits in nthletes up to 3 days postinjury Begin with
Several potential reasons for this discrepancy exist. using commercially availabl e balance systems. ' 1.l4.35 It ap­ progress to
First. it has been suggested tJlat there might be a link be­ pears that this deficit is related to a sensory interaction Progress to\'
tween staLic balance and' isome tric strength of the muscu­ problem in which the injured athlete fails to use the visual There are 5e1
lature at the ankle and knee. [sometric muscle strength system effectively. This research suggests that objective meet these goals.
could therefore compensate for any somatosenSOr)7 deficit balance assessment can be used for establishing recovery opeo area. when
present in the involved knee during a closed-chuin static curves for m<Jking return-to-play decisions in concussed a fall. [t is best t~
balance Lesl. Second. many studies fail to discriminate be­ athletes. Rehabilitation of concussed athletes using bal­ within arm's rea
tween jUl1ctiollallu unstable ACL-deJicient knees aod knees ance techniques has yello be studied . during the initial
thut were not funclionully unstable. This presents a design exercise duratio
flaw, especially considering that functionally stable knees can use eit.her
BALANCE TRAINING The athlete can
would most likely provide adequate balance despite liga­
mentous pathology. Another suggested rcason for not see­ Developing a rehabilitation program that includes exer­ progress Lo 30 r,
ing differences between injured knees and uninjuTed knees cises for improving balance and postural equilibrium is vi­ exercises for a 1:
on static balance measures could be explained by the role periods later in lh
tal for a successful return to competition from a
 CHAPTER 8 Regaining Postural Stability and Balance 169

lower-extremity injury. Whether the athlete has sustained

CLINICAL DECISION MAKING Exercise 8-3
a quadriceps strain or an ankle sprain. the injury has
caused a disruption at some point between the body's COG
How can the athletic trainer determine whether an alh­
and base of support. This is likely to have caused compen­
lele is ready La progress to a more cha llenging balance
satory weight shifts and gait changes along the kinetic
task andlor balance surface?
chain that have resulted in balance deilcits. These deficits
lest. damaged
may be detected through the use of functional assessment
not even be­
tests and / or computerized instrumentation for assessing
u nctional hop
balance. Having the advanced technology available to Classification of Balance Exercises
uld challenge
quantify balance deficits is an amenity but not a necessity.
Imagination and creativity are often the best tools avail­ Static balance is when the COG is maintained over a fixed
eq uiri ng more
able to athletic trainers with limited resources who are try­ base of support (unilateral or bilateral) while standing on
most likely dis­
ing to design balance-training protocols. a stable surface. Examples of static exercises are a single­
:\CL-deficient
Because virtually all sport activities involve closed-chain leg, double-leg, or tandem-stance Romberg task. Selllidy­
lower-extremity function. functional rehabilitation should namic balance involves one of two possible activities:
be performed in the closed kinetic chain. However, ROM, (1) The person maintains their coe over a !1xed base of
movement speed. and additional resistance may be more support while standing on a moving surface (Chattecx
easily controlled in the open chain initially. Therefore. ade­ Balance System or EquiTest) or unstable surface (Biodex
10to her quate. safe function in an open chain may be the first step in Stability System. BAPS. medium-density foam, or
hat fac­ the rehabilitation process. but should not be the focus of the minitramp); or (2) the person tra nsfers their COG over a
er bal- rehabilitation plan. The sports medicine athletic trainer fixed base of support to selected ranges and/or directions
should attempt to progress the athlete to functional closed­ within the LOS whille standing on a stable surface (Balance
chain exercises quickly and safely. Depending on severity of Master's LOS. functional reach tests. minisquats. or
injury. this could be as early as one day postinjury. T-Band kicks). Dynamic balance involves the maintenance
Because there are close relationships between so­ of the COG within the LOS over a moving base of support
matosensation. kinesthesia. and balance. many of the ex­ (feet). usually while on a stable surface. These tasks require
ercises proposed for kinesthetic training indirectly the use of a stepping strategy. The base of support is always
UfY has been
enhance balance. Several methods of regaining balance changing its position. [arcing the COG to be adjusted with
able. Athletic
have been proposed in the literature and are included in each movement. Examples of dynamic exercises are walk­
l.Ia ted head in­
the most current rehabilitation protocols for ankle43.7s.84 ing on a balance beam. step-up-and-over. or bOLlnding).
ality function and knee injury.ll.42.5 3.74.N J FUl1ctional balance tasks are the same as dynamic tasks
ideline test;
A variety of activities can be used to improve balance. with the inclusion of sport-speci!1c tasks such as throwing
re to postrure
'1" . -, .(,O .65.6~. 74 but the athletic trainers should consider flve general rules and catching.
~ iury. 31.l4.11 before beginning:
The exercises mllst be safe yet challenging. Phase I
nsible for link­
Stress multiple planes of motion.
ected as a re­
Incorporate a Inult,i sensory approach. The progression of activities during phase 1 should in­
ha\'e identiI1ed
Begin with static. bilateral. and stable surfaces and clude nonballistic types of drills. Training for static bal­
days postinjury
:'Ill _11.3U'Itap_
progress to dynamic. unilateral. and unstable surfaces. ance can be initiated ooce the athlete is able to bear
Progress toward sport-speciCtc exercises. weight on the extremity. T he athlJcte should first be asked
ry in teraction
There are several ways in which the athletic trainer can to perform bilateral20-second Romberg tests on a variety
o use the visual
meet these goals. Balance exercises should be performed in an of surfaces. beginning with a hard inI'm surface (see Fig­
that objective
open area, where the athlete will not be injured ·i n the event of ure 8-3A) and followed by more challenging surfaces
. h ing recovery
a fall. It is best to perform exercises with an assistive device (Figure 8-9 and Figure 8- 10). Once a comfort zone is es­
in concussed
within arm's reach (e.g., chair. railing, table. wall). especially tablished. the athlete should be progressed to performing
leles using bal­
during the initial phase of rehabilitation. \lVhen conSidering unilateral balance tasks on both the involved and tbe un­
exercise duration for balance exercises, the athletic trainer involved extremities on a variety of surfaces. The purpose
( an use either sets and repetitions or a time-based protocol. of the different surfaces is to safely chaUenge the injured
The athlete can perf()rm 2 or 3 sets of IS repetitions and athlete, while keeping the athlete motivated to rehabili­
progress to 30 repetitions as tolerated. or perform 10 of the tate the injured extremity.
a t includes exer­
exercises for a IS-second period and progress to 30-second The athletic trainer should make comparisons from
equilibrium is vi­
periods later in the program. these tests to determine the athlete's ability to balance
lpetition from a
170 PARTTVVO Achieving thc Goals of Rehabilit ation

Figure 8-9 Bilateral stance on Tremor Box , which Figure 8-10 Bilateral stance on Bosu Balance Figure 8-12
tremors <llong the horizontal plane in the A-P, M-L, and Trainer- bubble side up. foa m.
diagonal directions.

bilaterally and unilaterally. [( should be noted that cven

though this is termed "static" balance. the at hle te does
not remain perfectly motionless. To maintain static bal­
ance, the athlete must m ake m;my small corrections at
the ankle, hip. trunk. arms. or head (sec "Selection of
Movement Strategies. " p. InO). An athlete who is having
difficulties performing these activities should not be pro­
gressed to the next surface. Repetit ion s of modified
Romberg tests can be performed by first using the arms as
a counterbalance. then att.empting the activity without
using th e arms. Static balance activities should be llsed as
a precursor to more dynamic activities. The general pro­
gression of these exercises sh ould be from bilateral to uni­
lateral, with eyes open to eyes closed. The exercises shollld
attempt to eliminate or alter the various sensory informa­
tion (vis ual. vestibular. and somatosen sory) in order to
challenge the other systems. In most orthopedic rehabili­
tation situations, this is going to invol\7e eye closure an(l
changes in the support surface so the somalosensory sys­
tem can be overloaded or stressed . This principle is similar
to the overload principle in therapeutic exercise. Research
Figu re 8-11 Unilateral stance on minitramp. Figure 8-13
suggests that balance activ"ities. both with and without vi­
sual input. will enhance motor funclion at the brain stem As improvement occu rs on a firm surface, Single-leg up (Figure 8- 1-1
level. / ·7s However, as the athlete becomes more efJ1cien t at static balance drills should progress to an unstable surface up IFigure 8-1 ­
performing activities involving static ball ance. eye closure such as foam (see Figure 8-3E). minitramp (Fig ure 8-11). ally. the athletic I
is recommended so that oniy the somatosensory system is rocker board on foam (Figure 8-12). rocker board on hard or ches t laps to (
left to control balance. surface (Figure 8-13). Bosu Balance Trainer with nat side balance (Fig ure
 CH,\PTEH. fl Regaining Postural St<Jbility and Balance 171

ance Figure 8-12 Unilateral stance on rocker board and Figure 8-14 nilaLeral slance on Bosu Balance
foam. Trainer-nat side up.

figure 8-15 li nilaleral slance on Bosu Balance

Figure 8-13 Unila teral stance on rocker board.
Trainer- bubble side up.

urface, single-leg up (Figure 8-14). Bosu Balance Trainer w ilh bubble side
u nswble surface up (Figure 8-15 ), or HAPS board (rigure X-In). Addition­
p (Figure 8-11), a lly, the alhletic trainer can introduce Iighl shou lder, back,
ter board on hard or chest laps to challenge the uthlete's ability to maintain
balance ([-'igure 8-17). Finally. the use of mulliaxial de­
vices such as the Biodex Slabili ty Syslem on a relatively
easy level can be initiated during thc laler part of phase 1.
These exercises increase awa reness of the location of the
COG und er a chal lenged condition. th ereby helping to in­
crease ankle slrength in the closed kinetic cha in . Such
 172 PAHTTWO Achieving the Goals of Rehabilitation

training can also increase sensitivity of the muscle spindle

and thereby increase proprioceptive input to the spinal
cord. which may provide compensation for altered joint
afference. 48
Although static and semidynamic balance exercises
may not be very functional for most sport activities. they
are the first step toward regaining proprioceptive aware­
ness. reflex stabilization. and postural orientation. The
athlete should attempt. to assume a functional stance while
performing static balance drills. Training in different posi­
tions places a variety of demands on the musculotendi­
nous structures about the ankle. knee. and hip joints. For
example. a gymnast should practice static balance with
the hip in neutral and external rotation. as well as during
a tandem stance (see Figure 8-3C). in order to mimic per­
formance on a balance beam. i\ basketball player should
perform these drills in the "ready position " on the balls of
the feet with the hips and knees slightly nexed . Athletes re­
quiring a significant amo unt of stalic balance for perform­
ing their sport include gymnasts. cheerleaders. and
footballlinemen. 43 Figure 8-1 8
Figure 8-1 6 nilateral stance on BAPS board.

Figure 8·1 7 Athletic trainer causing perturbations us­
ing shoulder taps.
Phase 2
Phase 2 should be considered the transition phase from
static to more dynamic balance activities. Dynamic bal­
ance will be especially important for athletes who perform
activities such as running. jumping. and cutting. which
encompasses about 9 5 percent of all athletes. Such activi­
ties require the athlete to repetitively lose and gain balance
to perform their sport without falling or becoming in­
juredY Dynamic balance activities should be incorpo­
rated into the rehabilitation program only once sufficient
healing has occurred and the athlete has adequate ROM.
muscle strength. and endurance. This could be as early as
a few days postinjury in the case of a grade 1 ankle sprain.
or as late as 6 weeks postsurgery in the case of an anterior
cruciate reconstruction . Before the athletic trainer pro­
gre~ses the ath'lete to challenging dynamic and sport­
specific balanccdrills. several semidynamic (intermediate)
exercises :mould be in troduced .
These semidynamic balance drills involve displace­
ment or perturbation of the COG away from the base of
support. The athlete is challenged to return and/or steady Figure 8-1 9
the COG Clbove the base of support throughout several
repetitions of the exercise. Some of these exercises involve
a bilateral stance. some involve a unilateral stance. while the COG centen::
others involve transferring weight ~FOm one extremity tu should be positi
the other. slowly flexes th e
The bilateral-stance balance drills include the rninisquaL, proximatcJ'y 6() d
which is performed with the feet shoulder-width apart and athlete then retu
 CHA ER 8 Reg~inin g "ostur<ll Stability <lnd Balance 173

e muscle spindle
put to the spinal
for altered join t

=­ in Lfferen t posi­
musculotendi­
d h ip joints. For
balance with
well as during

figure 8-18 ~v[inisquat. Figure 8-20 Squat on Bosu Balance Trainer-nat side up.

task several Umes. Once ROlvl, strength . and stability have

improved. the athlete can progress to full squats. which ap­
.Llo n phase from
proach 90 degrees of knee flexion. These should be per­
-. Dynamic bal­
formed in front of a mirror so the athlete can observe ·bhe
[e who perform
amount of stability on their return to the extended position.
utling. which
A large Phy~ioball can also be used to perform sit-to-stand
_tes. Such activi­
activities (Figure 8- 19). Once the athlete reaches a comfort
and gain balance
zone, the balance squat exercise can be performed on more
_ r becoming in­
challenging surfaces such as tbe 130su (Figure 8-20) or Dy­
uld be incorpo­
nadisc (Figure 8-21). Other rotational maneuvers and
Iy once sufl1cienl
weight-shifting c.'(ercises ca n be conuucted to assist the ath­
. adeq uate RO~\1.
lete in controlling his or her cae during semidynamic move­
~ uld be as early as
ments (Figures 8-22 through 8-25) . These exercises are
important in the rehabili tation of ankle. knee. and hip in­
ase of an anterior
juries, as they help improve weight transfer. COG sway veloc­
etic trainer pro­
ity. and left/ right weight symmetry. They can be performed
cnamic and sport­
in an attempt to challenge anterior-posterior stability or
ic (intermediate I
medial-lateral stabil ity.
The athletic trainer has a variety of options for unilat­
involve displace­
eral semidynamic balance exercises. Unilateral minisquats
[rom the base f
Figure 8-19 Sit-to-stand using Physioball. are a good starling point. These can be performed whi'le
-urn and / or stead~
holding on to a cha ir or support rail with the uninvolved
hroughout severa
knee flexed to 45 degrees. The athlete should emphasize
exercises invol\'
e COG centered over a stable base of support. The trunk controlled hip and knee flexion, followed by a smooth re­
teral stance. wh i!
ould be positioned upright over the legs as the atillete turn to the starting position on the involved extremity.
one extremity t
\\Ily flexes the hips and knees into a partial squat-ap­ Once this skill is mastered. the aLhlete can progress to more
ximately 60 degrees of knee nexion (Figure 8-18). The dynamic exercises. such as a step- up. Step-ups can be per­
-h lete then returns to the starting position ami repeats the formed either in the sagittal plane (forward step-up) or in
er-width apart an
174 PJ\RT'l'WO Achieving the Goals of Rehabilitation

Figure 8-21 Squat on Dynadisc.

Figure 8-23 Unilateral stance rotation on Bosu Bal­ Figure 8-25

ance Trainer-bubble side up. Board.

Figure 8-22 Bilateral slimce rotation on Dynadisc.

the transverse plane (lateral step-up). These drills should
begin with the heel of the uninvolved extremity on the
floor. Using a 2 cou nt. the athl ete should shift body weight
toward the involved side and use the involved extremity to
slowly raise the body on to the step. 7; The involved knee
should not be "locked" into full extension. Instead. the
knee should be positioned in approximately 5 degrees of
Figure 8-24 Bilateral stance on Extreme Balance
Board.
flexion , while balancing on the step for 3 seconds. Follow­
ing the 3 count. the body weight should be shifled toward
the uninvolved side and lowered (0 th e heel of the unin­
volved side (Figures 8-26 and 8-27). St.ep-up-and-over Figure 8-26 FOI
 CHAPTER 8 Regaining Postural Stability and Balan ce 175

n Bosu Bal- Figure 8-25 Tandem stance on Extreme Balance

Board.

Figure 8-27 Lateral sLep-up.

activities are similar to step- ups but involve mOl"e dynamic

transfer of the COG. These shou ld be performed by having
the athlete either both ascend and descend us ing the in­
volved ex tremity (Figure 8-28) or ascend with the involved
extremily a nd descend with the uninvo lved extremity,
forcing the invol ved leg to support the body on th e descend
(Figure 8-1 9).
The athletic tra iner can also introduce the athlete to
more ch allenging sta tic tes ts during this phase. for exam­
ple, the very popular Thera Band kicks ('I'-B<-llld kicks or
steamboats) arc excellent for improving balance. Thera­
Band kicks arc perfor med with an clastic material (att ached
to th e ankle of the u.ninvolved leg) serving as a resistance
against a relatively fast kicking motion. The ath fe tc's bal­
a nce on the involved extremity is challenged by perturba­
tions ca used by th e kicking motion of the uninvolved leg
(Figure 8- 30). Four sets of these exercises should be per­
formed. one for each of four possible kicking motions: hip
l1exion. hip extension. hip abduction. and hip adduction.
I-Hand kicks ca n also be performed on foam or a minitramp
_ heel of the unin ­ if additional somatosensory challenges are desired ?4 An­
(ep-up-and-over Igure 8 -26 Forward step-up. other good exercise to introduce prior to advanCing to phflse
176 PART TWO Achieving tbe Goals of Rehabilitation

A I. ' • I B

f igure 8-30

Figure 8-28 Step up and over. A. Ascending on the uninvolved extremity. B, Descending on the involved extremity. 3 is a balance

proving the
and-ultimalel~'~
lower-extremil)
performed in a Id
The shoes consist
a rubber hemisp
ball posi tioned u
deSign of the san
perturbation dc\
any number of I
Single-leg stance;
A 1 I B
multiple dircclio
oca walking. etc. I.
Clinical use (J/
number of succe~l
standpoint. inclue
chronic lnslabllil.
drome. lower-leg
thopaedic problen
stability. Research
ance Shoes result!
proved postural 51
that functiona l a
Figure 8-29 Step up and over. A. Ascending on the involved extremity. B. Descending on the uninvolved extremity. gluteal muscle act
 CHAPTER 8
Figure 8-30 TheraBand kicks.
3 is a balance beam walk. which can be performed against
re is tance!o further challenge the athlete (Figure H· 3J).
The Balance Shoes (Orthopedic Physical Therapy
Pn ducts. :\linneapolis ) arc an(Jth~r (~ xcellent tool for im­
provin g the strength of lower-extremity musculature
nd- ultimately- improving balance. The shoes allow
wer-cx tremity balance a nd strengthening exercises to be
rformed in a functional. closed-kinetic-chain manner.
he shoes consist of a cork sandal with a rubber sole, and
ru bber hemisphere similar in co nsistency to a lacrosse
oa ll positioned under the midsole (sec Figure 23-28). The
ign of the sa ndals essentially creates an individualized
perturbation uevice for each limb that can be utilized in
y number of functional activities, ranging from static
ngle-leg stan ce to dynamic gait activities performed in
B "'1ultiple directions (I()rward wa lking. side-stepping, cari­
- walking. etc.).
Clinical llse of tbe Balance Shoes has resulted in a
um ber of sllccessful cli'l1ical outcomes frolll a subjective
an dpoint. including treatment of ankle sprains and
ro nic instability. anterior tibial com pa rtment syn­
prove lateral weight shifting and sidestepping should be in­
r me. lower-'lcg fractures, a nd a number of other or­
corporated into a program for a tennis player, whereas
opiJedic problems. as well as enhancement of core
drills to improve jumping and landing are going to be more
.dbili ty. Research hilS revea led that training in the Bal­
'e Shoes resul ts in reduced rearfoot motion and im­
ved postural stability in excessive pronalors, i> and
aL fun ction iJ l iJclivilies in the Balance Shoes incr~ ase
_ uleu[ muscle ac tivi ty9 ,i S
Regaining Postural Stability and Balance 177
Figure 8-31 Balance beam walk against resistance.
- - -
CLINICAL DECISION MAKING Exercise 8-4
What type of balance exercises would be t meet the needs
of a ten nis player recovering fr III a grade 2 anlerior
talofibular sprain?
Phase 3
Once the athlete can successfully complete the semidy­
namic exercises presented in phllse 2. she or he shou ld be
ready to perform more dynamic and fun ctional types of ex­
ercises. The general progression for activities to develop dy­
namic balance and control ,js from slow-speed to fast-speed
activities, [rom low-force to high-force activities, an d [rom
controlled to uncon trolled aclivities. 4 1 ln oth er words, the
athlete should be working towa rd sport-specific drills th at
will allow [or a safe return to their respective sport or ac­
tivity. These exercises will likely be different depending on
which sport the person plays. For example. drills to im­
important for a track athlete who performs the long jump.
Athletic trainers oiften need to use their imagination to de­
ve'lop the best protocols for their athletes.
Bilateral jumping drills are a good place to begin once
the athlete has reached phase 3. These can be performed
178 PART TWO Achieving th e Coals of Rehabilitation
Figure 8-32 Bilateral hops.
either fwntlo back or side to side. The athlete should con­
centrate on landing on each side of the line as quickly as
possible (Figure 8_32). 74 .7; As the athlete progresses
through these exercises. eye closure can be used to fur­
ther challenge the athlete's somatosensation. After mas­
tering these straight-plane jumping pallerns. the athlete
can begin diagonal jumping patterns through the usc
of a cross on the floor formed by two pieces of tape (Fig­
ure 8-33). The intersecting lines create four quadrants
that can be numbered and used to perform different
jumping sequences. such as 1-3-2-4 for the first set and
1-4-2- 3 for the second set. 74.7, A larger grid can be de­
signed to aJlow for longer sequences and longer jumps.
both of which require additional' strength. endurance.
and balance control.
Bilateral dynamic balance exercises should progress to
unilateral dynamic balance exercises as qUickly as possible
during phase 3. At this stage of the rebabilitalion. pain
and faUgue should be Less prominenl factors. All jumping
drills performed bilaterc]ily should now be performed uni-
Figure 8-33 Diagonal hops.
igure 8 -3 4
laterally. by practicing first on the uninvolved extremity
(Figure 8-33). If additional challenges arc needed. a verti­
cal component can be added by having the athlete jump
over an object. such as a box (Figure 8-34).
Tubing cun be added to dynamic unilateral training
exercises. The athlete can perform stationary running
against the tube's resistance, followed by lateral and diag­
onal bounding exercises. Diagonal bounding. which in­
volves jumping from one foot to the other. places greater
emphasis on lateral movements. It is recommended that
the athlete nrstlearn the bounding exercise without tub­
ing. and then attempt the exercise witb tUbing. i\ foam
[oil. towel. or other obstacle can be used to increase jump CLINICAL'
height and/or distancc'~1 (Figure 8-35). The Gnal step in
trying to improve dynamic balance involves incorporating
RAININ()
sport-related activities sucb as throwing and catching a
ball. At this stage of the rehabilitation program. the athlete m
should be able to safely concentrale on the functional ac­ ~re~
tivity (catching and throwing). while subconsciously con­
trolling dynamiC balance (Figures 8-3h and 8-37).
 CHAPTER 8 Regalning Posturu l Stability and Balance 179

Figure 8-35 Lateral boun ding.

Figure 8-34 Lateral jumps over box.

Iveu extremily

CLINICAL DECISION MAKING Exercise 8-5

lalionary runnin g t\ basketball player has been complaining of feeling pain

y la teral and di ag­ and I"xity upon laIlding frolll a rebound . He has no
ing. which in­ swelling or other signs of an acute injury. What exercises
cr. places grealer should be introduced to help improve the laxity?
rec ommended tha l
ercise with oul tub­
lh tublng. A foan
to increase jump CLINICAL VALUE OF HIGH·TECH
j I. The !inal step in TRAINING AND ASSESSMENT Figure 8-36 Control dynamic balance while throwing
oh-rs incorporalln e ball while balancing on Dynadisc.
and catching a 1 c benefit of using the commerCially availabl e balance
program . the athlete . tems is that not only can defi cits be detected , but
n the functi onal ac­ :;rogress ca n be charted quantitatively u si ng the sessing an at hlete's ability to perform coordinated move­
ubconsciously con­ m puter-gen erated result~. fo r example. NeuroCom's ments essential for sport pe rformance. The system,
-3 and 8-37). :a lance Master (with long forceplate ) is capable of as­ equipped w it h a 5-foot-long force platform , is capable of
180 PART TWO Achieving the Goals of Rehabililation
Figure 8-37 Control dynamic balance while throwing and
catching a ball during lateral bounding.
identifying specific components underlying performance
of several functional tasks. Exercises arc also available on
the system that help to improve the deficits. 6 [>
Results of a step-up-and-over test are presented in Fig­
ure 8-38. The components analyzed in this parlicular task
are (1) the lUi-up index, which quantifles the maximum
lifting (concentric) force exerted by the leading leg and is
expressed as a percentage of the person's weight: (2) move­
ment time, or the number of seconds required to complete
the task, beginning with initial weight shift to the nOI1­
stepping leg and ending with impact of the lagging leg
onto the surface: and (3) the impact index, which quantifies
Summary
1. There are very close relationships among propriocep­
tion, kinesthesia, and balance.
2. The most common form of proprioception training in­
volves unitateral balance drills on challenging sur­
faces.
3. Exercises performed on foam or multim.ial devices are
good precursors for more dynamic balance exercises
such as lunges, lateral bounding, and unilateral hop­
ping drills.
Name:
10:
OOB:
Height:
the maximum vertica l impact force (percellt<lge of body
weight) as the lagging leg lands on the surface. h 6
Research on the clinical applicabilit.y of these meas­
ures has revealed interesting resuhs. Preliminary observa­
tions from two studies in progress suggest that dcflcits in
impact control are a common feature of patients with ACL
injuries, even when strength and range of motion of the LEFT SIDE
involved knee are within normallimi!.s. Several other per­
formance assessments are available on this system, includ­
ing sit to stand, walk test, step and I]uick tllrl!, fOl'lvard lunge.
weight bcarin{/Isquat, lind rhythmic weight shift.
4. The goal of any rehabilitation program should be to Balance maste
move safely through a progression of balance exer­ 1989-1997. t\
cises (phase] through phase 3) . Figure 8-38
5. The usc of commerciar[[y manufactured balance sys­
tems adds a nice feature to balance training and assess­
ment. allowing the athletic trainer to quantify progress.
6. With a little creativity, the athletic trainer can design
low-cost , yet very effective exercises for regaining
balance.
 CHAPTER 8 Regaining Postural Stability and Balance 181

Name: Doe, John J Diagnosis: ACL Tear L Knee File: HBM1.QBM

10: ATID00001 Operator 10: Jodi Bower Date: 03/06/97
DOB: 11/22/55 Referred by: Dr. Tom Merkle Time: 6:35:06 PM
Height: 5'11 " Comments: 001: 7/4/96; DOS: 7/6/96

STEP UP/OVER TEXT (8 inch curb)

Lift-Up Index
% BodyWt % Difference % BodyWt
50 ,---r..--,.-----, 50,--------,
40 ­
46 401­ ~ I

30 ­ 30 I­ II (1)
II
20 20 r­
10 ­ 10 I­ I
o'---------'-----'---' oL----'-...JL---'
Mean 50 o 50 Mean
Coefficient of Variation Coefficient of Variation
33% 90%
Movement Time
sec % Difference sec
5.0,--------, 5.0,--------,
4.0 4.0 I­

3.0 3.0 '­ 2.58

r­ (2)
2.0 2.0r
1.21
1.0 1.0 I­
0.0 '--------"-----'L--_ 0.0 'L-_-'--...L-_-'
Mean 50 o 50 Mean
Coefficient of Variation Coefficient of Variation
15% 53%
Impact Index
% Body Wt % Difference % BodyWt
100 100
LEFT SIDE RIGHT SIDE 80 I­ 80
49
~ vera! other per­ 60 r­ 60 (3)
- system , includ- I 40

39
40r
20 20

o1
' --_..L..--'--_......J OL--_..L..-....I.-_-'
Mean 50 o 50 Mean
Coefficient of Variatio n Coefficient of Variation
14% 100%

LEFT SIDE LEFT/RIGHT DIFFERENCE RIGHT SIDE

Balance master® Version 6.0 and NeuroCom® arc registered trademarks of NeuroCom International Inc. Copyright ©
of balance cxer­ 1989-1997. AU Rights Reserved.
Figure 8-38 Results from a step-up-and-over protocol on the NeuroCom New Balance Master's long force plate.
cd balance sys­
mining and assess­
to quantify progress.
.. trainer can design
ises for regaining
182 PART TWO Achieving the Goals of Rehabilitation

cu.ssion in colle
References 263- 73.
- . Guskiewlcz. K.
1. Balogun. J. A., C. O. Adesioasi. and D. K. Marzouk. 1992. The battery on a rorce platform. ScandinavialJ jou/"llal o( Rehabilita­ Nash ner. 199 i
effects of a wobble board exercise training program on static tion Medicine 21:187-95. mild head inju'
balance performance and strength of lower extremity mus­ 19. Faculjak, P.. K. Ffroozbakshsh. D. Wausher. and M. McGuire. Exercise 29 (71:
cle. Physiotherapy Canada 44:23-30. 1993. Balance characteristics or normal and anterior cruci­ . Guyton. A. 1t
2. Barrack. R. L., P. Lund, and H. Skinner. 1994. Knee joint pro­ ate ligament deficient knees. PhYSical Therapy 73:S22. Philadelpbia; \
prioception revisited. Journal o( Sport Rclwbilitaliml 3:18- 42. 20. Fisher. 1\.. S. Wiel'lishach. and J. Wilberger. 1988. Adult per­ , - , Harrison. E.. :
3. Barrack. R. L., H. B. Skinner, and S. L. Buckley, 19S9. Propri­ rormance on three tests of equilibrium. American Journal oj EI7 alualiolJ or
oception in the anterior cruciatc deficient knee. American Occupatiollal Thempy 42(1): 30-- 35. ligament surge
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cussion in coiJegiate athlete. jOtlmal oj AthleUc Trainillg 36(3):
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~-5 This athl

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Spo,.t Rehabilitatioll 3:43-57.

SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES

8-1 A preseason baseline score can be obtained on a
measure such as the BESS for all athletes, and then
llsed for a postinjury comparison . Because there is
such variability within many of the balance meas­
ures, it is important to make comparisons only to an
athlete's individual baseline measure and not to a
normal score. It is best to determine recovery on a
measure by using the number of standard deViations
(SO) away from the baseline. For example. scores on
the BESS that are more than 2 SD or 6 total po!nts
would be considered abnormal. Repeated assess­
ments over the course of a rehabilitation progression
can be used to determine the effectiveness of the bal­
a nce exerc.ises.
8-2 The athletic trainer should ilrst ensure that tht: ath­
lete bas the necessary pain-free ROM and muscular
strength to complete the tasks that arc being incor­
porated into the program. Additionally, for exercises
beyond the phase 1 static exercises, the athlete must
be beyond the acute inflammatory phase of tissue re­
sponse to injury. Once these factors have been con­
sidered. the athletic trainer sh(mld focus on develop­
ing D protocol lhal is safe yet challenging, stresses
multiple pl1lnes of motion. and incorporates a multi­
sensory approach .
1S-3 It should be explained to the athlele, at the outset.
that tbe goal is to challenge her or his motor control
system, to the point that the last two repetitions of
each set of exercises shou ld be difftcult to perform.
When the last two repetitions no longer arc chal­
lenging to the athlete. he or she should be progressed
to the next exercise. This can be determined through
subjective information reported (rom the ath lete, as
well as the [)thletic trainer', objective observ[)lions. It
is very important to provide a variety of exercises
and levels of exercises so that the athlete maintains a
higb h:vel of motivation.
8-4 II will be important for the athletic trainer to begin
slowly, with phase 1 and 2 balance exercises, to de­
termine the athlete's readiness to move into more dy­
 CHAPTER 8 Regaining Postural Stabil.ity and Balance 185

4.l'actors affecting
nee. )\merican JOLlr­
-t. Stabilometry in
\'alue in predicting
'Xl'TCisc 16:64- 66.
ral control in single
1);8 33- 39.
, dynamic lllld fwlC­
/11, Master's thesis.
ew York:
- 5 This athlete most likely has a functionally unstable
namic tasks as part of phase 3. The progression out­
lined in the solution to eXercise 8-2 should be fol­
lowed. However, this is an example of how the
athletic trai.oer can begin to personalize the exercise
routLne. A tennis player competing at a high level
wLll need to pedorm a lot of lateral movement allong
the baseline. therefore necessitating the inclusion of
dynamic balance exercises a nd weight shifts in the
frontal plane. Several of the exercises described in
this chapter (see Figures 8-24, 8-27. 8-32) would
provide a good starting point for the athletic trainer
in accomplishing this goal.
ankle. Research has shown that balance exercises
can help improve functional ankle instability. In this
si tuation, the athletic trainer probably can skip
phase 1 exercises and move directly to phase 2 aod 3
exercises. The athletic trainer should design a pro­
gram that incorporates challenging unilatera l multi­
directional exercises involving a multisensory
approach (eyes open and eyes closed). The progres­
sion should include the progression suggested in this
chapter that includes the roam , Bosu Balance
Tra.iner, Dynadisc, BAPS board, Extreme Balance
Boar·d . balance beam, and Balance Shoes. Lateral
and diagonal hopping exercises will alIso Ibe a vital
part of this protocol. The goal should be to help
strengthen the dy namic and static stabilizers sur­
rounding the ankle joint. This should result in re­
bUilding some or the arferent path ways and
ultimately improving ankle joint stability.

. and W. Clancy.

ankle stability:
nships. IVllmal of

havc beeD COD­

OCllS Otl develop­
allengLng, stresses
::orporates a multi­

teo at the outset.

his motor control
two repetitions of
ffLclllt to perform .
o longer are chal­
u ld be progressed
:ietermLned through
!rom thc athlete. as
.ti,'e observations. It
variety of exercises
. ath letc mainta ins a

etic trainer to begin

nee exercises. to de­
) move into more dy­
 CHAPTER 9 ods of time wi
tory system su
body. Withou t ~

Maintaining Cardiorespiratory
possibly fun cll
the cCl rdioresp~
tcm of th e bodj
Fitness during Rehabilitation
TRAININe I

William E. Prentice CARDIOR

BaSically, tra nSI
volves th e coo
(1) the heart.
(4) th e lungs.
~ durance throu!,! l
pabili ty of car l
Study Resources • Differentia te between aerobic and
necessary oxygc
sion of the traini
To become more familiar with th e knowledge and skills anaerobic activity.

necessary to design . implement. and document therapeu ­ cur in the h ear'

tic rehabilitation programs as identifi ed in the NATA Ath­ • Discuss the importance of incorporat­ ma ke il casier 10
to be disc ussed
letic Training Educational Competencies and Clinical ing cardiorespiratory endurance exer­
Prqf)ciencies'Therapeulic Exercise conten t area. visit di orespiratorv er
cises into a rehabilitation program.
www.mhhe. cSlJIJmrenticell!:. Also. refer to the lab exer­
cises in the n ew Laboratory Manual and to eSims. which
simulates the athletic training cer tiflcalion exam. at
• Identify various aerobic activities that 'iiWWl"W
www.mhh e.com/esim s. For more online study resources,
can help maintain cardiorespiratory A fresh man
visit our Hea lth and Human Perform ance website at endurance. coach WRllls I
www. mhhe.com/ h.b.n. improve herCdl
pIes should
After Completion of This
WHY IS IT IMPORTANT TO
Chapter, the Student Should
MAINTAIN CARDIORESPIRATORY Adaptation '
Be Able to Do the Following:

FITNESS DUR ING THE The heart is the n

• Analyze the relationships between REHABILITATION PROCESS? oxygen ated blood
heart rate. stroke volume. cardiac out­ sues. The heart ('1
Althou gb strength, neuromuscular control. flexibility, and !lOU S system am
put. and rate of oxygen use. postural stability are commonly regCl rded as essential com­ pulmonary vesse ;
ponents in any inJury rehabilitation program , often rela­ exchanged for OX)
• Explain the function of the heart. blood
tively little consideration is given to maintaining levels of 10 the heart , frou
vessels. and lungs in oxygen transport. cardiorespiratory endurance. An ath lete spends a consid­ ar terial sys tem a n
• Examine the oxygen transport system erable amoun t of time preparing the cardiorespirat.ory sys­ plying oxygen to t
tem to be able to hClndle the increased demClnds made upon Heart Rate.
and the concept of maximal rate of it during a competitive season. When in jury occurs and muscles usc the (
oxygen use. the athlete is forced to miss training lime. levels of car­ heart must pum p
diorespiratory endurance can decrease rapidl y, Thus the creased demand.
• Compare the principles of continuous. athletic trainer must design or substitute alternative activ­ increased dema n,
interval, fartIek. and par cours training ities that allow the indiv idu al to maintain existing le ve ls of mtc shows a gradt
and the potential of each technique for fitness durin g the rehab ilitation period. 4 " by in creasing Pro l
improving cardiorespiratory endurance. By definition, cardiorespirator), endurance is lhe cise. and it will pI ;
ability to perform whole-body activities for extended ,peri­ minutes (Pigure 9
186
 CHAPTEI.t 9 IVlaintaining Cardiorespiratory Pitness during Rehabilitation 187

ods of time without undue fatigue. 1R,l'J The cardiorespira~

tory system supplies oxygen to the various tissues of the
body. Without oxygen, the cells in the human body cannot
possibly function, and ultimately death will occur. Thus
t
the cardiorespiratory system is the basic life~support sys~ oC1)
tem of the body.39 ...c
o
E
x
TRAINING EFFECTS ON THE o
E
-0
CARDIORESPIRATORY SYSTEM :::>
c./)

Basically. transport of oxygen throughout the body in~

valves the coordin<lted function of four components:
(1) the he<lrt. (2) the blood vessels. (3) the blood. and 2-3 minutes
(4) the lungs. The improvement of cardiorespiratory en­ Time
durance through training occurs because of increased ca­
Figure 9-1 For the heart rate to plateau at a given
pability of eaeh of these four clements in prov,i ding
level, 2 to 3 minutes are required.
necessary oxygen to the working tissues. 5 1 A basic discus­
and
sion of the training effects and response to exercise that oc­
cur in the heart, blood vessels. blood, and lungs should c­
make it easier to understand why the training techniques 'uo
0..
to be discussed later are so effective 10 improving car­ o
u
diorespimtoryendurance. u
.:.ao
:vo
CLINICAL DECISION MAKING Exercise 9-1
~it ies that o
E
ira tory A freshman goalie onlhe so ' er team is not very fit. The 'xo
E
coach wants to gel her startt'd on a training progrutll to
improve her cardiorespiratory endurance. What princi­ ""
o·
Maximum
ples should be considered when designing her program?
Heart rate (% maximum)
r TO Figure 9-2 Maximum heart rate is achieved at about
~ PIRATORY Adaptation of the Heart to Exercise the same time as maxima! aerobic capacity.

The heart is the main pumping mechanism and circulates

CESS? oxygenated blood tbroughoutthe body to the working Lis­
sues. The heart receives deoxygenated blood from the ve­
... I. flexibility, find nous system and then pumps the blood through the
pulmonary vessels to the lungs, where carbon dioxide ,is
e.xehanged for OlI:ygen. The oxygenated blood then returns
to the heart. from which it exits through the aorta to the
arlerial system and is Circulated lhroughoulthe body. sup~
plying oxygen to the tissues.
Heart Rate. As tbe body begins to exercise. the
muscles use the oxygen <It a much higher rate. and the
heart must pump more oxygenated blood to meet this in­
creased demand. The heart is capable of adapting to this
increased demand through several mechanisms. Henrt
mte shows a gradual adaptation to an increased workload
by increasing pmporlionally to the intensily of the exer­
cise, and it will plateau at a given level after aboul 2 to 3
minutes (Figure 9-1).
lv ionitoring !heart rate is an indirect method of estimat­
ing oxygen eonsumption. 1HIn genera'!. heart rate and oxy­
gen consumption have a linear relationship, although at
very low intensities as well as at high intensities this linear re­
lationship breaks down 1 (Figure 9-2). During higher-inten­
sity activities. maximal heart rate might be achieved before
maximum o;.:ygen consumption. wbich will continue to
rise. HTbe greater the intensity or Lhe exercise. the higher the
heart rate. Because of these existing relationships, it should
become apparent that tbe rate of oxygen consumption can
be estimated by laking the heart rate. l i
Stroke Volume. A second mechanism by which tbe
heart is able to adapt to increased demands during exercise
is to increase the stroke volume. the volume of blood being
pumped out with eaeh beal. The heart pumps out approx­
imately 70 ml of blood per beat. Stroke volume can con­
tinue to increase only to the point at which there is simply
188 PART II Achieving the Goals of Rel1abilitation

Maximum whereas diast

Blood pressure I
and might sta"
GJ
;; ugreement tha
E
::J Q.
;; will produce In
"'0

~
> 0 lOlic blood pr
...e
GJ u
0
ii
exercise. I 7
Vi 0 AdaptatiOD
u throughout the
red blood cells. J
that has the capi
ecules of Qxygcr
40% Maximum cardiorespirator
Heart rate Oxygen consumption blood volume.
Figure 9-3 Stroke volume plateaus at about 40 percent Figure 9-4 Cardiac output limits maximal aerobic amount of hem
or maximal heart rate. capacity. in circulating b
might actually d.
Adaptation
not enough time between beats for the heart to fill up. This
pulmonary fun Cl
occurs at about 40 to 50 percent of maximal oxygen con­ During exercise. females tend to have a 5 to 10 percent
relative to the un
sumption or at a heart rate of 110 to 120 beats per higher cardiac output than males do. at all intensities. This
can be inspired
minute; above this level, increases in the volume of blood is likely due to a lower concentration of hemoglobin in the
creased. The dill
being pumped out per unit of time must be caused entirely female. which is compensated for during exercise by an in­
creased. faciJitati
by increases in heart rate l4 (Figure 9-3). creased cardiac output'. 54
dioxide. Pulman
Cardiac Output. Stroke volume and heart rate col­ Adaptation in Blood Flow. The amount of blood
-creased. 32 The f(
lectively determine the volume of blood being pumped £lowing to the various organs increases during exercise.
training on the c.
through the heart in a given unit of time. Approximately However. there is a change in overall distribution of car­
Decreased res
5 L of blood are pumped through the heart during each diac output; the percentage of total cardiac output to the
Decreased he.
minute at rest. This is referred to as the cardiac output, nonessential organs is decreased. whereas it is increased
Increased stre
which indicates how much blood the heart is capable of to active skeletal muscle. Volume of blood now to the
nchanged Cl
pumping in exactly 1 minute.1 oThus. cardiac output is the heart muscle or myocardium increases substantially dur­
Decrease in rc
primary determinant of the maximal rate of oxygen con­ ing exercise. even though the percentage of total cardiac
sumption possible (Figure 9-4). During exercise. cardiac output supplying the heart muscle remains unchanged.
rncreased cap
Increased fun
output increases to approximately four times that experi­ Tn skeletal muscle there is increased formation of blood
Decreased mu
enced during rest (i.e .. to about 20 L) in the normal indi­ vessels or capillaries. although it is not clear whether new
vidual and can increase as much as six times (i.e .. to about ones form or dormant ones Simply open up and fill with
30 L) in the elite endurance athlete. 10 blood. 44
The total peripheral resistance is the sum of all forces CLINICAL DECI
Cardiac output = stroke volume x heart rate that resist blood Oow within the vascular system. Total
peripheral resistance decreases during exercise prima­ ,\ lacrosse player
A training effect that occurs with regard to cardiac the end or last s
output of the heart is fhat the stroke volume increases rily because of vessel vasodilation in the active skeletal
training ror his n
while exercise heart raLe is reduced at a given standard ex­ muscles.
training. whaLpi
ercise load. The hearf becomes more efficient because it is Blood Pressure. I3lood pressure in the arterial sys­
capable of pumping more blood with each stroke. Because tem is determined by the cardiac output in relation to total
the heart is a muscle. it will hypertrophy. or increase in size peripheral resistance to blood now. Blood pressure is cre­
and strength. to some extent. but this is in no way a nega­ ated by contraction of the heart muscle. Contraction of
tive effect of training. the ventricles of the heart creates systolic pressure. and re­ MAXIMAL
laxation of the heart creates diastolic pressure. During ex­
The maximal amc
Training Effect
ercise. there is a decrease in total periphera'l resistance and
exercise is refene
Increased stroke volume X decreased heart rate
an increase in cardiac ou tpu t. 13 Systolic pressure increases
cise physiologis(s
= cardiac output
in proportion to oxygen consumption and cardiac output,
pacity as maxima
 CHAPTER 9 Maintaining Cardiorespiratory Fitness during Rehabilitation 189

v
whereas diastolic pressure shows lillIe or no increase. 8
Blood pressure fa lis below preexercise levels after exercise
and might stay low for several hours. There is general
agreement that engaging in consistent aerobic exercise
will produce modes t reductions in both systolic and dias­ 11>
E
tolic blood pressure at rest as well as during submaximal >=
exercise. 17
Adaptations in the Blood. Oxygen is transported
throughout the system bound to hemoglobin. Found in
red blood cells. hemoglobin is an iron-containing protein
that has the capability of easily accepting or giving up mol­ % max imal aerobic capacity
ecules of oxygen as needed. Training for improvement of required during on activity

l~ Maximum cardiorespiratory endurance produces an increase in total

Figure 9-5 The greater the percentage of maximal aer­
blood volume. with a corresponding increase in the
obic capacity required during an activity. th e less time an
amount of hemoglobin. The concentration of hemoglobin activity can be performed.
b a l aerobic
in circulating blood does not change with training; it
might actually decrease slighLly.
Adaptation of the Lungs. As a result of training.
pulmonary Cunclion is improved in the trained individual cons idered to be the best indicator of th e level of car­
a - to ] 0 percent relative to the untrained individual. The volume of air that diorespiratory endurance. Maximal aerobic capacity is
all intcnsities. This can be inspired in a single maximal venlilalion is in­ most often presented in terms of the volume of oxygen
rnoglobin in the creased. The diffuSing capacity of the lungs is also in­ used relative to body weight per unit of time (ml·kg- I .
r= xercise by an in-
creased. facilitating the exchange of oxygen and carbon min -I ).1 A normal maximal aerobic capacity for most
dioxide. Pulmonary resista nce to air now is also de­ collegiate men and women athletes would fall in the
amount of blood c reased .l~ The follOWing list summari zes the effects of range of 50 to 60 ml·kg- 1. min- l A world-class ma le
dur ing exercise. training on the cardiorespiratory system: mara thon runner might have a maximal aerobic capac­
rribution of car­ Decreased rest! ng h eart rate ity in the 70 to 80 m!·kg-1·min - 1 ran ge. whereas a
iac output to the Decreased heart rate at speCific workloads world-class femal e marathoner will have a 60 to 70
_as it is increased Increased stroke volume ml'kg -- 1' min - 1 range. J4
ood 110w to the Unchanged cardiac output
ubstanlially dur ­ Decrease in recovery time
e of total cardiac Rate of Oxygen Consumption
Increased capillarizalion
ai ns unchanged. Increased funcliOlla l capacity in the lungs The performance of any activity requires a certain rate of
~m ation of blood Decreased muscle glycogen use oxygen consumption that is about the same for all persons.
dea r whether new depending on their present level of fitness. 5 Generally the
n up and fill with greater the rate or intensity of the performance of an ac­
CLINICAL DECISION MAKING Exercise 9-2 tivily. the greater will be the oxygen consumption. Each
e u m of all forces perso n has his or her own maximal rate of oxygen con­
:ular system. Tota l sumption. That person's ability to perform an activity is
A lacrosse player su tained a season-ending knee injury at
a exercise prLma­
the end of last season. During the off-season he began closely related to the amount of oxygen required by th at
'be active skeletal activity. This ability is limited by the maximal rate of oxy­
trainin g for his return to hockey. After everaJ months of
training. wha t physiological changes should be occurring? gen consumption the person is capable of delh'ering into
-~ in the arterial sys­ the lungs. Fatigue occurs when insufficient oxygen is sup­
1 in relation to total plied to muscles. It should be apparent that the greater per­
-:lOd pressure is cre­ centage of maximal oxygen consumption requ ired during
- Ie. Contraction 0 an activity, the less time the activity can be performed
lie pressure. and re­
MAXI MAL AEROBIC CAPACITY
(Figure 9-5).5
pre sure. During ex­ - h e maximal amount of oxygen that can be used during Three factors determine the maximal rate at which
'lheral resistance and xercise is referred to as maximal ((crobic capacit!l. Exer­ oxygen can be used: (1) external respiration. involving the
jc p res~ure increase~ .i e physio~ogists usually refer to maximal aerobic ca­ venLilatory process. or pulmonary function; (2) gas trans­
and cardiac output. acity as maximal oX!lgen consumptio n (V0 2 max). It is port. which is accomplished by the cardiovascular system
190 PAR)' II Achieving the Goals of Rehabilitation

(that is, the heart, blood vessels, and blood); and (3) inter­ A tissues, and eliI
nal respiration, which involves the use of oxygen by the 50 referred to as m
cells to produce energy. Of these three factors the most lim­ Muscles an
iting is generally the ability to transport oxygen through B energy to move.
the system; thus the cardiovascuLar system limits the over­ 40 certain nutrien l
all rate of oxygen consumption. 4 A high maximal aerobic :e­
'0 compound calif
capacity within a person's range indicates that all th ree 8. Work the ultimate U~
systems are working well. 8c
.':! 'f
30 -lood
- - 1- - - + -1--- + ATP is producec
-0"
o m glycogen. Fats a
Q) "
~-'"
erate ATP. Gl ue
Maximal Aerobic Capacity: ~E
0­
20 glycogen in the I
An Inherited Characteristic E

'xo the liver can l at~

~ ferred to the blo
The maximal rate at which oxygen can be used is a genet­ 10 [f the durad
ically determined characteristic: we inherit a certain range
the body relies II
of maximal aerobic capacity, and the more active we are,
to meet its energ
the higher the existing maximal aerobic capacity will be
witbi n that range. 425 ) A training program is capable of in­
o tivity. the greate
% moximol oerobic copocity th e later stages (
creasing maximal aerobic capacity only to its highest limit
Figure 9-6 Athlete A should be able to work longer maximal exertio
within ~ur range. 53
than athlete B as a result of a lower percen tage use of provide energy i
Fast-Twitch versus Slow-Twit.ch Muscle Fibers.
maximal aerobic capacity. Carbohydrate ill!
The range of maximal oxygen consumption that is inher­
taUy depleted. fc
ited is largely determined by tbe metabolic and functional
gardless of the
properties of skeletal muscle Dbers.40 As discussed in detail closely related to the percentage of maximal aerobic ca­
always available
in Chapter 7, there are two distin ct types of muscle fibers: pacity that a particular workload demands. ,2 For exam­
When all availal:
slow-t.witch and Inst-twitch fibers, each of which has dis­ ple, Figure 9-6 presents two persons, A and B. A has a
regenerated for [
tinctive metabolic as well as contractile capabilities. Be­ maximal aerobic capacity of 50 mllkg / min . whereas B
Various sPOI1
cause they are relatively fatigue resistant. slow-twitch has a maximal aerobic capacity of only 40 mllkg/ min. [f
ergy. For exampl!
fibers are associated primarily with long-duration, aero­ both A and B are exercising at the same inten sity. then A
output activities.
bic-type activities. Fast-twitch fibers are useful in short­ will be working at a much lower percentage of maximal
energy for a shar
term, high-intensity activities, which mainly involve the aerobiC capacity than B is. Consequently, A should be able
ming, on the O(j
anaerobic system. [n general. if an athlete has a high ratio to sustain his or her activity over a much longer period of
activities per um
of slow-twitch to fast -twitch muscle fibers, he or she will time. Everyday activities can be adversely affected if the
a prolonged time
be able to utilize oxygen more effiCiently a nd thus will have ability to use oxygen effiCiently is impaired . Thus, im­
of both high an
a high er maximal aerobic capacity. provement of cardiorespiratory endurance should be an
demands can be I
essential component of any conditioning program and
ergy can be sup
must be included as part of the rehabilitation program for
CLINICAL DECISION MAKING Exercise 9-3 the injured athlete. 12
Regardless of the training tec hniqu e llsed for the im­ Anaerobic,
A cyclist wants to know if you can test his maximal aero­
provement of cardiorespiratory endurance, one princi­
bic capacity. He ~-ays that be has reached a plateau in his Two major e I1er~
pal goal remains the sam e: to increase th e ability (~l the
training. There haso't been an increase in his maximal tissue: anaerobi
cnrdiorespirnt.ol'Y system to suppl!J a slIfficient nmozmt ol
aerobic capacity in about a year. What is your explana­ Each of these sy:
oxygen to working muscles. Without oxygen. the body
tion for why this is occurring? bursts of acti vit.
is incapable of producing energy for an extended period
can be rapidly ill
of time.
few seconds of i
of ATP are used
Cardiorespiratory Endurance PRODUCING ENERGY as an energ)7so
and Work Ability FOR EXERCISE ply glucose, whi
cells to genera te
Cardiorespiratory endurance plays a critical role in our All living systems need to perform a variety of activities Glucosecao
ability to carry out normal daily activities. 38 Fatigue is such as growing, generating energy. repairing damaged of ATP energy \.
 CHAPTER 9 Maintaining Cardiorespiratory Fitness during Rehabilitation
tissues, and eliminating wastes. All of these activities are
referred to as metabolic or cellular metabolism.
Muscles are metabolically active and must generate
B energy to move. Energy is prod uced from the breakdown of
certain nutrients from foodsluffs. This energy is stored in a
compound called adenosine triphosphate (ATP). which is
the ultimale usable form of energy for muscular activity.
. -~-- .~ ATP is produced in the muscle tissue from blood glucose or
glycogen. Fats and proteins can also be metabolized to gen­
erate ATP. Glucose nol needed immediately is stored as
glycogen in the resting muscle and liver. Stored glycogen in
the liver can later be converted back to glucose and trans­
ferred Lo the blood to meet the body's energy needs.9
If the duration or intensity of the exercise increases,
the body relies more heavily on fats stored in adipose tissue
to meel its energy needs. The longer the duration of an ac­
tivity, the greater the amount of fat used, especially during
aerobic capacity the later stages of endurance events. During rest and sub­
oJ work longer
maximal exertion, both fat and carbohydrates are used to Excess Postexercise Oxygen Consumption (Oxy­
n tage usc of
provide energy in approximately a 60 to 40 percent ratio. gen Deficit). As the intensity of the exercise increases
Carbohydrate must be available, to use fat. If glycogen is to­
tally depleted. fal cannot be completely metabolized. Re­
gardless of the nutrient source that produces ATB it is
'im a[ aerobic ca­ always available in the cell as an immediate energy source.
ands. 52 For exam­ When all available sources of ATP are used, more must be
A and B. A has a regenerated for muscular contraction to continue. I 1.27
_ min, whereas B Various sport activities involve specific demands for en­
. -10 m[/kg/min. If ergy. For example, sprinting and jumping are high-energy­
intensity, then A output activities, requiring a relatively large production of
.. ntage of maximal energy for a short time. Long-distance running and swim­
~'.. should be able
ming, on the other hand, are mostly low-energy-output
uLh longer period of activities per unit of time, requiring energy production for
. ly affected if the a prolonged time. Other physical activities demand a blend
paired. Thus, im­ of both high and low energy output. These varions energy
rance should be an demands can be mel by lhedifferent processes in which en­
m g program and ergy can be supplied to the skeletal muscles. 19
ta tion program for
e used fur the im­ Anaerobic versus Aerobic Metabolism
I 'rance. one princi­
Two major energy-generating systems function in muscle
ri,e ability oj tire
tissue: anae.robic metabolism and aerobic metabolism.
rfficiCllt amount of
Each of these systems produces ATP' 22 During sudden out­
o 'ygen, the body
bursts of activity in intensive, short-term exercise. ATP
. an extended period
can be rapidly metabolized to meet energy needs. After a
few seconds of in tensive exercise, however. the sma II stores
of ATP are used up. The body then turns to stored glycogen
as an energy source. Glycogen can be broken down lo sup­
ply glucose. which is then metabolized within the muscle
cells to generate ATP for muscle contractions. H
"ariet.y of activities Glucose can be metabolized to generate small amounts
repairing damaged of ATP energy without the need for oxygen. This energy
191
system is referred to as anaerobic metabolism (anaerobic =
occurring in the absence of oxygen). As exercise contin­
ues, the body must rely on a mQre complex form of carbo­
hydrate and fat metabolism to generate AT? This second
energy system requires oxygen and is therefore referred to
as aerobic metabolism (aerobic = occurring in the presence
of oxygen). The aerobic system of prodUCing energy gen­
erates considerably more ATP than the anaerobic one.
In most activities, both aerobic and anaerobic systems
function Simultaneously. The degree to which the two ma­
jor energy systems are involved is determined by th e inten­
sity and duration of the activity. 50 If the intensity of the
activity is such that suf.ficient oxygen can be supplied to
meet the demands of working Ussues, the acthrity is con­
sidered to be aerobic. If the activity is of high enough in­
tensity or the duration is such that there is insuffIcient
oxygen available to meet energy demands, the activily be­
comes anaerobic. S4
and insufficient amounts of oxygen are avai'lable to the tis­
sues, an oxygen deficit is incurred. Oxygen deficit occurs in
the begirming of exercise (within the fIrsl 2 or 3 minutes)
when the oxygen demand is greater than the oxygen sup­
plied. tt has been hypothesized that this oxygen debt is
caused by lactic acid produced during anaerobic activity
and that this "debt" must be "paid back" during the post­
exercise period. However, currently there is a different ra­
tionale for this oxygen deficit. referred to as "excess
postexercise oxygen consumption." According to this the­
ory, the deficit is caused by disturbances in mitochondrial
function due to an increase in temperature. 3.
TECHNIQUES FOR MA'I NTAINING
CARDIORESPIRATORY
ENDURANCE
There are several different training techniques that may be
incorporated into a rehabilitation program through which
cardiorespiratory endurance can be mainlained . Cer­
tainly. a primary consideration for the athletic trainer
would be whether thc injury ,involves the upper or lower
extremity. With injuries that involve the upper extremity,
weight-bearing activities, such as walking, running. stair
climbing, and modified aerobics, may be used. However, if
the injury is to the 10IVer extremity. alternative non­
weight-bearing activities, such as swimming or stationary
cycling. might be necessary. In a sport, such as soccer, that
requires a considerable amount of running, training using
appropriate non-weight-bearing activities will not keep
192 PART [[ Achieving the Goals of Rehabilitation

the athlete "match :Ilt." The only way to achieve match fit­ level during the entire workout Y Heart rate can be in­ exertion (Table '
ness is to engage in functional activities specific to that creased or decreased by speeding up or slowing down the higher ,level of (
sport. The goal of the athletic trainer in substituting alter­ pace. It has already been indicated that heart ra te in­ ture is directly r
native activities during rehabilitation is to try to maintain creases proportionately with the intensity of the workload ceived exertion .
a cardiorespiratory endurance base so that the athlete can and will plateau after 2 to 3 minutes of activity. Thus the taught to exerci
quickly regain match fitness once the injury has healed. athlete should be actively engaged in the workout for 2 to more objective Il
The principles of the training techniques discussed be­ 3 minutes before measuring pulse. 56 Type of EXI
low can be applied to running, cycling, swimming, stair There are several formulas that will easily allow the tinuous traini ng
climbing, or any other activity designed to maintain levels athletic trainer to identify a target training heart rate. 45 tivities that ge
of cardiorespiratory fitness. Exact determination of maximal heart rate involves exer­ large-muscle rnl
cising an athlete at a maximal level and monitoring the and that use lar
heart rate using an electrocardiogram. This process is dif­ rate. and maillla
Continuous Training ficult outside of a laboratory. However. an approximate es­ time. Examples (
timate of maximal heart rate (MHR) for both males and jogging. cycling.
Continuous training involves the FITT principles:
females in the population is thought to be about 220 beats bie dance exerc'
The Frequency of the activity per minutc. 4l MHR is related to age. With increasing age, The advanta
The I'ntensity of the activity MHR decreases. 3l Thus a relatively simple estimate of more intermittcl
The Type of activity MHR would be MHR = 220 - age. For a 20-year-old ath­ basketball, or tel
The Time (duration) of the activity lete, MHR would be about 200 beats per minute (220 - 20 tensity by either
= 2(0).1f yo u are interested in having an athlete work at Because we a Ire.
Frequency of Training. To see at least minimal
70 percent of maximal heart rate. the target heart rate can workload elicits I
improvement in cardiorespiratory endurance. it is neces­
be calculated by multiplying 0.7 . (22 0 - age). Again us­ allow us to mai
sary for the average person to engage in no less than three
ing a 20,year~0Id as an example, a target heart rate would level. " In termitt
sessions per week. A competitive athlete should be pre­
be 140 beats per minute (0.7' [220 - 20] = 140). intensities th at c
pared to train as often as six times per week. Everyone
Another commonly used formula that takes into ably. Although t
should take off at least 1 day per week to give damaged tis­
account your current level of fitness is the Karvonen ca rdiorespirato~
sues a chance to repair themselves.
Intensity of Training. The intensity of exercise is equation: 26 .28 to monitor in ten
that any type of
also a critical factor. though recommendations regarding Target training HR = cise. can impron
tmining intensities vary.25 This is particularly true in the Resting HR + (0.6 [Maximum HR - Resting HR]) Time (Dura
early stages of training. when the body is forced to make a
cur. a person mi
lot of adj ustments to increased workload demands. Beca use Resting heart rate generally fatls between 60 to 80
continuous ac ti1
heart rate is linearly related to the intensity of the exercise beats per minute. A 20-year-old athlete with a resting
working leveI. ~<
and to the rate of oxygen consumption. it becomes a rela­ pulse of 70 beats per minute, according to the Karvonen
workout/ac tivi _
tively simple process to identify a specinc workload (pace) equation. would have a target training heart rate of ] 48
levels. 3 GeneraU:
that will make the heart rate plateau at the desired levelY beats per minute (70 + 0.6[200 - 70] = 148).
the greater the
By monitoring heart rate. we know whether the pace is too Regardless of the formula used. to see minimal im­
durance. The COl
fast or too slow to get the heart rate into a target range. 30 provement in cardiorespiratory endurance. the athlete
45 minutes.
Monitoring heart rate. There are several points at must train with the heart rate elevated to at least 60 per­
which heart rate is easily measured. The most reliable is cent of its maximal rate.1.24 .29 The American College of
the radial artery. The carotid artery is simple to find, espe­ Sports Medicine (ACSM)3 recommends that the collegiate CLINICAL DEC
cially during exercise. However, there are pressure recep­ athlete train in the 60 to 90 percen t range when training
tors located in the carotid artery that. if subjected to hard continuously. Exercising at a 70 percent level is considered Your Ice hocke
pressure from the two I1ngers, will slow down the heart moderate. because activity can be continued for a long pe­ game. What lJ
rare. giving a false indication of exactly what the heart rate riod of time with little discomfort and still produce a train­ their fitness 5
is. Thus the pulse at the radial artery proves the most ac­ ing effect. 35 In a trained individual it is not difficult to
curate measure of heart rate. Regardless of where the sustain a heart ra te at the 85 percent leve1. 16 .49
heart rate is taken . it should be monitored within 15 sec­ Rating of perceived exertion. Rating of perceived
onds after stopping exercise. exertion (RPE) can be used in addition to monitoring heart Interval Tr.
Another factor must be considered when measuring rate to indicate exercise intensity.7 During exercise. indi­
heart rate during exercise. The athlete is trying to elevate viduals are asked to rate subjectively, on a numerical scale Un like continuol
heart rate to a specific target rale and maintain it at that [rom 6 to 20, exactly how they feel relative to their level of activities that a
 CHAPTER 9 Maint<lining Cardiorespiratory Fitness during Rehabilitation 193

t rate can be in­ exertion ('l'able 9-1). More intense exercise that requires a • TAB LE 9· 1 Rating of Perceived Exertion.
lowing down the higher level of oxygen consumption <lnd energy expendi­
t heart rate in­ ture is directly rclated to higher subjective ratings of per­ Scale Verbal Rating
ey of the workload ceived exertion. Over a period of time. athletes can be
activity. Thus the taught to exercise at a specific RPE that relates directly to 6
Ie workout for 2 to more objective measures of exercise ,intensily.21·J6 7 Very. very light
Type of Exercise. The type of activity used in con­ 8
ill asily allow the tinuous training must be aerobic. Aerobic activities are ac­ 9 Very light
ining heart rate. ' 4 tivWes that genera1lly involve repetitivc. whole-body, 10
rate involves exer­ large-muscle movements that are rhythmical in nature 11 Fairly light
d monitoring the and that use l<lrge amounts of oxygen, elevate the heart 12
Thi process is dif­ rate, and maintain it at that levcl for an extended period of 13 Somewhat hard
m approximate es­ time. Examples of aerobic activities are walking, running. 14
r both males and jogging. cycling. swimming, rope skipping, stepping, aero­ 1 :; Hard
about 220 beats bic dance exercise. rollerblading. and cross-country skiing. 16
m increasing age. The advantage of these aerobic activities as opposed to 17 Very hard
pie estimate of more intermittent activities. such as racquetball. squash. 18
a ::!O-ye<lr-old ath­ basketba'll. or tennis. is that it is e<lsy to regulate their in­ 19 Very. very hard
-ninute (220 - 20 tensity by either speeding up or slowing down the pacc. n
an athlete work at Because we already know that the given intensity of the From G. A. Borg, Psychophysical basis of perceived exertion,
rget he<lrt rate can workload elicits a given heart rate. these aerobic activities Medicine and Science ill SporLs (md Exercise] 4:377 (1982).
- age). Again us­ allow us to maintain heart rate at a specified or target
_ heart rate would level. ,; IntermitLent activ>ities involve \'ariable speeds and
consists of alternating periods of relatively intense work
_ ] =140). intensities that cause the heart rate to fluctuate consider­
and active recovery.Ii It allows for performance of much
that t<lkes into ably. Although these intermittent activities will improve
more work at a more intense workload over a longer period
the Karvonen cnrdiorespiratory endurance. they are much more difficult
of time than if working continuously. \A/e have stated that
to monitor in terms of intensity. It is important to point out
it is most desirable in continuous training to work at an in­
that any type of activity. from gardening to <lerobic exer­
tensity of about 60 to 80 percent of maximal heart rate.
cise. can improve fitness.]7
Obviously. sustaining activity at a relatively high intensity
- Resting HR]) Time (Duration). For minimal improvement to oc­
over a 20-minute period would be extremely difficult. The
cur. a person must participate in at least 20 minutes of
\'een 60 to 80 advant<lge of interval training is that it allows work at this
continuous activity with the heart rate elevated to its
I!V with a resting 80 percent or higher level for a short period of time fol­
work,ing level. 48 ACSrvl recommends 20 to 60 minutes of
to the Karvonen lowed by an active period of recovery during which the in­
workout/activity with the heart rate elevated to training
eart r<lte of 148 dividual works at only 30 to 45 percent of maximal heart
levels. 3 Generally, the greater the duration of the workout.
= 14 ). rate. Thus the intensity of the workout and its duration
the greater the improvement in cardiorespiratory en­
see minimal im­ can be greater than with continuous training. 6
durance. The competitive athlete should train for at least
rance. the athlete Most sports (for exam pIe. football, basketball. soccer. or
45 minutes.
at least 60 per­ tennis) are anaerobic. involving short bursts of intense ac­
erican College of tivity followed by a sort of active recovery period. Training
that the collegiate CLINICAL DECISION MAKING Exercise 9-4 'w ith the interval technique allows a more sport-speciftc
ng when training workout. Interval training allows application of the overload
" lew I is considered Your ice hockey player. have been fatiguing arly in the principle. making the training period much more intense.
nued for a long pe­ game. What type of training will best help 1 em Improve There are several important considerations in interval train­
produce a train­ their fitness specifically lor their sporl? ing. The training period is the amount of time during which
. not difl1cult to continuous activity is actually being performed, and the re­
1. 16.-19 covery period is the time between training periods. A set is a
lating of perceived group of combined training and recovery periods. and a rep­
11monitoring heart Interval Training etition is the number of training/ recovery periods per set.
nng exercise. indi­ Training time or distance refers to the rate or distance of the
a n umerical scale Unlike continuous training. interval training involves training period. The traininglrecovery ratio indicates a time
m'e to their level of activities that are more intermittent. Interval training ratio for training versus recovery.
194 PART II Achieving the Goals of Rehabilitation

An example of interval training would be a soccer "speed play." It is similar to interval training in that the can be suppl i
player running sprints. An interval workout would involve athlete must run for a specified period of time; however, must be repa
running 10 repetitions of 120-yard sprints, each in 18 specific pace and speed are not idenlilied. It is recom­ normal restir
seconds with a 90-second walking recovery in between the mended that the course for a fartlck workout be some type 7. Continuous (
repetitions. During this training session the soccer player's of varied terrain with some level running. some uphill cardiorespira
heart rate would probably il'l crease to 85 to 95 percent of and downhill running. and some running through a livi ty that is
maximal level during the dash and should probably fall to course with obstacles such as trees or rocks. The object is three limes p;
the 35 to 45 percent level during the recovery period. to put surges into a running workout, varying the length 20 minutes 1\
Older adults shouldJ be ca utious about using interval of the surges according to individual purposes. One ad­ percent of m ~
training as a method for improving cardiorespiratory en­ vantage of fartlek training is that because the pace and 8. Interval train
durance. The intensity levels attained during the active pe­ terrain always change, the traini ng session is less regi­ lively il1tem
riods might be too high for the older adult. mented and provides a refreshin g change of pace in the
Combining Continuous and Interval Training. training routine. 4 J
As indicated previously, most sport activities involve some Again. if fartlek training is going to improve cardiores­
combination of aerobic and anaerobic metabolism. 56 Con­ piratory endurance, it must elevate the heart rate to at References
tinuous training is generally done at an intensity level that least minimal training levels. Fartlele might best be used as 1. Astrand. p. 0 .. a
primarily uses the aerobic system. ]n interval training the an off-season conditioning activi ty or as a change-of-pace ogy. New York.:
intensity is sufficient to necessitate a greater percentage of activity to counteract the boredom of training using the 2. Aslrand. P. O. )
anaerobic metabolism. 211 Therefore the sports therapist same activity day after day. lalion of uerobi
should incorporate both training techniques into a reha­ work. Journa l 0,1
bilitation program to maximize cardiorespiratory fitness . 3. American CoU~t
ercLse testin[J nn/
Par Cours 4. Bassetl. D. R..
CLINICAL DECISION MAKING Exercise 9-5 Par cours is a technique for improving cardiorespiratory maximum O:\}
performa nee. .\
endurance that basic<I lly combines continuous training
31( 1):70.
In an interval workout. at what intensities should an ath­ and circuit training. This technique involves jogging a ) . Bergh . U.. B. Ek;
lete work during the work period and during the active short distance from station to station and performing a gcn uptake "ell!
recovery period? designated exercise at each station according to guidelines Medicine and Sf..
and directions provided on an instruction board located at 6. Billal. L. V. 1 001
that station. Par cours circuits provide an excellent means !ilk and empir'i
Fartlek Training for gaining some aerobic benefits while incorporating middle- and JOD;
some of the benefits of calisthcnics. Par cours circuits arc vallraining. Sp..
The fartlek training technique is a type of cross-country found most typically in parks or recre<Ilional areas within - Borg. G. A. J 982
running that originated in Sweden. Fartlck literally means metropolitan areas.
8.

9 . Brooks.G .. a ndJ
Summary
and lipid utiliza
JOllrnal oj App/k
10. Ccrny. F.. and H
1. The athletic trainer sho uld routinely incorporate into 4. Heart rate is directly related to the [£lte of oxygen con­
the rehabilitation program activities that will help sumption. It is thercfore possible to predict the inten­ II.
maintain levels of cardiorespiratory endurance. sity of the work in terms of the rate of oxygen use by Spo rts .Hedicllll' I
2. Cardiorespiratory endurance involves the coordinated monitoring heart rate. ; 2. Chiiiag.S. A . 19
and nonort hopc.
function of the heart. lungs. blood, and blood vessels 5. Aerobic exercise involves activity in which the level of
.Hedieillc 79(10.
to supply sufficien t amounts of oxygen to the working intensity and duration is low enough to provide a suf­ , 3. COlllcrtino. \~ A
tissues. ficient amount of oxygen to supply the demands of the and orth ostalic
3. The best indicator of how efficiently the cardiorespira­ working tissues. enet s Rel'iell's 1 5
tory system functions is the maximal rate at which 6. In anaerobic exercise the intensity of the activity is so '-t. Cox. i\.J.. 1991. Ex!
oxygen can be used by the tissues. high that oxygen is being llsed more quickly than it lOry adaptation.
 CHAPTER 9 Maintaining Cardiorespiratory Fitness during Rehabilitation 195

ining in that the can be supplied. thus an oxygen debt is incurred that ods. [nterval training a llows performance of more
,f ti me; however. must be repa id before working ti ssue ca n return to its work at a relatively higher workload tban in continu­
led. It is reeo m­ normal resting state. ous training.
~o u t be some type 7. Conti nuous or sustained training lor maintenan ce of 9. During reha bilitation . continuous and interval train­
mg. some uphill cardiorespiratory endurance involves selecting an ac­ ing techniques should be incorporated.
lDi ng through a tivity that is aerobic in nature and training at least 10. Fartlek makes usc of jogging or running over varying
·ks. T he objec t is three times per week for a time period of no less than types of terrain at changing speeds.
uy ing the length 20 minutes with the heart rate elevated to at least 60 11. Par cours is a training technique that combines con­
ur poses. One ad­ percent of maxilTtal rate. tinuous train ing with exercises done at stations along
use the pace and' 8. Interval training involves alternating periods of rela­ the course.
ion is less regi­ tively intense work follow ed by active recovery peri-
ge of pace in the

pr V(J cardiores­
heart rate to at References
_ 1 best be used as 1. f\s trand, PO.. and K. RodahL 1986. Textbook of work pll!Jsial­
c h ange-of-pace OilY. \'ew York: McGraw-HilL
'"Rilling using the 2. Astrand. P. O. 1954. Astrund-RhymLng nomogram for ca lcu­
lation of aerobic capacity (rom pulse rat e during su bmaximal
work. Journal of Applied Physiolo!lY 7:218.
1. American College of Sports ~'1edLcin e. 2001. GlIidelinesJor ex­
ercise testing and prescription. Philadelphia: Lea & Pebiger.
4. Bassell. D. R.. and IE. T Howley. 2000. Limiting factor s [or
maximum oxygen uptake and determinants or endurance
-ardiorespiratory
performance. :Vledicine alld Scimcc in Sports alld Exercise
nLin uous training 3 2(1 ):70 .
• olves jogging a J. Bergh.U.. B. Ekblom . and P. O. Astrand. 20nO. ivlaximal oxy­
d performing a gen uptake "classical" versus "contemporary" viewpOints.
g to guidelines ,vledirine and Scimer in Sports and Exercise 32( 1):8 5.
a rdlocated at 6. BHlat. L. V. 2001. Interval training for performance: i\ scien­
ex lIent means tific a nd empirical practice. Special recommendations for
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7. Borg, C. A. 1982. PSJ'chophys icaJ basis or perceived exertion.
na l areas within
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9. Brooks. G.. and J. Mercier. 1994. The balance of carbohydrate
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f oxygen usc by
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to provide a suf­ 13. Convertino. V. A. 1987. Aerobic fitness. endmance training.
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i 5. deVries. H. 1986. Physiology oj exercise for ph!Jsical education
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17. Dmstein. L., R. Pate. and D. Branch. 1993. Cardiorespiratory
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18 . F<Jhey. 1. 1995. Encyclopedia oj sports medicine and exercise
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19. Foss. M., and S. Ketcyia n . 1998. Fox's physiological basis for
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Edumtion 12:77-82.
22. Green. j.. and A. Patla. 1992. Maximal aerobic power: Neu­
romuscular and metabolic considerations. Medicine (/Il// Sci­
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pulse rate to estimate exercise heart rate foll owing [ou r in­
tensities of bench step exercise. Rescarell Qllarterly Jor Exercise
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24. Hage. P. 1982. Exercise guidelines: Which to belic\'ei Physi­
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25. Hawley, j.. K. Myburgh, and T Noakes. 1995. Maximal oxy­
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26 . Hickson, R. C.. C. Foster. M. Pollac, et at 1985. Reduced train­
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diac growth. Journal oj Applied Physiology 58(2): 492.
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27. Honig, C, R. Connett. and 1'. Gayeski. 1992. O2 transport and
its intera ction with metabolism. Medicine and Scimce ill Sports
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28. Karvonen, M. J" E. Kcntala, and O. Mustala. 1957. The effects
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29. Koyanagi, 1\" K. Yamamoto. and K, Nishijima. 1993. Recom­
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SOLUTION
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 CHAPTER 9 Maintaining Cardiorespiratory Fitness during Rehabilitation 197

SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES

9-1 Frequency. intensity. type. and time. All of these
should be specific to the demands of hcr sport. For
example. she would ben efit more from interval train­
ing than endurance as she performs in short bursts
during a game. Her exercise should also incorporate
fl exibility and agility activities that would enhance
her fun ctional performance in the goal.
9-2 He should h ave a marked decrease in resting heart
rate and blood pressure. This is due in part to an in­
crease in stroke volume and cardiac output. He
should have a decreased body fat percentage as rest­
ing metabolic rate increases. encouraging energy
expenditure.
2. Exercise prescrip­
9-3 He might be reaching his maximum aerobic capac­
ity. Everyone has a limited inherited range of aerobic
capacity. Once an ath!lete reaches the upper end of
that range. it is unlikely the additional Significant im­
provement will occur.
9-4 Interval training. because the sport requires quick
sprints interrupted by short recovery periods.
9-5 They should be working at 85 to 90 percent of their
maximum heart rate during the work period and at
35 to 45 percent of their maximum heart rate dur­
ing the active recovery period.

0_ reserve and the

e;;pir aLO ry fitness.
H(l : 152-57.
198 7.Is vcnLilatory
nee capacity ? 111­
]90.
aspecb of oxygen
. Sport s Medicine

989. Percentage of

q Habitual level of
ndurance capacity
, Physiology 5H(~):

B ing. 1993. Excr­

lderations. Sports

!J of sport alld ('xer­

1. Effect of exercise
function. Medici ne
- 30.
n

iJ

J
 PART THREE

The Tools of Rehabilitation

10 Core Stabilization Training in Rehabilitation

11 Plyometrics in Rehabilitation

12 Open- versus Closed-Kinetic-Chain Exercise in Rehabilitation

13 Isokinetics in Rehabilitation

14 Joint Mobilization and Traction Techniques in Rehabilitation

15 PNF and Other Soft-Tissue Mobilization Techniques in Rehabilitation

16 Aquatic Therapy in Rehabmtation

17 Functional Progressions and Functional Testing in Rehabilitation

 CHAPTER 10 ell1ciently and L
-hain activities. ­
Traditionall)
olute strengt h I

Core Stabilization Training

planes of matior
planar and req
n amic stabiLizaLJ
in Rehabilitation
on e-plane domiJ
namically stabil
efl'iciency.l Undf
Mike Clark
quire a hi ghly c(
etic trainer to m
th e entire ki netr
and establish in!
ne uromuscu lar
dictates that \\1'
d dynamic sm
reate the rationale for core stabiliza­ netic chain acri\
Study Resources
A dynamic (
To becom e more familiar with the knowledge and skills tion training. be a key compon
n ecess~ry to design, implement. and document therapeu­
• Set up the guidelines for core stabiliza­ kinetic-chain n
tic rehabilitation programs as identified in the NA1i1 f lth­
'~ re stabiJizatior
letic Training Edllcalional Competencies and Clinical tion training. ntrol. ensure
Projlcimcies' Therapeutic Exercise content area, visit
ar throkinema tic
w\vw,mhbe,com/prenticell e, Also refer to the lab exer­ • Demonstrate appropriate exercises for
10\\1 for the ex.'Pn
cises in the new Laboratory Manual and to eSims, which each of the four levels in core stabiliza­ im prove neurOID
simulates the athletic training certi[ic1ition exam, at
tion training, netic chain. 2.1 ~ -
www.mhhe.comlesjms. For more online study resources .
visit our Health and Human Performance website at
www.mhhe.com/ hhp.
s we stress throughout this book. the athletic trainer WHAT IS
After Completion of This

Chapter, the Student Should

A needs to follow a comprehensive. systematic. and in­

tegra ted functional approach when rehabilitating an
athlete. To develop a comprehensive functional rehabilita­
The core is dcfil
The core is \\'
Be Able to Do the Following:
tion program. the athletic trainer must fully und erstand where all mo\'e
that attach (0 t
the functional kinetic chain-which requires understand­
• Describe the functional approach to ing the definition of function. Function is integrated. mul­ fic ient core a lJOl
tens ion rel atil
kinetic chain rehabilitation. tidimensional movement. 34,42.63 Functional kinetic chain
antagonists. \\-~
rehabititation is a comprehensive approach that strives to
• Explain the concept of the core. improve all components necessary to allow a patient to re­ oonships in Ih
turn to a high level of function. The athletic trainer must ille normal lent
• Organize the anatomical relationships understand that the kinetic chain operates as an inte­ rel ationships ~
between the musculature of the core. grated. interdependent, functional unit. Functional ki­ lumbo-pelvic-n
ID ovements. 9~"
netic chain rehabilitation must therefore address each link
• Review how the core functions to in the kinetic chain and strive to develop functional efficiency in the
acceleration.
maintain postural alignment and dy­ strength and neuromuscular eff1ciency. Functional strength
the entire ki n
namic postural equilibrium during is the ability of the neuromuscular system to reduce force,
produce force. and dynamically stabilize the kinetic chain It also provid
functional activities. during functional movements, upon demand, in a smooth ext remity move
coordinated fashion. 2 Neuromuscular efficiency is the ability The core
• Organize a procedure for assessing whereby the e
of the central nervous system (eNS) to allow agonists, an­
the core. tagonists. synergists. stabilizers, and neutralizers to work produce force.

200
 CHAPTER 10 Core Stabilization Training In RehabiJitation 201

efficiently and interdependently during dynamic kinetic against abnormal force,2 In an efficient state. each struc­
chain activities. l tural component distributes weight. absorbs force. a nd
Traditionally. rehabilitation has focused on isolated ab­ transfers ground reaction forces. 2 This integrated, inter­
solute strength gains. In isolated muscles. utilizing single dependent system needs to be trained appropriately to a'l­
planes of motion. However. aH functional activities are t ri­ low it to function efficien tly during dynamic kinetic chain
planar and require acceleration. deceleration. and dy­ achvities.
namic stabilization.'2.4l.li ) Movement might appear to be
one-plane dominant . but the other planes need to be dy­
namically stabilized to allow for optimal neuromuscular
CORE STABILIZATION TRAINING
efficiency.l Understanding that fun ctiona l movements re­ CONCEPTS
quire a highly complex. integrated system allows the ath­
Many individuals have developed the functional strength.
letic trainer to make a paradigm shift and focus on training
power. neuromuscu1lar control. and muscular endurance
the entire kinetic chain. utilizing all planes of movement
in speci.fic muscles to perform functional activities .2.34.54.lil
and establishing high levels of fUllctional strength and
ne uromuscular efficiency. IR.lil.li9. 71.H 1.91 The paradigm shift However. few people have developed the muscles required
for spina'l stabilization. 53 . 54 . >; The body's stabilization sys­
dictates that we train force reduction. force production.
tem has to be functioning optimally to effectiveIy utilize the
and dynamic stabilization to occur efficiently during all ki­
strength, power. neuromuscular control. and muscular
abiliza­ netic chaln activities. 12. 31
endurance that they have developed in their prime movers,
A dynamic core-stabilization training program shouJd
If the extremity muscles are strong and the core is weak.
be a key component of all comprehensive functional c1osed­
kinetic-chain rehabilitation programs. 1O.I S.12.21.14AH 1 A there will not be enough force created to produce efficient
stabiliza­ movements. A weak core is a fundamental cause of ineffi­
rare stabilization program will improve dynamiC postural
cient movements that lead to injury. 5 l.S4.ii.63
ro ntrol. ensure appropriate muscular balance and joint
The core musculature is an integral component of the
arthrokinematics around the lumbo-pelvic-hip complex. al­
.ercises for protective mechanism that relieves the spine of deleterious
10\\1 for the expression of dynamic functional strength. and
e tablliza­ forc es that are inherent during functional activities. 18 A
improve neuromuscular efficiency throughout the entire ki­
netic chain. 2.12.18.34. 16.42.h1.62.68.71.7273.92.9l core stabilization training program is designed to help an
individual gain strength. neuromuscular control. power.
and muscle endurance of the lumbo-pelvic hip complex.
This approach facilitates a balanced muscular functioning
at hletic trainer WHAT IS THE CORE?
of the entire kinetic chain. 2 Greater neuromuscular con­
lem atic. and in­
The core is defined as the lumbo-pelvic-hip complex. 2.B trol and stabilization strength will offer a more biome­
reh abilitating an
The core is where our center of gravity is located and chanica!!y efficient position for the entire kinetic chain .
i na l rehabilita­
where all movement begins.4h.47.R1.S2There are 29 muscles therefore allowing optimal neuromuscular efficiency
fully understand
hat attach to the lumbo-pelvic-hip complex. 7.8.34.8h An ef­ throughout the kinetic chain.
wres understand­
ficient core allows for maintenance of the normal length­ Neuromuscular efficiency is established by the appro­
integrated. mul­
ens ion relationship of functional agonists and priate combination of postural alignment (static/ dy­
aJ inetic cha in
antagonists, which promotes normal forc e-couple rela­ namic) and stability strength, which allows the body to
b that strives to
tionships in the lumbo-pelvic-hip complex. Maintaining decelerate gravity. grouod reaction forces. and momen­
\\" a patien t to [e­
the normal length-tension relationships and force-couple tum at the right joint, in the right plane. and at the right
eric trainer must
relationships allows optimal arthrokinematics in the time. U .n.62 If the neuromuscular system is not effiCient. it
crates a s an inte­
lumbo-pelvic-hip complex during functional kinetic chain will be unable to respond to the demands placed on it dur­
'r. uncLional ki­
movements.92.93.98 This provides optimal neuromuscular ing functional activities.l As the effIciency of the neuro­
f ad dress each link
effiCiency in the entire kinetic chain, allowing for optima! muscular system decreases, the ability of the kinetic chain
\ elo p function a l
acceleration, deceleration, and dynamiC stabilization of to maintain appropriate forces and dynamic stabilization
Functional strength
th e entire kinetic chain during functional movements, decreases significantly. This decreased neuromuscular effi­
ml to reduce force.
It a,lso provides proximal stability for efficient lower­ ciency leads to compensation and substitution patterns. as
the kinetic chain
extremity movements. 2. 34,46.47.» .fi l.Rl.R2.Y2.Yl well as poor posture during functional activities.Jh.92.93
mand. in a smooth
The core operates as an integrated functional unit. The resulting mechanical stress on the contractile and
'iellcy is the ability
\'hereby the entire kinetic chain works synergistically to noncontractile tissue produces repetitive microtrauma.
allow agonists. an­
produce force. reduce force, and dynamically stabilize abnormal biomechanics. and injury. 18.36.69.70
l"Utra lizers to work
202 PART THREE The Tools of Rehabilitation

sland fun ctional anatomy, lumbo-pelvic-hip complex sta­ fidus. These mu

CLINICAL DECISION MAKING Exercise 10-1
bilization mechanisms, and normal force-couple relation­ advantage fo r !
ships. 5.7.H.8h primarily type
A gymnast bas been having low bACk pain. She is other­
wise a very fit and healthy ath lete. You suspect th ilt her
A review of the key lumbo-pelvic-hip complex muscu­ for primarily I
lature will help the athlelic trainer understand funclional round that th e
pain might be disc related. How might core weakness be
anatomy and develop a comprehensive kinetic chain reha­ two to sLx ti m
contribuling to her problem. and how can carl' strength­
bilitation program. The key lumbar spine muscles include larger muscles.
ening benefit herr
tite transversospinalis group, erector spinae, quadratus group is pri mcu
lul11boru111, and latissimus dorsi (Figures 10-1 and 10-2). propriocepli\'e I
The key abdominall11uscIes include the rectus abdominis, ble for inter/i n l
external abdominal oblique. internal abdominal oblique. eccen tric decel<1
REVIEW OF FUNCTIONAL and tra nsversus abdol11inis (Figure 10-2). The key hip unit during r~
ANATOMY musculature includes the gluteus maximus. gluteus ospinalis grou
medius. and psoas (Figure 10-3). pressive a nd te
To fully under~tand functional core stabilization training The trunsver sospinalis group includes the rotatores. an d therefore nl
and rehabilitation. the athletic trainer must fully un der­ inLerspinales. inlertransversarii. semispinalis, and multi­ n amic postural
efficiency or th
th e most im porj
has the abilit}
we lumbar spi
creased segment

Superior nuchal line

Atl?s (( 1)
Axis ((2)
• .' 'f1t,
t ,-
'- 'It~.
. rtfr .
J ,
Mastoid process . .
Semispinalis capills
m ultifidus.
Thekeybac
catus lu mboCUlll
m uscle grou p fl
Longissimus capitis } •
Splenius capitis ~ til . . . . . . Spinous process ((7)

Serratus posterior superior ... ~A l~

Splenius cervicis ----I---~~d.U1~ii

l'locosta I'IS ______~~"'.I~~1I6t!i1~,i·II---Semispinalis

• thoracis
Erector
spinae
muscle uLongissimus -------:~~rt
Spinalis

Serratus posterior inferior ~..a:...

External intercostals
Pectore

j~t Rotatores
~ . ~.;;" :r Multifidus
Internal abdominal oblique • ": Interspinalis '
External abdominal oblique I":~l ..... Quadratus lumborum Linea a lb

Iliac crest ~-:;' '---Intertransversorius

Rectus
Umbilic
......,. Erector spinae (~utl
Linea se:

Aponeun
abdomi

Figure 10-1 Spinal muscl es. Figure ]


_-h ip complex sta­ fidus, These muscles are small and have a poor mechanical
~e -couplerelation- advantage for contributing to motion. J2.~1i They contain
primarily lype I muscle l1bers and arc therefore deSigned
p complex muscu­ for primarily ,for stabilization. l1 . xh Researchers llh have
er land functional found that the transversospinaUs muscle group contains
tinetic chain reha­ lWo to six times the number of muscles spindles found in
1 m uscles include la rger muscles. Therefore, il has been established that this
pinae, quadratus
group is primarily responsible for providing the e NS with
.1 0-1 and 10-2).
proprioceptive information. R(, This group is also responsi­
. rec tus abdominis,
ble for interlinl ra segm entlll slllbili'l.ation and segmental
ominal oblique, eccentric deceleration of flexion and rolation of the spinal
-2\' The key hip unit during functional movemen ts. i.~h The lransver­
aximus, gluleus sospinalis group is constanLly pUl under a variety of com­
pressive and tensile forces during func tional movements
Jdes the rolatores, and therefore needs to be trained adequa tely to allow dy­
. a ils, and multi­ namic postural stabilization and optimal ne uromuscular
efficiency of the entire kinetic chain. sh The muJUfidu,5 is
th c most ,important of the transversospinalis mllscles. Tt
has th e ability to provide intrasegmental stabiliZUlion to
the lumbar spine in all positions.1 2 .99 VVilke 99 found in­
creased segmental stiffness at L4-L5 with activatio n of t he
multifidus.
The kcy back muscles include the eredor spinae, quad­
rat us lumborum, and latissimus dorsi. The erector spinae
:nuscIe group functions to provide dyoamic intersegmeIl-
Pectoralis major - - - ---1--0#--
Linea alba - - - - - - - - ---....- t - - - j
Rectus sheath ---------J[Io,.......:;~
Umbilicus - - - - - - - - - ­ A-......,....,."..­
Linea semilunaris - - - - - - - - - - ,....-'--fII
Aponeurosis of external - - - ­ -:---";..::..,.,-:-­
abdominal oblique
Figure 10-2 Abdomina l muscles.
CHAPTER 10 ('ore Stabilization Tr'aining in Rehabilitation 203
tal stahilization and eccenlric deceleration of "r unk f1ex,i on
and rotation during kinetic ch a in activities. R6 The quadra­
tus lumborum muscle functions primarily as a frontal
plane stabilizer that works synergistically with the gluteus
m edi us a nd tensor fas cia lata . The latissimus dorsi has the
la rges l mo ment arm of nil back musGles and thererore has
lhe grealest effect oOn th e Jumbo-pelvic-hip complex. The
latissimus dorsi is th e bridge belwecn the upper extremity
a nd the lumbo-pelvic-hip cornp'lcx. Any [unctional upper­
extremity kinetic chain rehabililation has to pay particu­
lar atLenlion to the latissimus dorSi and its function on the
lumho-pelvic-hip complex 86
The abdorninals are made up of four muscles: rectus
ahdominis. exle rnnl abdominal oblique, internal abdomi­
nal oblique, and It-,lI1sversu s ahdominis .86 The abdominals
operate CIS an integra ted fu nc tional unit, which helps
l11C1intain optimal spinul kinem a tics. ) .7., .R6 When working
efficienLiy, the a bdominals offer sagittal. frontal. and trans­
versc plane stabili.zation by controlling forces that reach
th e lumho-pelvic-hip complex.H6 The reclus abdominis ec­
ce nlrically dccclerates trunk extension and lateral ,flexion,
and provides dyn<1mic stabilization during functional
Il1CJvemenls. The extern a l obHques work concentrically to
produce contralateral rolation and ipsilateral lateral flex­
ion , and work ecce ntrically to decelera le trunk extension ,
iOl-~.,.:r--- Latissimus dorsi
:J.,.ir.t~--'::-':":--- Serratus anterior
External abdom inal
-'-,r;r-"----'-- -
oblique
t--T-:::::::;II~:------- Rectus sheath (cut edges)
--i c 'e'!""'~-----Transversus abdominis
··~b-:.!------Internal abdominal oblique
+ ­ -=-=':-"--:­ - - - - - Rectus abdominis
- :'----:------Inguinal ligament
r:--­ - -::-'-- - - - ­ Inguinal canal
204 PART THREE The Tools of RehabiHtation

Iiacus
Iliopsoas
Psoas

External
Adductor
obturator
magnus
Adductor
brevis
Adductor \ ~ ....
longus

Adductor ''II
magnus

Gracilis ,"\ 1 -.

Fibula : d
Tibia • ,
Insertio~
gracilis on
A tibia

Figure lO-3A Hip muscles, A. Anterior.

(Reproduced. with permission. from K. S. Saladin. Anatomy and Physiol­

ogy. New York. WCB/McGraw-Hill. 1998. pp. 363 and 367.)

min is works b}
tional stabilization of the spinal unit. 4 7 .55
The transversus have demon:
rotation. and lateral llexion during functional move­
do minis preced
ments. R6 The internal oblique works concentrically to pro­ abdominis is probably thc most important of the abdomi­
nal muscles. The transversus abdominis functions to in­ contraction of
duce ipsilateral rotation and lateral flexion. and works
crease intra-abdominal pressure. provide dynamic (he direction
eccentrically to decelerate extension. rotation. and lateral
stabilization against rotational and translational stress in demonstrated
flexion. The internal oblique attaches to the posterior layer
the lumbar spinc. and provide optimal neuromuscular ef­ dominis is actJ\1
of the thoracolumbar fascia. Contraction of the internal
ficiency to the entire lumbo-pelvic-hip complex .53. 54.;;'56.(,5 thatlhis mu
oblique creates a lateral tension force on the thoracolum­
1i7.a lion . >i
bar fascia, which creates intrinsic translational and rota­ Research has demonstrated that the transversus abdo­
 CHAPTER 10 Core Stabilization Truining in Rehabilitation 20S

14----Gluteus medius

00...-:;,.......­ Gluteus maximus

r - - - - , : .- Addudor magnus

Vastus laterolis

Hamstring muscles
Biceps femoris
:""';"---long head
'-­- - ­ Short head

.........._ - - Semitendinosus

~--.=~--- Semimembranosus

Figure 10-38 Continued Hip muscles. 8, Posterior.

minis works by a feed-forward mechanism." Researchers Key hip muscles include the psoas. gluteus medius,
have demonstrated tha t con traction of the transversus ab­ gluteus maximus, and hamstrings. 7.R.HI> The psoas pro­
- - '> The
transversus
dominis precedes the initiation of limb movement and duces hip flexion and external rotation in the open-chain
of the abdomi­
contraction of all other abdominal muscles. regardless of position. In Ule closed-chain position, it produces hip flex­
is functions to in-
:he direction of reactive forces. 3J.5S Cresswell JO .11 has ion, lumbar extension, lateral flex ion. and rotation. The
provide dynamic
dcmonstrated th at, like the multifidus. the transversus ab­ psoas eccentrically decelerates hip extension and internal
slation al stress in
clominis is active during all trunk movements. suggesting rotation, as well as tru nk extension. lateral flexion, and
neuromus cular ef­
com plex. 5J .)4 . \ 5.56.6; that this muscle has an importa nt role in dynamic stabi­ rotation. The psoas works synergistically with the supcrfi­
lization. 54 cial erector spinae and creates an anterior shear force at
transversus abdo-
206 PART THREE The Tools of Rehabilitation

L4-LS. 86 The deep erector spinae. multifidus. and deep ab­ tivity during functional activities leads to pelvic instability segments in tt
dominal wall (transverse. internal oblique. and external and decreased neuromuscular control. This can eventu­ leads to abn o,
oblique)s6 counteract this force. It is extremely common ally produce muscle imbalances. poor movement patterns. segmen ts in til
for athletes to develop tightness in their psoas. A tight and injury. dysfunctional ·
psoas increases the anterior shear force and compressive The hamstrings work concentrically to flex the knee. ex­ patterns and tl
force at the L4-LS junction. s6 A tight psoas also causes re­ tend the hip. and rotate the tibia. They work eccentrically to ment creates.
ciprocal inhibition of the gluteus maximus. multifidus. decelerate knee extension. hip flexion. and tibial rottltion. positions to m ~
deep erector spinae. internal oblique. and transversus ab­ The hamstrings work synergistically with the ACL. 86 kinetic chain .'
dominis. This leads to extensor mechanism dysfunction All of the muscles mentioned play an integral role in tion program \\
during functional movement patterns.6 1.68.70.71.72.8r,.92 the kinetic chain by providing dynamic stabilization and lion patterns
Lack of lumbo-pelvic-hip complex stabilization prevents optimal neuromuscular control of the entire lumbo­ control during
appropriate movement sequencing and leads to synergis­ pelvic-hip complex. These muscles have been reviewed to
tic dominance by the hamstrings and superficial erector emphasize to the athletic trainer that muscles not only
MUSCUL
spinae during hip extension. This complex movement dys­ produce force (concentric contractions) in one plane of
function also decreases the ability of the gluteus maximus motion. but also reduce force (eccentric contractions) and :\n optimally rL
to decelerate femoral internal rotation during heel strike. provide dynamic stabilization in all planes of movement ment of muse].
which predisposes an individual with a knee ligament during functional activities. When isolated. these muscles The human mG
injury to abnormal forces and repetitive micro­ do not effectively achieve stabil.ization of the lumbo-pelvic­ em of interrel.
trauma. I8.2 1.6 1.71.72 hip complex. It is the synergistic. interdependent function­ The function al
The gluteus medius functions as the primary frontal­ ing of the entire lumbo-pelvic-hip complex that enhances man movement
plane stabilizer during functional movements. 81l During the stability and neuromuscular control throughout the efficiency. Aller;
closed-chain movements. the gluteus medius decelerates entire kjnetic chain. balance. and n
femoral adduction and internal rotation. so A weak gluteus functioning of l
medius increases frontal- and transverse-plane stress at of the kindic cI
CLINICAL DECISION MAKING Exercise 10-2
the patellofemoral joint and the tibiofemoral joint. 86 A a ny pathology 0
weak gluteus medius leads to synergistic dominance of Ihe tion involvin g S(J
Last year a tennis player sufi'ered a knee injury. She tore
tensor fascia latae and the quadratus lumborum.2).6 o.6l merous compell
her ACL. MeL. and meniscus. She is competlng now but
This leads to tightness in the iliotibial band and the lumbar interplay of m ill
complains of recurrent back pain. She bas rather poor
spine. This will affect the normal biomechanics of the the coordinated
posture and significant postural sway. Could sh e benefit
lumbo-pelvic-hip complex and the Ubiofemoral joint as normal arth ro
from core training. and how would you go about selecting
well as the patellofemoral joint. Research by Beckman 9 has normallength-tc
exerclses for her?
demonstrated decreased EMG activity of the gluteus couple relatio nsl
medius following an ankle sprain. The athletic trainer control. If one q
must address the altered hip muscle recruitment patterns its degree of a
or accept this recruitment pattern as an injury-adaptive neutralizers ha\.'
POSTURAL CONSII)ERATIONS tightness has a
strategy and thus accept the unknown long-term conse­
quences of premature muscle activation and synergistic The core functions to maintain postural alignment and dy­ \fuscle tightn
dominance. 9 .36 namic postural equHibrium during functional activities. rionship.92 Th ' - .
The gluteus maximtls functions concentrically in the Optimal alignment of each body part is a cornerstone to a hjp. When one I
open chain to accelerate hip extension and external rota­ functional training and rehabihtation program . Optimal changes the n
tion. It functions eccentrically to decelerate hip flexion and posture and alignment will allow for maximal neuromus­ partners. 18. 6S. 9~ .A
femoral internal rotation. 86 It also functions through the cular emciency. because the normal length-tension rela­ gtSlic fu netion 0
iliotibial band (ITB) to decelerate tibial internal rotation. 86 tionship. force-couple relationship. and arthrokinematics abnormal pres5uJ
The gluteus maximus is a major dynamic stabilizer of the will be maintained during functional movement pat­ :;oft tissues. 1\lu
sacroiliac joint. It has the greatest capacity to provide in­ terns.IR.l4.l6.19-61.6l.65.h9.7l.n9J If one segment in the ki­ iLion. IS .36.,8-bl
creased compressive forces at the SI joint secondary to its netic chain is out of alignment. it will create predictable .hroughout the
anatomical attachment at the sacrotuberous Jigament.% patterns of dysfunction throughout the enUre kinetic ,'n tire kinetic cba
It has been demonstrated by Bullock-Saxton 16.1 7 that the chain. These predictable patterns of dysfunction are re­ ,'iprocal inhibidq
EMG activity of the gluteus maxlmus is decreased follow­ ferred to as serial distortion pattcms. 34 Serial distortion pat­ abdomjnis. inl
ing an ankle sprain. Lack of proper gluteus maximus ac­ terns compromjse the body's structural integrity because Th is muscle im
 CHAPTER 10
segments in the kinetic chain are out of alignment. This
leads to abnormal distorting forces being placed on the
segments in the kinetic chain that are above and below the
dysfunctional segment.1 8. J4.36.63 To avoid serial distortion
flex the knee, ex­ patterns and the chain reaction that one misaligned seg­
- e centrically to ment creates , the athletic trainer must emphasize stable
d tibial rotation. positions to maintain the structured integrity of the entire
kinetic chain.ls.J4.h3.71.72 A comprehensive core stabiliza­
~ the ACL. 86
~n integral role in tion program will prevent the development of serial distor­
.labilization and tion patterns and provide optimal dynamic postural
e entire lumbo­ control during functional movements.
been reviewed to
muscles not on'ly MUSCULAR IMBALA'NCES
in one plane of
:on tractions) and An optimally functioning core helps prevent the develop­
ment of muscle imbalances and synergistic dominance.
The human movement system is a well-orchestrated sys­
.he lumbo-pelvic­ tem of interrelated and interdependent components. 1R.6H
n dent function­ The functional interaction of each component in the hu­
man movement system allows for optimal neuromuscular
x tbat enhances
throughout the efficiency. Alterations in joint arthrokinematics, muscular
balance, and neuromuscular control affect the optimal
functioning of the entire kinetic chain. 1B.92.93 Dysfunction
of the kinetic chain is rarely an isolated event. Typically
Exercise 10-2 any pathology of the kinetic chain is part of a chain reac­
tion involving some key links in the kinetic chain, with nu­
erous compensations and adaptations developing. f>R The
in terplay of many muscles about a joint is responsible for
the coordinated control of movement. If the core is weak,
normal arthrok,i nematics are altered. This changes the
ut selecting normal length-tension relationships and the normal force­
ouple relationships, which in turn affects neuroffillsculax
ontrol. If one muscle becomes weak or tight. or changes
Its degree of activation. then synergists, stabilizers, and
neutralizers have to compensateY·3h.68.71.72.71.92.93 Muscle
~TIONS
tightness has a significant impact on the kinetic chain.
alignment and dy­ \Iuscle tightness affects the normal length-tension rela­
ctional activities. tionship. 92 This impacts the normal force-couple relation-
a cornerstone to a hip. When one muscle in a force-couple becomes tight, it
program. Optimal ba nges the normal arthrokinematics of two articular
aximal neuromus­ rtners.1 8.68.92 AUered arthrokinematics affect ,t he syner­
glb-tension rela­ gi tic function of the kinetic chain. JB.J6.6R.92 This leads to
a n brokinematics abnormal pressure distribution over articular surfaces and
at movement pat­ ft tissues. Muscle tightness also leads to reciprocal inhi­
ition.18.J6.58-bl.b8.95.98 Therefore, muscle imbalances
gillent in the ki­
create predictable ..hroughout the lumbo-pelvic-hip complex can affect the
lhe entire kinetic entire kinetic chain. For example, a tight psoas causes re­
y 'fun ction are re­ procal inhibition of the gluteus maximus. transversus
ominis, internal oblique. and multifidus. ;l.60.6l.80.86
n al distortion pat­
integrity because h is muscle imbalance pattern may decrease normal
Core Stabilization Training in Rehabilitation 207
lumbo"pelvic-hip stability. SpeCific substitution patterns
develop to compensate for the lack of stabilization, includ­
ing tightness in the iliotibial band. 36 This muscle imbal­
ance pattern will lead to increased frontal and transverse
plane stress at the knee. A strong core with optimal neuro­
muscular effiCiency can help prevent the development of
muscle imba'lances. Therefore. a comprehensive core sta­
bilization training program should be an integral compo­
nent of all rehabilitation programs.
NEUROMUSCULAR
CONSIDERATIONS
A strong and stable core can improve optimal neuromuscu­
lar efficiency throughout the entire kinetic chain by helping
to improve dynamic postural control. ;Ul.i5.64.KH.9l.91
Several authors have demonstrated kinetic chain imbal­
ances in individuals with altered neuromuscular con­
trol. Y.16. 17.j,~ . S J .5-1.55.5 b. is-f>2.hH.69.iO.i J.i2.73.79.811.88.91 Research
has demonstrated that people with low back pain have
an abnormal neuromotor response of the trunk stabiliz­
ers accompanying limb movement. 5J.i4.80 It has been
shown that individuals with low back pain have signifi­
cantly greater postural sway and decreased limits of sta­
bility, and that approximately 70 percent of patients
suffer from recurrent episodes of back pain. Further­
more, individuals have decreased dynamic postural sta­
bility in the proximal stabilizers of the lumbo-pelv,i c-hip
complex following lower-extremity ligamentous il1­
juries.9.16.17.18 It has also been demonstrated that joint
al1d loigamentous injury can lead to decreased muscle ac­
tivity.31.36.9i.98 Joint and 'ligament injury can lead to joint
effusion, which in turn leads to muscle inhibition. 33This
teads to altered neuromuscular control in other seg­
ments of the kinetic chain secondary to altered proprio­
ception and kinesthesia. 9. J6 Therefore, when an
individual with a knee ligament injury has joint effu­
sion, all of the muscles that cross the knee can be inhib­
ited. Several muscles that cross the knee joint are
attached to the lumbo-pelvic-hip complex. 8b Therefore. a
comprehensive rehabilitation approach should fOCll S on
reestablishing optimal core function .
Research has also demonstrated that muscles can be
inhibited from an arthrokinetic reflex.IR.68.9i.98 This is
referred to as atherogenic muscle inhibition . Arthroki­
netic reflexes are reflexes that are mediated by jOint re­
ceptor activity. II' an individual has abnormal
arthrokinematics. the muscles that move the joint will
be inhibited. For example, if an individual has a sacral
208 PART THREE The Tools of Rehabilitation

Figure 10-5

Figure 10-4 Cores strength can be assessed using a straight leg lowering test.

It bas heen dt
torsion, the multifidus and the gluteus medius can be in­ function for muscle imbalances and arthrokinematic percenL of the g'
hibited. 52 This will lead to abnormal movement in tbe ki­ deficits. Many reference sources provide tborough expla­ pain. 4 It has also
netic chain. Tbe tensor fascia latae will become nations of a comprehensive muscle imbalance assessment low back pain
synergistically dominant and become the primary proced u re.l. 1R.21.2 2.21. 34'so. 58.62." 1.73.92 .91.98
erector spinae
frontal-plane stabilizers 6 Tbis can lead to tigbtness in Core strengtb can be assessed by utilizing the straigbt abnormal dyn a
the iliotibial band. Tbis can also decrease frontal- and leg lowering test4.56.65.79.92.9J (Figure 10-4). The atblete is functional acti\ i
transverse-plane control at the knee. Furthermore, if placed supine. A blood pressure cuff is placed under ,t be muscular contr
the multifidus is inbibited ,52 the erector spinae and tbe lumbar spine at approximately L4-L5 . The cuff pressure is an assessment 0'
psoas become facilitated. This will furtber inbibit tbe raised to 40 mmHg. Tbe athlete's legs are maintained in Erector spinae Il
lower abdominals (internal oblique and transversus ab­ full extension while the athlete flexes the hips to 90 de­ ,he athlete 'lie Pq
dominis) and tbe gluteus maximus. 53 . 54 decreasing grees. The athlete is instructed to perform a drawing-in behind the head;
frontal- and transverse-plane stability at tbe knee. An ef­ maneuver (pull bellybutton to spine) and tben flatten tbeir axis of a goniol1l
ficientcore will improve neuromuscular efficiency of tbe back maximally into the table and pressure cufr. Tbe ath­ the lateral side
entire kinetic cbain by providing dynamic stabilization lete is instructed to lower tbeir legs toward tbe table while urm is para'llel to
of the lumbo-pelvic-bip complex and tberefore improve maintaining their back flat. The test is over when the pres­ tcnd at the lum
pelvofemoral biomechanics. This is yet another reason sure in the cuff decreases. The hip angle is then measured lion for as lon g
that all rehabilitation programs should incl'ude a com­ with a goniometer to determine the angle. limes tbe test. 4
prebensive core stabilization training program. Lower abdominal neuromuscular control, is assessed in Power of the
a similar fashion 4 . 56 (Figure 10-5). The athlete is supine wei!. Power prod
ASSESSMENT OF THE CORE with tbe knees and hips flexed to 90 degrees. The pressure sessed by perforn
cuff is placed under the lumbar spine at L4-LS and inflated The athlete is i n ~
Before a comprehensive core stabilization program is imple­ to 40 mmHg. The athlete is instructed to perform a drawing­ tween their leg, a
mented', the atblete must undergo a comprebensive assess­ in maneuver to stabilize the lumbar spine. and then to jump as high a
ment to determine muscle imbalances. arthrokinemalic slowly lower the legs until the pressure in the cuff decreases. the medicine ball
deficits. core strengtb, core neuromuscular controL core This indicates the ability of the lower abdominal wall to pref­ is measured froll
muscle endurance, core power, and overall function of tbe erentially stabilize tbe lumbo-pelvic-hip complex. When the medicine ball std
lower-extremity kinetic chain. lumbar spine begins to move into extension. the hip f1exors power proc!uctio
Because muscle imbalances and artbrokinematic begin to work as stabilizers. This increases anterior shear i\ lower-extfl
deficits can cause abnormal movement patterns tbrough­ forces and compressive forces at tbe L4-LSlum'bar segments carried out on ill
out the entire kinetic chain, it is extremely important to and inhibits the transversus abdominis, internal oblique, fhesc tests shOll
thoroughly assess each athlete with a kinetic chain dys­ and multifidus. jump tests. powe(
 CHAPTER 10
A B
Figure 10-5 Lower abdominal neuromuscular assessment. A, Beginning position. B, Ending position.
It has been demonstrated that approximately 80 to 85
percent of the general population suffers from low back
p<lin. 4 It h<lS also been demonstrated that individuals with
low back pain have decreased muscle endurance in the
erector spinae muscle group.4. 11.16.46.47 This leads to
abnormal dynamic stabilization and movement during
runctional. activities. which will res ult in abnormal neuro­
muscular control. Therefore. all athletes should undergo
an assessment of muscle endurance in the lumbar spine.
Erector spinae performance can be assessed by having
the athlete lie prone on a treatment table. hands crossed
a drawing-in behind the head. The axilla is used as a reference for the
the n fla tten their axis of a goniometer. The adjustable arm is aligned with
cuff. The ath­ the lateral side of the body and chin while the st<ltionary
ard the table while arm is parallel to the table. The athlete is ,i nstructed to ex­
:end at the lumbar spine to 30 degrees and hold the posi­
tion for as long as they can while the athletic trainer
limes the test. 4
ntrol is assessed in Power of the core musculature needs to be assessed as
e athlete is supine welL Power production of the core musculature can be as­
_rees. The pressure sessed by per!ocming an overhead medicine ball throwY
L4-L5 and 'inf1ated The <lthlete is instructed to hold a 4-kg medicine ball be­
perform a drawing­ Iween their legs as tlley squat down. They arc instructed to
spine. and then to jump as high as possible while simultaneously throwing
n the cuff decreases. the medicine ball backward over their head. The distance
minal wall to pref­ is measured from a starting line to the point where the
c mplex. When the medicine ball stops. This is an assessment of total body
i n. the !-tip f1exors power production with an emphasis on the core.
as s anterior shear A [ower-extremity functional proi1le should also be
l 'i lumbar segments carried out on all athletes with kinetic chain dei1cits.4H
j . internal oblique. [ hese tests should include isokinelic tests. balance tests.
iump tests, power tests. and sport-specillc functional tests.
Core Stabilization Training in Rehabilitation 209
CLINICAL DECISION MAKING Exercise 10- 3
As parI of a preparticipation screening you want to look
for athletes who may be prone to low back pa in. What
evaluative test can you use to do this?
SCIENTIFIC RATION'ALE FOR
CORE STABILIZATION TRAINING
Most individuals train their core stabilizers inadequately
compared to other muscle groups.2 Although adequate
strength. power. muscle endurance. and neuromuscular
control are imporlant for lumbo-pelvic-hip stabiljjzation.
performing exercises incorrectly or performing exercises
that are too advanced is detrimental. Several authors have
found decreased l1ring of the transversus abdominis. inter­
nal obl,ique. multil1dus. and deep erector spinae in individ­
uals with chronic low back pain. 53.54.15.56.80.87 Performing
core training with inhibition of these key stabilizers leads
to the development of Illuscle imbalances and inefficient
neuromuscular control in the kinetic chain. It ha ~ been
demonstrated that abdominal training without proper
pelvic stabilization increases intradiscal pressure and com­
pressive forces in the lumbar spine.4.10.Sl.i4.ii.i6.77.7H rur­
thermore. hyperextension training without proper pelv,ic
stabilization can increase ,in tradiscal pressure to danger­
ous levels. cause buckling of the ligamentum l1avurn. and
lead to narrowing of the intervertebral foramen. 4.1().7S
Research has also demonstrated decreased stabiliza­
tion endurance in individuals with chronic low back
210 PART TH REE The Tools of Rehahilitation

pain. 11l . l9 .4h.47The core stabilizers arc primarily type r slow­ Uons). and dynamic stabilization (isometric contTactions). dynamic. com
twitch muscle I1bers.4fi.47.S1.82 These muscle's respond best The core stabilization program should begin in the most si ty 21.2l.14 .'E ;(
to time under tension . Time under tension is a method of challenging environmenl the athlete can control. A pro­ The goal of
contraction thatlasl~ for 6 to 20 seco nds and emphasizes gressive continuum of function should be followed to sys­ mal levels of
hypercontractions at end ranges of motion. This method tematically progress the athlete. The program should be lion. 1Hl Neun
impr(lves intramuscular coordination. which improves manipula ted regularly by changing any of the following program in51l
static and dynami c stabilization. To get the appropriate variables: plane of motion. range of moLion . loading pa­ gains. lH . H .;5 .....
training stimulus. the athletic trainer must prescribe the rameters (Physioball. medicine ball. bodyblade. power lizing a m u!
appropriate speed of movement for all aspects of exer­ sports trainer. weight vest. dumbbell. tubing. etc.). body Physioball. OJ
cises.21.2 l Core strength endurance must be trained appro­ pOSition. alJlount of control. speed of execution . amount of cobra belt. dun
priately to allow the athlete to maintain dyn a mic postural feedback. duration (sets. reps. tempo. time under tension) . portant than iJ
control for prolonged periods of time.4 and frequency. Please refer to Tables 10-1 through 10-4 cept of qua li ty
Decreased cross-sectional area of the muitindus has for specil1c guidelines. ua ining is spec
been found in subjects with lower back pain. with no spon­ and neLlrom u
taneous recovery of the multindus folloWing resolution of n cerned Ilitt
CLINICAL DECISION MAKING Exercise 10-4
symptoms.;2 It has also been shown that the tradi tional the C'\S. A n a1
curl-up increases intradiscal pressure and increases com­ poor neurom w
You have had a track athlete on a core stabilization pro­
pressive forces at L2_L3. 4 . 10. 77 .7S terns and poor
gram for several weeks. She has been progressing well but
Additional research has demonstrated increased EMG
needs a different challenge. What can you do to change
activity and increased pelvic stabilization w'h en an abdom­
up her program?
inal drawing-in maneuver was performed prior to init,i at­ • TABLE
ing core training.4.lll,l.i.21. ill.; Uh .76. 79.SS 1\ Iso. main tain ing
the cervical spine in a neutral position during core train­ Plane of III
ing will improve posture. muscl e balance. and stabiliza­ , Ran ge of
tion. If the head protracts during movement. then the Specific Core Stabilization Guidelines Loading p
sternocleidomastoid is prelerentiaJly recruited . This in­ "Vhen designing a functional core stabilization training - Body posil'
creases the compressive forces at the O-Cl vertebral junc­ ~peed of III
program . the ath 'letic trainer should create a propriocep­
tion . This can also lead to pelvic instability and musCole tively enriched environment and select the appropriate ex­
,i mbalances secondary to the pelvo-occular reflex. This re­ ercises to elicit a maximal training response (,fable 10-] ). - Dur ation
flex is important to maintain the eyes level. 68.h9 If the ster­ Frequ eD<l
The exercises must be safe and challenging. stress multiple
nocleidomastoid muscle is hyperactive and extends the planes. incorporate a multisensory env,i ronment. be de­
upper cervical spine. then the pelvis will rotate anteriorly rived from fundClmental movement skills. a_od be aclivity­
to realign the eyes. This can lead to muscle imbalances and specific (Tables 1'0-2 and 10- 3) .
decreased pelvic stabilization. 6 s .6 9 • TABLE
The athletic tra iner should follow a progressive func­
tional continuum to allow optimal adaptations. H.42.5lJ.63
GUIDELINES FOR CORE The following are key concepts for proper exercise progres­
sion: slow to fa st. simple to complex. known to unknown.
STABILIZATION TRAINING
low force to high force. eyes open to eyes closed. static to
Prior to performing a comprehensive core stabiJization
program. each athlete must undergo a comprehensive
evaluation to determine muscle imbalances. myokine­ • TAB LE 10-1 Guidelines for Core Stabi­
matic deficits. arthrokinematic deflcits. core strength! lization Training Program.
neuromuscular control/power. and overall kinetic chain TABLE
function. All muscle imbalances and arthrokinerna tic 1. The program should be bascd on science.
del1cits need to be corrected prior to initiating an aggres­ 2. The program should be systematic. progressive. and
sive core-training program . fun ctional.
A comprehensive core st.abUizaLion training program 3 . The program sho uld begin in the most challenging cn­
should be systematic. progressive. and functional. 'flle re­ viwnment the athlete can control.
habiJitation program should emphasize the entire mu scle 4. The program should be performed in a propriocep­
contraction spectrum. focusing on force production (con­ tively cnriched environment.
centric contracLions). force reduction (eccentric contrac-
 CHAPTER 10 Core Stabilization Training in Rehabilitati on 211

tric co ntraclions) . dynamic. correct exec ution to increased reps/sets/inten­ • TABLE 10-5 Guidelines for a

begin in the most

si ty 22.1 3.IH2.S0.h3 (Table 10-4). Functional Core

n contml. A pro­
The goal of core stabilization should be to develop opti­ Stabilization Program.

be followed to sys­
mal levels of functional strength and dynamic stabiliza­
rogram should be tion .2.W Ne ural adaptations become the focus of the 1. Is it dynamic?

y of the followi.ng
program instead of striving for absolute strength 2. Is it multiplanar?

otion. loading pa­

gains. 1H.H.51.h4.7Y fncreasing proprioceptive demand by uti­ 3. Is it multidime nsional?

b dybladc. power
lizing a multisensory. multimodal (Tubing. body blade. 4. Is it proprioceptively enriched?

t ub ing. etc. ). body

l'hysioball. medicine ball. power sports trainer. weight vest. 5. Is it systematic?

u lio n . a mount of
cobra belt. dumbbell. etc. ) environment becomes more im­ 6. Is it progressive?

e under tension ).
por tant than increasing the external resistan ce. The con­ 7. Is it activity-specific?

C -1 through 10-4
cept of quality before qu a ntity is stressed. Core stabilization 8. Is it based on functional anatomy and science?
training is specifically designed to improve core stabilization
und neuromusc ular efficiency. The athletic trainer must be
concerned with the sensory information that is stimulating
Exercise 10-4 must be on function. To determine whether a program is
the eNS. An athlete who train s with poor technique a nd functional. answer the questions in Table] 0_5.34.42.63
poor neuromuscular control will develop poor motor pat­
lization pro- terns and poor stabilization. 14.63 The focus of the program
CLINICAL DECISION MAKING Exercise 10-5

iI Guidelines
illzation tra ining
cate a propriocep­
lhe appropriate ex­
use ('J'able 10-1).
• TABLE 10·2 Program Variation. You have been trAining a softball player on a corc­
strengthening program for a week. She has been making
1. Plane of motion improvements. and you think that it is time to progress
2. Range of motion her. What is your goal. and what parameters hould you
3. Loading parameter consIder when progre Ing her,
4. Body position
5. Speed of movement
6. Amount of control
7. Duration
CORE STABILIZATION TRAINING
PROGRAM
8. Frequency
Figures 10-6 through 10-9 illustrate the exercises used in

. ami be activity- a comprehensive core stabilization training program .

• TABLE 10·3 Exercise Selection. There are four levels to th e core stabilization training pro­

a progressive func­ gram: level 1 (stabilization) (Figure 10-6): level 2 (sta bi­
aptations. H .41 . 'O.h I 1. Safe lization and strength) (F igure 10-7): level 3 (integrated
r exercise progres­ 2 . Challenging stabilization stre ngth) (Figure 10-8 ); and levcl4 (explosive
wn to unknown. 3. Stress multiple planes
stabilization ) (Figure 10-9). The athlete is started with the
closed. static to
4. Proprioceptivelyenriched exercises at the high est level at which they can maintain
5. Activity-specific stability and optimal n euromuscular control. They are
progressed through the program when they achieve mas­
for Core Stabi­ tery of the exercises in the previous level. l.1·un. 12. 15.
1 7. l 8.11.2 3.14.25. 29.34,19.4 2.4 3.4-1.-15.4 h.4 7 AS. 5 5, ~6.62.6 ~.64. 7 t 76, 79. 90. 9 1
raining Program.
• TABLE 10·4 Exercise Progression.
CLINICAL DECISION MAKING Exercise 10 6
1. Slow to fa st
2. Simple to co mpl ex A golfer has been out of activity for several wceks follow­
o. t challenging en- 3. Stable to un stable lng a IBlissimus dorsi strain . As part of hls rehabUitatio n
4. Low force to high force program. you have been progr Ing him through a ore­

in a propriocep­ 5. General to specil1c strengthening program. Describe a level 4 exercise that

6. Correct execution to increased intensity would be ideal for him.
 212 1'i\1{,["flll{EE The Tools of Rehabil itation

A I ......... i II r_ -... B

C I .... I I '- 'J D

E f

Figure
K, Lu n

G H

Figure 10-6 Level l (stabilization ). A, Lower abdomina l draw ing-in maneuver. B, Bridging. C, Quadriped drawiJlg-in

maneuver. 0 , Prone cobra. E, Side-lying iso-a bdominal. F, Human arrow. G, Quadriped opposite arm / leg raise. H, Diago­

nal cr unch .

 CHAPTER 10 Core Stabilization Training in Rehabil itation 213

K L

Figure 10-6 (Continued) Level 1 (s tabiliza tion ). I, Lateral shuftle with tUbing. j. Reverse crunch.
K, Lunge. L, Single-leg Junge with abdominal bracing.
214 P/\R'J'THREE The Tools of Rehabilitation

A I _ .~ . --=--. I I ... • LW .. B

c D

E F

Figu re 10-7 (Ci

Figure )10-7 tcvel 2 (stabilization and strength). A, Bridge with leg extension. B, Dead bug. C. Stability ball bridging. H. StabiUty ball
D. Stability ball diagonal crunch. E. Stability ball crunch. F. Stability ball hamstring curl.
 CHAPTER 10 Core Stabilization Training in Rehabilitation 215

B
H
G

'F

Figure 10-7 (Continued) Level 2 (stabilization and strength). G, Stability ball PNF pattern with weighted ball.
Hity ball bridging. II, St.abiIity ball push-up. I, Prone hip extension. J, Stability ball rotation with power ball. K, Wall squat with stability ball.
216 PARTTHREE The Tools or Rehabilitation

L
M
A

o
Figure 10-7 (Continued) Level 2 (stabilization a ne! strenglh). L. Stabilily baH hip exlension. M. Stabi lilY ball slraight
leg raise. N. Stability ball trunk extension.

Figure 10-8 L
chest rotuliol1 paj
pu ll-over on a s l~
 CHI\PTER l ~) Core Stabilizution Training in Rehabilitation 217

M
A c

D E
lity ball straight

figure 10-8 Level 3 (Integrated stabilization strength). A, Stagger stance weighted b,li! chest pass. B. VVeighted baH
hest. rotatiun pass. C. WeighLed ball sLde oblique pass. D. Weighted baill dynamk llexion/exLension . E, Weighted ball
ull-over on a stability ball.
 G
F

Figure 10-9
, qual. C, Weight

Figure 10-8 (Continued) Level 3 (integrnted stabilization strength). F, PNP Bodyblade. G, Two-ball pron e push-up.

H, One-arm press with rotation on stability ball. I, Squats with abdominal bracing. J, Side-lying hip lift s on stability ball.

218
 CHAPTER 10 Core Stabilization Training in Rehabilitation 219

A c

Figure 10-9 Lcvcl4 (explosive sta bilizaLion). A, Weighted ball sing e-leg up-jump. 6, Weighted ball vertical jump from
~ljual. C, VVeighted ball overhead throw. D, Weighted ba ll forward jump from sq uat.

II prone push-up.
if on slability ball.
220 Pi\RT'l'lmEf~ The Tools of Rehabililation

Summary

1. Function al
each JjJlk
function al
2. A core sta
F componenl
E
kinclic- ch 1

References
1.

2. Aaron. G. 1
talion oj [h
Course.
3. Aru in. f\.. a
postural m
fUSl vol u llla~
I ()): 323- ~~
4. Ashmen. ~
Slrength
chronic 101-
5:275-8
5. Aspden.
spinal liga~

G ... 1",;.,··...;, $ /
-~
U "1r' -, IH I n.
Allatomy .5: 3
i\xlcr.C.T..
riel)' or abel
inal challenj
29(6): 804-j
I. Basmajian. J
Wilkins,
S. Basmajian .
l:MG, 5th e
9, Beckman, ~ .
and hype~
lromyograpb
ReJwiJiiil alic
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10, Beim. G.. J.
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Fu, 199 7.
live EMG stu
11.
literal ure reI
6 55-70.
12. Blievcrnic ht.
13. Bod uk. N.. a
!Jar spine. :\e
14, Eousiell . S.. a
j uslmcn Is pn
22:263-70.
 CHAPTER 10
Summary
1. Functional kinetic chain rehabilitation must address
each link in the kinetic chain and strive to develop
functional strength and neuromuscular efftcienq>.
2. A core stabilization program should be an integral
component for all athletes participating in a closed­
F
kinetic-chain rehabilitation program.
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46. Gracovetsky. S.. and H. Farfan] 986. The optimum spine. Manipulative Physiotherapists Association of Australia. paill: Persp.
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47. Cracovclsky. S.. H. Farfan. and C. Heuller. 1985. The abdom­ of back problems. Physiotherapy 6 6:108- 1 l.
inal mechanism. S/?ine 10:317- 24 . 67. Lavender. S. A.. Y. H. Tsuang, and G. B. J. AJldersson . 1993.
48. Gray. G. W. 199 6. Chain reaction Jestival [Course manual]. Trunk muscle activation and co-contra(;tion while resisting SOLUTION!
Chicago. movements in a tWisted posture. Ergunomics 36:1145- 57.
49. Greenman . P E. 1991. Prillciples oj manual medicine. Balti­ 68. Lewit. K. 1999. Muscu la r and articu lar factors in movement
more: Williams &. Wilkins. restriction. Mal1ua l Medicine 1: 83-85. 0 -1 Decreased
-0. Gustavsen. R.. and R. Slreeck. 1993. Trainillll tllerap!l: Pro­ 69. Lewit. K. 1985 . Manipulative LllI!rapy ill til e relrabilitalioll oj the wi lli low
pllylaxis and rehabilitatioll. New York: Thieme Medical. locolliotar syst em. London: l3ulterworth s. transvers ~
51. Ilall, T.. A. David. ). Geerc. and K. Salvenson. 19 95. Relative 70. Lewit. K. 19~4. Myofasciul pain: Relief by post-isometric reia.'(­
an d deep
recruilmenl of the abdominal muscles during three levels of ation. fire/Jives oj PII!lsicm .v/('(licill(' ilnd Rdwhiliwtion h 5:4 52.
con trol of
exertion during abdomina l hollowing. Gold Coast. Queens­ 71. Liebenson. C. L. 1989. Activc mllsc"ir relnxMion techniques.
land: Ivlanipulatil7e Physiotherapists Association of Australia. Part J: BaSic principles and methods. JOt//"I1al iVlrmipu/a(ive imbal an
52. Hides. I. 1\.. M.). Stokes. M. Saide. G. 1\. lull. and D. H. Cooper. Physiological Therapy 12(6): 44h-54 . ity ca n leJ
:1 994. Evidence of lumbar multifidus wasting ipsilateral to 72. Liebenson. C. L. 1989. Active muscle relaxation techniques. traini n g \
symptoms in subjects with acute/subacute loll' back pain. Part II: Clinical application. JOll/"l1al .Vlllllipulativt' Physiologi.cal balance.
Spine 19: 165-77 . Therapy 13(2): 121- 27. 0-2 It could
53. Hodges. P. W.. and C. A. Richardson. 1995. Neuromotor dys­ 73. Liebenson. C. L. 1996. Rehabilitatiol1 of tile spine. Baltimore: ca u se of a
fun ction of the trunk musculature in low back pain patients. WiUiams & Wilkins. neuromu

11}(J\'cmcnt of thc
II IlJ91i, Evaluation
and c.Ii nical tests of
uup!ll{csearcl! Int er­
port. Halil'ax: 1)al­
on : Bulterworths,
)dromes for the eer­
l iT/ nem syndromes
by: R. Granl. "CII'
I .~, terns .
\'c ntion. and cor­
L .\: • \ Lh.letic Press.
- rd . 199 1. Slratc­
{S Associatiol1 0/
for management
-11.
An dersson. 1993.
lars in movement
rr/wl>i/itatiol1 0/ the
t-isometric rdax­
IhiJj taliOIl6~:4S2.
xa Lion techniques.
hunwl A1anipl/Illlil'c
'!'d.axation techniques,
ulalive PhUsiologiml
{ile -pine. Baltimore:
CHAPTER 10
74. Mayer. T. G.. and R. J. Gatchel. 1988. FllI1ctional restoration for
spinal disorders: Tile sports llIedicine approac/I. Philadelphia: Lea
& Febiger.
7 '-. Mayer-Posner, 1995. Swiss ball applications for orthopedic and
sports medicine. Denver. CO: 13alllJynamics International.
7b. iLler, M. I., and J. M. Medeiros. In 7. Recruitment of the in­
terna l obUque and transverse abdominus muscles on the ec­
centric phase of th e curl-Up. Physical1'l1erap!l6 7(8): 1213-17.
77. achemson. A. 1.966. The load on the lumbar discs in differ­
en l positions of the body. Cliniml Orthopedics 45: 107-22.
78. orris. C. M. 1993. Abdominal muscle training in sports.
British Journal of Sports Medicine 27(1): 19-27.
79. O·Sullivan. P. E., L. Twomey, and G, Allison. 1995. Evaluation
of specific stabilizing exercises in the treatmellt of chrollic low
back pain with radiological diagnosis of spondylolisthesis. Gold
Coast. Queensland: Manip ulat,ive Physiotherapists Associa­
tion of I\u st ralia.
!lO. O·Sullivan . P. B.. L. Two mey, G. Allison. J. Sinclair. K. Miller.
and J. Knox. 1997. Altered patterns of abdominal muscle ac­
tivation in patients wit h chronic low back pain. Australian
Joul'llal of PIlysiotherapy 43(2): 91-98.
1. Panjabi. M. M. I 992 .'fhe stabiUzing system of the spine. Part
I: runction. dysfunction. adaptation. and enhancement.
Jour/wI oj Spinal Disorders 5:383-89 .
l 2. Panjabi. M. M .. D. Tech. and A. A. White. 1980. Basic biome­
chanics of the spine. Neurosurgery 7:76-93.
lB. Paquet, .. F. Malouln. and C. L. Richards. 1994. Hip-spine
movement interaction and muscle activation patterns during
sagittal trunk movements in low back pain patients. Spine
19(5): 596-603.
4. Peck. D.. D. F. Buxton. and A. J. Nitz. 1984. A comparison of
sp indle concentrations in large ancl small muscles acting in
parallel combina tions. Journal Morphologyl 80:243-52.
5, Pope. M.. J. Frymoyer. and M. Krag. 1992. Diagnosing ,i nsta­
bility. Clil1ical Ortlwpeilics lind Related Research 296:60--67.
6. Portcri1eld. J. A.. and C. DeRosa. 1991. ;vItchanical low back
pain: Perspectives ill functiollal allatomy, Philadelphia: W B.
Saunders.
SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES
10-1 Decreased stabilizalion end urance in individuals
with low back pain with decreased firing of the
transversus abdominis, i.nternal oblique, multifidus,
and deep erector spinae. Training without proper
conlrol or these muscles can lead to i.mproper muscle
imba lances and force transmission . Poor core stabil­
ity can lead to increased intradiscal pressure. Core
trai.ning will improve the gymnast's posture, muscle
balance, and static and dynamic stabilization.
10-2 It could be that she has poor postural control be­
cause of a weak core. She probably never regained
neuromuscular control of her core following the
Core Stabilization Training in Rehabilitation 223
87. Richardson. C. A .. and G. Jull. Muscle control-pain control.
What exerciscs would yo u prc. cribe? Manual Medicine
1:2- 10.
88. Richardson. C. /\. .. G. Jull. R. 'f oppcnberg. and M. Comerford.
1992. Techniques (or aclive lumbar stabilization for pin a l
protection. Australian JOl/rnal of Physiot/Jerapu 3 8:105-12.
89. Robinson, R. 1992. The new back school presc ription: Stabi­
lization training. Part I: OCCI/patiolial Medicine 7: 17- 31,
90. SaaL J. A. 1992. The new back school prescription: Stabiliza­
tion training. Part II, Occupational Medicine 7:33--4 2 .
91. Saal. J. 1\. 1989. Nonoperative treatment of herniated disc:
An outcome study. Spine 14:431-37.
92. Sahnnann. S. 1992. Posture and muscle imbalance: Faulty
lumbo-pelvic alignment and associated musculoskeletal pain
syndromes. OrthopediC Divisioll Reviews- Canadian Ph!lsical
TllCnlPyI2:13 - 20.
93. Sahrmann, S. 1997. DiagnOSis and treatmmt of /Ilusele imbal­
ances Wid musculoskeletal pain s!1m/rome [Continuing educa­
tion course l. Sl. Louis.
94. Strohl. K.. J. lvlcad. R. Banzetl. S. Loring. and E Kosch. 1911 I.
Regional differences in abdominal activity during various
maneuvcrs in humans. Joumal af AWlied Pllusiology
51:1471-76.
95. Stokes, M., and A. Young. 1984. The contribution of renex
inhibition to arthrogenoll s mllscle weakness. Clinical Science
67:7- 14.
96. Tesh, K. M. J. ShawDuDn, and J. H. Evans. 1987. TQC abdom­
ina l muscles and vertebral stability. Spil1e 12:301-8 .
97. Throstensson, A.. and A. Ardidson. 1982. Truuk strength
and low back pain. Scandinavian Jm/rnal of Rehabilitation :vIed­
icine 14:69- 75.
98. Warmerdam. A. 1. A. 1996. Arthrokinetic titerapy: .'v1arrllal
therapy to improve mllsde and jointIlIll('tianing [Continuing ed­
ucation course1. Marshlleld, WI.
99. Wilke. H. J.. S. Wolf. ancl L. E. C1aes. 1995. Stability il1crease
of the lumbar spine with different muscle groups: A biome­
chanical in vitro study. Spine 20:192-98.
knee injury. Tennis requires a lot of upper-body
movement, so she would probably benent from core
strengthening that would allow her to control her
lumbo-pelvic-hip compl ex while she plays. In
choosing her exercises, you should make sure that
they are safe and challenging and stress multiple
planes that are functional as they are applied to ten­
nis. The exercises should also be proprioceptively
enriched and activity-spec inc.
10-3 Individuals with poor core strength are likely to de­
velop low back pain due to improper muscle stability.
The straight leg lowering test is a good way to assess
224 PART TJ-lREE The Tools of RehabLiitation
core strength. The athlete should lie supine on a table
with hips flexed to 90 degrees and lower back com­
pletely flat against the table. To decrease the lordotic
curve. instruct the athlete to perform a drawing-in
maneuver. The athlete th en lowers the legs slowly to
the table. The test is over when the back starts to arch
off of the table. A hlood pressure cuff can be used un­
der the low back to observe an increase in the lor­
dotic curve. Someone with a weak core will not be
able to maintain the flattened posture for very long
while lowering the legs.
10-4 To progress the athlete and keep her interested in her
rehahilitation program. change her program fre­
quently. Consider these variables as you plan
changes: plane of motion. range of motion , loading
parameter (Physioballs, tubing. medjci ne balls. body
blades. etc.). body position (from supine to standing).
speed of movement. amount of control. duration
(sets and reps). and frequency.
10-5 Your ultimate goal with core strengthening is func­ c
tional strength and dynamic stabili ty. As the athlete
progresses. the emphasis should change in these
ways: from slow to fast. from simple to complex.
from stable to unstable. from low force to high force.
from general to speCific. and from correct execution
p
to increased intensity. Once the athlete has gained
tel
awareness of proper muscle firing. encourage her
Ii
to perform her exercises in a more functional man­
nero Because activities in most sports require multi­
plane movement. design her exercises to mimic
those requil'ements.
10-6 Dynamic PNF with a power ball would be ideal for
him. The ball will provide a loading parameter. and
his range of motion will be functional for the de­
mands of his sporl. A.dding a twisting component is
important so that he is not just training in a sLngle
plane of motion prior to swinging his club.
\\'w w.mhb"'i
'n gthening is func­
CHIAPTER 11
Ji lily. As the athlete
.d c hange in these
;irnpie to complex,
. for ce to high force,
D correeL execution
Plyometrics i'n Rehabilitation
at h lete has gained Steve Tippett
mg. encourage her Michael Voight
rre fu nctional man­
:>orLS require multi­
~ercises to mimic

wo uld be ideal for

ling parameter. and
!l tional for the de­
tin g component is
training in a single
.., hi club. Study Resources • Explain how a plyometric program can
To become more familiar with the knowledge and skills be modified by hanging intensity. vol­
necessary to design. implement. and document therapeu­
ume, frequency, and recovery.
tic rehabilitation programs as idenlilled in the , ATA Ath­
letic Training Educational Competencies and Clinical • Discuss how plyometrics can be

I'rojicifllcies' Therapelltic Exercise content orca. visit

integrated into a rehabilitation

www.mhhe.com/prenticcllc. Also refer to the lab exer­

cises in the !lew Laboratory :Vlanual and to eSims. whieh program.

simulates the athletic training ccrlWcation exam. at

\1'II'w.mhhc.com/esims. For more online study resources.
• Recognize the value of different plyo­
visit our Health and Human Performance website at metric exercises in rehabilitation.
www.mhhc.com/hhp.

After Completion of This

Chapter, the Student Should

Be Able to Do the Following:

WHAT IS PLYOMETRIC
• Define plyometric exercise and
identify its function in a rehabilitation
program.
• Assess the mechanical. neurophysio­
logical, and neuromuscular control
mechanisms involved in plyometric
training.
• Review how biomechanical evalua­
tion, stability, dynamic movement, and
flexibility should be assessed before be­
ginning a plyometric program.
EXERCISE?
In sports training and rehabi litation of athletic injuries,
the concept of specificity has emerged as an important pa­
rameter in determining the proper choice and sequence of
exercise in a training program. The jumping movement is
inherent in numerous sport activities such as basketball.
volleyball, gymnastics, and aerobic dancing. Even ru n ning
is a repeated series of jump-landing cycles. Therefore jump
training should be used in the deSign and implementation
in the overaH training program.
Peak performance in sport requires technical skill and
power. Skill in most activities combines natural athletic
ability and learned specialized proficiency in an activity.
Success in most activities is dependent upon the speed at
which muscular force or power can be generated. Strength

225
226 PART THREE The Tools of Rehabilitation

and conditioning programs throughout the years have at­ stop the forward momentum and change ,it into an upward tric contracti on
tempted to augment the force production system to maxi­ direction. As this happens, the muscle undergoes a length­ begi ns from a st"
mize the power generated. Because power combines ening eccentric contraction to decelerate the movement by an eccentric
strength and speed, it can be increased by increasing the and prestretch the muscle. This prestretch energy is then pares it for th e f
amount of work or force that is produced by the muscles or immediately released in an equal and opposite reactiol1, piing of this eo
by decreasing the amount of time required to produce the thereby producing kinetic energy. The neuromusoular sys­ known as the sL
force. Although weight training can produce increased tem must react quickly to produce the concentric shorten­ this stretch-shor
gains in strength, the speed of movement is limited. The ing contraction to prevent falling and produce the upward components: pre
amount of time required to produce muscular force is an change in direction. Most elite athletes will naturally ex­ crties of muscle I
important variable for increasing the power output. A hibit with great ease this ability to use stored kinetic en­ produce a respol
form of training that attempts to combine speed of move­ ergy.Less gifted athletes can train this ability and enhance for the purpose c
ment with strength is plyometrics. their production of power. Consequently. speCific func­
The roots of plyometric training can be traced to east­ tional exercise to emphasize this rapid change of direction
Mechanical
ern Europe, where it was known simply as jump training. must be used to prepare patients and athletes for return to
The term plyometrics was coined by an American track and activity. Because plyometric exercises train specific move­ The mechanical
field coach, Fred Wi'It. 19 The development of the term is ments in a biomechanically accurate manner, the mu,s­ represcn ted by a
confusing. Plyo- comes from the Greek word ply thein, c1es, tendons. and ligaments are all .s trengthened in a contractile com
which means "(0 increase." Plio is the Greek word for functional manner. ISEC). and paraJl
"ore," and metric literally means "to measure." Practically, Most 01 the literature to date on plyometric training has produce a forc e c
plyol1letrics is del1ned as a quick, powerful movement in­ been focused on the lower quarter. Because all movements cal point of mOl
volving prestretcl1ing the muscle and activating the in athletics involve a repeated series of stretch-shortening important rol e ir
stretch-shortening cyCile to produce a subsequently cycles. adaptation of the plyometric principles can be used individual Ilbers'
stronger concentric contraction. It Lakes advantage of the to enhance the specifiCity of training in other sports or ac­ lengthening prO(
length-shortening cycle to increase muscular power. tivities that require a maximum amount of muscular force lure in the fo rm (
In the Ilate 1960s and early 1970s when the Eastern in a minimal amount of time. Whether the athlete is jump­ When a!1l U
Bloc countries began ,to dominate sports requiring power, ing or throwing, the musculature around the involved of the force th aI
their training methods became the focus of attention. Af­ joints must first stretch and then contract to produce the lilaments sli ding
ter the 1972 Olympics, articles begat1 to appear in coach­ explosive movement. Because of the muscular demands lerna/ly by being
ing magazines outlining a strange new system of jumps during the overhead throw, plyometrics have been advo­ centric contra cLi
and bOU31ds that had been used by the Soviets to increase cated as a form of conditioning for the overhead throwing spring. With th is I
speed. Valery Borzov, the 100-meter gold medalist, cred­ athlete. lidS Although the principles are similar, different allowed to CO ll U
ited plyometric exercise for his success. As it turns out, the forms of plyometric exercises should be applied to the upper Therefore the tou
Eastern Bloc countries were not tbe originators of plyo­ extremity to train the stretch-shortening cycle. Addition­ prod uced by th e (
metrics, just the organizers. This system of hops and jumps ally, the intel1sity of the upper extremity plyometric pro­ ogy would be th,
has been used by American coaches for years as a met.hod gram is usually less than that of the lower extremity. due to stretch is appli ed
of conditioning. Both rope jumping and bench hops have the smaller muscle mass and type of muscle function of the it returns to iLs on
been used to improve quickness and reaction times. The upper extremity compared 10 the lower extremity. Signil1cant incrcl
organization of this t raining method has been credited to The role of the c.ore muscles of the abdominal region lion have been dl
the legendary Soviet jump coach Yuri Verhoshanski, who and the lumbar spine in providing a vital link for stabiHty by an eccentric I
during the late 19605 began to tie this method of miscel­ and power cannot be overlooked. Plyometric training for partly due to thf
laneous hops and jumps into an organized training plan."! these muscles can be incorporated in isolated drills as welJ muscles are a ble
The main purpose of plyometric training is to heighten as functional activities. When the musclE
the excitabiHty of the nervous system for improved reac­ clastic energs' thi
tive ability of the neuromuscular system.]i Therefore, any and used to au gm
type of exercise that uses the myotatic stretch reflex to pro­ BIOMECHANICAL AND ity to use tbis slofl
duce a more powerful response of the contracting muscle PHYSIOLOGICAL PRINCIPLES abIes: lime. ma gn i
is plyometric in nature. All movement patterns in both ath­ The concentric c(
letes and activities of daily living (ADL) involve repeated
OF PLYOMETRIC TRAINING
precedi.ng eccenLr
stretch-shortening cycles. Picture a jumping athlete The goal of plyometric training is to decrease the amount formed quickly \\ I
preparing to transfer forward energy to upward energy. As of time required between the yielding eccentric muscle this concept expel
the I1nal step is taken before jumping, the loaded leg must contraction and the initiation of the overcoming concen­ versus un dam(Je(

• it into an upward tric contraction . Torma I physiological movement rarely
ndergoes a length­ begins rrom a stati~1g position but rather is preceded
te the movement by an eccentric prestretch that loads the muscle and pre­
pares it for the ensuing cOllcentric contraction. The cou­
eh energy is then
opposite reaction, pling of this eccentric-concentric muscle contraction is
uromuscular sys­ known as thc stretch-shortening cycle. The physiology of
ne ntric shorten­ this stretch-shortening cycle can be broken down into two
components: proprioceptive reflexes ami the elashc prop­
oduce the upward
\\' ill naturally ex­ erties 01 muscle fibers. These components work together to
ta red kinetic en­ produce a response. but they will be discussed separately
lIity and enhance for the purpose of understanding.
tly. specific func­
an ge of direction Mechanical Characteristics
etes for return to
The mechanical characteristics of a musde can best be
represented by a three-component model (Figure 11-1). A
contractile component (Ce), series elastic component
(SEC). and paralliel clastic component (PEC) a'll interact to
produce a force output. /\lthough the CC is usually the fo­
se all movements cal point of motor control. the SEC and PEC also play an
uetch-shortening important role in providing stability and integrity to the
dples can be used individual flbers when a muscle is lengthened. During this
ilier sports or ac­ lengthening process, energy is stored within the muscula­
or III uscular force ture in the form of kinetic energy.
e alhlete is jump­ vVhen a muscle contracts in a concentric fashion. most
nd the involved of the force that is produced comes from the muscle fiber
filaments sliding past one another. Force is registered ex­
ternally by being transferred through Lhe SEC. When ec­
have been advo­ centric contraction occurs, the muscle lengthens like a
erhead throwing spring. With this lengthening, the SEC is also stretched and
imilar, differen t allowed to contribute to the overall force production.
lied to the upper Therefore the total force production is the sum of the force
g cycle. i\ddition­ produced by the CC and the stretching of the SEC. An anal­
. plyometric pro­ ogy would be the stretching of' a rubber band. When a
ext remity. due Lo stretch is applied. potential energy is stored and applied as
Ie functLon of the it returns to its original length when the stretch is released.
Significant increases in concentric muscle force produc­
tion have been documented wh en immediately preceded
by an eccentric contraction.1.4·9 This increase might be
ctric training for partly due to the storage of clastic energy. because the
lated drills as well muscles arc able to use the force produced by the SEC.
When the muscle contracts in () co ncentric manner. the
clastic energy that is stored in the SEC can be recovered
und used to augment the shortening contraction. The abil­
•CIPLES ity to usc this stored clastic energy is affected by three vari­
ables: time, magnitude of stretch, and velOCity of stretch. IS
The concentric contraction can be magnified only if the
INING preceding eccentric contraction is of short range and per­
re ase the amount formed quickly without delay. l.~.9 130sco and Komi proved
!!.eccentric muscle :his concept experimentally when they co mpared damped
ercoming concen­ H'rsus undamped jumps. 4 Undamped jumps produced
CHAPTER 11 Plyometics in Rehabilitation 227
PEC
Force
SEC CC
Figure 11-1 Three-component model.
minimal knee flexion upon landing and were followed by
an immediate rebound jump. With damped jumps, the
knee flexion angle increased Significantly. The power out­
put was much higher with the undamped jumps. 'rhe in­
creased knee flexion seen in the damped jumps decreased
elastic behavior of the muscle. and the potential elastic en­
ergy stored in the SEC was lost as heat. Similar invesLiga­
tions produced grealer vertical jump height when the
movement was preceded by a counlermovement as op­
posed to a static jump.l.,.6.14
The type of muscle lIber involved in the contraction
can also affect stQrage of clastic energy. Bosco et al. noted
a difference in the recoil of elastic energy in slow-twitch
versus fast-twitch muscle I1bers. fl' his study indicates that
fast-twitch muscle fibers respond to a high-speed, small­
amplitude prestretch. The amount of elastic energy llsed
was proportional to the amount stored. When a long, slow
stretch is applied to muscle, slow- and fast-t witch fibers ex­
hibit a similar amount of stored elastic energy: however.
this stored energy is used to a greater extent with the slow­
twitch fibers. This trend would suggest that slow-twitch
muscle fibers might be able to use elastic e nergy more effi­
ciently in ballistic movement characterized by long and
slow prestretching in the stretch-shortening cycle.
Neurophysiological Mechanisms
The proprioceptive stretch rel1ex is the other mechanism by
which force can be produced during the stretch-shortening
cycle. Mechanoreceptors located within the rnLlsele provide
information about the degree of mllscular stretch. This in­
formation is transmitteclto the central nervous system and
becomes capable of influencing muscle tone, molor execu­
tion programs. and kinesthetic awareness. The mechano­
receptors that are primarlly responsibl e for th e stretch
reflex arc the Golgi tendon organs and muscle spindles. 2b
The muscle spindle is a complex stretch receptor that is
228 PART THREE The Tools of Rehabilitation
located in parallel within the muscle fibers. Sensory infor­
mation regarding the length of the muscle spindle and the
rate of the applied stretch is transmitted to the central nerv­
ous system. If the length of the surrounding muscle fibers
is less than that of the spindle. the frequency of the nerve
impulses from the spindle is reduced. When the muscle
spindle becomes stretched. an afferent sensory response is
produced and transmitted to the central nervous system.
i'<emological impulses are in turn sent back to the muscle.
causing a motor response. As the muscle contracts. the
stretch on the muscle spindle is relieved. thereby removing
the original stimulus. The strength of the muscle spindle
response is determined by the rate of stretch.26 The more
rapidly the load is applied to the muscle. the greater the fir­
ing frequency of the spindle and resultant reJJexive muscle
contraction.
The Golgi tendon organ lies within the muscle tendon
ncar the point of attachment of the muscle fiber to the
tendon. Unlike the facililory action of the muscle spindle.
the Golgi tendon organ has an inhibitory effect on the
muscle by contributing to a tension limiting reflex. Be­
cause the Golgi tendon organs are in series alignment
with the contracting muscle fibers. tbey become activated
with t.ension or stretch withi.n the muscle. Upon activa­
tion. sensory impulses are transmitted to the central nerv­
ous system. These sensory impulses cause an inhibition of
the alpha motor neurons of the contracting muscle and
its synergists. thereby limiting the amount of force pro­
duced. With a concentric muscle contraction. the activity
of the muscle spindle is reduced because the surrounding
muscle [[bers are shortening. During an eccentric muscle
contraction. the muscle stretch reflex generates more ten­
sion in the lengthening muscle. When the tension within
the muscle reaches a potentially harmful level. the Golgi
tendon organ fires. thereby reducing the excitation of the
muscle. The muscle spindle and Golgi tendon organ sys­
tems oppose each other. and increasing force is produced.
The descending neural pathways from the brain help to
balance these forces and ultimately control which reflex
will dominate. 28
The degree of muscle fiber elongation is dependent
upon three physiological factors. Fiber length is propor­
tional to the amount of stretching force applied to the
muscle. The ultimate elongation or deformation is also de­
pendent upon the absolute strength 01' the individual mus­
cle tlbers. The stronger the tensile strength. the less
elongation that will occur. The last factor for elongation is
the ability of the muscle spindle to produce a neurophysi­
ological response. A muscle spindle with a low sensitivity
level will result in a difficulty in overcoming the rapid elon­
gation and therefore produce a less powerful response. Ply­
ometric training will assist in enhancing muscular control muscular COOl
within the neurological system. cular contraCI
The increased force production seen during the dinaLion, Tn ot
stretch-shortening cycle is due to the combined effects of set speed ran!
the storage of elastic energy and the myotatic reflex acti­ Training wi th
vation of the muscle. 2 ",g,Y,2',29 The percentage of contri­ improvc the n
bution from each component is unknown. 5 The increased muscular perl
amount of force production is dependent upon the time changes wil hiJ
frame between the eccentric and concentric contractions. 9 individual to h
This time frame can be detlned as the amortization and its synergJ
phase. 13 The amortization phase is the electromechanical absenve of mo
delay between eccentric and concentric contraction dur­ neural adapla:
ing which time the muscle must switch from overcoming ing the ner\,ou
work to acceleration in the opposite direction. Komi found
that the greatest amount of tension developed within the
muscle during the stretch-shortening cyclc occurred dur­
ing the phase of muscle lengthening just before the con­
centric contraction. 23 The conclusion from this study was A high sch
that an increased time in the amortization phase would olT-season (
lead to a decrease in force production. and depth j
Physiological performance can be improved by several jurrction with
mechanisms with plyometric training. Allbough there has cu la r l110l'.'
been documented evidence of increased speed of the parapalellar I
stretch reflex. the increased intensity of the subsequent that she can
muscle contraction might be best attributed to better re­ coach feels 1.
cruitment of additional motor ul1its.]] 1'he force-velocity tioning and
relationship states that the faster a muscle is loaded or can be done
oiengthened eccentrica.JJy. the greater the resultant force increase the
output. Eccentric lengthening will also place a load on the
elastic components of the muscle fibers. The stretch reflex
might also increase the stiffness of the muscular spring by Tn summari
'r ecruiting additional muscle fibersY This additional stiff­ nn the rate of 5
ness might allow the muscular system to use more exter­ phasis shou ld I
nal stress in the form of elastic recoil. 1 1 phase. If the a ~
Another possible mechanism by which plyometric is lost as heat ~
training can increase the force or power output involves \'crsely. the qUf
the inhibitory effect of the Golgi tendon organs on force \ielding ('ceen
production. Because thc Golgi tendon organ serves as a [he more pO Wl"
tension-limiting reflex. restricting the amount of force
that can be produced. the stimulation threshold for the
Golgi tendon organ becomes a limiting factor, Bosco and
Komi have suggested that plyometric training can desensi­ pecifieity is I
tize the Golgi tendon organ . thereby raising the level of in­ ~ port-specifi
hibition. 4 If the level of inhibition is raised. a greater down into basi
amount of force production and load can be applied to the me nt pallcrns
musculoskeletal system, ion. based lI PO
Developme n t of
Neuromuscular Coordination tablishiog a n a
body Lo wi th sta
The last mechanism in which plyometric training might
improve muscular performance centers around neuro­
 CHAPTER 11 Plyometics in Rehabilitation 229

Lg muscular contro'j muscular coordination (sec Chapter S). The speed of mus­ Additionally, a larger cross-sectional area can contribute
cular contraction calil be lbnited by neuromuscular coor­ to the SEC and subsequently store a greater amount of
secn during the dination. In other words, the body can move only within a elastic energy.
ombined effects or set speed range, no matter how strong thc muscles are. Plyometric exercises can be characterized as rapid ec­
nyotatic reOex acti­ Training with an cxplosive prcstretch of the muscle can centric loading of the musculoskeletal complex. ll This type
~Tc entage or contri­ improve the neuralj efficiency, thereby increasing neuro­ of exercise trains the n euromuscular system by teaching it
)\\'[1. i The increased muscular performance. Plyometric training can promote to more readily accept the increased strength loads. l A]so,
de nt upon the time changes with in the neuromuscular system that allow the the nervous system is more readily able to react IV·ith max­
_nlric contractions,'l individual to have bettcr control of the contracting muscle imal speed to the lengthening muscle by exploiting the
I he amortization and its synergists, yielding a greater net force even in the stretch reOes. Plyometric training attempts to line tune the
e electromechanical absence of morphological adaptation of the muscle. This neuromuscular system, so all training programs should be
ric contraction dur­ neural adaptation can increase performance by enhanc­ designed with specificity in mind.27 This goal will help to
Lh from overcoming ing the ll.ervous system to become more automatic. ensure that the body is prepared to accept the stress that
ifection. Komi found will be placed upon it during return to function.
\'e loped within the
:ycle occurred dur­ CLINICAL DECISION MAKING Exercise 11-1
Plyometric Prerequisites
ust before the con-
Olil this study was
A high school female basketball plBYl'r is engaged in an Biomechanical Examination. Before beginning a
on~season conditioning program that involves box jumps
Dat ion phase would plyometric training program. a cursory biomechanical ex­
and depth jumps. As a result of these actlvities in con­ amination and a battery of Ifunctional tests should be
'm proved by several juuction with a running program to enhance cardlovas­ performed to identity potential contraindications or precau­
, -\lthough there has cular I1tness. she now complains of unilateral tions. Lower-quarter biomechanics should be sound to help
-ea ed speed of the parapa tel\ar pain. The knee pain ls significan t enough ensure a stable base of support and normal force transmis­
of the subsequent th at she cannot take part in the plyometric program. The sion. Biomechanical abnormalities of the lower quarter are
'buted to better re­ coach feels the athlete needs to add ress both her condi ­ not contraindications for plyometrics but can contribute to
The force-velocity tio ning and her power training. and wants to know what stress failure-overuse injury if not addressed. Before initiat­
uscle is loaded or can be done to improve the athlete's performance but not
ing plyometDic training, an adequate strength base of the
me resultant force increase the knee pain. How can you help? stabilizing musculature must be present. Functional tests
place a load on the are very effective to screen for an adequate strength base be­
. The stretch reOex fore initiating plyometrics. Poor strength in the lower ex­
m uscular spring by In summary, effective plyometric training reHes more tremities will result in a loss of stability when landing and
This additional stiff­ Dn the rate of stretch than on the length of stretch. Em­ also increase the amount of stress that is absorbed by the
to use more exter­ phasis should center on the reduction of the amortization weight-bearing tissues with high-impact forces, which will
phase. If the amortization phase is slow, the elastic energy reduce performance and ,increase the risk of injury. The
.- which plyometric is lost as heat and the stretch ref1ex is noL activated. Con­ Eastern Bloc countries arbitrarily placed a one-repetition
\'ef output involves versely, the quicker the individual is able to switch from maximum in the squat at 1.5 to 2 times the individual's
on organs on force yielding eccentric work Lo oVercoming concentric work, body weight before initiating lower-quarter plyometrics. 3 If
Ion organ serves as a the more powerful the response. this were to hold true, a 200-pound individual would have
lh c mount of force to squat 400 pounds before beginning plyometrics. Unfor­
n threshold for the tunately, not many individuals would meet this minimal cri­
PROGRAM DEVELOPMENT
ling factor. Bosco an d teria. Clinical and practica~ experience has demonstmted
: uaining can desensi­ Specificity is the key concept in any training program. that plyometrics can be started without that kind of leg
rn1 in g the level of in­ port-specific activities should be aIlalyzed and broken strength.!! A simple functional parameter !o use in deter­
11 ' raised. a greater down into basic movement patterns. These specific move­ mining whether an indjviduru is strong enough to initiate a
d can be applied to the ment patterns should then be stressed in a gradual fash­ plyometric training program has been advocated by ChuY
n. based upon individual tolerance to these activities. Power squat testing with a weight equal to 60 percent of the
Development of a piyometric program should begin byes­ individual's body weight is used. The individual is asked to
..ablishing an adequate stren gth base that will allow the perform live squat repetitions in 5 seconds. If the individual
:ltion
"ody to withstand the large stress that witl be placed upon cannot perform this task, emphasis in the training program
metric training mig ht 1. A greater strength base will allow for greater force pro­ should again center on the strength-training program to de­
rolers around neu l'O­ duction due to increased muscu lar cross-sectional area. velop an adequate base.
230 PART THREE The Tools of Rehabilitation

Plyometric Static Stability Testing llexibilityexerci

CLINICAL DECISION MAKING Exercise 1l-2
involved in th e
• Single-Leg Stance - 30 sec static and short
A coUege track sprinter has been instructed by ber - Eyes open
- Eyes closed When the iI
strength coach to begin oIT-season plyometrics consisting
namic control 0:
of box jumps and high stepping drills. The athlete suf­ • Single-Leg 25% Squat - 30 sec low-intensity in
fered a second-degree upper hamstring strain during the - Eyes open
metric training
last half of track season and is reluctant to start the plyo­ - Eyes closed
progress slowly i
metric program. What can be done to prevent this inlury
• Single-Leg 50% Squat - 30 sec foundation in m
from recurring? - Eyes open be introduced. '\1
- Eyes closed
backgrounds ca
Figure 11-2 Static stability testing. metric exercises ,
Because eccentric muscle strength is an important been classified 111
component to plyometric training. it is especiall)1 impor­ plyometric prO!
tant to ensure an adequate eccentric strength base is pres­ isolated strengthening of the weak muscles. For dynamic Chu]o·ll.ll has (
ent. Before an individual is allowed to begin a plyometric jump exercises to be initiated. there should be no wobbling into six categorif
regimen, a program of closed-chain stability training that of the support leg during the quarter knee squats.
focuses on eccentric lower-quarter strength should be ini­ After an individual has satisfactorily demonstrated PLYOMET
tiated. In addition to strengthening in a functional man­ both Single-leg static stance and a Single-leg quart.er squat,
ner, dosed-chain weight-bearing exercises also allow the 1110re dynamic tests of eccentric capabilities can be initi­ As with any con
individual to use functional movement patterns. The ated. Onoe an individual bas stabilization strength, the ing program Cill
same holds true for adequ ate upper-extremity strength concern shifts toward developing and evaluating eccentric abies: i.e., din'c
prior to initiating ao upper-extremity plyometric pro­ strength. The limiting factor in high-intensity. high­ athlete, speed oj
gram . Closed-chain activities such as wall push-ups, tra­ volume plyometrics is eccentric capabilities. Eccentric \'olume, frequ en
ditional push-ups and their modification, as well as strengtl1 can be assessed with stabilization jump tests. If an
functional tests can be utilized to ascertain readiness for individual has an excessively long amortization phase or a Direction 0:
upper-extremity plyometrics.1 9.3o.31 Once cleared to par­ slow switching from eccentric to concentric contractions.
ticipate in the plyometric program. precautionary safety the eccentric strength levels are insufftcient. Horizontal bod:;
tips should be adhered to. Dynamic Movement Testing. Dynamic move­ movemen t. Th is
Stability Testing. Stability testing before initiating ment testing will assess the individual's ability to produce lete and the tec hl
plyometric training can be divided into two subcategories: explosive, coordinated movement. Vertical or Single-leg jumps.
static stability and dynamic movement testing. Static sta­ jumping for distance can be used lor the lower quarter. Re­
bility testing determines the individual's ability to stabilize searchers have investigated the use of single-leg hop for
and control the body. The muscles of postural support distance and a determinant for return to play after knee in­
must be strong enough to withstand the stress of explosive jury. A passing score on their test is 85 percent in regard to
training. Static stability testing (Figure 11-2) should begin symmetry. The invohred leg is tested twice. and the average
with simple movements of low motor complexity and between the two trials is recorded. The noninvolved leg is
progress to more difficult high motor skills. The basis lor tested in the same fashion, and then the scores of the oon­
lower-quarter stability centers around Single-leg strength. involved leg are divided by the scores of the involved leg
Difl1cult)' can be increased by having the individual close and multiplied by 100. This provides the symmetry index
his or her eyes. The basic static tests are one-leg standing score. Another functional test that can be used to deter­
and single-leg quarter squats that are beld for 30 seconds. mine whether an individual is ready for plyometric train­
An individual should be able to perform one-leg standing ing is the ability to long jump a distance eq ual to the
for 30 seconds with eyes open and closed before the initia­ individual's height. In the upper quarter. the medicine ball
tion of plyometric training. The individual should be ob­ toss is used as a functional assessment.
served for shaking or wobbling of the extremity joints. If FleXibility. Another important prerequisite for plyo­ Weight of tl
there is more movement of a weight-bearing joint in one metric training is general and specific llexibility, because a
direction than the other, the musculature producing the high amount of stress is applied to the musculoskeletal The heavier the
movement in the opposite direction needs to be assessed for system. Therefore all plyometric training sessions should placed on the a
speCific weakness. If weakness is determined, the individ­ begin with a general warm-up and flexibility exercise pro­ place jump fClr
ual's program should be limited and emphasis placed on gram. The warm-up should produce mild sweating. lI The demand activity
 CHAPTER 11 Plyometics in Rehabilitation 231

Dexibility exercise program should address muscle groups Chu's Plyometric Categories
resting
involved in the plyometrie prog ram and should include
sec slatic and short dynamic stretching techniques. 2o • In-place jumping
• Standing Jumps
Wben the individual can demonstrate static and dy­ • Multiple-response Jumps and hops
namic control of their body weight with Single-leg squats, • In-depth, jumping and box drills
30 sec low-intensity in -place plyometrics can be initiated. Plyo­ • Bounding
metric training should consist of low-intensity drills and • High-stress sport-specific drills
progress slowly in deliberate fashion. As skill and strength Figure 11-3 Six categories 01 plyomctric training.
30 sec foundation increase, moderate-intensity plyometrics can
be introduced. Mature athletes with strong weight-training
backgrounds can be introduced to ballistic-reactive plyo­
metric exercises of high intensity. 12 Once the individual has Speed of Execution of the Exercise
been classified as beginner. intermediate, or advanced, the Increased speed of execution on exercises like single-leg
plyometric program can be planned and initiated. hops or alternate-leg bounding raises the training demand
Ie . For dynamic ChU IlU1 . 11 has divided lower-quarter plyometric training on the individual.
Id be no wobbling into six categories (Figure 11-3).
ee squats.
..-uv demonstrated PLYOMETRIC PROGRAM DESIGN External Load
-Ie quarter squat.
-Iitles can be iniH­ As with any conditioning program, the plyometric train­ Adding an externail load can Significantly raise the train­
ion strength. the ing program can be manipulated through training vari­ ing demand. Do not raise the external load to a level tbat
alualing eccentric ables: i.e., directiol1 of body movement, weight of the will signil1cantrly slow the speed of movement.
~"l-in tensity, high­ athlete, speed of the execution, external load, intensity,
• bilities. Eccentric volume, frequency, training age, and recovery.
n jump tests. If an Intensity
iZation phase or a Direction of Body Movement Intensity car! be dellned as the amount of effort exerted.
~llJi c contractions,
With traditional weight lifting, intenSity can be modilled
n t. Horizontal body movement is ,less stressful than vertical
by changing the amount of weight that is lifted. With ply­
Dyn amic move­ movement. This is dependent upon the weight of the ath­ ometric training, intensity can be controlled by the lype of
abil ity to produce letc and the technical proficiency demonstrated during the
exercise that is performed. Double-leg jumping is less
. a l or single-leg ;umps .
stressful than single-leg jumping. As with all functional
lowe r quarter. Re­ exercise, the plyometric exercise program should progress
'in gle-leg hop for from simple to complex activities. Intensity can be further
CLINICAL DECISION MAKING Exercise 11-3
- play after Iknee in­ increased by altering the specific exercises. The addit,ion of
fc ent in regard to external weight or raising the height of the step or box will
The coach of a juniorfootballlcaguc team (ages 10 and
-e. an d the average also increase the exercise intensity.
11 ) wants to institute a plyometric conditioning program
non involved leg is
for the team . The coach has met some resistance from
ores of the non-
concerned parenls regarding the intensity of this type or
f the involved leg Volume
training. A meeting IIdth the parents has been scheduled
1-)1' symmetry index
and the coach wants you to discuss plyomeLric training
. n be used to deter­ Volume is the total amount of work that is performed in a
with them. What thing should the athletic tra iner ad­
()I' plyometric train­ sing ~e workout session. With wcight training, volume
dress in this meeting?
an ce equal to the WQuld bc recorded as the total amount of weight lhat was
:l"r. the medicine ball l.ifted (weight limes repetitions). Volume of plyometric
training is measured by counting the total number of foot
erequisite for plyo­ Weight of the Athlete contacts. The recommended volume of foot contacts in
1exibility. because a anyone session will vary inversely with the intensity of the
!.he musculoskeletal The heavier the athlete, the greater the training demand exercise. 1\ beginner should start with low-intensity exer­
llllg sessions should placed on the athlete. What might be a low-demand in­ cise with a volume of approximately 75 to 100 foot con­
·xi.bLlity exercise pro­ place jump for a lightweight athlete might be a high­ tacts. As ability is increased, the volume is increased to
nild sweating. 21 The de mand activity for a heavyweight athlete. 200 to 250 foot contacts of low to moderate intensity.
232 PARTTH REE 'rh eTools of Rehabilitation

the athlete she

Frequency with decreased amorti:wtion timc should be stressed. Initi­
strength and
ation of lower-quarter plyometric training begins with
"requency is the number of limes an exercise session is (3) exhibit co
low-intensity in-place and multiple-response jumps. The
pcrformed during a training cycle. With weight training, (4) free of pain
individual should be instructed in proper exercise tech­
the frequency of exercisc has typicaHy been three limes nique. The feet should be nearly 118t in all landings, and the It should ~
weekly. l:nl'ortunately. research on the frequency of plyo­ is not desig ned
individual should be encouraged to "touch and go." An
metric exercise has not been conducted. Therefore thc op­ athlete. Rath er
analogy would be landing on a hot bed of coals. The goal is
timum frequcncy for increased performance is not known. training progn
to reverse the ,l anding 8S quickly as possible, spending only
It has been suggested that 48 to 72 hours of rest arc nec­ ity training. (
a minimal amount of time on the ground.
essary for full recovery before the ncxt training stimulusY training for ski
Intensity. however, plays a major role in detcrmining the bining the ply(
frequency of training. IT an adequate recovcry period does CLINICAL DECISION MAKING Exercise 11-4 niques, the eITe
not occur, muscle fatigue will result with a corresponding Table 11- ]
increasc in neuromuscular reaction times. The beginner During the off-season. a college lineman has set personal and 10wer-eXlrl
should allow at least 41:; hours between training sessions. goals to increase his weight rrom his present playing
weight of 270 pounds to 290 pounds. lie also wants to
GUIDELI.
improve his quickness off the line. He is engaged in tradi­
Training Age tiemal strength training and an aerobic program. and he PROGRAI
Training age is the number of ),ears an athlete has been in wants to add plyometrics to the program. Is his body
The proper exet
a formal traiJling program. At younger training ages the weight a contraindication for a plyometric program?
must continu al
overall training deman d should be kept low. Prepubescent lion from wh i
and pubescent athletcs or both genders are engaged in
morc intense physical training programs. Many of these Success of the plyometric program will depend on how • TA 'B LE
programs contain plyometric drills. Because youth sports well the training variables arc controlled, modified, and ..............................
involve plyomc.Lric movements. training for these sports manipulated. In general, as the intensity of the exercise is
should aJso involve plyol11etric activities. The literature increased, the volume is decreased. The corollary to this is l. WarOl-[l
does not have long-term data looking at the effects of ply­ that as volume increases, the intensity is decre ased. The PlyobalJ a:
ometric acti vities on human articular cartilage and long overall key to successfully controlling these variables is to Plyoball s
bone growth. Research demonstrates that plyometric be flexible and listen to what the atblete's body is telling Plyoball \Ii
training does indeed result tn strength gains in prepubes­ you. The body's response to the program will dictate the ER /IR I\'iq
cent athletes, and that plyomctric training may in fact con­ speed of progression . Whenever in doubt as to the exercise PNFD2 p.
tribute to increased bone mineral content in young intensity or volume, it is better to underestimate to prevent II. Throwinl
fcmales. 15.40 injury. Two-hand
Before implementing a plyometric program. the sports Two-hall
Recovery therapist should assess the type of athlete that is being re­ Two-ha n
habilitated and whether plyometrics arc suitable ror that Tubing ER,
Recovery is the rest rime used betwecn exercise sets. Ma­ individual. In most cases. plyometrics should! be used in the Tubing P
nipulation of this variable will depend on whether the goal l'a lter phases of rehabilitation, starting in the advanced One-ha nd
is to increase power or muscular endurance. Because ply­ strengt.hening phase once the athlete has obtained an ap­ One-hand
ometric training is anaerobic in nature, a longer recovery propriate strength b8se. J ~. l8 When uti'lizing plyometric One-hand
period should be used to allmv restoration of metabolic training in the uninjured athlete. the application of plyo­ Plyo push
stores. With power training. a work rest ratio of 1: 3 or 1:4 metric exercise should follow the concept of periodiza­
should be used. This time frame will allow maximal recov­ tion. )5 The concept or periodi:lation refers to the Ill. Throwin~
ery between sets. for endurance training, this work/rest year-round sequence and progression of strength train­ Two-hand
ratio ca n be shortened to 1:1 or 1:2. Endurance training ing. conditioning, and sport-specific skills. 3R There are four Two-ha nd
typic81ly uses circuit training. where the individual moves speCific phases in the year-round periodization model: the Two-han d
from onc exercise sel to another with minimal rest in be­ competitive season, postseason training, the preparation One-hand l
tween. phase. and the transitional phase. 35 Plyometric exercises
The beginning pl:y omelric program should emphasizc shoul'd be performed in the latler stages of the preparation
the importance of eccentric versus concentric muscle con­ phase and during the traositional phase ror optimal results
tractions. The: rc:le:vancc of the stretch-shortening cycle and safety. To obtain the benefits or a plyomelric program.
 CHAPTER 11 Plyomelics in Rehabilitation 233

the athlete should (1) be well conditioned with sufl1cient be established. It must be remembered that jumping is a
.Id be stressed. Initi­
strength and endurance, (2) exhibit athletic abilities, continuous interchange between force reduction and
~inin g begins with
( 3) exhibit coordination and proprioceptive abilities, and force production. This interchange takes place through­
"SpOnse jumps. The
(4) free of pain from any physical injury or condition. out the entire body: ankle, knee. hip, trunk, and arms. The
per exercise tech­
It should be remembered tha t the plyometric program liming and coordinatioll of these body segments yields a
~ I landings, and the
is not designed: to be an exc'lusive (mining program for the positive ground reaclion that wil t result ,i n a high mte of"
ouch and go." An
athlete. Rather, it should be one part of a well-structured force production.
f coals. '!'he goal is
training program that includes st rength training, flexibil­
~ i Ie. spending only
ity training, cardiovascular fitness, and sport-speci!1c
.nd.
tr aining for skHl enhancement and coordil1atlon. By COID­ CLINICAL DECISION MAKING Exercise 11-5
bining the plyometric program with other training tech­
Exercise 11-4 niques, the effects of training are greatly enhanced. A teenage amateur remale swimmer s\\~ms distance
Table 11-1 and Table 11-2 suggest upper-extremity freestyle events and has generalized ligamentous laxity.
<;et personal and Lower-extremilY plyometric drills. (h'eT the course of the previous season he complained of
1 playi ng shoulder pain. Her pain was accompanied by increased
<;() wants to
GU IDELINES FOR PLYOMETRIC times in all of her events. Her physician diagnosed her
. ged in tradi­ with lIlultidlrectionallnstability and secondary shoulder
~ .andhe
PROGRAMS impingemerrt syndrome. The physician wants the athlete
I hls body The proper execution of the p'lyometric exercise program to begin a plyometric program. How v.T\II you incorporate
:>rOgram? must continually be stressed. A sonnd tec hnical founda­ plyolIletrics into the training program?
ti on from which higher~ intensity work can build should

ill de pend on hOI\" • TAB LE 11-1 Upper-Extremity Plyometric Drills .

. modified, and
of th e exercise is
::oro llary to this is I. Warm-Up Drills IV. Trunk Drills

. decreased. Thc Plyoball trunk rotation Plyoball sit-ups

va riables is to Plyoball side bends l'lyoball sit-up and throw

e' body is telling Plyoball wood chops Plyoball back extension

m w ill dicta te the ER/IR with tubing Plyoballiong silting side throws

eas to the exercise PNF D2 pattern with tubing

V. Partner DrilJs
'1im a te to prevent II. Throwing Movements-Standing Position Overhead soccer throw

Two-hand chest pass Plyoball baek-to-back twists

_ram. the sport, Two-hand overhead soccer throw Overhead pullover throw

1e rhat is being re­ Two-hand side throw overhead Kneeling side throw

e uitable for that Tubing ER/IR (Both at side & 9()O abduction) Backward throw

a Id be used in tilt: Tubing PNF D2 pattern Chest pass throw

g in the advancc(: One-hand base baH throw

as obtained an ap­ VI. Wall Drills

utilizing plyometri:
application of plyo­
ee pt- of periodiza­
n refers to the III. Throwing Movements-Seated Position
on of strength train­
IUlls. 3 There are four
diza tion model: the
ing. the preparati on
Piyo metric exercise;,
of the preparation
tse fo r optimal resu lb
piyometric progra m
One-hand IR side throw
Two-hand chest throw
One-hand ER side throw
Two-hand overhead soccer throw
Plyo push-up (against wall)
Two-hand underhand side-to-side throw
One-hand baseball throw
Two-hand overhead soccer throw One-hand wall dribble
Two-hand side-to-side throw
VII. Endurance DriUs
Two-hand chest pass
One-hand wall dribble
One-hand baseball throw
Around-the-back circles
Figure eight through the legs
Single-arm ball l1ips
 234 PART THREE The Tools of Rehabilitation

• TABLE 11·2 Lower-Extremity Plyometric Drills. 7. Plyometric

mOre than
of training .
I. Warm·Up Drills IV. Advanced Level Drills
During the
Double-leg squats
Singl e-Leg Box Jumps
metric trair
Double-leg leg press
One-box side jumps
with the inl
Double-leg squat-jumps
Two-box side jumps
important.
Jumping jacks
Single-leg plyo leg press (4 corners)
8. Dynamic te
Two-box side jumps with foam
II. Entry Level Drills-Two·Legged will provide
Four-box diagonal jumps
Two-Legged Drills
feedback.
One-box side jumps with rotation
Side to side (Jloor / line)
9. In addi lioo
Two-box side jumps with rotatton
Diagonal jumps (floor / 4 corners)
proper eq ui ,
One-box side jump with catch
Diagonal jumps (4 spots)
allow for th l
One-box side jump rotation with catch
Diagonal ziglzag (6 spots)
su rfaces she
Two-box side jump with catch
Plyo leg press
absorption i
Two-box side jump rotation with catch
Plyo leg press (4 corners)
adequate sh
V. Endurance/Agility Plyometrics

Ill. Intermediate Level Drills

Side-to-side bounding (20 feet)

Two-Legged Box Jumps

Side jump lunges (cone)

One-box side jump

Side jump lunges (cone with foam)

Two-box side jumps

Altering rapid step-up (forward)

Two-box side jumps with foam

Lateral step-overs

Four-box diagonal jumps

High stepping (forward)

Two-box with rotation

High stepping (backwards)

One/Two box with catch

Depth jump with rebound jump

One/Two box with catch (foam)

Depth jump with catch

Single-Leg Movements
Jump and catch (plyoball)

Single-leg plyo leg press

Single-leg side jumps (floor)
Single-leg side-to-side jumps (floor/4 corners)
Single-leg diagonal jumps (1100r/4 corners)

As the plyometric program is initiated, the individual
must be made aware of several guidelines. 3 5 Any deviation
from these guidelines will result in minimal improvement
and increased risk for injury. These guidelines include the
following:
. 1. Plyometric training should be specific to the individ­
ual goals of the athlete. Activity-specific movement
patterns should be trained. These sport-specific skills
should be broken down and trained in their smaller
components and then rebuilt into a coordinated
activity-specific movement pattern .
2. The quality of work is more important than the qUc:ll1­
tity of work. The intensity of the exercise should be
kept at a maximal leve!.
3. The greater the exercise intensity level, the greater
the recovery time.
4. Plyometric training can have its greatest benefit at the
conclusion of the normal workout. This pattern will
best replicate exercise under a partial to total fatigue
environment that is specific to activity. Only low- to
medium-stress plyometrics shoutd be used at the con­
clusion of a workout, because of the increased poten­
tial of inj ury with high-stress drills.
5. When proper technique can no longer be demon­
strated. maximum volume has been achieved and the
exercise must be stopped. Training improperly or with
fatigue can lead to injury.
6. The plyometric training program should be progres­
sive in nature. The volume and intensity can be modi­
fied in several ways:
a. Increase the number of exercises.
b. Increase the number of repetitions and sets.
c. Decrease the rest period between sets of exercise.
 CH /\ PTER 11 Plyometics in Rehabilitation 235

I. Plyometric training sessions should be conducted no
more than three times weekly in the preseason phase
of training. During this phase. volume should prevail.
During the competitive season. the frequency of plyo­
metric training should be reduced to twice weekly.
with the intensity of the exercise becoming more
important.
8. Dynamic testing of the individual on a regular basis
will provide important progression and motivational
feedback.
9. In addition to proper technique and exercise dosage.
proper equipment is also required. Equipment sho uld
allow for the safe performance of the activity. landing
surfaces should be even and allow for as much shock
absorption as possible. and footwear should provide
adequate shock absorption and forefoot support.
The key e'lement in the execution of proper techn,i que
is the eccentric or landing phase. The shock of landing
from a jump is not absorbed exclusive'ly by the foot but
rather is a combination of the ankle. knee. and hip joints
all working together to absorb the shock of landing and
then transferring the force.
INTEGRATING P.LYOMETRICS
INTO THE REHABILITATION
PROGRAM: CLINICAL CONCERNS
When used judiciously. plyometrics are a valuable asset in
the sports rehi:tbilitation program (Figure 11-4). As previ­
ously stated. the majority of lower-quarter sport function oc­
curs in the closed kinetic chain. Lower-extremity plyometrics

A B

fhi s pall ern will

aI to tota l fatigue
1lY. Only low- to
be used at the cun­
e increased poten- c D

Figure 11-4 Plyomclric exercises. A, Partner medicine ball toss.

B, Bounding activity. C, Depth jump. D, Plyoback. (Photos courtesy
of Perform Better, Cranston Rl.)
236 PART THREE I he Tools of Rehabilitation

are an effective functional closed-chain exercise that can

be incorporated into the sports rehabilitation program.
Through the eccentric prestretch. plyometrics place added
stress on the tendinous portion of the contractile unit. Ec­
centric loading is beneficial in the management of tendini­
tis. l7 Through a gradually progressed eccentric loading
program. healing tendinous tissue is stressed. yielding an in­
crease in ultimate tensile strength. This eccentric load caD be
applied through jump-downs (Figure 11-5).
Clinical plyometrics can be categorized according to
the loads applied to the healing tissue. These activities in­
clude (1) medial/lateral loading. (2) rotational loading.
and (3) shock absorption/deceleration loading. In addi­
tion. plyometric drills will be divided into (1) in-place ac­
tivities (activities that can be performed in essentially the
same or small amount of space); (2) dynamic distance
drills (activities that occur across a given distance; and
(3) depth jumping (jumping down from a predetermined
height and performing a variety of activities upon land­
ing). Simple jumping drills (bilateral activities) can be pro­
gressed to hopping (unilateral activities).

Figure 11-5 Jump-down exercises.

CLINICAL DECISION MAKING Exercise 11-6

A professional soccer player sustained aD Achilles tendon

rupturt' J 0 weeks ago. The tendon was surgically re­
paired . The athlete was in II brace that was gradually ad­
justed to allow rull weight bearing and dorsinexion 10
neutral in the brace. He has been out of the brace com­
pletely and walking wIthout a limp for 2 weeks. He wants
to begin a Jumping and hopping program to increase
strength and power in the calf. What type of guidelines
should be employed to sa rely begin these activities?
Medial-Lateral Loading
Virtually all sporting activities involve cutting maneuvers.
Inherent to cutting activit ies is adequate function in the
medial and lateral direcLions. i\ plyometric program de­
signed to stress the athlete's ability to accept weight on the
involved lower extrem.ity and then perform cutting activi­
ties off that leg is imperative. Individuals who have suf­
fered sprains to the medial or lateral capsular and
ligamentous complex of the ankle and knee. as well as the
hip abductor/ adductor and ankle invertor/ evertor muscle
follOWing injury to the medial soft tissue around the knee
arter a valgus stress. By graduCllly imparting progressive
valgus 'loads. tissue tensile strength is augmented .4 1 In the Figure 11-6
(Courtesy of Pc
rehabilitation setting. bilateral support drills can be pro­
gressed to unilateral valgus 10Clding efforts. Specifically.
lateral jumping drills are progressed to lateral hopping ac­
tivities. However. the medial structures must also be
trained Lo accept greater valgus loads sustained during
culling activities. As a prerequisite to full-speed cutting.
lateral bounding drills should be performed (Figure] 1-6).
These eff(Jrts are progressed to activities that add accelera­
tion. deceleration . and momentum. Lateral sliding activi­
ties that require the individual to cover a greater distance
can be performed on a slide board. If a slide board is not
available. the same movement pClllern can be stressed with
plyol11etrics (Figure 1 1-7).
IN-PLACE ACTIVITIES
Lateral bounding (quick step valgus loading)
Slide 'bounds
Figure 11-7 U

strains. arc candidates for medial/lateral plyometric load­ DYNAMIC DISTANCE DRILLS
IPhoto Courtesy 1
ing. Medial/lateral loading drills should be implemented Crossovers
 CHAPTER 11 P lyometics in Rehabilitation 237

g progressive
" me nted Y [n the Figure 11-6 Lateral bounding drills.
drills ea n be pro­ Cour tesy of Perform Better Cranston RI)
rts. Specifically.
[e ra l hopping ac­
must also be
_u -tained during
ull -speed culting.
ed (F igure I I-Ii I.

ere I sliding aelivi­

a greater di sta net:
, Iide board is nol
"an be stressed w ith

luading)

figure ] 1-7 Lateral sliding activities.

Photo ourtesy of Perform Better, Crans to n RI)
238 PART THREE The Tools of Rehabilitation

Rotational Loading One way to prepare the athlete for shock absorption
drills is to gradually maximize the effects of gravity, such References
Beca use rotation in the knee is controlled by the cruciate as beginning in a gravity-minimized position and pro­
ligaments, menisci, and capsule. plyometric activities with 1. Adams, T. I
gressing to performance against gravity. Popular activities training exer
a rotational component are instrumental in the rehabilita­ to minimize gravity include water activities or assisted ef­ alld Field Qlla
tion program after injury to any of these st ructures. As forts through unloading. 2. Asmussen. E.
previously discussed. care must be taken not to exceed tic energy in
healing time constra ints when using plyometric training. IN-PLACE ACTIVITIES dinuvia 9] : 3
Cycle jumps 3. Bielik. E.. D. C
IN-PLACE ACTIVITIES Five-dot drill tical considl
Spin jumps Strength and (
4. Bosco. C.. am
DYNAMIC DISTANCE DRILLS DEPTH JUMPING PREPARATION ieal behavior
Jump downs stretching. :\.
Lateral hopping
5. Bosco, C.. an~
lhe activities listed above are a good starting point In lixercise un.:
Shock Absorption from which to develop a clinical plyometric program. Ma­ IL: Human K~
<Deceleration Loading) nipulations of volume, frequency. and intensity cao ad­ 6. Bosco. C.. j. T.
vance the program appropriately. Proper progression is of ergy and ill)'
Perhaps some of the most physically demanding plyomet­ prime importance when using plyometrics in the rehabili­ stretch-shortc
ric activities are shock absorption activities. which place a tation program. These progressive activities are reinjuries Sports Mediein
tremendous amount of stress upon muscle. tendon. and waiting to happen if the progression does not allow for ad­ 7. Bosco. C.. J. r
articular cartilage. Therefore, in the I1nal preparation for a recoil of elast.
equate healing or development of an adequate strength
tal muscles . .i.
return to sports involving repetitive jumping and hopping , base. i\ close working relationship fostering open commu­ Cavagna. G.\
shock absorption drills should be included in the rehabili­ nication and acute observation skills is vilal in helping en­ work done by ~
tation program. sure that the program is not overly aggressive. Physiology 14i
9. Cavagna. G..
alive work on
Summary isolaLeum uSC'
10. Cbu. D. 1 9 84.
ditionillg As
11 . Chu. D. 19
1. Although the effects of plyometric training are not yet training often results in boredom and a lack of moti­
fully understood, it still remains a widely used form of vation.
combining strength with speed training to function­ 5. Program variety can be manipulated with different
ally increase power. While the research is somewhat types of equipment or kinds of movement performed. Leisure Pr
contradictory, the neurophysiological concept of plyo­ 6. Continued mot4vation and an organized progression 1 3. Chu. D. and L
metric training is on a sound foundation. arc the keys to successful training.
2. A successful plyometric training program should be 7. Plyometrics are also a \7aluable asset in the rehabilita­
carefully designed and implemented after establishing tion program after a sport injury.
an adequate strength base. 8. Used after lower-quarter injury, plyometrics arc effec­
3. The effects of this type of high-intensity training can tive in facilitating joint awareness, strengthening tis­
be achieved safely if the individual is supervised by a sue during the healing process. and increasing
knowl edgeable person who uses common sense and sport-specific strength and power. 16. Dunsen ev.
follows th e prescribed training regimen. 9. The most important considerations in the plyomelric Sports Review l
4. The plyometric training program should use a la rge program are common sense and experience. 17. Dunsenev. C. I.
variety of different exercises, because year-round Field QLlanerly
 CHAPTER 11 Plyometics in Rehabilitation 239

or shock absorption
eets of gravity, such References
!d position and pro­ 1. /\dams, 'r 1984. An investigation of selected plyometric 18, Enoka, R, M, 1989, NwrolllechallicaI basis of kinesioIom}.
~: Popular activities training exercises on muscular leg strength and power. Track Champaign, IL: Human Kinetics,
ilies or assisted ef­ and Field Quarterly Review 84( 1 ): 36-40. 19, Goldbeck, 1., and G, Davies, 2000, Test-retest reliability of the
2. Asmussen, E., and F. Bonde-Peterson. 1974. Storage of elas­ closed chain upper extremity stability test: A clinical field test.
tic energy in skeletal muscles in man. Acta Physiologien Sen/!­ journal of Sport Rehabilitation 9:35-45,
dillavia91:385. 20. Javorek, L 1989, P tyometrics. National Strength and Condition­
3. Bielik. E.• D. Chu. F. Costello, et al. 1986. Roundtable: 1. Prac­ ing Association journal 11 :52,
t,ical considerations for utilizing plyomctrics. National 21. Jensen, C, 1975, Pertinent facts about warming, Athletic jour­
Strength and Conditioning AssociationjoumaI8:14. naI56:72.
4. Bosco, C., and P. V Komi. 1979. Potentiation of the mechan­ 22, Katchajov, S.. K. Gomberaze, and A. Revson, 1976. Rebound
ical behav,i or of the human skeletal muscle through pre­ jumps. Modem Athlete and Coach 14(4): 23,
stretching. fleta Physiologica Scandinavia 106:467. 23. Komi, P. V 1984. Physiotogica.1 and biomechan.1cal correlates
.). Bosco. C., and P. V Komi. .1982. Muscle elasticity in athletes. of muscle function: Effects of muscle structure and stretch­
good starling point In Exercise and sports biology, edited by P. V Komi. Champaign, shortening cycle on force and speed, In Exercise and sports sci­
me program, Ma­ IL: Human Kinetics. ences review, edited byTerjung, Lexington, lv1A: Collamore Press,
inl~ nsily can ad­ 6. Bosco, C, j. Tarkka, and P. V Komi. 1982, Effect of elastic en­ 24. Komi, P. V. and C Bosco. 1978. Utilization of stored elastic
progression is of ergy and myoelectric potentiation of triceps surea during energy in leg extensor muscles by men and 1V0men, Medicine
stretch -shortening cycle exercise. International journal oj and Science in Sports and Exercise 10(4): 261.
in the rehabili­
Sports ,'vledicine 2: 13 7. 25, Komi, P. V.. and E. Buskirk, 1972, Effects of eccentric and con­
/. Bosco, C., J. Tihanyia, and P. V Komi, et al. 1987, Store and centric muscle conditioning on tension and electrica.1 activity
recoil of elastic energy in slow and fast types of human skele­ of human muscle. Ergonomics 15:417,
adequate strength tal muscles. Acta Pilysiologica Scandinavia 1l6:343. 26. Lundon. P. 1985, A review of plyometric training, National
S. Cavagna, O. A .. B. Dusman, and R. Margaria, 1968, Positive Strength and Conditioning Association journal 7:69,
work done by a previously stretched muscle, Journal of Applied 27. Rach, P. J,. M. D. Grabiner. R. J. Gregor, et al. 1989, Kinesiology
Pllysiology 24:21. and applied anatomy. 7th ed, Philadelphia: Lea & Febiger.
9. Cavagna, G., F. Saibene. and R. Margaria. 1965, Effect of neg­ 28, Rowinski, M, 1988, The role of eccentric exercise. Biode.x Corp,
ative work on the amollnl of positive 1V0rk performed by an Pro Clinica,
isolated muscle, jOllrllal of Applied Physiology 20: l5 7, 29. Thomas. D. W. 1988. Plyometrics-More than the stretch re­
10 . Chu, '1 l 19R4. Plyometric exercise. National Strcngth and Con­ Hex. National Strength and Conditioning Association journal
ditiol1.ing Association jOllrllal6: 56. 10:49,
11. Chu, D. 1989. Conditioning/pIyometrics. Paper presented at 30. Tippett. S. 1992, Closed chain exercise. Orthopaedic Physical
and a lack of rno '­ 10th Annual Sports Medicine Team Concept Conference. San Therapy Clinics of NortiJ America 1:253-67,
Francisco, December. 31. Tippett. S.. and M. Voight. 1995. FUllctional progressionsIor
ted with differe , 2. Chu, D. 1992. jumping into plyometrics, Champaign, IL: sport rehabilitatioll. Champaign. IL: Human Kinetics,
Leisure Pr ess. 32. Verhoshanski, Y 1969, Are depth jumps useful? Ycsis Review
~ me ut performe
• 3. Chu, D. and L. Plummer. 1984. The language of plyometrics. of Soviet Physical Education and Sport 4: 74-79.
~ cd progrc si
National StrCl1gth amI Conditioning 11ssociation journal 6:30. 33. Verkhoshanski. Y 1969, Perspectives in the improvement of
14 , Curwin. S., and W. D. Stannish. 1984. Tendinitis: Its eUoloilY speed-strength preparation of jumpers, Yesis Review oj Soviet
I Ln the rehab lliw­ and treatment. Lexington, MA: Collamore Press, Physical Educatioll and Sports 28-29,
. ), Diallo, 0 .. E, Dore, P. Duchercise, et al. 2001. Effects of plyo­ 34. Verhoshanski. y, and G, Chomonson, 1967. Jump exercises
me tries are ell metric training followed by a r educed training programme on in sprint training. Track and Field Quarterly 9: 1909.
trengt'hening­ physical performance in prepubescent soccer players. journal 35. Voight. M,. and P. Draovitch. 1991. Plyometrics. In Eccentric
, and increa_ . ~"' of Sports Medicine and Physical Fitness 41:342-48. muscle training ill sports and orthopedics, edited by M, Albert.
'6. Dunsenev, C. L 1979. Strength training for jumpers, Soviet ;ew York: ChurchUI Livingstone.
in the plyome ~ Sports Review 14:2. 36. Voight. M .. and D. Bradley. 1994, Plyomctrics, In A com­
17. J)unsenev. C, L 1982, Strength training of jumpers. Track and pendiwll of isokilletics ill clinical usage and rehabilitation tech­
-perience,
Field (JuarterIy82:4, niques, 4th ed., edited by G. J, Davies, Onalaska, WI: S & S,
240 PART THREE The Tools of Rehabilitation
37. Von Arx, F. 1984. Power development in the high jump. Track
Technique 88:2818-19.
38. Will" K. Eo, M. L. Voight, M. A. Keirns, V. Gambetta, J. An­
drews. and C. J. Dillman. 1993. Stretch-shortening drills for
the upper extremities: Theory and clinical application. Jour­
nalof Orthopaedic and Sports Physical Tllcrapy17:22 5-39 .
39. Wilt. 1'.1975. Plyometrics-What it is and how it works. Ath­
IclicJoul'IlaI55b :76.
SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES
11-1 Although the athlete is in the off-season and actual
performance is not jeopardized, her overall activity
level must be adjusted to allow for pain-free perfor­
mance of her conditioning program. The intensity
of the plyometric program must be adjusted. In­
stead or box jumps and depth jumps, the athlete
should regress to beginner skills such as in-place
jumping (both legs) and progress to unilateral ac­
tivities as tolerated. If these activities cause pain.
the plyometric program should be discontinued
until symptoms improve. At the heart of the ath­
lete's problem may be underlying biomechanical
concerns that predispose her to knee pain. A thor­
ough assessment of her lower-extremity biome­
chal1ics, f1exibility, and strength should be
performed. Core strength and stability of the low
back and hips must be assessed. Assessment of the
patellofemoral joint must also be performed. Ap­
propriate interventions to address any dysfunction
must be included as a vital prerequisite prior to ad­
vancing the plyometric program.
11-2 As the high-stepping drills involve hip flexion, care
must be taken in performing these drills. There is a
good chance that the initial injury occurred with
hip flexiol1 and knee extension while sprinting. so
reintroducing the athlete to these positions is an
absolute must in the rehabilitation program. A
gradual return to these activities is essential to
maximize strenglh without reinjlury. Symmetrical
flexibility of the hamstrings is a must. Single-joint
conc.entric and eccentric strengthening should be
performed without pain to the point of symmelry
with the opposite side. When she has an adequate
strength and flexibility base, she can begin bilateral
and then unilateral plyometric leg-press activities
(with less-than-body-weight resistance) on the
40. Witzke.. K.. and C. Snow. 2000. Effects of plyometric jump tiona I weigh
training on bone mass in adolescent girls. Medicine and Sci­
made approp
en c.e in Sport;; tlnd J;xercise 32:1051-57.
strengthenin:
41. Woo. S. L.. M. Inoue. E. McGurk-Burleson. et al. 1987. Treat­
ment of the medial collateral ligament injury: Structure and
be introdUCe(
function of canine knees in response LO differing treatment tant that th
regimens. LllllcricanJoumal oj Sport s Medicine 1 5(1): 22-29. weight with p
tional guideliJ
1] - 5 Of all sporlin
one with the
tivity. This do
to develop po
the swimmer '
for starts a nd
Shuttle, followed by weight-bearing beginner plyo­ for power in I
metrics Uumping and hopping). Emphasize activi­ rics in this au
ties involving degrees of hip f1exion similar to tile shoulder inSUI
amount of hip flexion involved in sprinting. When strength in t
these activities are tolerated well. the athlete can proper postur
then begin high-knee running drills. box jumps. Combinations
and depth jumps. and external I
11-3 Plyometrics have been shown to be beneficial in volving thron
producing strength gains in athletes of this age. stress in an an
Plyol11etrics certainly can el1hance anaerobic con­
ditioning as well. Plyometrics. however. are but one
component of the entire conditioning program.
Proper attention should also be given to safe
strength training. flexibility. aerobic conditioning.
as well as proper football techniques and protective
equipment. There are no long-term data to show
that plyometrics are detrimental to the growing
athlete. and many of the activities inherent to foot­
ball are plyometric in nature. Keep the plyol11etric
activities at the beginner phase and use the begin­
ner skills to develop an adequate strength base.
Stress correct form and technique. Watch for sub­
stitutions of movement and progress to intermedi­
ate ac[i.vities if and when the athletes demol1strate
correct performance of the beginner skills. Finally.
because the athletes are in the playing season. fre­
quency of plyometrics should be minimized.
11-4 Athletes of al'l sizes can safely take part i[l plyomet­
rics if they have an adequate strength base.
Chances are that this athlete is familiar with plyo­
metric training already. so technique and progres­
sion should not be an issue. As the athlete gains
weight, however. the relative load on his weight­
bearing joints increases. His exercise dosage should
reflect his change in weight. Adequate closed­
chain strength must increase to support the addi­
 CHAPTER I I Plyometics in Rehabilitation 241

or plyomelric jump Lional weight prior to plyometrics. After he has horizontal adduction as well as weight-bearing ac­
~lI"ls. Medicine and Sci­ made appropriate gains in controlled closed-chain tivities in a prone or quadruped position may apply
strengthening (leg press. squats). plyometrics can excessive stress in a posterior direction. Try to keep
n.et at. 19 87.Trcat­ be introduced and progressed. It is equally impor­ activities bilateral and symmetrical. Emphasize
, Uljury: Structure and
tant that the athlete's weight gain be fat-free scapular retraction, and try to have the athlete
differing treatment
weight with proper attention given to sound nutri­ keep and attempt to maintain scapular slability.
dirine 15(1): 22-29.
tional guidelines. 11-6 Obviously. plyometrics can be llsed to facili ~ ate
11-5 Of all sporting acHvities, swimming might be the strength gain in the entire lower extremity. How­
one with the least amount of eccentric muscle ac­ ever, excessive stress to the healing tendon can be
tivity. This does not mean that plyometric training detrimental in terms of tendinitis. lendinosis, and
to develop power is not important. Plyometrics for possibly even re-rupture. Plyometrics should not
the swimmer should include lower-extremity work even be considered until the athlete is able to
for starts and turns, as well as trunk plyometrics demonstrate normal strength (symmetrical unilat­
for power in the water. Upper-extremity plyomet­ eral toe raises), symmetrical gastrocnemius-soleus
. g beginner plyo­
rics in this athlete may be problematic due to her Ilexlibility, as we'll as pain-free and subslilution-[ree
" . Em phasize activi­
shoulder instabi1iity. Be sure that she has adequate gait. Only after attaining these goals should plyo­
"011 similar to the
strength in her scapular stabilizers as well as metrics be instituted. The program should begin
n prinHng. When
proper posture to minimize an anterior glenoid. with bilateral nonsupport activities and progress to
I. the athlete can
Combinations of abduction, horizontal abduction, unilateral nonsupport activities. Loads with less
drills . box jumps.
and external rotation common in plyometrics in­ than body weight 011 the Shuttle are an effective
volving throwing motions might app-ly excessive precursor to weight-bearing activities.
o be beneficial in
stress in an anterior direction. Activities involving
I]letes 01 this age.
ce anaerobic con­
wever. are but onc
tjOiling program.
be given to safe
bie conditioning.
ue and protective
=-term data to show
.al [0 the growing
inherent to foot­
eep the plyometric
an use the begin­
ate strength base.
ue. Wa tch for sub­
"ress to intermedi­
etes demonstrate
ncr sl\.ills. FinaUy.

take part in plyomet­

_ ate strenglh base,
fam Uiar with plyc­
~hnique and progres­
the athlete gain
load on his weight·
~ 'ercise dosage should
l. dequate closed­
. to support the addi-
 CHAPTER
Open- versus Closed-Kinetic­
12 exercises such ~
machine.
Closed-kinetic...
rehabilitation of in
are also useful in re.
ex tremity acli~ille,

Chain Exercise ,in Rehabilitation functions in an'opt

freely, as in thrO\\'ir
activities ill wh ich
William E. Prentice closed kinetic chain
nastics or assum ln~
Despite the Cl'CI
exercises, it must b
ki neti c-chain exerc

~ Live process. 19 Tb i
of both open- a nd
process .
Study Resources • Compare how both open- and closed­
To become more familiar \\ ilh th e knowledge and skills kinetic-chain exercises should be used THE CONCE
necessary fo design. implement. and document therapeu­
in rehabilitation of the lower extremity. KINETIC CH
tic reh abUi Lat ion programs as identified in the tVlITA Atll­
leUc Trailling Educational Compeu llcies alld Clinical • Identify the various cIosed-kinetic­ The concept of the J
Projiciwries 'Therapculic Exercise content urea. visit
chain exercises for the lower extremity. ' 970s a nd was inil
www.mhhe.com/ prenLicel l e. Also refer to the lab exer­ lechanical engi n{'l
cises in (he new Laboratory Manual a nd to eS ims. which • Examine the biomechanics of closed­ connect a se ri es of
simulate!: th e athletic trainin g certification exam. at
kinetic-chain exercises in the upper 1-1 ). If both ends
wlVw.mhhc. com /esjms. For more online study resources .
'Tlovable frame. tbe
visit our He.aJ th and Human Performance website at extremity.
ma l or the dista l
www.mhhe.com/hhp.
• Explain how closed-kinetic-chain exer­ moving body segm
rces to adjacent bd
After Completion of This
cises are used in rehabilitation of the affected by the
Chapter, the Student Should
upper extremity. lased link syste m .
Be Able To Do the Following:
k'table movemen t.
• Recognize the various types of closed­ closed link systed
• Differentiate between the concepts of kinetic-chain exercises for the upper he lower extremity.
an open kinetic chain and a closed ki­ extremity. 'n extremity (that .
fixed. muscle r
netic chain.
ents arc differe n t
• Contrast the advantages and disadvan­
·"rem­ have been
tages of using open- versus closed­ n recen t years the concept of c1osed-kinetic-chain Whenever tb e Ii
kinetic-chain exercise.
• Recognize how c1osed-kinetic-chain
I exercise h as received considerable atten tion as (l usefu l
and effective technique of reh abilitation, particularh
for injuries involving the lower eXb'emity.hS The ankle
ed . as is the case il
e more proxima l
n. If the fooi or b
exercises can be used to regain neuro­ knee, and hip joints constitute the kin etic chain for the etic chain. m O\'.
muscular control. lower extremity. When the distal segment of the lower ex, ·tbin the chain arc
tremity is stabilized or fix ed, as is the case whe n the foot b To a large exten
• Analyze the biomechanics of c1osed­ weight-bearing on the ground. the kinetic chain is said t, come to mean ..
kinetic-chain exercise in the lower be closed. Conversely. in a n open kinetic chain, the dista ou gh all weight-bd
segment is mobile and is not fixed. Traditionally. rehabili ta, closed-kinetic-ch!
extremity. tion strengthening protocols have used open-kinetic-ch air. a in activities are \.
242
 CHAPTER 12 Open- versus Closed-Kinetic-Chain Exercise in Rehabilitation 243

exercises such as knee nexion and extension on a knee

machine,
Closed-kinetIc-chain exercises are used more often in
rehabilitation of injuries to the lower extremity, but they
,•• are also useful in rehabilitation protocols for certain upper­
extremity activities. For the most part the upper extremity B
functions in an open kinetic chain with the hand moving
tion
freely, as in throwing a baseball. But there are a number of
activities in which the upper extremity functions in a
closed kinetic chain, as in performing a handstand in gym­
nasti cs or assuming a down position in wrestling.
Despite the recent popularity of closed-kinetic-chain
exercises, it must be stressed that both open- and closed­
kinetic-chain exercises have their place in the rehabilita­
tive process.! ~ This chapter will attempt to clarify the role
of both open- and closed-kinetic-chain exercises in that
process. Figure 12-1 If both ends of a link system are fixed,
- and cLosed­ movement at one joint produces predictable movement at
uld be used THE CONCEPT OF THE all other jOints.

-er extr mity. KINETIC CHAIN

-kinetic­ The concept of the kinetic chain was first proposed in the Muscle Actions in the Kinetic Chain
er extremity.
197Us and was initially referred to as the link system by
mechanical engineers. >i In this link system , pin joints Muscle actions that occur during open-kin eLic-chain ac­
f c1osed­
connect a series of' overlapping, rigid segments (Figure tivities are usually reversed dur,i ng c1osed-kinelic-chain
l2-l). If both ends of this system are connected to an im­ activities. In open-kinetic-chain exercise. the origin is fixed
the upper
and muscle contraction produces movement at the inser­
movable frame, there is no movement of either the proxi­
mal or the distal end. In this closed link system, each tion. In closed-kinetic-chain exercise, the insertion is fixed
moving body segment receives forccs from and transfers and the muscle acts to move the origin. Although this may
c-chain exer­
be important biomechanically, physio]oglcally the muscle
fo rces to adjacent body segments and thus either affects or
ation of the
is aflected by the motion of those components,li In a can lengthen, shorten, or remain the same length, and
closed link system, movement at one joint produces pre­ thus it makes little difference whether the origin or inser­
ictable movement at all other jOints. 55 In reality, this type tion is moving in tcrms of the way the muscle contracts.
-pes of dosed­ of closcd link sys tcm does not exist in e.ither the upper or
r the upper the lower extremity. However, when the distal segment in The Concurrent Shi.ft
an cxtremity (that is. the foot or hand) mects resistance or in a Kinetic Chain
i fixed. muscle recruitment patterns and joint move­
1cnts are dHTerent than when the distal scgment moves The concept of die concurrent shift applies to biarticu­
freely. i i Thus. two systems- a closed system and an open lar muscles that havc distinctive muscle actions within the
system~have been proposed . kinetic chain during weight-bearing activities. For exam­
losed-k inetic-chain Whenever the foot or the hand meets resistance or is ple, the rectus femoris shortens as the knee Oexes and
attention as a usefw r ed, as is the case in a c10scd kinetic chain. movement of lengthens as the hip extends. Thus thc muscletength
'!italion, particul ar!_ the more proximal segments occurs in a predictable pat­ changes vcry little even though Significant motion is oc­
~ ity,('i The ankle (ern. If the foot or hand moves freely in space as in an open curring at both the hip and the knee. Also, the rectus
kinetic chain for th t '[netic chain, movements occurring in other segments femoris is exhibiting distinct muscle actions involving si­
~e nt or the lower ex­ within thc chain arc not neccssarily predictable, I! multaneous eccentric contraction at the hip and concen­
'ase when the foot To a large extent the term closed-kinetic-chain exercise tric contraction at thc knee. This concurrent shift occurs
-' etic chain is said has come to mean "weight -bearing excrcise." However. al­ only during c1osed-kinetic-chain exercises.
netic chain, the disla though all weight-bearing exercises involve some elements The concepts of the reversibility of muscle actions and
rad itionally, rehabili La­ of c1osed-kinetic-chain activities. not all c1osed-kinetic­ the concurrent shift are hallmarks of closed-kineLic-chain
~ open-kinetic-chair chain activities are weight-bcaring. 54 exercises. 54
244 PART THREE The Tools of Rehabilitation

ADVANTAGES AND training must be emphasized to maximize carryover to lar control of body
functional activities on the playing l1eld. s4 perform a motor sk
DISADVANTAGES OF OPEN· With open-kinetic-chain exercises. motion is usuall'y correct mOIllen t ar
VERSUS CLOSED·KINETIC· isolated to a single joint. Open-kinetic-chain activities may parts in a coordinal
include exercises to improve strength or range of mo­ is controlled by th e (
CHAIN EXERCISES
tion. l7 They may be applied to a single joint manually. as in input from joint aJ
Open- and closed-kinetic-chain exercises offer distinct ad­ proprioceptive neuromuscular facilitation or joint mobi­ within the kinetic c
vantages and disadvantages in the rehabilitation process. lization techniques. or through some external resistance requires constant ir
The choice to use one or the other depends on the desired using an exercise machine. Isolation-type exercises typi­ control center infon
treat men t goal. Characteristics of closed-kinetic-chain ex­ cally use a contraction of a specific muscle or group of In the lower extJ1
ercises include increased joint compressive forces ; in­ muscles that produces usually single-plane and occasion­ tivity requires IUUS<
creased joint congruency and thus stability; decreased aily multiplanar movement. Isokinetic exercise and testing a nd in syne rgy will
shear forc es; decreased acceleration forces; large resis­ is usually done in an open kin etic chain and can provide Single step requires
tance forces; stimulation of proprioceptors; and enhanced important informalion relaUve to the torque production muscle contractions
dynamic stilbility- all of which are associated with weight capability of !chat is01ated joint. 4 in the fool: ankle d
bearing. Characteristics of open-kinetic-chain exercises When there is some dysfunction associated with in­ flexion . extension. "
incluue increaseu acceleration forces: decreased resistance jury, the predictable pattern of movement that occurs dur­ sion. and rotation. L
forces; increaseu distraction and rolational forces; in­ ing c1osed-kinetic-chain activity might not be possible due jury in one join t I'
creased deforma tion of joint and muscle mechanorecep­ to pain. swelling. muscle weakness. or limited range of mo­ segment moves.41
tors; concentric ucccleration and eccentric deceleration tion. Thus. movement compensations result that interfere To perform this si
forces; and promotion of l'unctional acti vity. These are typ­ with normal moUon and muscle activity. If only c1oseu­ of the joints and m u
ical of non-weight-bearing acti vities. )7 kinetic-chain exercise is used. the joints proximal or distal cises that act to il1lCl
Prom a biomechanical perspective. it has been sug­ to the injury might not show an existing deficit. Without functioning element:
gested that c1osed-kinetic-chain exercises arc safer and using open-kinetic-chain exercises that isolate specific ate. Closed-kinetic-cJ
produce stresses and forces that are potentially less of a joint movements, the deficit might go un corrected. thus knee. and hip m usel
threat to healing structures than open-kinetic-chain exer­ interfering with tota l rehabilitation. I 7 The athletic trainer malloading and m Ol'
cises. i 1 Coactivation or co-contraction of agonist and should use the most appropriate open- or c1osed-kinetic­ the kinetic chain. a~
antagonist muscles must occur during normal movements chain exercise for the given situation. woulu appear to be
to proVide joint stabilization. Co-contraction. which oc­ Closed-kinetic-chain exercises use varying combina­ Quite often . open
curs during closed-kinetic-chain exercise. decreases the tions of ,i sometric. concentric, and eccentric contractions marily to ue velop m
shear forces acting on the joint. tous protecting healing that must occur Simultaneously in different muscle is given to the im
soft tissue structures that might otherwise be damaged by groups. creating multiplanar motion at each of th e joints reestablish propriO<j
open chain exercises. 1i Auditionally. weigh t-beDri ng activ­ within the kinetic chain. Closed-kinetic-chain activities re­ Closeu-kinelic-cha irlj
ity increases joint compressive forces. further enhancing quire synchronicity of more complex agonist a nu antago­ proprioceptive fced b~
joint stability. nist muscle actions. 23 Ruffini enuings, Go~
It has also been suggested tbat closeu-kinetic-chain ex­ organs. and Golgi­
ercises. particularly those involving the lower extremity, tional use of l11ultij o'
tend to be more functional than open-kinetic-chain exer­ CLINICAL DECISION MAKING Exercise 12-1
cises because they involve weight-bearing activities. 6 1 1'he
Following an ACL surgery. an athletic trainer is ready to
majority of activities performed in daily liVing. such as
incorporate some closed-chain exercise into the rehabili­
BIOMECHAN
walking, climbing. and rising to a standing position. as
well as in most sport acllvities. involve a closeu-kinetic­ tation program. What are some of the options. and what VERSUS CL(
are advantages of each? CHAIN ACTI'
chain system . Because the foot is usually in contact with
the ground. activities that make use of this closed system LOWER EXTI
arc sa id to be more functional. With th e exception of a
kicking movement, there is no question that c1osed­ Open- and closed-k'
kinetic-chain exercises are more sport - or activity-specWc. USI NG CLOSED·K'I NETIC·CHAI N biomechanical cffec
involVing exercise that more closely approx imates the de­ EXERCISES TO REGAIN ity.! n Walking and i
sired activity. ror example. that knee extensor muscle NEUROMUSCULAR CONTROL change direction. reG
st rength in a closed kinetic chain is more closely related to complex series of 1\
jumping ability than knee extensor strength in a closed ki­ fn Chapter 5 it was stressed that proprioception, jOint posi­ chanically. shock ab
n et ic chain .h In a sports medicine setting. specifiCity of tion sense. and kinesthesia are cri tical to the neuromusc u­ tion. acceleration al
 CHAPTER 12 Open- versus Closed-Kinelic-C hain Exercise in Rehabilitation 245

miz e carryover to lar control of body segments within the kinetic chain. To and joint stabilization must occur in each of the joints in
I. ,~ perform a motor skill, muscular forces, occurring at the the lower extremity for normal function .44 Some under­
molion is usually correct moment and magnitude, interact to move body standing of how these biomechanical events occur during
aiD ac tivities may parts in a coo rdinated manner,'14 Coordinated movement both open- and c1osed-kinetic-chain activities is essential
or range of mo­ is controlled by the central nervous system that integrates for the athletic trainer.
'int manually, asin input from joint and muscle mechanoreceptors acting
lion or joint mobi­ within the kineti c chain. Smooth coordinated movement The Foot and Ankle
l"Xterna l resistance requires constant integration of receptor, feedback, and
. _~ exercises typi­ control center information H The foot's function ,in the support phase of weight bearing
nuscle or group of In the lower extremity. a fun ctional weight-bearing ac­ dudng gait is twofold. At heel strike, the foot must act as a
e and occasion­ livity requires muscles and joints to work in synchrony shock absorber to the impact or ground reaclion forces
r [5e and tesling and in synergy with one another. For example, taking a and then adapt to the uneven surfaces. Subsequently. at
an d can pwvide Single st.ep requires concentric. eccentric, and isometric push-off, the foot funclions as a rigid lever to transmit the
rque produclion muscle contraclions to produce supination and pronation explosive force from the lower extremity to the ground .oI
in the fool; ankle dorsif1exion and plantarf1exion; knee As the foot becomes weight-bearing at heel strike. cre­
iated with in­ nexion. extension . and rotation; and h·ip nexion, exten­ ating a closed kinetic chain. the sublalar joint moves into
llhat occurs dur­ sion. and rotation. Lack of normal motion secondary to in­ a pronated pOSition in which the talus adducts and the
l be possible due jury in one join t will a.ffect the way another joint or plantar f1exes while the calcaneous everts. Pronation of
iled range of mo­ segment moves.44 the foot unlocks the midtarsal joint and al10ws the foot to
ul t that interfere To perform this single step in a coordinated manner, all assistin shock absorption. It is imporlan t during initial im­
I~ . If only closed­ of the joints al1d muscles must work together. Thus, exer­ pact to reduce the ground react10n forces and to distribute
proximal or distal cises that act to integrate. rather than isolate, all of these the load evenly on many diflerent anatomical structures
g deficit. Without functioning clemenLs would seem to be the most appropri­ throughout the lower-extremity kinetic chain. As prona­
al i a late specific ate. Closed-kinetic-chain exercises that recruit foot, ankle, tion occurs at the subtalar joint, there is obligatory inter­
un orrected . Ihus knee. and hip muscles in a manner that reproduces nor­ nal rotation of the tibia and slightllexion at the knee. The
n' athletic trainer mal loading and movement forces in all of the jOints within dorsillexors contract eccentrically to decelerate plantar
- r closed-kine tic- the kinetic chain. arc similar to functional mechanics and f1exion. In an open kinetic chain, when the foot pronates.
would appear to be most useful. H the talus is stationary while the foot everts, abducts. and
Clrying combina­ Quite often, open-kinetic-chain exercises arc used pri­ dorsiflexes. The muscles that evert the foot appear to be
_ nrric co ntractions marily to develop muscular strength while little attention most active. oJ
different muscle is given to the importance of including exercises that The foot changes its function from being a shock ab­
eac h of the joints reestablish proprioception and joint position sense. 1 sorber to being a rigid lever system as the foot begins to
--chain activilies re­ Closed-kinetic-chain activities facilitate the integration of push off the ground. In weight bearing in a closed kinetic
u isL and antago- proprioceptive feedback coming from Pacinian corpuscles, chain. supination consists of the talus abducting and dor­
Ruffini endings. Golgi-Mazzoni corpuscles. Golgi-tendon sif1exing on the calcaneus while the calcaneus inverts on
organs. and Golgi-Iigament endings through the func­ the talus. The tibia externally rotates and produces knee
Lional use of multijoint and mulLiplanar movementsY extension. During supination the plantar f1exors stabilize
Exercise 12-1 the foot, decelerate the tibia. and f1ex the knee. In an open
kinetic chain. supination consists of the calcaneus invert­
er is ready to
BIOMECHANICS OF OPEN­ ing as the talus adducts and plantarf1exes. The foot moves
10 the rehabili­ ,i nto adduction, plantarfilexion, around the stabilized
ons. and what VERSUS CLOSED-KINETIC­ talus. 61 Changes in foot position (i.e., pronation or supina­
CHAIN ACTIVITIES IN THE tion) appear to have little or no effect on the EMG activity
~~. "" "''' ''''''''' '''''''''''' LOWER EXTREMITY of the vastus medialis or the vastus lateralis .3o

Open- and closed-kinetic-chain exercises have different

IC-CHAIN
oce ption, joint posi­
to the neuromLlSCLl-
biomechanical effects on the joints of the lower extrem­
ity.I6 Walking a nd running, along with the ability to
change direction , require coordinated joint motion and a
complex series of well-timed muscle activations. Biome­
chanically, shock absorption. foot f1exibility, foot stabiliza­
tion. acceleration and deceleration, multiplanar motion,
The Knee Joint
It is essential for the athletic trainer to understand forces
that occur around the knee joint. Palmi tier et al. have
proposed a biomechanical model of the lower extremity
that quantifies two critical forces at the knee joint43 (Fig­
ure 12-2) . A shear force occurs in a posterior direction
 246 PART THREE The Tools of Rehabilitation

"'-,

I
1[1\
A B c D
I Figure 12-3 Resistive forces applied in different posi­
I
I tions alter the magnitude of the shear and compressive
I /
,( forces. A, Resistive force applied ilistal~y. B, Resistive force
// II applied proximally. C, Resistive force applied axially.
/ D. Resistive force applied distally with hamstring co­
/ contraction.

produced when a force is exerted on the body that is pivoted

about some flXed point (Figure 12-4). Co-contraction of the
hamstring muscles helps to counteract the tendency of the
Figure 1l-2 Mathematical model showing shear and quadriceps to cause anterior tibial translation . Co-contrac­
compressive force vectors. S = shear, C = compressive. fi gure 12-4 Clo
tion of the hamstrings is most efficient in redUcing shea r hamstring contra('~
force when the resistive force is directed in an axial orienta­ l , Hip, B. Knee, C...
tion relative to the tibia, as is the case in a weight-bearing
that would cause the tibia to translate anteriorly if not exercise. 43 Several studies have shown that co-contraction
checked by soft tissue constraints (primarily the anterior is usefu'l in stabilizing the knee joint and decreaSing shear
cruciate ligament).12 The second force is a compressive forces. 29.33.45.53 the effects of a haIl!
force directed along a longitudinal axis of the tibia. The tension in the hamstrings can be further en­ duces maximal shea!
Weight-bearing exercises increase joint compression, hanced with slight anterior flexion of the trunk. Trunk created by isome tri
which enhances joint stability. !lexi011 moves the Genter of gravity anteriorly, decreasing exte nsion at 30 and
In an open-kinetic-chain seated knee joint exercise, as the knee flexion moment and thus reducing knee shear han with closed-kin
a resistive force is applied to the distal tibia, the shear and force and decreasing patellofemoral compression forces. 41 lerior tibial djsplace
compressive forces would be maximized (Figure 12-3A). Closed-kinetic-chain exercises try to minimize the flexion chain knee !lexion
When a resistive force is applied more proximally. shear moment at the knee while increasing the !lexion moment arthrometry has als(
force is signilkantly reduced. as is the compressive force at the hip. The Patellofeml
(Figure 12-3B). If the resistive force is applied in a more ax­ A !lexion moment is also created at the ankle when the us closed-kinetic-d
ial direction, the shear force is also smaller (Figure 12-3C). resistive force is applied to the bottom of the foot. The joint must also be cd
II' a hamstring co-contraction occurs, the shear force is soleus stabilizes ankle flex,ion and creates a knee extension extension exercise.
minimized (Figure 12-3D). moment, which ugain helps to neutralize anterior shear knee extends from
Closed-kjnetic-chain exercises induce hamstring con­ force (see Figure 12-4). Thus the entire lower.extremily ki­ Increasing tension iJ
traction by creating a flexion moment at both the hip and netic chain is recruited by applying an ax1al force at the Th us the patellofe
tbe knee, with the contracting hamstrings stabilizing the distal segment. creased, with peak 0
hip and the quadriceps stabilizing the knee. 58 A moment is In an open-kinelic-chain exercise involving seated leg nexiotl. 21 As the k
the product of force and distance from the axis of rotation . extensions, the resistive for ce is applied to the distal tibia. patellofemoral conIC!
Also referred to as torque, it describes the turning effect creating a flexion moment at the knee only. This negates contact stress per u
 CHAPTER 12 Open- versus Closed-Kinetic-Chain Exercise in Rehabilitation 247

In closed-kinetic-chain exercise. the Ilexion moment

increases as the knee flexes, once again causing increased
quadriceps and patellar tendon tension and thus an in­
crease in patellofemoral joint reaction forces. However. the
patella has a much larger surface con't act area with the fe­
mur. and contact stress is minimized. i .l l. l1 Closed-kinetic­
chain exercises might be better tolerated in the
patellofemoral joint. because contact stress is minimized.

CLOSED·KINETIC·CHAIN
EXERCISES ,FOR
D
REHABILITATION OF LOWIER·
EXTR,E MITY INJURIES
For many years. athletic trainers have made use of open­
kinetic-chain exercises for lower-extremity strengthen­
ing. This practice has been partly due to design
constraints of existing resistive exercise machines. How­
ever. the current popularity of closed-kinetie-chain exer­
cises can be attributed primarily to a better understanding
of the kinesiology and biomechanics. along with the neu­
body that ,is pivoted romuscular control factors. involved in rehabilitation of
xon traction of the lower-extremity injuries.
Jle tendency of the RF For example. the course of rehabilitation after injury to
arion. Co-contrac­ fi gure 12-4 Closed-kinetic-chain exercises induce the anter,ior cruciate ligament (ACL) has changed drasti­
in reducing shear !alT1string contraction by creating a flexion moment at cally in recent years. (Specific rehabilitation protocols will
in a n axial orienta­ . Hip. B. Knee. C, Ankle. be discussed ,in detail in Chapter 22.) Technological ad­
. a weight-bearing vances have created significant improvement in surgical
that co-contraction techniques. and this has allowed athletic trainers to
d decreasing shea~ change their philosophy of rehabilitation. The current lit­
e effects of a hamstring co-contraction and thus pro­ erature provides a great deal of support for accelerated re­
:-an be further en­ uces maximal shear force at the knee joint. Shear forces habilitation programs that recommend the extensive use
the trunk. l'runk ated by isometric open-kinetic-chain knee nexion and of dosed-kinetic-chain exercises. 7 .13.1 B.lI.l9.12.,9.h6
leriorly. decreasing ·tension at. 30 and 60 degrees of knee flexion are greater Because of the biomechanical and functional advan­
ffiuc ing knee shear an with closed-kinetic-chain exercises. 1S Decreased an­ tages of closed-kinetic-chain exercises described earlier.
pression forces .·: rior tibial displacement during isometric closed-kinetic­ these activities are perhaps best suited to rehabilitation of
'nimize the flexi on aIn knee flexion at 30 degrees when measured by knee the ACL. 18 The majority of these studies also indicate that
the Oexion moment rthrometTY has also been demonstrated. 62 closed-kinetic-chain exercises can be safely incorporated
The Patellofemoral JOint. The effects of open- ver· into the rehabilitation protocols very early. Some athletic
[ the ankle when the closed-kinetic-chain exercises on the pateLlofemoral trainers recommend beginning within the first few days af­
m f the fool. The int must also be considered. In open-kinetic-chain knee ter surgery.
a knee extension ension exercise. the flexion moment increases as the In the sports medicine setting. several different closed­
alil.,e anterior shear ee extends from 90 degrees of llexion to full extension. kinetic-chain exercises have gained popularity and have
~ 100~rer-cxtremity ki­ 'lCreasing tension in the quadriceps and patellar tendon . been incorporated into rehabilitation protocols. 14 Among
m a..xlal force at th us the patellofemoral joint reaction forces are in­ those exercises commonly used are the minisquat, wall
~ ased. with peak force occurring at 36 degrees of joint slides. lunges. leg press . stair-climbing machines. lateral
100'0lving seated leg ·on. 21 As the knee moves toward fuIi extension . the step-up. terminal knee extension using tubing. and
~ to tbe distal tibia. lellofemoral contact area decreases. causing increased stationary bicycling. slide boards. BAPS boards. and the
:e on ly. This negates ntact stress per un it area. ,.1 1 Fitter.
248 PAR'J'THREE The Tools of Rehabilitation

--../
figure 12-7 Lu
Figure 12-5 Minisquat performed in 0- to 40-degree Figure 12-6 Stan ding wall slide. ('ccen trica lIy.
range.

with resistance lo\\'

of exercising each
Minisquats, Wall Slides, and Lunges an open-chain exercise in full extension 2 6 A full squat
has been recomm
markedly increases the flexion moment at the knee and
fo rmed in a 0 to 6U
The minisqunt (Figure 12-5) or wall slide (Figure 12-6) thus increases anterior shear of the tibia. As mentioned
Tt has also be
involves simultaneous hip and knee extension and is per­ previously. slig htly .flexing the trunk anterior,ly will also in­
chines allow full h
formed in a 0 to 40 degree range."!> As the hip extends. the crease the hip flexion moment and decrease the knee mo­
lage of tbe kine!i
rectus femoris contracts eccentrically while the ham­ ment.. It appears that hlcreasing the width of the slance in
achieved in a supin l
strings contract concentrically. Concurrently, as the knee a wall squat has 110 effect on EMG activit'y in the quadri­
knee fleXi on and
extends. the hamstrings contract eccentrically while the ceps. 2 However. moving the feet forward docs seem to in­
lhe concurrent shil
rectu s femoris contracts co ncentrically. Both concentric crease activity in the quadriceps as well as the plantar
recruilm ent. 43
and eccentric contractions occur simultaneously at either flexors. 9 The foot plates
end of both muscles. producing a concurrent shift con­ Lunges should be used later in a rehabilitation pro­
a rc of motion ra t
traction. This type of contraction is necessary during gram to facilitate eccentric strengtht:ning of the quadri­
ment would fa cil i!ll
weight-bearing activities. It will be elicited with all closed­ ceps to [lct as a deceierator(» (Figure 12-7). Like the
ing the hip flexi oi
kinetic-chain exercises and is impossible with isolation minisquat and wall slide. it faLilitates co-contraction of the
momen l. Foot plat
exercises. ;) hamstring muscles.
frontal plane of th l
These concurrent shift contractions minimize the .flex­
moment created by
ion moment at the knee. The eccentric contraction of the
hamstrings helps to neutralize the effects of a concentric
Leg Press
quadriceps cont raction in producing anterior translation Theorctically the leg press takes full advantage of the ki­ Stair Climbinl
of the tibi a. 1o Henning et al. found that th e half squat pro­ netic chain and at the same time provides stability. which
Stair-climbing mac!
duced significantly less anterior shear at the knee than did decreascs strain on the low back. 36 It also allows exercise
iarity, not only as
 CHAPTER 12 Open- versus Closed-Kinetic-Chain Exercise in Rehabilitation 249

figure 12-8 Leg-press exercise,

Figure 12-7 Lunges arc done to strengthen quadriceps

'~ccen lrica\ly.

.\·ith resistance lower than body weight and the capability

26
of exercising each leg independently 43 (Figure 12-8). It
sion . A full squat
has been recommended that leg-press exercises be per·
1t:11l at the k.nee and
fo rmed in a 0 to 60 degree range of knee l1exion. 66
·hia . As mentioned
It has also been recommended that leg-press ma­
,meriorly l.vill also in­
chines allow full hip extension to take maxtmum advan­
rease the knee mo­
lage of the k.i netic chain. full hip extension can only be
idth of the stance in
ac hieved in a supine position. In this position, full hip and
nh'ity in the quadri­
knee flexion and extension can occur. thus reproducing
.-a.rd does seem to in­ the concurrent shift and ensuring appropriate hamstr·ing
, we ll as the plantar
recruitment. 4 \
The foot plates should also be designed to move in an
a re habilitation pro­
arc of motion rather than in a straight line. This move­
ening of the quadri­
ment would facilitate hamstring recruitment by increas­
,ure 12-7). Like the
in g the hip flexion mornent and decreasing the knee
c -contraction of the
oment. foot plates should be fixed perpendicular to the
frontal plane of the hip to maximize the knee extension figure 12-9 Stairmaster stepping machine.
moment created by the soleus.

Stair Climbing useful in rehabilitation. but also as a means of improving

adva ntage of the -' ­
cardiorespiratory endurance (Figure 12-9). Stair-climbing
)\-ides stability, which
-tair-climbing machines have gained a great deal of popu­ machines have two basic designs. One involves a series of
l also allows exercise
larity, not only as a closed-kinetic-chain exercise device rotating steps similar to a department store escalator: the
250 PART THREE The 'fools or Rehabilitation

other uses two foot plates that move up and down to simu­
late a stepping-type movement. With the lalter type of
stair climber. also sometimes referred to as a stepping ma­
chine. the foot never leaves the foot plate. making it a true
closcd-kinetic-chain exercise device.
Stair climbing involves many of the same biomechan­
ical principles identified with the leg-press exercise. 51
When exercising on the stair climber, the body should be
held erect with only slight trunk flexion. thus maximizing
hamstring recruitment through concurrent shift contrac­
tions whi'le increasing the hip flexion moment and de­
creasing the knee flexion mom.ent.
Exercise on a stepping machine produces increased
electromyogram (E'\,!G) activity in the gastrocnemius. Be­
cause the gastrocnemius attaches to the posterior aspect of
the femoral condyles, increased activity of this muscle
could produce a flexion moment of the femur on the tibia.
This motion would cause posterior translation of the fe­
mur on the tibia. increasing strain on the ACL. Peak firing
of the q lladriceps might offset the effects of increased EMG
activity in the gastrocnemius. I>

Step-Ups
Lateral. forward, and backward step-ups are widely used
closed-kinetic-chain exercises (Figure 12-10). Lateral
-
Figure 12-H 1
step-ups seem to be used more often clinically than for­
tubing resistance.
ward step-ups. Step height can be adjusted to patient ca­
Figure 12-10 Lateral step-ups.
pabilities and generally progresses up to about 8 inches.
Heights greater than 8 inches create a large flexion mo­ ranslation or the t
ment at the knee, increasing anterior shear force and mak­ rhe 0 to 30 degree
ing hamstring co-contraction more difficult. 1n . l ; duce more EMG activity than eccentrk contractions in a moment. furth er re
Step-ups elicit significantly greater mean hamstring lateral step-up.5()o
usc of rubber tu bin
EMG activity tban a stepping machine, whereas the lhe quadriceps wh
quadriceps are more active during stair climbing. 6Y When Terminal Knee Extensions Using bearing termina l k.
performing a step-up, the entire body weight must be Surgicall Tubing EMG activity in th
raised and lowered, whereas on the stepping machine the
center of gravity is maintained at a relatively constant It has been reported in numerous studies that the greatest
height. 'rhe lateral step-up can produce increased muscle amount of anterior tibial translation occurs between ()
Stationary Bi
and joint shear forces compared to stepping exercise. I ; and 30 degrees of flexion during open-kinetic-chain exer­ Thc stationarv bie;
Caution should be exercised by the athletic trainer in using cise. 22.24.32.41.4 ;.1 6. 66 Avoiding open-kinetic"chain terminal medicine. pril~arilj
the lateral step-up in cases where minimizing anterior knee extension after surgery became a well-accepted rule II1jured athlete caIlj
shear forces is essential. Contraction of the hamstrings ap­ among athletic trainers. Unfortunately. this practice 12-12). However. I
pears to be of insulTicien£ magnitude to neutralize the led to quadriceps weakness. flexion contracture, and ( losed-kinetic-ch a~
shear force produced by the quadriccps.1O ~n situations patellofemoral pain.'l x The advantage
where strengthening of the quad'riceps is the goal. the lat­ Closed-kinetic-chain terminal knee extensions using closed-kineLic-c haj
eral step-up has been recommended as a benellcial exer­ surgical tubing rcsistance have creatcd a means of safely the amount or lhe
cise. 7u However. lateral stepping exercises have failed to strengthening terminal knce extcnsion~ 9 (Fig ure 12-1J). jured lower cxtrc lll
increase isokinetic strength of the quadriceps muscle. It Application of resistance anteriorly at the femur produces iwtions. The sca t
also appears tbat concentric quadricep contractions pro­ anterior shear of the femur. which eliminates any anterior minimize the kn e
 CHAPTER 12 Open- versus Closed-Kinetic-Chain Exercise in Rehabilitation
- Figure 12-11 Terminal knee extensions using surgical
tubing resistance.
translation of the ti bia. This type of exercise performed in
Lhe 0 to 30 degree range also minimizes the knee l1exion
ic contractions in a moment. further reduCing anterior shear of the tibia. The
use of rubber tubing produces an eccentric contraction of
the qu adriceps when moving into knee Clexion. Weight­
Using bearing terminal knee extensions with tubing increase the
EivlG activity in the quadriceps.hY
. that the greatest
Stationary Bicycling
occ urs between 0
The stationary bicycle has been routine ly used in sports
eli -chain terminal medicine. primarily for conditioning purposes when the
well-accepted rule injured athlete cannot engage in running activities (Figure
rely. this practice 12-12). However. it also can be of significant value as a
contracture. and closed-kinetic-chain exercise device.
The advantage of stationary bicycling over other
extensio ns using closed-kinetic-chain exercises for rehabilitation is that
a means of safely the amount of the weight-bearing force exerted by thein­
~9 (Figure 12-11). jured lower extremity ca n be adapted within patient Hm­
[he fe mur produces itations. The seat height should be carefully adjusted to
ninates any anterior minimize the knee flexion moment on the downstroke.
251
IF igure 12-12 Stationary bicycle.
However. if the stationary bike is being used to regain
range of motion in flexion. the seat height sho uld be ad­
justed to a lowered position using passive motion of the
injured extremity. Toe cl ips will facilitate hamstring con­
tractions on the upstroke.
BAPS Board and Minitramp
The BAPS board (Figure 12-13) and minitramp (figure
12-14) both provid e an unstable base of support that helps
to facilitate reestablishing proprioception and joint posi­
tion sense in addition to strengthening. Working on the
BAPS board allows the athletic trainer Lo provide stress to
th e lower extremity in a progressive and comrolled man­
ner. I I rt a llows the athlete to work Simultan eo usly on
strengthening and range of motion. while trying La rega in
neuromuscular control and balance. The minitramp may
be used to accomplish the same goals. bu t it ca n also be
used for more advanced plyometric training.
252 min THREE The Tools of Rehabilitation

Figure 12-13 Bf\PS board exercise. Figure 12-14 Minilramp provides an unstable base of
support to which other functional plyometr ic activities
may be added.
CLINICAL DECISION MAKING Exercise 12-2

Why would the SAPS board and mi.nitramp be good tools

in a rehabilitation program for a dancer recovering from
an Ac hilles tendon repair;

Slide Boards and Fitter

Shifting the body weight from side to side during a more
BIOMECI
fun ctional activity on either a slide boa rd (Figure 12-] 5 ) VERSUS

or a Fitter (J7igure 12-16) heJps to rees tablish dynamic CHAIN /IJ

control as well improving cardiorespiratory flLness. 11 ~

These motions produce va lgus a nd varus st resses and UPPER E

strains to the joint th at are somewhat un iq ue to these two
pieces of equipment. Latera l slide exercises have been
shown to improve knee ex tension strength following ACL
reconstruction. ' Figure 12-15 Slide board training.
 CHAPTER 12 Open- versus Closed-Kinetic-Chain Exercise in RehabiliLation 253

tremily, the upper extremity is most funcLional as an open­

kinetic-chain system. Most sport activities involve move­
ment of the upper extremity in which the hand moves
freely. These activities are generally dynamic movements,
often occurring at high velocities, such as throwing a base­
ball. serving a tennis ball. or spiking a volleyball. In these
movements. the proximal segments of th.e kinetic chain
are used for stabilization while the distal segments have a
high degree of mobility. Push-ups, chinning exercises. and
handstands in gymnastics are all examples of closed­
kinetic-chain activities in the upper extremity. In these
cases, the hand is stabilized, and muscular contractions
around the more proximal segments, the elbow and shoul­
der. function to raise and lower the body. Still other activi­
ties such as swimming and cross-country skiing involve
rapid sLlccessions of alternating open- and c1osed-kinetic­
chain movements, much in the same way as running does
in the lower extremity.'"
For the most part in rehabilitation, closed-kine tic­
chain exercises are Llsed primarily for strengthening and
establishing neuromuscular control of Lhose muscles that
act to stabilize the shoulder girdle. io () In particular. the
scapular stabilIzers and the rotator cuff muscles function
at one time or another Lo control movements about the
shoulder. It is essential to develop both strength aod neu­
romuseu1lar con trol in tJhese muscle groups, thus allowing
them to proVide a stable base for more mobile and dynamic
movements that occur in the d,istal segments. 60
It must also be emphasized that although traditional
upper-extremity rehabilitation programs have concen­
un stable base or fi gure 12-16 The Fitter is useful for weight shifting. trated on treating and identifying the involved structures,
el ric activities
the body does not operate in isolated segmcnts but instead
works as a dynamic unit. 40 More recentls! rehabilitation
programs have integrated c1osed-kinetic-chain exercises
CLINICAL DECISION MAKING Exercise 12-3
with core stabilization exercises and more functional
Why would a slide board not be an appropriate choice for
movement programs. Athletic trainers should recognize
someone beginning a rehabilitation program for an MeL
the need to address the importance of the legs and trunk
as contributors to upper-extremity function and routinely
sprain!
incorporate therapeutic exercises that address the entire
kinetic chain. 4o

BIOMECHANICS OF OPEN­ CLINICAL DECISION MAKING Exercise 12-4

VERSUS CLOSED-KINETIC­
A football players suffers from chronic shoulder disloca­
CHAIN ACTIVITIES IN THE tions. What type of exercises can be used to increase sta­
UPPER EXTREMITY bility of the shouldel'?

. Ithough it is true that closed-kinetic-cha in exercises are

most often used in rehabilitation of lower-extremity in­
uries, there arc many injury situations where c1osed­
Idnetic-chain exercises should be incorporated into upper­
xtremity rehabilitation protocols. Unlike the lower ex­
The Shoulder Complex Joint
Closed-kinetic-chain weight-bearing activities can be used
to both promote and enhance dynamic joint stability. Most
254 PARTTHREE The Tools of Rehabilitation
ofLen closed-kinetic-chain exercises are used with the hand
fixed and thus with no motion occurring. The resistance is
then applied either axially or rotationally. These exercises
produce both joint compression and approximation . which
act to enhance muscular co-contraction about the joint
producing dynamic stability."i
Two essential force couples must be reestablished
around the glenohumeral joint; the anterior deltoid along
with the infraspinatus and teres minor in the frontal plane.
and the subscapularis counterbalanced by the infraspina­
tus and teres minor in the transverse plane. These oppos­
ing muscles act to stabilize the glenohumeral joint by
compressing the humeral head within the glenoid via
muscular co-contraction.
The scapular muscles function to dynamically position
the glenoid relative to the position of the mOlTing humerus.
resulting in a normal scapulohumeral rhythm of move­
ment. However, they must also provide a stable base on
which the highly mobile humerus can functioo. If the
scapula is hypermobile, the function of the entire upper ex­
tremity will be impaired. Thus force couples between the
inferior trapezius counterbalanced by the upper trapezius
and levator scapula-and the rhomboids and middle
trapezius counterbalanced by the serratus anterior-are
critical in maintaining scapular stability. Again. c1osed­
kinetic-chain activities done with the hand fixed should be
used to enhance scapular stability.3 5
The Elbow
The elbow is a hinged joint that is capable of 145 degrees
of l1exion from a fully extended position. In some cases of
joint hyperelasticity, the joint can hyperextend a few de­
grees beyond neutral. The elbow consists of the humeroul­
nar. humeroradial. and radioulnar articulations. The
concave radial head articulates with the convex surface of
the capitellum of the distal humerus and is connected to
the proximal ulna via the annular ligament. The proximal
radioulnar joint constitutes the forearm, which when
working in conjunction with the elbow joint permits ap­
proximately 90 degrees of pronation and 80 degrees of
supination .
In athle tiC activity, the elbow must perform several
functions in an open kinetic chain. In throwing sports, the
elbow helps to propel an object at a rapid velocity with ac­
curacy. In power sports, such as hitting. the elbow must
possess static stability and adequate dynan1ic strength to
be able to transfer force to a hitting implement. In swim­
ming. the elbow must be able to produce power and stabil­
ity to propel the swimmer through the water. In
gymnastics or wrestling. the elbow functions in a closed ki­
netic cha in in both static and dynamic modes to provide
stability and propulsive power.
OPEN· AND CLOSED·KINETIC·
CHAIN EXERCISES FOR A
REHABILITATION OF UPPER·
EXTREMITY INJURIES
Most typically. closed-kinetic-chain glenohumeral jOint
exercises are used during the early phases of a rehabiliU:I­
lion program. particularly in the case of an unstable
shoulder to promote co-contraction clOd muscle recruit­
ment. in addition to preventing shutdown of th e rotator
cuff secondary to pain and / or inflammation. l likeWise.
closed-kinetic-chain exercise should be used during the
late phases of a rehabilitation program to promote mus­
cular endurance of muscles surrounding the gleno­
humeral and scapulothoracic joints. They may also be
used during the laler stages of rehabilitation in conjunc­ B
tion with open-kinetic-chain activities to enhance some
degree of stability. on which highly dynamic and ballistic
motions may be superimposed. At some point during the
middle stages of the rehabilitation program. traditional
open-kinetic-chain strengthening exercises for the rota­
tor cuff. deltoid. and other glenohumeral and scapu lar
muscles must be incorporated .2 7. (,7
In the elbow. exercises should also be designed to en­ figure 12-17
hance muscular balance and neuromuscular control of
the surrounding agonists and antagonists. Closed-kinetic­ Weight
chain exercise should be used to improve dynamic stability
of the more proximal muscles surrounding the elbow in :\ variety of \ \ '('1
those sports where the elbow must provide some degree of in facilitatin g g
proximal stability. such as in tbe case of a football lineman lability through
blocking. Open-kinetic-chain exercises for strengthening hifting can be
l1exion. extension, pronation. and supination are essential bi ped (opposite ke
to regain high-velocity dynamic movements of the elbow table surface su
that are necessary in throwing-type activities. 12-17 A-D). or 0"
BAPS board , a \\(}
\Figure 12-1 8A- D
CLINICAL DECISION MAKING Exercise 12-5 ward and back\\',
be adjusted from a
A female basketball player has been experiencing some on top of the othe!
hip pain and general lower-extremlty fatigue thaI you adjust the amou Ol
think is due to gluteus medius weakness. You want to im­ The athletic traind
prove her awareness of this muscle as well as improve her in a random man n
neuromuscular control. How can c1osed- and open-chain cally stabilize andJ
exercises both hel p you achieve your goals? a tripod to force th
a co-contraction al
 CHAPTER 12 Open- versus Closed-Kinetic-Chain Exercise in Reh<lbilitation 255

clion s in a closed ki­

modes to provide

A c

- of an unstable

a tion. ) Likewi e.
u sed during the
to promote mus­
ndi ng lhe glen .
They may also be
italion in conjunc­ B D
_ to enhance som
am ic and ballisli '
e poin t during the
ogra m. tradiliona
reises for the ro[a­
era l and sC<lpular

be designed to en­ Figure 12-17 Weight shifting. A, Standing. B, Quadruped . C. Tripod. 0, Opposite knee and arm.
U5c ulm' con trol
. Closed-kincti ­
Weight Shifting
.-\. variety of weight-shifting exercises can be done to assist
in facilitating glenohumeral and scapulothoracic dynamic
stability through the use of axial compression. 14 Weight
shifting can be done in standing. quadruped. tripod. or
biped (opposite leg and arm). with weight supported on a
stable surface such as the willi or a treatment table (Figure
·(i\'it ies. 12-17 A-D). or on a movable. unstable surface such as a
BAPS board. a wobble board. the KAT system. or a plyoball
Figure 12-18A-D). Shifting may be done side to side. for­
Exercise 12-5 ward and backward, or on a diagonal. Hand position may
be adjusted [rom a wide base of support to one hand placed
nencing 'orne
on top of the other to increase difficulty. The ath lete can
gue thalyou
adjust the amount of weight being supported as tolerated.
You want to 100­
The athletic lrainer can provide manual force or resistance
in a random manner to which the ath'lete must rhythmi­
- and open-chain
cally stabilize and adapt. A 02 Pi\'P pattern may be used in
ISf
a tripod to force the con tralateral support limb to produce
a co-contraction and thus stabilization (Figure 12-19).67
Rhythmic stabilization can a Iso be used regain neuromus­
cular control of the scapular muscles with the hand in a
closed kinetic chain and random pressure ilpplied Lo the
scapular borders (Figure 12-20).
Push-Ups, Push-Ups with a Plus,
Press-Ups, Step-Ups
Push-ups and/or press-ups are also done to rees tablish
neuromuscular control. Push-ups done on an unstable
surface such as on a plyoball require a good deal of
strength in addition to providing an axial load that re­
quires co-contraction of agonist and antagonist force cou­
ples around the glenohumeral and scapulothoracic joints
while the distal part of the extremity has ~ome limited
movement (Figure 12-21 ). A variation of a standard
push-up would be to have the athlete use reciprocating
contractions on a stair climber (Figure 12-22) or dOing
single-arm lateral step-ups onto a step (Figure 12-23).
256 PA]{TTHREE The Tools or Rehabilitation

A I: It -I _.i'th' _ • • • 1"'"' ......t'II. ..-. C

figure 12-21 P

B D

Figure 12-18 Weigh t shift ing. A. On a BAPS board. B. On a wobble board. C, On the KAT system. D. On a Plyoba ll.

figure 12-22 P

Also. the ath lct e III

itions. includin g
2000 " (Figure 1
strengt he n th e
scapu la r dynami
12-2:;). Press-u p.
gleno hum eral Sl ai;

Slide Board
'pper-extrcmity <:1
on a slide board al1
and sta bility bul
durance. >7.h7 1n a
Figure 12-19 02 PNF pattern in a tripod to produce Figure 12-20 Rhythmic stabilization for the sca pular
stabilization in thc contralateral support limb. muscles. ciprocal ing mol!
backward. side II
 CH/\PTER 12 Open- versus Closed-Kinetic-Chain Exercise in Rehabilitation 2S 7

Figure 12-21 Push-ups done on a Plyoball. Figure 12-23 Singlc-arm lateral step-ups.

Figure 12-22 Push-ups done on a stair climber.

Figure 12-24 Push-ups can be done in a \'<lricty of po­
sitions on a Shuttle 2000,

Also. the athlete may perform push-ups in a variety of po­

sitions. including to ovcrhead position on the Shuttle
2000 >7 (Figure 12-24). Push-ups with a plus are done to
strengthen the serratus anterior. which is critical for
scapular dynamic stability in overhcad activities (Figure
12-2 'i). Prcss-ups involve an isometric contraction of the
glcnohumeral stabilizers (Figure 12-26).

Slide Board
Cpper-cxtremity c1osed-kinctle-chain exercises perrormed
on a slide board arc useful not only for promoting strength
,md stability but also for improving muscular en­
fo r the scapular durance.> 7.1>7 In a knecling position, the athlete uses a re­
ciproe<lLing motion. sliding thc hands forward and
backward. sidc to side. in a "wax on-wax off" circular Figure 12-25 Push-ups with u plus,
258 PART THREE The Tools of Rehabilitation

ummary

-\ dosed-kineth:,
.al seg ment of t
pen kirletie
'lot fixe d.

cha in exercise~.
- Open- and cl o~
ad\'an tages and
process.The ch
the desired treat

·"tremity.

Figure 12-26 Press-ups Figure 12-27 Slide board strengthening exercise.

eferences

pattern. or both hands laterally (Figure 12-27). It is also Andersen . S.. D.

possible to do wall slides in a standing position. son of open- \
ilcasur ing joilll
,*( 3): 165- 71.
Isokinetic Closed-Kinetic­ __ ,\nderson. R.. C.
Chain Exercise
the unloading
Biodex manufactures an attac hment for existing equip­ Sporl Relwbiliwl
ment that will allow for isokinetic conditioning and tesling 3. Andrews. J.. J. De
of the lower extremity in a closed-kinetic-chain seated po­ of closed-ch ain
sition (Figure 12-28). Data on reliability. validity. and ef­ physician's per~
fec tiveness of the particular piece of equipment are not yet 64-70.
,\ugus! sson. J.. el i
available.
cles using closed
son of pcrform an
CLINICAL DECISION MAKING Exercise 12-6 Sports Physical TI
- Baratta. R .. 1\1. ~

An athlete has general back weakness. You think that this

could be the cause for some a nterior shoulder pain. He ap­
pears to have winging scapula. and he is having symp­
toms consistent with impingement. What type of exercises
would you introduce to help him with this problem? Figure 12-28 Biodex upper-extremity closcd-kinelic­
chain exercise system.
 CHAPTER 12 Open- versus Closed-Kinelic-Chaln Exercise in Rehabilitation 259

Summary

1. j\ closed-kinetic-chain exercise is one in which the dis­
tal segment of the extremity is fixed or stabilized. In an
open kinetic chain. the distal segment is mobile and is
not fixed.
2. Both open- and closed-kinetic-chain exercises have
their place in the rehabilitative process.
3. The concepts of the reversibility of muscle actions and
the concurrent shift arc hallmarks of closed-kinetic­
chain exercises.
-1:. Open- and closed-kinetic-chain exercises offer distinct
advantages and disadvantages in the rehabilitation
process.The choicc to use one or tbe othcr depends on
the desired trcatmcnt goal.
'i. It has been suggested that closed-kinetic-chain exer­
cises arc safer due to muscle co-contraction and joint
compression; that closed-kinetic-chain exercises tend
to be more funcLional; and that they more effectively fa­
cilitate the integration of proprioceptive and joint posi­
tion sense feedback than open-kinetic-chain exercises.
h. Open- and closed-kinetic-chain exercises have differ­
ent biomechanical effects on the joints of the lower
extremity.
7. Closed-kinetic-chain exercises in the lower extremity
decrease the shear forces. reducing anterior tibial
translation. and increase the compressive forces,
which increases stability arolmd the knee joint.
8. Minisquat. wall slides, lunges, leg press, stair-climbing
machines. lateral step-up, terminal knee extension us­
ing tubing . stationary bicycling, slide boards, BAPS
boards. and the Fitter arc a.ll examples of closed­
kinetic-chain activities for the lower extre mity.
9. Although it is true that closed-kinetic-chain exercises
are most often used in rehabilitation of lower-extremity
injuries. there are many injmy situations where
closed-kinetic-chain exercises should be incorporated
into upper-extremity rehabilitation protocols.
10. C!osed-kinetic-cbain exercises in the upper extremity
are used primarily for strengthening and establishing
neuromuscular control of those muscles that act to
stabilize the shoulder ginlle.
1 J . Closed-kinetic-chain activities, such as push-ups,
press-ups. weight-shifting. and slide board exercises.
are strengthening exercises used primarily for improv­
ing shoulder stabilization in the upper extremity.

g e. 'ercise.
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il1g 34(4): 358.
36. LaFree. J.. A. Mozingo. and T Worrell. 1 '19 5. Comparison of
open-kinetic-chqin knee and hip extension to closed-kinet ic­
chain leg press performance. JOUr/wi of .'>/lort [{elllli>ilitati(lI1
3(2): '19- 107.
37. Lepart. S.. and T Henry. 199 'i. The physiological basis fm
open- and cIosed-kinetic-chain rehabilitation for the upper
extremity. Jotlmal of Sport Rehabilitation 5( 1): 71 - 87.
38. Lutz, G., M. Stuart. and H. FrankLin. 1990. Hehabilitatil1'
techniques for atbletes after recon struction of the anteri nr
crudate ligament. ;vrayo Clillie Proceedillgs 65:1 322-29.
3'1. Malone. '1'.. and W. Garretl. 1992. Commentary und hjslori­
cal perspective of anterior cruciale ligament rehabilitati on.
JOllrJ1al oJ Orthopaedic and Sports Physical I'lll'mp!! 15( 6 1'
265- 69.
40. McMullen , J., and T. L. Uhl. A kinet.ic chain approach fl
shoulder rehabilitation. JOIlrlwl of Athletic Training 35(3
329.
41. NiseJl. R.. !I,I. Ericson, and G. Nemeth. et al. 198'1
Tibiofemoral joint forces during isokinctic knee extensior
All1ericall JOllrnal oJ Sports Medicine I i:49-54.
42. Ohkoshi. Y.. K. Yasuda. K. Kanedn. ct al. 199 I. BiomechalL.·
cal analysis of rehabilitation in tbe standing position. Ll mm­
JourIlal of Sports Medicille 19(6): A05- J I.
CIlII
43. Palmitier. R .. 1\. Kai-Nan. S. Scott. et al. 1991. Kinetic-cha
exercise in knee rehabilitation. Sport s lV1edicillc l l!
402- 13.
44. Hivera. j. 1994. Open- versus closed-kinctic-chain rehabili
lion of the lower extremity: A functional and biomecha ru.:
analysis. JOIIrIIllI of Sport Relllll>ili[atioll 3(2): ].54- 67.
45. Renstrom. E. S. Arms. T. Stanwyck. et al. 198l'i. Strain I\; tb
the anterior cruciate ligament during hHmstring and qu ad.­
ceps activity. ilmeriCiln JOllmal oJ Sports ,'vledicilll' 14:8 3
46. Reynolds,:'II.. T. Worrell. and D. Perrin. 1992. Effect of lat'
step-up exercise Protilcol on quadriceps isokinctic (lL
torque values and thigh girth. JOL//'Iwl of Ortl/Opacdif
Sports Pilysical Therapy 15( '»: 15 J -56.

Illysical Tl!erapu 29(2):
Biomechanics of the
· 144:9- 15.
erior tibiofemoral dis­
efforts. The rol e~ of
~_ .-\mericall Journal of
an terior cruciate Iiga­
r '.1/ of Sports Medi ci lle
effects of arm dom­
e. work. and power
mal of Atilktic Traill­
99 S. Comparison of
clion of the anterior
g5 65: 1322-29 .
ntury a nd histori­
cnt rehabilitation
~w l Til era py 15 (6):
chain approach for
35 (3):
eth. et al. 1989.
1991 . Biomcchani­
. 1991. Kioetic- chail:
elk -chain rehabUi ta·
!!! a nd biomechani a.
3( 2): 154-67.
al. 1996 . Strain within
hamstring and qu udri­
.\/eilicilll' 14:8 3- 8/.
. 1992 . Effect of latera
CHAPTER 12 Open- versus Closed-Kinetic-Chain Exercise in Rehabilitation
47. Ross. M. D.. C. R. Dcnegar. and j. A. Winzenricd. 2001. Im­
plementation of open and closed kinetic chain quadriceps
strengthening exercises after anterior cruciate ligament re­
construction. JOllrnal of Strengtll and Conditioning Research
15(4):466-73.
48. Sachs. R.. D. Daniel. and M. Stone. et al. 1989. Patellofemoral
problems after anterior cruciat e ligament reconstruction.
Ilmerican Journal of Sports Medicille 17:760-6 5.
49 . SGhulthies. S. S.. :\1. D. Ricard. K. j. Alexander. and j. W. Myrer.
199 8. An electromyographic investigation of 4 elastic-tubing
closed kinetic chain exercises after anterior cruciate ligament
reconstruction. JOlll'l1al of Athletic Training 3 3(4): 328-35.
)0. Selseth. A.. et al. 2000. Quadriceps concentric EMG activity
is greater than eccentric E.MG activity during th e lateral step­
up exercise. Journal of Sport Rehabilitation 9(2); 124.
) 1. Sheehy, P.. R. G. Burdett. j. J'. Irrgang. and j. VanSwearingen.
199R. An electromyograph ic study or vastus medialis
oblique and vastus lateru lis activity while ascending and de­
scending stairs. Journal of Orthopaedic and Sports Phusiml
Therapy 27(6}: 423- 29.
52. Shellbourne. D.. and P. Nitz. 1990. Accelerated rehabilitation
arter anterior eruciate liga me nt reconstruction. America.n
Journal of Sports Medici /Ie Ig :292-99.
53. Solomonow. M.. R. Barata. B. Zhou. et al. 198 7. The syner­
gistic action of the anterior cruciate ligament and thigh mus­
cles in maintainin g joint stability. American Journal of Sports
Medicine 15:207-13.
54 . Snyder-Mackler. L. 1995. Scientific rationa le and physiologi­
cal basis for the use of closed-kinetic-chain exercise in the
lower extremity. Joumal of Sport Relwhi/itatiol1 5(1): 2-12.
J) . Steindler. A. 1977. Kinesiolom! of the humal1 body under nor­
mal and patilOlogiml collditions. Springfield, IL: Charles C.
Thomas.
56 . Stiene. [1.. T. Brosky. and ,vI. Reinking. 199h. A comparison of
dosed-kinetic-chain and isokinetic joint isolation exercise in
patients lVith patcUofemo ral dy sfunction. Journal of Or­
tilOpaecuc a/1d Sport s Ph!fsical Tilcrapu 24(3): 1 36-4l.
.:; 7. Stone. j .. j. Lueken . and ~. Partin . 1993. Closed-kine tic­
chain rehabilitation of the glenohumeral joint. Journal of
Athletic Tmilling 2!l( 1); 34- 37.
58 . Tang. S. E T.. C. K. Chen. R. Hsu. S. W. Chou. W H. Hong. and
H. L. Lew. 2001. Vastus medialis obliquus and I'astus lateralis
activity in open and closed kin etic chain exercises in patients
SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES
12-1 An exercise bike is a good tool when rehabilitating
lower-extre mity injuries. The athlete can work
through a full ROM without bearing weight. The
seat height ean be adjusted to target a specific
ROM. And most muscles of the leg are utiJ,ized.
Most bikes have an option of upper-body activity
as well. A stairclimber or elliptical machine pro­
261
l'lith patellofemoral pain sy ndrome: An c1ectromyographic
study. Archives of Phusical Medicil1e al1d Rehabilitation 82(10 ):
1441-45.
59. Tovin. B.. T. 'I'ovin. and M . Tovin. 1992. Surgical and biome­
chan ica l co nsiderations in rehabilitation of patients with
intra-articular ACL reconstruc tions. Journal of Orthopaedic
and Sports Phusical Therapy IS (6): 317-22.
60. Ubinger. M. E" W. E. Prentice. and K. M. Guskiewicz.1999. Ef­
fect of closed kinetic chain training on neuromuscular con­
tro l in th o upper extremity. JOllmal of Sport Rehabilitation ~(3):
184- 94.
61. Valmassey. R. 1996. Clillical biomecllanics of the lower extrem­
ities. St. Louis: Mosby.
62. Voight. M.. S. Bell. and D. Rhodes. 1992. Instrumented test­
ing of tibial tnmslalion during a positive Lachman's test and
selected closed-chain activities in anterior cruciate deficient
knees. Journal of Orthopaedic and Sports Physical Therapy
15:49.
63. Voight. M., and G. Cook. 1995. Clinical application of closed­
chain exercise. JOI/rnal of Sport Rehabilitation 5(1 ): 25-44.
64. Voight. M.. and S. Tippett. 1990. Closed kinetic chail!. Paper
presented at 41st Annual Clinical Symposium of the Na­
tional AthlelicTrainers Association. Indianapolis. june 12.
65. Wawrzyniak. j.. j. Tracy. and P. Catizone. 1996. Effect of
closed-chain exercise on quadriceps femoris peak torque and
functi onal performance. Joumal of Athletic Traillillg 31(4):
335-45.
66. Wilk. K.. and j. Andrews. 1992. Current concepts in the
treatment of anterior cruciate ligament disruption. Journal of
Orthopaedic and Sports Physical Therapy 15(6): 279-93.
67. Wilko K., C. Arrigo. and j. Andrews. 1995. Closed- and open­
kinetic-chain exercise for the upper extremity. Joumal of Sport
Rehabilitation 5(1): 88- 102.
68. Willett. G.. et al. 1998 . Lower limb EMG activity during se­
lected stepping exercises. Joumal of Sport Rellabilitation 7(2);
102.
69. Willett. G.• et al. 19 98. Medial a nd lateral quadriceps muscle
activity during weight-bearing knee extension exercise. Jour­
,lUI of Sport Rehabilitatioll 7(4): 248.
70. Worrell. T. W.. E. Crisp. and C. LaRosa. 1998. Electromyo­
graphic reli ability and analysis of selected lower extremity
muscles during lateral step-up conditions. Journal of Athletic
Training 33(2): 156.
vides weight-bearing exercise that is nonimpact.
Later in closed-chain progression. la teral step-ups
can be used for neuromuscular control and in­
creased quadriceps firing.
12-2 Neuromuscular control and balance are crucial to
the performance of a dancer. The BAPS board and
minitramp provide unstable surfaces on which the
262 PART THREE The Tools of Rehabilitation

athlete is required to stand. Such controlled sys­ side-lYing exercises it is easy to teach the athlele to CHA
tems are ideal because they challenge propriocep­ isolate the muscle. Once that is accompJ.ished.
tion more than the stable ground. The athlete who more funclional closed-chain exercises can be im­
has mastered balance on an apparatus such as the plemented. Closed-chain exercises will encourage
minitramp can be progressed to functional activity
such as catching a ball while balancing on an un­
neuromuscular control. as the athlete is expected
to balance in addition to targeting the particular
Ils(J
stable surface. muscle.
Junine (
12-3 Unique to the slide board are the valgus and varus 12-6 He needs to strengthen his scapular stabilizers so
strains elicited by the movement. Too much valgus that his shoulder wiLl not rest anteriorly. Any exer­
spress while the ligament and musculature are still cise that perturbs the shoulder complex will cause
weak could exacerbate the injury. the scapular stabilizers to fire. Push-ups with a plus
12-4 Closed-chain exercises in which the arm is fixed are done to strengthen the serratus anterior. Push­
and the shoulder joint is perturbed cause contrac­ ups performed on a BAPS board or on a Plyoball ~
tion of the scapular stabilizers and the rotator cuff. also promote stability and neuromuscular control
This encourages overall stability of the joint. of the shoulder complex.
12-5 Open-chain exercises will allow you to apply sig­ S1
nificant resistance and isolate the muscle. With To become more
necessary to d
tic rehabilitation
jl'iic Training £,
Proficicncies'The
>Y\\'\I'.mhhc com
cises in the Del\ I

exercise.
• Contrast]
ages of
• Identify
kinetic

tion in t
• Analyze
as a reh
popu\aU
 :eClch the athlete to CHIAPTER 13
II is accomplished.
exercises can be im­
:' s will encourage
~ ath lete is expec t.ed
eti ng the particular
Isokinetics in Rehabilitation

Janine Oman
apular stabilizers so
Ulleriorly. Any exer­
. complex will cause
'ush-ups with a plus
'3lU a.nterior. Push­
rrd or on a Plyoball
ITIJID uscular con [ro l
ISOKINETIC EXERCISE
Study Resources
To become more ['amiliar with the knowledge and skills The concept of isokinetic exercise was described in 1967
necc$sary to design. implemenl. and document thera.peu­ by Hislop and Perrine. 2u Isokinetic exercise can best be
tic rehabilitation programs as identified in Lh.e 1\'A T!1 lith­ described as movement that occurs at a constant angular
leUc Traillillg Educational Competellcies alld Cli nical veloCity with accommodating resistance. Maximum mus­
Projlcifllcics' Therapeutic Exercise con tent area, visit cle tension can be generated throughout the range of mo­
www.m.h l1e.com/prcnliceJJ e. Afso refer to the lab exer­ tion because the resistance is variable to match the muscle
cises in the new l aboratory Manual and tu eSims. which tension produced at the various points in the range of mo­
simulates the athlelic training certification exam. at tion. Isokinetic machines allow the angular veloCity to be
wl\'w.mhhe corn/esirns. For more online study resources. preset. Once the speCified angular veloCity is achieved, the
visit our Health and Human Performance website at machine provides accommodating resistance throughout
Il'wlv.mhhe.com/hhn. the specified range of motion.
Isokinetic evaluation and rehabilitation are limited by
the technological advances of isokinetic dynamometers.
After Completion of This

Isokinetic dynamometers now provide concentric and ec­

Chapter, the Student Should

centric resistance. Velocities are variable depending on the

Be Able to Do the Following:
machine, although the average range is from zero to 300
• Identify the concepts of isokinetic
exercise,
• Contrast the advantages and disadvan­
tages of isokineti exercise,
• Identify the various computerized iso­
kinetic systems,
• Analyze the use of isokinetic evalua­
tion in the athletic population.
• Analyze the use of isokinetic exercise
as a rehabilitation tool in the athletic
population.
degrees/second in the eccentric mode. Some machines al­
low concentric velocities greater than 500 degrees/second.
Historically, the two primary advantages associated
with isokinetic exercise are the ability to work maximally
throughout the range of motion and the ability to work at
various velocities to simulate functional activity.45 Care
should be taken, however, when inferring functional ca­
pacity based on results of dynamic isokinetic testing. 33 Ve­
locities achieved during functional activity greatly exceed
the velOcity capacities of isokinetic dynamometers. Angu­
lar velocities produced by professional baseball pitchers
have been shown to range between 6,500 and 7,200 de­
grees/second. 9 Velocities measured at the hip and knee
during a soccer kick exceeded 400 degrees/second and
1,200 degrees/second, respectively.32 The majority of iso­
kinetic testing is done in a non-weight-bearing position
that is not representative of functional activities. It is im­
portant to remember that many variables contribute to

263
264 PART THREE The Tools of Rehabilitation

overall athletic performance. fsokinetic testing evaluates

just one of these many variables. However. given these lim­
itations. isokinetic exercise can be a very powerful tool [or
the athletic trainer in the evaluation and rehabilitation of
sport-related injuries.

ISOKINETIC DYNAMOMETERS
Various isokinetic dynamometers are commerciaUy avail­
able to the athletic trainer. The different systems all offer
variable types of resistance and velocities. This section is
not meant to endorse a particular isokinetic system but is
provided to give the athletic trainer information on the
speCifications of some of the more common commercially
available isokinetic dynamometers. Table 13-1 provides a
comparison of the different dynamometers with infonna­
tion related to the manufacturer's address. exercise modes
available. velocities. and torque maximums. The only sys­
tem currently being manufactured is the Biodex System 3
dynamometer. The Cybex and Kin-Com dynamometers
are still in use but no longer produced. Figure 13-1 Biodex System 3 isokinetic dynamometer.

Biodex
The Biodex System 3 isokinetic dynamometer allows con­
centric and eccentric motion (Figure 13-1). This system
has isometric. isotonic. CPM, and isokinetic exercise
modes. Concentric velocities range from 30 to 500 de­
grees/second. Eccentric velocities range from 10 to 300
degrees/second. Maximum torque values allowed for
safety purposes are 500 ftlb concentrically and 300ft lb
eccentrically. l The Biodex also has lift (lumbar Oexion /ex­
tension. torsion rotation. work simulation) and closed­
chain allachments.
One advantage of the Biodex is that it allows for high­
speed concentric activity while being fairly user friendly.
The Biodex also can be set up easily for strengthening in di­
agonal planes. The J3iodex generates a very comprehensive
report after isokinetic evaluation. Another advantage is
thaI. as just mentioned, it is the onry dynamometer cur­
renlly in production. The Biodex does have a lower eccen­
tric maximum, which may be a limitation when used in
the athleLic population.
Figure 13-2 Cybex 6000.
Cybex 6000
The Cybex 6000 allows concentric and eccentric motion to previous Cybex dynamometers. The powered mode pro­
(Figure 13-2). All other Cybex dynamometers allow only vides both concentric and eccentric activity and continu­
concentric activity. The 6000 has powered and nonpow­ ous passive motion (CPM). The Cybex 6000 has J 8
ered modes. The non powered mode allows free limb accel­ exercise/ test patterns available. Nonpowered concentric
eration with concentric/ concentric activity that is similar velocities range from 15 to 500 degrees/ second. The
 g ~... x ....;.
f7II
...,
~ 0..
Vl I"'"'( ,...... ,..
__ ("!) 0\ ,< ("5
en 0... CO;""" 3
OJ
C::l '""
(1)
88 0 0..0..
a a
o
::l::l
P-8g-g&
cn
0
a
(1)
r-3::::J ,-Cb (ti
::r;::; 5·~
'1; r;o ;x C, 0, "

• TABLE 13-1 lsokinetic Equipment Information.

Isokinetic Equipment
and Manufacturer Exercise Modes Available Speeds Torque Maximum*

BIODEX Isokinetic (conccntric and eccentric) I.sokinetic: Concentric: 500

1.sometric Concentric: 30- 500/sec Eccentric: 100 rt Ib
Biodcx Corporation Continuous Passive Motion (CPM) Eccen tric: l()- 300/sec
PO BoxS CPM: minimum speed capabiliLies
Shirley. NY 1196 7 or .25°/second

CYBEX isokinetic Powered Concentric: 15-120/sec Powered Concentric:

no longer in production Concentric: powered and Non-powered Concentric: I5-500/sec 500 rt Ib

www.csmisolulions.com/numac non-powered mode Powered Eccentric: 30-120/sec Powered Eccentric:

Eccentric: powered mode CPM: 5-120/sec 30- 5 5/sec: 250 rt Ib

CPM 60- 120/sec: 300 rl Jb g

>­
'"0
KIN-COM Isometric Isokinetic: Isometric: 450 rt Ib >-0
rro
;::;:l
no longer in production Isokinetic (concentric and eccentric) Concentric: 1-250/sec IsokineLic: ~

Isotonic Eccentric: 1-250/sec Concentric: 450 rt Ib w

CPM Isotonic: I-250/sec
CPM: 1-250/sec
Eccenlric: 450 rllb
Isotonic: 2-450 ft Ib
-
on
o
3:­
:l
~
;::;.
*'1'0 COllvert fooL-pounds to Newton-meters. multiply by 4.45.
'":l
:;x:I
'"
::r
OJ
~

or
o·
:l

N
en
(II
266 PART THREE The Tools of Rehabilitation

torque maximum for nonpowcred concentric activity is Kin-Com. It also has a balance station option kit. The Kin­ istics of muscle. Th
500 ft lb. Powered concentric velocities range [rom 15 to Com dynamometers olTer isometric. isotonic. continuous ing the results of SI
300 degrees/ second. The torque maximum for this mode is passive motion (C PM) . and isokinetic modes. The velocities plying the result s \,
also 500 ft lb. Powered eccentric velocities range from 15 for isotonic. CP.M. and isokinetic (concentric and eccen­ the literature.
to 300 degrees/second. The torque maximums vary de­ tric) modes range from 1 to 250 degrees/s econd. Tbe force Primarily. force
pending on the velocity in this mode. The torque maxi­ maximums are 450 n Ib (20()() 1\ewtons) for all of the ex­ eralure. Force can
mum for velocities bet ween 15 and 5::; degrees/second is ercise modes. All of the Kin-Com dynamometers are com­ produced by t1:W-ac
250 ft lb. The torque maximum in the eccentric powered puter controlled. l l measured in pou nd
mode for velocities between 60 and 300 degrees/ second is The Kin-Com dynamometers offer the highest force force applied dunr
300 [t lb. The velocities in the continuous passive motion maximums combined with high velocities for eccentric surcd in foot-pOli O(
mode vary between 1 and 300 degrees/ second .7 New soft­ testing and rehabiIitaUon. which is a distinct advantage in tel' can be used in iSI
ware and support are now provided by CSMI Solutions. the athletic setting. The Kin-Com is also extremely user not interchangeab
The HUMAC/ Cybex 6000 sysLem replaces the computer. friendly. The Kin-Com does not provide as comprehensive a oamometers use Lo
DOS application software. and interface cards. data report as other dynamometers . The Kin-Com is lim­ The force and te
One of the primary advantages of this dynamometer is ited to 250 degrees/second ·in the concentric mode. which to either peak or E
that it is a Cybex product. The nonpowered mode of this is slower than other avaiJable isokineLic dynamometers. force/torque is th e
dynamometer is the sa me as prcvious Cybe-x dynamome­ tion. l i Average for(
ters. so the normative and rese.arch data can be used as across the whole I
comparison data w'ith this machine. This machine also is CLINICAL DECISION MAKING Exercise 13-1 forc e/ torque can al
very versatile in that it can be used for many exercise pat­ weight-adjusted fO[1
terns for the upper and lower extremity. Cyhcx has in­ You perfonned an isokinetic evaluation on CI bCl,eball are also identifled in
creased its speeds in the powered concentric <Ind eccentric pitcher with impingement syndrome who demonstrated fo ree multiplied b~
mode. The non powered mode has the highest velocities an altered external rotation / internal rotation (ER /IR) ra­ ,;ented as the area u
and torque maximums avai];lblc. The disadvulltage of the tio. What isokinetic exercises 1V0uld you add to his pro­ dcflned as the ra Le
Cybex is similar to that of the Biodex. with lower cccentric grmn and why? power characteristi ,
torque maximums velocities when llsed in the athletic a mount of work pc:
population. durance parameter
reductions in peak
CLINICAL DECISION MAKING Exercise 13-2
repetition. Another
Kin-Com
time it takes to d ro
A female soccer player had right J\CL reconstruction 4
The Kin-Com isokinetic dynamometer was the flrst active
months ago. Her physician has referred her for isokineLlc
system available that allowed concentric and eccentric ae­
testing. What velocities and ROM would you assess? CLINICAL DECIS
Itivity (Figure 13-3). The Kin-Com has options for a dual­
channel EMG system to Llse in combination with the

CLINICAL DECISION MAKING Exercise 13-3

A female basketball player has weakness in her ham­

string muscle group. What isokinetic exercises would
you stari?

reflect a true
ISOKINETIC EVALUATION
Parameters CLINICAL DECISI
Various parameters of force and torque are used to COI11­
pare extremities during isokineti c. eva'lualion. One of the What parameter
limitations of the isokinetic Iiterat me is that mallY pCll-am­ an isokinetic tesli
Figure 13-3 Kin- Com 500H isokinetic dynamomclcr. ters arc used in describing isokinetic strength character­

ist ics of muscle. The athletic trainer is faced with evaluat­
ing the results of specific isokinetic tesls and correctly ap­
plying the results with nonnative data that is avuilable in
tbe literat ure.
Primarily. force or torque data arc used in isokinetic lit­
erature. Force can best be described as the push or pull
produced by the action of one object on another. Force is
measured in pounds or Newtons. Torque is the moment of
fo rce applied during rotational motion . Torque is mea­
ured in foot-pounds or ewton-melers. 24 Either parame­
· Cl advantage in ter can be useu in isokinetic testing. but force and tori/li e are
extremely user noL interchangeable terms. Most of the isokinetic dy­
namometers usc torque as the measured parameter.
The [c)rce and torque parameters in the literalure relate
to either peak or average force / torque production. Peak
force/ torque is the point or highest forcelLorque produc­
lion. 17 Average rorce/ torque is the rorce/torque produced
across the whole range of motion ..l! Peak and average
Exercise 13-1 force/torque can also be compared to body weight for a
weight-adjusted force/ torque. Work and power parameters
are also idenLilled in isokineLic literature. Work is dell ned as
10nslratcd orce multiplied by displacement. 24 Work is best repre­
(ER/ fR) ra- nted as the area under the torque or force curve. Power is
dellned as the rate or performing work. Data relating to
power characteristics are best evaluated by identirying the
a mount or work perrormed in a specil1c time period. En­
duran ce parameters arc also evaluated in relationship La
reductions in peak torque from the Ilrst repetition to the last
Exercise 13-2
repetition . Another parameter that may be evaluated is the
li me iltakes to drop to 50 percent or peak torque. 12
r isokinetic
CLINICAL DECISION MAKING Exercise 13-4
An athletic trainer performs a repeat isokinetic evalua­
tion on athlete to recheck her quadriceps and hamstring
Exercise 13-3 stren gth. The repeat evaluation indicates a 35 percen t
difference in quadriceps with no hamstring deficits pres­
ent. The previous tcst had only a 15 percent deficit be­
tween the qnadrtceps muscles. You retest in one week and
the deficit is now 10 pl'rcent between the quadriceps.
What are the potentifll sources of variation. and does this
reflect a true strength change?
CLINICAL DECISION MAKING Exercise 13-5
What parameters should the athletic trainer evaluate in
an isokinetic test?
CH APTER 13 lsokinetics in Rehabilitation 267
Testing
Isokinetic evaluation is dependent on many difrerent vari­
ables Lo prod LIce a reliable test. Two of th e variables are
speed of testing and the position of the athlete during test­
ing. These variables need to be controlleu emu shoulu be
consistent from test session to test session. The athletic
trainer needs to test the athlete at specillc speeds ir com­
parison to normative data is desired.
The literature provides a vast array of testing speeds
ror upper- anu lower-extremity isokineLic evalua­
tions . 19 .22.33 Previous research suggested that testing at
uilTerent speeus allowed the sports therapist to test dllTer­
ent characterisLics or muscular strength and power.x The
current research supports the view that torque. work. and
power characteristics are determined independent of test
velocity. The results are not inuicativc of the ability of' the
individual muscle to perform difrercnt strength or power
tasks. J 1
Generally. 6U uegr~es/second has been used as the pri­
mary test speed for concentric isokinetic testing. Eccentric
testing speeds tcnd to be more variable. Hageman and
Sorenson 17 recommend 150 degrees /second as the upper
limit for eccentric testing in the general population and
] 80 degrees /second as the upper limit in the atbletic pop­
ulation . Coactivation or the antagonistic musculature oc­
curs with faster speed testing. 1S This co activation happens
because the antagonistic musculature produces rorce to
slow down the lever arm in preparation ror the end poin t of
the range or motion with open kinetic testing. ReCiprocal
testi ng of antagonistic musculature might not be accurate
at faster speeds because of the ,i ncreased force prouuced by
the antagonistic musculature. \
This coactivalion most probably occurs in the non­
powered mode of isokinelic testing because of free acceler­
aLion of the lever arm. No resistance is applied until the
subject meets the preset velocity. This is the most probable
cause of increased antagonistic activity to slow down the
lever arm . The powered mode entails the usc or a preload.
This necessitates the production of a predeterm.ined
amount of rorce before isokinetic contraction can be initi­
ated. eliminating the free acceleration or the lever arm.
This is one variable that can arrect accurate isokinetic
assessment.
The other is pain inhibition-a protective neuromus­
cular response or an involved muscle to limit maximal re­
cruitment or muscle f'ibers secondary to pain and swelling.
Pain inhibition can lead to variations in torque production
rrom one testing session to another. To limit this effect. test­
ing shoulu be performed when the injured body part is not
errused or swollen. J 1
268 PART THREE The Tools of Rehabilitation

Testing of mu lti
Recommended pOSitioning of the athlete during an The athletic trainer should keep thiS in mind when per­
ankle, can make it
isokinelic evaluation varies depending on the specific liter­ forming isokinelic evaluations on ACL injuries.
ondary to the comI
ature reviewed. POSitioning of the jOint should account for
tions in aligning th
the gravity effect and the healing phase of the injured Reliability mechanical axis of
structures. The gravity effect torque must be calculated if
shown very poor I
the athletic trainer is analyzing reCiprocal group ratios In IsokineUc Exercise {Ind AssesslIlent, Perrin 3 1 recommends
peak torque for ank
such as the quadriceps and hamstrings. Failure to account a speciJ1c protocol for isokinetic testing. Table 13-2 OU t­
geslion to limit th
for this torque skews the agonist / antagonist ratio if the lines his protocol.
during a tesNng s__
athletic trainer tests tbe two muscles in the same pOSition. It is important that the athletic trainer have reliable
comparisons betwe.
An easy way to control this effect is to test the different and reproducible test results. Test reliability is dependent
needs to recogn ize
muscles in different pOSitions so that each muscle is in an on many factors but is probably the most overlooked aspect
multiaxial joints.
a ntigravity position during testing. :'vIany of the new dy­ of isokinetic evaluation. Because of the wide variety of test
Retesting the aL
namometers correct for the gravity effect torque if desired. protocols in the literature, the cliniCian should include sev­
uate the progress n
The athletic trainer may need to modify the testing po­ eral essential components within the isokinetic test to fa­
Broad statements r
sition to protect healing structures. For example. early cilitate reliability of measurement. The clinician needs to
ability of the tesleo
testing of the shoulder musculature after an episode of evaluate the use of a warm-up period and a rest period, the
cause isokinetic e\'a
subluxation / dislocation should be performed with the number of test repetitions, and test velocity. The recom­
ability to perform fu
arm attbe side and not in the abducted position. Wilk and mended rest period between different test velocities is flO
ing of the invol ved
Arrigo 41 proposed performing shoulder strengthening seconds. 29 These variables need to be consistent between
trainer to evalualt
initially at 0 degrees of abduction, progressing to the tesling sessions for comparison data as well as faci:litflling
program. Improvcn
plane of the scapula and Jlnally to YO degrees of abduc­ maximal torque production. Kues 22 recommends that pa­
week of testing prot
tion . This progresses the shoulder from a position of max­ tients have two practice sessions IJrior to the actual test.
of the involved mue;
ima l joint stability to a pOSition of minimal joint stability.. Reliability can also be influenced by the testing mode. Ec­
athlete's familia rity
The plane of the scapula is achieved by placing the centric testing especially involves a significant learning
lar changes withi n
humerus in a position 30 to 45 degrees anterior to the curve because of the athlete's unfamiliarity with this exer­
volving hypcrtropj
frontal plane. 17 Resea rch has indicated that there is no dif­ cise mode, but test-retest reliability in this mode has been
req uire 4 to (i wee:
ference in torque production between the traditional and established. 14
and hypertrophi c sl
the scapular plane. 39
uate. but the athl e~
POSitioning the tested joint so that it reproduces func­
strength changes ~
tional activity can be beneficial for the a thletic trainer. The
• TABLE 13·2 Isokinetic Assessment cur within a shorl !
effect of hip position on the torque values of the quadri­
Protocol. 31 Reliability and ;
ceps and hamstrings has been studied by Worrell ct al. 41
for the Biodex Sysl
Their results indicated that peak torque was greater in the
1. Musculoskele ta l screening regarding pOSition.
seated position and less in the supine position. However,
2. General body stretching and warm-up high degree of reli
the authors state that evaluation of peak torque might be
more appropriate from the supine position to mimic hip 3. Patient set-up with optimal stabilization
position during functional activity. 4. Alignment oj' joint and dynamometer axes of
CLINICAL DECIS
The length of the lever arm of the dynamometer af­ rotation

fects the ability to produce torque. Torque production is 5. Verbal introduction to isokinetic concept of exercise
significanLly affected when the lever arm is changed in 6. Cravity correction when appropriate
length . The athletic trainer can limit torque production 7. Warm-up (3 submaximal. 3 maximal relJetitions) has 12 percen t
ea rly in the healing phase of injury by decreasing the 8. Rest (30 seconds to 1 minute) hamstring defici
length of the lever arm. However. the length of tbe lever 9. Maximal lest at slow velocity (4 to 6 repetitions) hamstring/quad
arm needs to be consistent between testing sessions if the 10. Rest (30 seconds to 1 minute)
athletic trainer is comparing previous testing sessions to 11. Maximal test at fast velocity (4 to 6 repetitions) determine the a
the current test. \Vilk and Andrews 40 studied the effect of 12. Rest (30 seconds to 1 minute)
pad placement and angular velocity on tibial displace­ 13. Multiple-repetition endurance test
ment. Their results indicated that proximal pad placement 14. Testing of contralateral extremity
resulted in less anterior tibial translation than distal pad ] 5. Recording of test details 10 ensure replication on I nterpretati~
placement. With respect to velocity. the greatest amount of retest
SpeCific ratios of f(
tibial translation occurred at 60 degrees/second as com­ 16. Explanation of results to patient
lied during isokine
pared to 180 degrees/ second and 300 degrees /seco nd.

Testing of multiaxial joints, such as the shoulder and
mind wben per­
ankle, can make it difficult to reproduce test results sec­
~iuries. ondary to the complexity of setups, as well as the limita­
tions in aligning the axis of rotation of the limb with the
mecllanical axis of rotation of the machine. Results have
shown very poor reliability between repetitive trials of
peak torque for ankle plantarflexion/dorsillexion. 38 A sug­
gestion to limit the error is to always test both extremities
during a testing session. The athletic trainer should limit
'oer have reliable
comparisons between testing sessions. The athletic trainer
iJity is dependent
needs to recognize the limitations associated with testing
overlooked aspect
multiaxial joints.
ide variety of test
Retesting the athlete allows the athletic trainer to eval­
h uld include sev­
uate the progress made with the rehabilitation program.
kinetic test to fa­
Broad statements regarding the strength and functional
ability of the tested musculature should be limited, be­
cause isokinetic evaluation may not be correlated with the
ability to perform functional activity.1.l 5.n However, retest­
ing of the involved musculature does enable the athletic
nsistent between
trainer to evaluate the effectiveness of the rehabjHtatlon
well as facil 'i taling
program . Improvements in test results that occur within 1
mmends that pa­
lVeek of testing probably do not reflect changes in strength
LO the actua I tesL.
of the involved musculature but are indicative of either the
athlete's familiarity with testing or possibly neuromuscu'
lar changes within the muscle.2 True strength changes in­
volving hypertrophic changes in the muscle usually
require 4 to 6 weeks of training. 26 Both neuromuscular
and hypertrophic strength changes are important to eval­
uate. but the athletic trainer needs to understand that true
strength changes of the involved musculature do not oc­
cur within a short period of time.
\ssessment
Reliability and validity testing were recently performed
for the Biodex System 3 multijoint isokinetic dynamometer
regarding position, torque, and velocity: resLllts indicated a
high degree of reliability and validity of test data. 10.17
tion
CLINICAL DECISION MAKING Exercise 13-6
ncept of exercise A men's volleyball player had left ACL reconstruction 6
te months ago. The resu lts of an isokinetic test indicate he
mal repetitions) has 12 percent dellcits in quadriceps strength with no
hamstring deficits present bilaterally. The
hamstring/quadriceps ratio is 75 percent on the involved
leg at slow-speed testing. What -riteria would you use to
determine the atWe e's rt'adincss to return to play?
I nterpretation of Graphs
replication on
$pecillc ratios of force, torque, work, or power are identi­
fied during isokinetic testing to determine differences be-
CHAPTER 13 Isokinetics in Rehabilitation 269
tween the two tested extremities. The most commonly
used ratios are peak/ average torque ratios between in­
jured / noninjured extremities, agonist/antagonist ratios,
and concentric /ecce ntric ratoios. Historically. normal peak
and average force/torque ratios comparing the injured to
the uninjured extremity typically use the 85 to 90 percent
ratio to allow the athlete to return to competition.)O How­
ever, the athletic trainer should not use a percentage crite­
rion as the sole indicator for return to activity. because
functional activity has many variables that need to be
present for optimal sports performance. 15 .2 1.23,2ti, J7
Agonist/antagonist ratios are another commonly used
ratio in isokinetic evaluation. The hamstring/ quadriceps
ratio is the most analyzed ratio. HistOrically, based on Cy­
bex evaluations. a 66 percent ratio between the ham­
strings and the quadriceps at 60 degrees/second is
described as the normative value. 8This testing is only done
in the concentric mode. The athletic trainer needs to be
careful in comparing the hamstring/ quadriceps ratio.
Likewise, agonist/ antagonist ratios have been identilled for
other muscle groups such as shoulder ,i nternal/external
rotation. New research by Smedley et a!. identilled signill­
carlt differences between dominant and nondominant
sides in baseball and softball players with signillcant
increases in internal rotator strength as compared to
college-age control subjects. 3s It is thercl'ore very impor­
tant for athletic trainers to compare their results with re­
search that was performed in the same manner with
respect to gravity correction, velocity, and activity status.
The athletic trainer shoLlld know which of the agonist/
antagonist muscles are capable of producing the most
force so that the athletic trainer can then evaluate the re­
sults and make appropriate adjustments to the rehabilita­
tion program, Perrin 31 provides detailed descriptions of
normative data for all joints.
Finally, the eccentric/ concentric ratio is another pa­
rameter to evaluate with isokinetic testing. Blacker 4 re­
ports that eccentric testing should produce a 5 to 70
percent increase in force/torque as compared with con­
centric testing. Bennett and Stauber 2 identilled eccentric
to concentric quadriceps torque deficits in approximately
30 percent of their patients with anterior knee pain. The
dellcit was defined as less than an 85 percent peak torque
ratio between eccentric and concentric activity. The re­
searchers felt that the dellcit might have been one cause of
the subjects' increased pain. The symptoms and isokinetic
dellcits were reversed through a training program.
Trudelle-}ackson et al. ,36 however. tested asymptomatic
subjects concentrically and eccentrically and reported a
signillcant percentage of healthy subjects who demon­
strated eccentric to concentric dellcits of greater than 15
percent. One reason for the difference is that eccentric
270 PART THREE The Tools of Rehabilitation

CONCENTRIC, Accepted ECCENTRIC

3 3

Right

B/A: 122%
CIA: 72"'{'

:;

""""''"''-'~'''.--.:-...........,..
...,.....,-.;.;.~.-"' ..:,: D/A: 85%

200­
200
N • 1, A=218N Force
B = 266 N N

CONCENTRIC I Accepted ECCENTRIC

3 2

left
D/C: 118%
D/B: 70%
B/C: 169%
..... r ........... _____ ...
".,.,_ .. .;-;............. .

200
200 Force Average N.
N _ , ~=, 15,7 N D = 185 N Left Right
Angle ~--'--'
deg
deg o 60 120 o 60 120 5 110
Figure 13-4 Isokinetic torque curve abnormality, Figur

testing involves a greater variability than concentric test­ hibited a break in the torque curve that lasted for 10 de" 100 degrees of flexio
ing. 25 The sports therapist needs to evaluate concentric grees at approximately 45 degrees of flexion. The break centric control thr(
and eccentric force production. The athlete should be able was associated with a load reduction of approximately 25 curve also reveals a d
to produce more force eccentrically, but the sports thera­ percent of the patient's weight. Pain inhibition was hy­ Oexion . A rehabilita
pist should be aware that a greater variance exists with pothesized to be the cause of the break in the curve. luded eccentric COl
eccen tric testing. Clinically, deficits in the shape of the curve should be tric/concentric quic
identified. One repetition that produces a torque abnor­ the leg curl motion iIi
Shape of the Curve mality should not lead the athletic trainer to conclude that of tbe hamstrings.
the athlete has altered function. Testing should include
The information provided by evaluation of the curve varies multiple repetitions to idenlify consistent torque curve
depending on the researcher. Rothstein, Lamb, and May­ deficits. The athletic trainer should then design a specific ISOKINETIC
hew l3 state that the shape of the torque curve might be due rehabilitation program to attempt to correct for these
to machine artifact and might not be related to patient per­ deficits. Force-Velocitj
formance. These researchers stale that the athletic trainer Figure 13-4 shows a torque curve abnormality. These
should not draw speciftc conclusions regarding pathologi­ graphs involve an isokinetic evaluation of a patient who The use of isokineti
cal conditions based on the shape of the torque curve, How­ had history of significant patellofemoral pain after an ACI... {Jlely to evaluation I
ever, there is some evidence that the shape of the torque reconstruction. The lower two graphs are of the involved able rehabilitation tl
curve might be related to patient function. side. Evaluation of the concentric force curve reveals con­ signing an exercise
Engle and Faust l J tested patients with a history of sistent del1cits between 25 and 60 degrees. The eccentric hould be the basis
shoulder subluxation. The testing involved performing tra­ force curve is very inconsistent with a decrease in force program.
ditional and diagonal patterns of shoulder motion. The re­ production from 35 EO 60 degrees. Pain inhibition was The force-veloci
searchers idenlified consistent torque defects in thought to he the contributing factor (0 these force curve components that aLI'
symptomatic and asymptomatic patients. Torque curve abnormalities. A rehabilitation program was designed to italion program-Ii
abnormalilies were found from 70 to 110 degrees with attempt to correct for these detkits and to avoid painful studies have been p
flexion/abduction/external rotation diagonal in patients ranges identified on the force curves. duction with cone
with rotator cuff weakness. The abnormalities were seen figure 13-:; shows an isokinetic evaluation of a de­ cbanges in velocity (
at 85 degrees in the extension/adduclion/internal rola­ cathlete with hamstring strain. This athlete had a history lion of the force-velo
tion diagonal in patients with posterior labral tearing. Dvir of recurrent hamstring strains of both extremities. The 00 the y axis, and t ~

et al. l l tested patients with patellofemoral pain. The re­ lower two graphs are of the involved side. Evaluation of the axis. Concentric m01
searchers identified a large percentage of palients who ex­ eccentric force curve reveals a divot bilaterally from 90 to axis, and eccentric i
 CHAPTER 13 Isokinetics in Rehabilitation 271

(CONCENTRIC . Accepted ECCENTRIC

3 3
Left
122% 8/A: 101%
- ',-- .. -- ',
CIA: 40%
72%
85% O/A: 46%
,. '

200
N
I
1
1-1
""
---'-----:--=-=-c~-----'
A= 384 N
Force
B = 389 N

( CONCENTRIC ECCENTRIC
Accepted
3 3 O/C : 115%
18%
Right
70%
0/8: 45%
69% B/C: 254%

; - ",

200 Force Averoge

ge C = 153 N 0= J76 N
Right N " , I Left Right
deg o 30 60
Angle o 30' , 60 o 75
110
Figure 13·5 Isokinetic evaluation of an athlete with a hamstring strain.

at lasted for ]() de­ 100 degrees of flexion. The athlete exhibits diminished ec­
nex-ion . The break ~entric control throughout the motion. The eccentric
approximate'ly 2 5 ,'urve also reveals a decay of force from 30 to 50 degrees of
inhibition was hy­ flexion. A rehabilitation program was designed that in­
:n the curve. luded eccentric control of the hamstrings and eccen­
be curve should be [ric/concentric quick reversals in the standing position for
a torque abnor­ .he leg curl motion in addition to traditional strengthening FORCE
er to conclude that r the hamstrings.
mg should include
ent torque curve
en design a specific ISOKINETIC TRAINING
correct for these
Force-Velocity Curve
abnormality. These
Eccenlric 0 Concenlric
f a patient who The use of isokinetic dynamometers should not be limited
al pain after an ACL solely to evaluation purposes. Isokinetic training is a valu­ Figure 13·6 Force-velocity curve.
are of the involved able rehabilitation tool and should not be overlooked in de­
e curve reveals con­ 'gning an exercise program. The force-velocity curve
grees. The eccentric hould be the basis for designing an isokinetic training Velocity increases from left to right with concentric mo·
a decrease in force ogram. tion, and velocity increases from right to left with eccentric
f'ain inhibition was The force-velocity curve identifies two of the major motion. Force production decreases with increases in ve­
'.0 these force curve
_omponents that athletic trainers can control in a rehabil­ locity with concentric motion. 6 Conversely, eccentric force
am was designed to .:ation program- force and speed. Numerous research production might increase with an increase in the velocity
; d to avoid painful .,rudies have been performed that identify the force pro­ of motion. 4 2 However. some researchers disagree and feel
.mcl'ion with concentric and eccentric activity with eccentric torque remains the same with increases in veloc­
evaluation of a de­ ..:banges in veloCity of motion. Figure 13-6 is a representa­ ity.6.16 It is important to remember that research relating
Iblete had a history on of the force-velocity curve. Force production is located to specificity of training for speed and mode of exercise is
nh extremities. The n the y axis, and the velocity of motion (speed) is on the x extremely variable.
de. Evaluation of the 'is . Concentric motion is located on the right side of the x The athletic trainer should use the force-velocity curve
'laterally from 90 to .uis, and eccentric motion is on the left side of the x axis. as the basis for deSigning a rehabilitation program. The
272 PART THREE The Tools of Rehabilitation

veloCity and the mode of exercise should be chosen with tiona1and diagonal planes of motion for maximal isotonic leUr trainer should
regard to the type of injury and the potential for force pro­ and isokinetic resistance. age criteria for a r
duction with the different velocities a nd modes of exercise. Isokinetic training usualty follows a protocol similar to 9. The athletic train
In the acute phase of healing a fter injury, force production testing, including warm-up, train.jng sessions, and rest ses­ torque curve for c.
should be kept to a minimum to allow appropriate healing sions. The duration of the training set should be approxi­
of the injured structures. Eccentric isokineti c tra ining is mately 30 seconds, followed by a rest pe riod of 60
not advised in this phase because of the potential for in­ seconds. 29 The appropriate training frequ e ncy to maintain
References
creased force production. strength gains is one time per week.2 7
Hageman and Sorenson 17 describe an eccentric training 1. Anderson . i\L J. Gie
progression. The authors suggest a good warm-up followed ships among isomel
SAMPLE PROGRESSION and eccentriC qua dri
by an orientation to the eccentric isokinetic mode. Training
Some of the isokinetic dynamometers offer the ability to should include one to three sets of ten repetitions beginning ponents of athletic
Sports Ph!lsical Thrill
provide other types of resistance, such as isotonic, isomet­ at 60 degrees/second in the concentric-eccentric mode. The
2. Bennett. J.. and \'\'.
ric, and passive motion, that allow the athletic trainer clinician should advance by 30 degrees/second increments
of anterior knee paJ
more f1exibiJity in the use of dynamometers in the rehabil­ up to ISO degrees /second, continuing with two to three sets Science in Sports Illld
itation program. Progression through the rehabilitation of ten repetitions with each advancing speed. The sugges­ 3. Biodel( Informati on;
program should be based on the attainment of short-term tion would be to train across a velocity spectrum to maxi­ -t Blacker, H. Measun:
goals and th e phase of healing after injury. In the acute mize poten tial strength gains. menlo In Kin-COlli
phase of injury, the goals should be related to regaining The disadvantage of isokinetics, as was previously lanooga Corp.
motion and maintenance of strength. The isokinetic dy­ mentioned, is that motion is performed in an open isoki­ ). Brown. L. E., cd.
namometer ca n be used in this phase to provide isometric netic chain, which is not representative of functional activ­ Champaign. 1L: Hw
and submaximal isotonic resistance and passive motion if ity. However, some dynamometers can be adjusted to Chandler. J., and P­
trie force-velocity
needed. Positioning of the athlete for rehabilitation ses­ provide closed-kinetic-chain resistance in the form of leg­
muscle. Physical Th
sions may n eed to be altered to lessen the gravity effect press motions and standing terminal knee extension or
, . Cybex In form ation;
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scar proliferation stage (7 to 21 days), graded resistive their dynamometer. The addition of closed kinetic activities LaCrosse. WI: S & S
stresses can be applied to initiate the strengthening phase makes the dynamometers more versatile in the rehabilita­ Dillman . C. J., G.­
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menls. 10!mwi of
used to alt er velOCity and force production using tradi- program.
' 1. Dvi r. Z., N. Halpe'
tion and patellor.
ScietJLe l( 1): 3] ­
'2. Dv ir. Z. )9 9 5. lsoi
Summary icnlllpplicatioli s. '
1 3. Engle. R., and J.
rior shoulder SlI
1. Isokinetic exercise is movement tha t occurs at a con­ 6. The athletic trainer needs to be consistent with isoki­ i2-74.
stant angular velOCity with accommodating resistance. netic testing from one session to another. Speed and 14. Frisiello, S.. A. GI
Waugh. )994. T,
2. Force can be best described as a push or pull produced position of the athlete should remaj n the same.
valucs for shou l
by the action of one object on another. 7. The athlete may need a practice session before isoki­ Bi odex isokineli
3. Torque is defined as the moment of force applied dur­ netic testing to be familiarized to the testing sequence Spar ls Physical
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Vllork is measured as the area under the torque curve. and eccentric/ concentric ratios are commonly used to assessmen t of
5. Power is defined as the rate of performing work. evaluate the results of isokinetic testing. but the ath­ llwpaedic (llld Sp

ror maximal isotonic
. a protocol similar to
ions. and rest ses­
et should be approxi­
f re t period of 60
req uency to maintain
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~ aneccen tric training
warm-up followed
etic mode. Training
second increments
'ith tvvo to three sets
.g speed. The sugges­
as was previously
ed in an open isoki­
of functional activ-
Lan be adjusted to
:'e in the form of leg­
al knee extension or
'hment for use with
d kinclie activities
we in the rehabiUta­
leUC evaluation and
tic tTainer. isokinetic
fun ctional ability in
er needs to evaluate
. jng and use isokinet­
the rehabilitation
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~ session before isoki­
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: 5. Grecnbergcr. H.B .. and M. V. Paterno. 1995. Relationship of
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Ire commonly used to
_ le ting. but the ath ­
CHAPTER 1 3 Isokinelics in Rehabilitation
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9. The athletic trainer needs to evaluate the shape of the 10. The force-velocity curve shou'id be the basis for design­
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22. Kues. J. M.. J. M. Rothstein, and R. L. Lamb. 1992. Obtain­
ing reliable measurements of knee extensor torque
produGed during maximal voluntary contractions: An
experimental investigation. PhYSical Therapy 72(7):
492-504.
23. Lephart. S. M.. D. H. Perrin. F. H. Pu. J. C. Gieck. P. C. J.!cCLIe.
and J. J. lTrgang. 1992. Relationship between selected physi­
cal characteristics and functional capacity in the anterior
cruciate ligament-insufficient athlete. JOllrnal oj Ortlzopaedic
and Sports Physical Therapy 16: 1 74-81.
24. Leveau. B. 1992. Willimlls and Lister's biomechanics of hlllllan
1II01itlll. 3d cd. Philadelphia: vv. B. Saunders.
25. Malerba, J. L., M. L. Adam. B. A. Harris. and D. E. Krebs.
1991. Reliability of dynamic and ·i sometric testing 0[' shoul­
der internal and external rotators. JOllrnal oj OrlllOpa<,dic and
Sports Physical Therap!l18(4 ): 543- 52.
26. Mathews. P.. and D. M. St-Pierre. 1996. Recovery of muscle
strength following arthroscopic meniscectomy. Journal of Or­
thopaediC alld Sports Plzysical Therapy 23(1): 18-26.
27. McCarrick. M. J.. and J. G. Kemp. 2000. The effect of strength
training and reduced training on rotator cuff musculature.
Clinical Biomechanics 15(51): 42-45.
28. Ostenberg. A.. E. Roos. C. Ekdahl. and H. Roos. 1998. [soki­
netic kne.e ext.ensor strength and functional performance in
healt: ,y fema'ie soccer players. Scandinaviall Jotlrnal oj NIcdi­
cine wId Scicllce in Sports 8(5-1): 257-64.
274 Pl'drl'THREE The 'fools of' RehabililCltion

29. Parcell . A. C.. R. D. Sawyer. V. A. Triooli. and T. D. Chinevere. 38. Wennerberg. D. 1991. Reliability or an isokinctic dorsiJlexion arm muscul ature
2002. Minimum rest period fo r strength recol'cry during a and plantarflexj on apparatus . American JOllrnal of Sports Med­ Joumal of Sports .\
common isokin eti c testing protocol. Medicille and SciCllce ill icille 19(5): 519- 22 . \lont. M. 1\. . D. 13. Cot
Sports alld Exmise 34(6): 1018-22. 39. Whitcom b. L. J.. M. J. Kelley. and C. 1. Leiper. J 995. A com­ MathUI. 1994. I
30. Perrin. 0 .. R. Robertson . and R. L<1y. 198 7. Bilatera l isokilletic parison or torque produ cti on during dynami c strength test­ ing or shou IdeI' n
peak torque. torque acceleration energy. power. and work re­ ing or shoulder abduction in the coronal pl a ne and the plane formance enh ant
lationships in athletes and non-athletes. JOl/r/lal of 01'­ or the scapUla. Journal of Orthopaedic and Sports Physical Ther­ Journal of Sport s:'
tllOpacdicalld Sports Pirysical 1'Irerap!I 9(5): 184-H9. apy 21 (4): 227- 32. Porter. M. M.. A. A.
31. Perrin. D. H. 1993. Isokillciic eX'crcise and assesslllellL, Cham­ 40. Wilk . K. E.. and J. R. Andrews. 199 3. The effects of pad place­ method of measu
paign. IL: Hum an Kinel'ics. ment and angular velocity on libinl displclcement during iso­ flexion peak torqL
32 . Poulmcdis. p.. G. Ro ndoyannis. A. 'vlitsou. ct <11.1988. The in­ ki.netic exercise. Joumal of Orthopaedic wnl Sports PhYSical cise 2H(4): 'il6 -~
flu ence of i's okinetic mu scle torque exerted in various speeds Therapy 'J 7(1): 24. Schwendncr. K. l.. A.
on soccer ball vdority. JOl/rnal of OrUlOlJaec/ic alld Sports Pil!Js­ 41. Wilk. K. E.. and C. A. Arrigo. 1993. Current concepts in the Burr. 1995. RerO'
ieal Till'l'llP!I J' O(3): 93-96. rehabilitali on or the athletic shoulder. Journal of Orthopaedic isakinetic rati gue
33. Rothstein . J.• L. Lamb. and T. May he\\'. 19H7. Clinical uses or lind Sport s PhYSical The rapy 18: 305. cine ]6( 3): 18 :;-'
isokinetic m easurements. Ph!lsical Therap!l 67(12): 42. Worrell, T.. D. Perrin. and C. Denegar. 1989. The inlluence or
l!l40-44. hip position on quadriceps a nd hamstring peak torque and
34 . Sirota. S. c.. G. A. Ma la nga. J. J. Eischen. and E. R. Laskowski. reciprocal muscle group ratio values. Jouma l uf Orthupaedic
SOLUTIONS T4
19~ 7. l\n eccentric and concentric strength proflle of shoul­ and Sports Physical Tllcmp!l11(3): 104-7.
der external and in tern,il rotator mLl scies in profcs~ional 43 . Worrell. T. W. D. H. Perrin. B. 1\11. Cansned er. and J. H. Gieck.
1 3-1 The isokinet
basebnll pitchers. American JOlirnal of Sports .VIcdicinc 25(1): 1991. Comparison or isokinetic slrength and Oex ibilily
'i~ - o 4. measures between hamstring injured and non-injured ath­
o degrees at
35. Smedley. B., G. Norra l. R. KeIscy. <lnd J. Max. 2()Ol. Concen­ 4 wccks to 9
letes. JOllrnal of Orthopllcdic and Sports Physical Therapy 13:
tr ic shoulder externa l to internal strengt h ratios for collegiate 118- 25 . thc athlete's f
at hletes and non-athletes. JOl/mal of i\tlliccic Tra ining 36(2 5) : 44. Worrell. T. W.. B. Borc hert. K. Erner. J. Fritz. and P. Leerar. ducc Impingl
52 . 1993. EITect or a lateral slep-up exercise protocol on quadri­ en compass a
36. Trudcllc-Jackson. E.. N. Meske. C. Highgenbotcn . et al. Eccen­ ceps and lower extremity performance. JOl/l'Ilal of Orthopaedic unit rccruiUl
tric/concen tric torque dencils in the quadriceps muscle. Jour­ and Sports Physical Therapy 1 H(6): 646-53 . pain . bccaUSl
nal of OrLiwpaedic and Sports Pllysiml Therapy 11 (4): 142 . 45. Wyatt. M" and A. Edwards. 1981 . Comparisons or qu adri ­ 3-2 Due to th e al
37. Valovich. ·[ C.. J. M. Drouin. S. J. Shultz. 0.11. Perrin. and 13. M. ceps nnd ham-string torque valu es during isokinc tic exercisc. be restric lel:
Gansnedcr. 200 1. Reliability of the 13iodcx System J Pro iso­ Journal of OrtilOparw c IIml Sports l'hysim] TiJerap!/ 3(2):
should be w
kinetic dynamomeLer vclocily. torqu e, and position measure­ 48 - 56.
pad placeme
me nts. JOlimal of ilthletic Training 36(2 '5): .1 03.
shear str ess .
quadri ceps, t
ited bccause
Suggested Readings danger is les:
Brown. L. E.. M. VVhitehurst. R. Gilbert. a nd D. N. Buchalter. Iossil'idou . A. N.. and V. Baltzopoulos. 2000. Inertial efrects on 13-3 You shou ld fi
1995. The errect of velOCity and gender o n load range during momenl deve lopment during isokinetic concentr ic knee ex­ a rcsult of a I
knee extension and Ocxion exercise on an isokinetic exercise tension testing. Juuma) of Orthopedic and Sports Ph!JsicaIThrr­ wcakn ess. j[
on a n isokinetic dev ice. JOl/rn1l1 of Ortlwpacdic and Sports apy 30(0) : 3 17- 23. strcngtheni
Physical Tllerclp!/21 (2): 107-12 . Kan g. S. W.. J. H. Moon. and S. L Chun. 199 5. Exercise effect or injury, put It
Ellenbecker. T. S.. 1995 . Rehabilitation or sho ulder and elbow in­ modified co ntralateral stabilization bar darin g one-legged the hamslriJ
juries. Clinics in Sports ,VIedicine 14(1): H7- 107. isokin etic exercise. Archives of PI,!/sical .\'le£iicille alld Rellllliili­
relalionsh ipj
Ellenbecker. T. S. a nd 1\. J. Mattalino. 1997. Concentric isokinetic (olion 70(2): 1 77-H2. without p UI
shoulder internal and exle'rnal rot alion stre ngth in prores­ KauFfmnn. K. R.. K. N. An . and E. Y. Chao. 19 9~. A comparison of
lially. the p ~
sional baseball pitchers. JOlil'llal of OrtllOpedfc ami Sports Ph!lS­ intersegmental joint dYllamics to isokinetic dynamumeter
slow-velocit j
i((ll Therap!l2S(5): 323 - 2H. measurements. JOllrna l 0) BicmlC'cllIlllics 28( I 0): 124 3-56.
structures.
Crii'l1n . J. W.. R. E. looms. R. vanderZwa ag. T. E. Bert orini. and Keating. J. L.. and 1'. A. Matyas. 1996 . The in fluen ce or su bjcCl
'vI. IL. O·Toole. 1991. Eccentric muscle perrorman ce or elbow and test design on dynamometrjc measurement, or extre m­ progrcss hi ~
Dnd kn ee muscle groups in untrained men and women . .'11ed­ ily muscles. Physical Therapy 76( R): 86 6. hip ncar 0 d
icille and Science in Sports lind Iixercise 25(8): 936-44 Kellis. E.. and V. Baltzopoulos. 199H . Mu scle acth'ation dme r­ sentilti.vC oq
He.idcrschcit. B. C.. K. P. McLciln. and G. J. Davies. 19%. The er­ ences between ecccntric and concentric isokinetic exercise. ]oeity over tl
rects or isokinetic venus plyometric training on lhe shoulder Medicine Gnd Science in Sports lind exercise 30( 11): 1616-23.
internal rotators. Joul'Ilal of Orthopaedic and Sports Physical Mikesky. A. E.. J. E. Edwards. J. K. Wigglesworth. and S. Kunk.,!.
TIlC'rap!J 23(2): 125-33. 1995. Eccentric and concentric strength of th e sho ulder and

!5Okinetic dorsil1cxion
~Jo[/ n)(ll of
Sports Med­
u iper. 199'i. A com­
~Da mic strength test­
a! plane and the plane
ports Ph!lsical Ther­
e effects of pad place­
;placement during iso­
all d Sports Physical
urrent concepts in tJ1e
1'lI f11n l of OrtiJoparilic
'9 9. The influenco of
-ring peak torque and
II rnal of OrtilOpardh
er. and j. H. Gicck.
rength and fle:dbillty
nd non-injured ath­
Physical Therapy 13:
FrilZ. and P. Leerar.
protocol on quadri­
luum al of Orthopaedic
0--- :; 3.
pa.risons o[ quadri­
~ I!, 1 okinetic exercise
11 Im1 Therapy 3(2 ):
. Inertial effec ts on
llC concentric knce ex­
Sports Pll!Isical Th er­
99 5. Exercise effect of
r during one-legged
\Iedici nc (/wl Rehabili­
'99 S. t\ comparison of
-inetic dynamometer
1 (J 0): 1243-5 6.
~ in.i1uence of subject
structures. As the structure continues to heal.
. UIements of ext rem­
progress hip positioning to near supine to put the
"Il,
(Iscle activation differ­
!ric iso kinelic exercise.
l.ise 30(11): 1616- 2 .
"l"Orth. and S. Kun kel
gth of the shoulder and
arm musculature in collegiate baseball pitchers. American
Journal of Sports ~-1edicille 23(5): 63S--42.
Mont. i\L A.. D. B. Cohen. K. R. Campbell. K. Gravara, and S. K.
Mathur. 1994. Isokinetic concentric versus eccentric train­
ing of shoulder rotators with functional evaluation of per­
formance enhancement in elite tennis players. American
Journal of Sports :vIeilicil1e 22( 4): 5 13- 17.
Porter, M. M.. A. A. Vandervoort. and J. F. Kramer. 1996. A
method of measuring standing isol:i.inetic plantar and dorsi­
flexion peak torques. Medicine and Sciellce ill Sports and Exer­
cise 2S(4): 516-22.
chwcndner. K. r., A. E. Mikesky, j. K. Wigglesworth, and D. B.
Burr. 1995. Recovery of dynamic muscle [unction following
isokinetic fatigue tcsting. International Journal of Sports lVIedi­
cine 16(3): lSS - tl9.
SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES
1 3-1 The isoK-inetic training program should start at
o degrees abduction and progress over the next
4 weeks to 90 degrees abduction, once strength of
the athlete's external rotators starts to improve to re­
duce impingement symptoms. The progr am should
encompass a velocity spectrum for maximal motor
unit recruitment. The exercises should not cause
pain, because this could result in pain inhibition.
1 3-2 Due to the athlete's healing ACL graft. ROM should
be restricted dur,i ng the testing session. ROM
should be within 90 to 45 degrees with proximal
pad placement to limit. anterior tibial translation
shear stress. Higher-speed concentric-concentric
quadriceps/hamstring exercises should also be lim­
ited because of the same shear stress, although this
dallger is lessened by restricting ROM.
1 3~ 3 You should first determine whether the weakness is
a result of a muscle strain injmy or just generalized
weakness, in order to choose the best position for
strengthening. If the weakness is caused by a strain
injury, put the athlete in a seated position. This puts
the hamstring muscles in a better length-tension
relationship, ,Jlltowing optimal force production
without pulling stress on healing structures. Ini­
lially. the program should emphasize submaximal
slow-velocity strengthening to protect healing
ferent factors, including ROM, strength, proprio­
ception, satisfactory functional progression, and
hip near 0 degrees extension, which is more repre­
sentative or function. Also continue to increase ve­
locity over the spectrum as tolerated by the athlete.
CHAPTER 13 Isokinetics in Rehabilitation 2 75
Weir, J. P.. S. A. Evans, and M. L. Housh. 1996. The effect of ex­
traneous movements OIl peak torque and constant joint an­
gle torque-velocity curves. Journal of Orthopaedic and Sports
Physical Thaapy2 3(5): 302-S.
Wilk, K. E.. J. R. Andrews. C. A. Arrigo. tv!. A. Keirns. and D. J. Er­
ber. 1993. The strength characteristics of internal and ex te r­
nal rotator muscles in professional baseball pitchers.
American Journal of Sports ,vIedicjne 21 (1): 11- 66
Wilk, K. E.. W. 1'. Romaniello, S. M. Soscia. C. A. Arrigo. and j. R.
Andrews. 1994. The relationship between subjective knee
scores, isokinctic testing, and functional tesling in the AI-­
reconstructed knee. JOl/mal of Orthopaedic ami Sports Physical
Therapy 20(2): 60-73.
1 3-4 The primary source of variation relates to quadri­
ceps inhibition secondary to pain and/or swelling.
This can account for sigl1il1cant variations in
torque production from week to week and is not in­
dicative of true strength changes in the muscle. Do
not perform isokinetic tesling if the athlete has in­
volved muscle or if the joint is effused or painful.
13-5 The athletic trainer should try to capture the best
overall representation of muscular strength by
evaluating various torque variables, Average
torque is a better criterion than peak torque, which
may be subject to artifact during testing either be­
cause of torque overshoot in older dynamometers
or substitution by other muscle groups. The Lest
should encompass different velocities to evaluate
for differences throughout a velOCity spectrum.
Power and endurance variables can also be as­
sessed to better develop individualized rehabilita­
tion programs.
13-6 'I'he r esults of isokinelic testing should not be used
to determine when the athlete is ready to return to
play. Use isokinetic testing to guide your judgments
related to the a t hlete's overall strength and in mod­
ifying the rehabilitation program based on the re­
sults. Return to play should be determined by the
physician and athletic trainer based 011 many dif­
the athlete's mental readiness to return to his sport.
fsokinelic testing, in isolation, should not be usee!
to deterrnine his readiness.
 CHAPTER 14 jOint. or to reduce
prove joint funeti Oi
(IVO extremely eff1.'4
[he rehabilitation 0

Joint Mobilization and Traction THE RELAT

Techniques in Rehabilitation PHYSIOLO(
ACCESSOR'
William E. Prentice
fo r the athletic In
ram. some under
movement is esser
movement that gm
better known of lh l
~ '~/ogicill movements I
centric ac tive m u
join t. This type of
• Differentiate indications and con­

Study Resources motion. A bone CaJ

To become more familiar with the knowledge and skills traindications for mobilization.
joint into flexion. el
necessary to design. impl eme nt. and document therapeu­ ration. The second
tic rehahilil,ltion programs a~ identified in the NA TA Ath­
• Distinguish the use of various traction cessory motion
letic Traillillg L{hwltiollal COlllpelelJcies and Clinical grades in treating pain and joint articulating join! 51
Projlt:ielJdes'Thcrapeutic Exercise content area. visit hypomobility. ological movemen
www.mhhe.com/prentice) I e. Also refer to the lab exer­ normally accompa
cises in (he new Laborato ry Manual and to eSims. which • Explain why traction and mobiliza­ c ur simultaneOl
simulates (he athletic training certification exam. at tion techniques should be used annot Occur indl
www.mhhc.mmiesims. For mQre online study resources. some external fan
simultaneously.
visit our Health and Human Performance website at dons must occur fd
www.mhhe.comlh hp. • Demonstrate specific techniques of take place. If any ~
restricted. normal
mobilization and traction for various me nts will not a ce
After Completion of This

joints. bUitated if the joinl

Chapter, the Student Should

Traditionall\' 1
Be Able to Do the Following:

tended to concen l~
• Differentiate between physiological ments without pal

F
ollowing injury to. a joint, there will almost a. lways be
some associa ted loss of motion. That loss of move­ lions. The quesli
movements and accessory motions. lex-ion or exteo si
.. ment may be attributed to a number of pathological
factors. including contracture of inert connective tissue anyone ask. "Ho\\
• Analyze the concept of joint

(for example. ligaments and joint capsule); resistance of It is critical 1'0

arthrokinematics.
the injured joint t
the contractile tissue or the muscuIotendinous unit (for ex­
ample. muscle. tendon. and fascia) to stretch; or some physiological mo\'
• Explain how specific joint positions can
combination of the twO. 6 . 7 If left untreated. the joint will tendinous units o~
enhance the effectiveness of the treat­ become hypomobile and will eventually begin to sholV \'olving the j,oint Cl
ment technique. signs of degeneration. 2l movement is res~
Joint mobilization and traction are manual therapy stretching activi V
• Demonstrate the basic techniques of techniques that iDvolve slow. passive movements of artic­ Stretching exerci.
joint mobilization. ulating surfaces. 2n They arc used to regain normal active istance of the co ~
joint range of motion , to restore normal passi~le motions to stretch. Stretchl
• Identify Maitland' s five oscillation
that occur about a joint, to repOSition or realign a joint. to end of physiologie
grades.
regain a normal distribution of forces and stresses about a to one direction. l

276
 CHAPTER 14 Joint Mobilization and Traction Techniques in Rehabilitation
joint. or to reduce pain, all of which will collectively im­
prove joint function. 2o Joint mobilization and traction are
tlVO extremely effeclive and widely utilized techniques in
the rehabilitation of sport-related injuries.
~n
THE RELATIONSHIP B'ETWEEN
PHYSIOLOGICAL AND
ACCESSORY MOTIONS
For the athletic trainer supervising a rehabilitation pro­
gram, some understanding of the biomechanics of joint
movement is essenlial. There are basically two types of
movement that govern motion about a joint. Perhaps the
better known of the tlVO types of movement are the physi­
ological movements that result from either concentric or ec­
centric active muscle contractions that move a bone or a
joint. This type of motion is referred to as osteokinemntic
dcon­ motion. A bone can move about an axis or rotation or a
lion. joint into f1exion. extension, abduction, adduction, and ro­
tation. The second type of motion is accessory motion. Ac­
ous traction cesso ry motions involve the manner in which one
d joint articulating joint surface moves relative to another. Physi­
ologicHI movement is voluntary: accessory movements
normally accompany physiological movement. 2 The two
mobiliza­ occur simultaneously. Although accessory movements
~ used ' an not occur independently. they can be produced by
some external lorce. Normal accessory component mo­
tions must occur for full-range physioJogical movement to
aiqlles of take place. If any of the accessory component motions are
restricted. normal physioiogica'i cardinal plane move­
fo r various ments will not occur. l i . iS A muscle cannot be fully reha­
bilitated if the joint is not free to move, and vice versa.2J
Traditionally in rehabilitation programs we have
tended to concentrate more on passive physiological move­
'U i:llmo~t always be men ts without paying much attention to accessory mo­
Th at loss of move­ lions. The question is always being asked, "How much
ther of pathological nexion or extension is this patient lacking?" Rarely will
rt connective tissue anyone ask, "How much is rolling or gliding res tricted?"
)slIle); resistance of H is critical for the athletic trainer to closely evaluate
ndin ous unit (for ex­ the injured joint to determine whether motion is l imited by
to tretch : or some physi ological movement constraints involving musculo­
·ealed . the joint will te ndinous units or by limitation in accessory motion in­
aJly begin to sholl" 'olving the jOint capsule and ligamentsY If physiological
movemen t is restricted, the athlete should engage ,in
IC'emanual therapy stretching activities designed to improve f1exibility.
n vements of artic­ tretching exercises should be used whenever there is re­
egain normHI aClive sistance of the contractile or musculotendinous elements
n al passive motion to stretch, Stretching techniq ues are most effective at the
or realign a joint. t end of physiological range of movement; they are limited
an d stresses about a [Q one direction. and they require some element of dis­
277
comfort if additional range of motion is to be achieved.
Stretching techniques make use of long lever arms to ap­
ply stretch to a given muscle. l ] Techniques of stretching
have been discussed in Chapter 6. and PNF stretching
techniq ues will be presented.tIl Chapter 15 .
If accessory motion is limited by some restriction of the
joint capsule or the ligaments, the athletic trainer should
incorporate mobilization techniques into the treatment
program. Mobilization techniques should be used when­
ever there are tight inert or noncontractile articular struc­
tures; they can be used effectively at any point in the range
of motion , and they can be used in any direction in which
movement is restricted. Mobilization techniques use a
short lever arm to stretch lligaments and joint capsules,
p'l acing less stress on these structures, and consequent,ly
are somewhat safer to use than stretching techniques. 4
CLINICAL DECISION MAKING Exercise 14-1
Following a grade 2 sprain of the lateral collateral liga­
ment. a high jumper is having trouble regaining full knee
extension. Describe a rehabilitation protocol that can
help her regain full ROM.
JOINT ARTHROKINEMATICS
Accessory motions are also referred to as joint
arthrokinematics, which include spin. roll. and glidc l l l.14
(Figure 14-1A-C).
Spin occurs around some stationary longitudinal me­
chanical axis and can be in either a clockl-vise or a coun­
terclockwise direction . An example of spinning is motion
01 the radial head at the humeroradial joint as occurs in
forearm pronation/supination (Figure 14-1A).
Rolling occurs when a series of points on one articu­
lating surface comes into contact with a series of points on
another articu1lating surface. An analogy would be the
rocker of a rocking chair rolling on the fiat surface of the
f1oor. An anatomical example would be the rounded
femoral condyles rolling over H stationary nat tibial
plateau (Figure 14-1B).
Gliding occurs when a speCific point on one articulat­
ing surface comes into contact with a series of points on
another surface. Returning to the rocking chair analogy,
the rocker slides across the f1at surface of the !loor without
any rocking at all. Gliding is sometimes referred to as trans­
latioll. Anatomically, gliding or translation would occur
dur ing an anterior drawer test at the knee when the fiat
278 PART THREE The Tools of Rehabilitation

Spin
¢ Glide ::>

A B c 51

Figure 14-1 Joint arthrokinematics. A. Spin . B. Roll, C, Glide

tibial plateau slides anteriorly relative to toe Oxed rounded

CLINICAL DECISION MAKING Exercise 14-2
femoral condyles (Figure 14-1C).
Pure gliding can occur only if the two articulating sur­
A gymnast has ankle instability. As a resull of severa l
faces are congruent where either both are llat or both are biJe joint using eit
sprains. she has a buildup of scar tissue lhalls lImiling
curved . Virtually all articulating joint surfaces are incon­ ua lly performed in
plantar flexion . The decreased ROM and instability are af­
gruent, meaning that one is usually flat while the other is ,he appropriate res.
fecting her performance because most of her activity re­
more curved, so it is more likely that gliding will occur si­ ints.
quires balance and a great deal of joint mobility. What
multaneously with a rolling motion . Rolling does not oc­ Placing the join
can you do to help her situation?
cur alone, because this would result in compression or ows the join t to (ill
perhaps dislocation of the joint. ..be articulatLngj oi,
Although rolling and gliding usually occur together, Figure 14-31\). 1\ I
they are not necessarily in similar proportion, nor are they This relationship between the shape of articulating here ,is maximal d
always in the same direction. If the articulating surfaces joint surfaces and the direction of gliding is defined by the r bones with the
arc more congruent. more gliding will occur. whereas if convex-conmve nile (Pigure 14-2). If the concave joint sur­ Fi gure 14- 3B) . In j
they are less congruent. more rolling will occur. Rolling face is moving on a stationary convex surface. gliding will ex h ibit th e greatesl
will always occur in the same direction as the movement. occur in the same direction as the rolling motion. Con­ lose-packed posi ti
For example. in the knee joint when the foot is fixed on the versely, if the convex surface is moving on a stationary e-packed posi ti.
ground . the femur will always roll in an anterior direction concave surface. gliding will occur in an opposite direction io n and traction.
when moving into knee extension and conversely will roll to rolling. Hypomobile joints are treated by llsing a gliding Both mobilizatio
posteriorly when moving into flexion . technique.Thus it is critical to know the appropriate direc­ alional movement
The direction of the gliding component of motion is de­ tion to use for gliding. lher. This transt all!
termined by the shape of the articulating surface that is .her perpendicular
moving. If you consider the shape of two articulating sur­ The treatment pla n~
faces. one joint surface can be determined to be convex in
JOINT POSITIONS to. a line runn i
shape while the other may be considered to be concave in Each joint in the body has a position in which the joint cap­ x surface to lh l
shape. In the knee. the femoral condyles would be consid­ sule and the ligaments are most relaxed. allowing for a urrace 1 l . H (Figur
ered the convex joint surface. while the tibial plateau maximum amount of joint play.l l. H This position is ,itrnn the conca\'e i
would be the concave joint surface. In the glenohumeral called the resting position. It is essen[ialto know specifi­ e treatment plane
joint, the humeral head would be the convex surface. while cally where the resting positi on is. because testing for joint ,lan e will move alq
the glenoid fossa would be the concave surface. play during an evaluation, and treatment of the hYPol1lo­ zation techniques ~
 CHAPTER 14 JOint Mobilization and Traction Techniques in Rehabilitation
A
Tibia
stationary
Figure 14-2 Convex-concave rule. A, Convex moving on concave. B, Concave moving on
Exercise 14-2 convex.
bile joint using either mobili:tation or traction. are both
usually performed in this position . Table 14-1 summarizes
lhe appropriate resting positions for many of (he major
- ints.
Placing the jOint capsule in the resting position al­
lows the joint to assume a loose-packed position in which
lhe articulating joint surfaces arc maximally separated
Figure 14-3/l). A close-packed position is one in w'hich
ape or articulating here is maximal contact of the articulating surfaces
n a is defmed by the r bones with the capsule and ligaments tight or tense
concave joint sur­ Figure 14-3B).ln a loose-packed position the joint will
-urface. gliding wiJl xhibit the greatest amount of jOint play. whereas the
lli n g motion . Con­ :lose-packed position allows for no joint play. Thus the
ng on a stationary oose-paeked position is most appropriate for mobiiliza­
to opposite directio n ion and traction.
~ by u sing a gliding Both mobilization and traction techniques use a trans­
e appropriate direc- ational movemen t of one joint surface relative to the
lher. This translation can be in one of two directions: ei­
her perpendicular or parallel to the trea tment plane.
Th treatment plane falls perpendicular to. or at a right an­
_ e to. a line running from the axis of rotation in the con-
wh ich the joint cap­ ex surface to the center of the concave articular
ued. allowing for a mrfacelJ.J.l (Figure 14-4) . Thus the trcatment plane lies
~ This posiUon i :ithin the concave surface. If the convex segment moves.
'lti a l to know speclfi­ .he treatment plane remains Cixed. However. the treatment
a use testing for joint I ne will move along with the concave segment. Mobi­
Dent of the hypomo­ ...zation techniques use glides that translate one artlculat­
279
B
iog surface along a line parallel with the treatment plane.
Traction techniques translate one of the articulating sur­
faces in a perpendicular direction to the treatment plane.
Bot!h techniques use a loose-packed joint position. 13
JOINT MOBILlZA1"ION
TECHNIQUES
The techniques of joint mobilization are used to improve
joint mobility or to decrease jOint pain by restoring acces­
sory movements to the jOint and thus allowing rull. nonre­
stricted, pain-rree range of motion. 19 .27
Mobilization techniques may be used to attain a vari­
ety of either mechanical or neurophYSiological treatment
goals: reducing pain; decreasing muscle guarding; stretch­
ing or lengthening tissue surrounding a joint. in particu­
lar capsular and ligamentous tissue: reflexogenic effects
that either inhibit or facilitate muscle tone or stretch re­
flex; and proprioceptive effects to improve postural and
kinesthetic awareness .l.l0.1R.2J.23
Movement throughout a range of motion can be quan­
tified with various measurement techniques. Physio'logi­
cal movemen t is measured with a goniometer and
composes the major portion of the range. Accessory mo­
tion is thought of in millimeters. although precise mea­
surement is dimcult.
280 P'I\RTTHREE The Tools of Rehabilitation

• TABLE 14·1 Shape, Resting Position, and Treatment Planes of Various Joints
A
Convex Concave
Joint Surface Surface Resting Position Treatment Plane

Sternoclavicular Clavicle" Sternum' Anatomical position [n sternum

Acromioclavicular Clavicle Acromion Anatomical position, in In acromion /
horizontal plane at 60 degrees '.
to sagittal plane
Glenohumeral Humerus Glenoid Shoulder abducted 55 degrees, In glenoid fossa in
horizontally adducted 30 de­ scapular plane Fil!
grees, rotated so forearm is in Pll(
horizontal plane
Humeroradial Humerus Radius Elbow extended, forearm In radial head
supinated perpendicular to
long axis of radius
Humeroulnar Humerus Ulna Elbow flexed 70 degrees, fore­ In olecranon fossa,
arm supinated 10 degrees 45 degrees to long
axis of ulna
Radioulnar Radius Ulna Elbow flexed 70 degrees, fore­ In radial notch of
(Proximal) arm supinated 35 degrees ulna, parallel to long
axis of ulna
Radioulnar (Distal) Ulna Radius Supinated 10 degrees In radius, parallel to
long axis of radius
Radiocarpal Proximal carpal Radius Line through radius and third In radius, perpendi­
bones Proximal metacarpal cular to long axis of
phalanx radius
Metacarpophalangeal Metacarpal Distal phalanx Slight flexion In proximal phalanx
Interphalangeal Proximal phalanx Acetabulum S'lightflexion In proximal phalanx
Hip Femur Hip flexed 30 degrees, abducted In acetab ull:lm
30 degrees, slight external
rotation
Tibiofemoral Femur Tibia Flexed 25 degrees On surface of tibia,l
plateau
PatcIlofemoral Patella Femur Knee in full extension Along femoraI
groove
Talocrural Talus Mortise Plantarflexed 10 degrees In the mortise in
an terior/posterior
direction
Accessory 1110
Subtalar Calcaneus Talus Subtalar neutral between inver­ In talus, paraUel to
hyper mobile. S Eao
sion/eversion foot surface
u um with an an ~
Intertarsal Proximal Distal Foot relaxed In distal segment
termined by both i
articulating articulating
issue. In a hypoQ
surface surface
"cI'erred to as a pa
Metatarsophalangeal Tarsal bone Proximal Slight extension In proximal phalanx
of the anatomica l
phalanx
istance. A hypen
Interphalangeal Proximal Disl.al phalanx Slight flexiol1 In distal phalanx
limit because of i
phalanx
hypomobile joint
bilization and tri
• [n the sternoclavicular joint the clavicle surface is convex in a superior/inferior direction and concave in an anterior/posterior treated with sir
direction.
<i ncl, if indicated.
 CHAPTER 14 Joint Mobilization and Traction Techniques in Rehabilitation 281

ilts

rreatment Plane
A

! "" , \
\
\
\
I

~
I
ternum I
I
,, I

,, / I

glenoid fossa in ,
r apular plane Figure 14-3 Joint capsule resting position. A, Loose-packed position. B, Close­
packed position.

~ radial head Glide

r p ndicular to
n g axis of radius
n olecranon fossa.

o radius. paraHel to

'.~,
OIlg axis of radius dl
C
In radius. perpentli­ o Traction
a.
::ular to long axis of i:
dl
"adius E
In proximal phalanx '0dl
In proximal phalanx ..=
[n acetabulum

Do udacc of tibial
----------J
ateau
\long femoral Figure 14-4 The treatment plane is perpendicular to a line drawn
groove from the axis of rotation to the center of the articulating surface of the
n lhc mortise in concave segment.
am rior / posterior
liirc .tion
Accessory movements can be hypomobile. normal. or In a hypomobile joint, as mobilization techniques are
In w lus. parallel to
:typermobile. i Each joint has a range of motion contin­ used into the range of motion restriction. some deforma­
t surface
lum with an anatomical limit (AL) to motion that is de­ tion of soft tissue capsular or ligamentous structures oc­
n distal segment
:ermined by both bony arrangement and surrounding soft curs. If a tissue is stretched only into its elastic range, no
:issue. In a hypomobUc joint, motion stops at some point permanen t structural changes will occur. However, if that
~eferred to as a pathological point of limitation (PL), short tissue is stretched into its plastic range, permanent struc­
Q proximal phalanx
of the anatomical limit caused by pain, spasm, or tissue re­ tural changes will occur. Thus, mobilization and traction
, istance. A hypermobile joint moves beyond its anatomical can be used to stretch tissue and break adhesions. If used
In distal phalanx
li mit because of laxity of the surrounding structures. A inappropriately, they can also damage tissue and cause
ypomobile joint should respond well to techniques of mo­ sprains of the joint. 23
iLization and traction .s A hypermobile jOint should be Treatment techniques designed to improve accessory
tt'rior / posterior reated with strengthening exercises , stability exercises, movement are generally slow, small-amplitude move­
and, if indicated , taping. splinting, or bracing.12.11 ments, amplitude being the distance that the joint is moved
282 PART THREE The Tools of Rehabilitation

.. Grade III
·1
Grade IV at 1
Grade I
.. Grade II limit of range
~. ~I"
Grade V
~

BP

(Beginning

PL
(Point of
limitation)
AL
(Anatomic
A
--
Statio.

point in
limit)
range of motion)

Figure 14-5 Maitland's five grades of motion. PL = point of limitation; AL = anatomical limit.
Figure 14
opposite lC
passively within its tot al range. 9 Mobilization techniques Grade Ill. A large-amplitude movement up to the PL restriction
use these small-amplitude oscillating motions that glide or in the range of movement. Used when pain and
slide one of the articulating joint surfaces in an appropri­ resistance from spasm. inert tissue tension. or tis­
ate direction with in a specific parl of the range. 16 sue compression limit movement near the end of mobilized . gliding of I
the range. the same direction as
Grade Iv. A small-amplitude movement at the very end (Figure J 4-hB). For
CliNICAL DECISION MAKING Exercise 14-3 of the range of movement. Used when resistance would be considered II
limits movement in ~he absence of pain and spasm. humeral head movi nl
Following shoulder surgery a swimmer is hming trouble Grade V. A small-amplitude. quick thrust delivered at der abduction is restn
regaining full ROM. His slroke \\ill be affected if he can­ the end of the range of movement. usually accom­ in an inferior directi(}
not regain full eXlension and lateral rotation. What type panied by a popping sound. which is called a ma­ the motion restrictior
of joint mobilization protocol could you implement to nipulation. Used when minimal resistance Ii.mits the concave tibia sh
help him? the end of the range. Manipulation ,is most effec­ where knee extensior
tively accomplished by the velocity of the thrust appropriat e directi on
rather than by the force of the thruSt. 24 Most au­ stiffness. the athletic
Maitland has described various grades of oscillation thorities agree that manipulation should be used in the opposite dirt'{
for joint mobilization (Figure 14-5). The amplitude of only by individuals trained specifically in these the appropriate dire _
each oscillation grade falls within the range-of-motion techniques. because a great deal of skill and judg­ Typical mobiLi zat
continuum between some beginning point (BP) and the ment is necessary for safe and effective treatment. 2S of three to six sets 01
AL. li . I S Figure 14-5 shows the various grades of oscilla­ 60 seconds each.
tion that are used in a jOint with some limitation of mo­ -.;ccond.li.l ll
CLINICAL DECISION MAKING Exercise 14-4
tion . As the severity of the movement restriction
increases. the PL will move to the left. away from the AL.
How might a chiropractor apply the concepts of joint
However. the relationships that exist among the five CLINICAL DEClSI
mobilIzation?
grades in terms of their positions within the range of mo­
ti on remain the same. The five mobilization grades are de­ Following an an I>.
fined as follows : I'cnting full plant;
JOint mobilization uses these oscillating gliding mo­
used to help regal
Grade I. A small-amplitude movement at the begin­ tions of one articulating joint surface in whatever direc­
ning of the range of movement. Used when pain tion is appropriate for the ex isting restriction. The ....................................

and spasm limit movement early in the range of
motion. 29
Grade II. A large-ampHtude movement \\rjthin the
midrange of movement. Used when spasm limits
movement sooner with a quick oscillation than
with a slow one or when slowly increasing pain
restricts movement halfway into the range.
appropriate direction for these oscillating glides is deter­
mined by the convex-concave rule described previously. Indications f(]
When the concave surface is statiol1Cl'r y and the convex
surface is mobilized, a glide of the convex segmen t In \-1aitland's systel
should be in the direction opposite to the restriction of treatment of pain. i
joiot movement.ll .14.2R(Figure] 4-6A). rr the convex ar­ ing stiffness. Pain
ticular surface is stationary and the concave surface is (l nd. ls Painful CO (
 CHAPTER 14 JOint Mobilization and Traction Techniques in Rehabilitation 283

B
A
AL
(Anatomic
limit)

Hgure 14-6 Gliding motions. A, Glides of the convex segment should be in the direction
opposite to the restriction. B, Glides of the concave segment should be in the direction of the
rment up to the PL restriction.
led when p&in and
ue tension, or Lis­
nt near the end of
mobilized. gliding of the concave segment should be in basis. The purpose or the small-amplitude oscillations is to
the same direcLion as the restriction of joint movement stimulate mechanoreceptors within the joint that can

e nl at the very end

Il'igure 14-6B). For example. the glenohumeral jOint limit the transmission of pain perception at the spinal cord
when resislance
would be considered to be a convex joint with the convex or brain stem levels.
or pain and spasm.

humeral head moving on the concave glenoid. If shoul­ Joints that are stiff or hypomobile and have rcstricted
.hrus t delivered at

der abduction is restricted . the humerus should be glided movement should be treated 3 to 4 times per week on al­
fnt. usually accom­

in an inferior direction relative lo the glenoid to alleviate ternating days with active motion exercise. The athletic
I h is called a ma­
the motion reslriction. ) \I\'hen mobilizing the knee joint, trainer mllst continuously reevaluale the joint to deler­
d resistance limits
(he concave libia should be glided anteriorly in cases mine appropriate progression from one oscillation grade to
mon is most cffec­
where knee extension is restricted. If mobilization in the another.
-ry of the thrusl
appropriate direction exacerbates complaints of pain or Indications lor specific mobiJization grades are rela­
thr uSt."4 Most au-
Liffness, the athletic trainer should apply the technique tively straighlforward. If the alhlele complains of pain be­
n should be used
in the opposiLe direction unLii the patient can tolerate fore the athletic trainer can apply any resislance to
cifically in these
he appropriale direclion. 28 movement, it is too early and all mobilization techniques
aJ or skill and judg­
Typical mobilization of a joint might involve a series should be avoided. If pain is elicited when resistance to mo­
dTective treatment. 2'
of three to six sets of oscillations lasting belween 20 and tion is applied, mobilization using grades I and Il is appro­
60 seconds each. with one to three oscillations per priate. If resistancc can be applied before pain is elicited.
Exercise 14-4 second. J 7.18 mobilization can be progressed to grades III and IV. Mobi­
lization should be done wilh both the athlete and the alh­
cepts of join ( letic trainer positioned in a comfortable and relaxed
CLINICAL DECISION MAKING Exercise 14- 5 manner. The athletic trainer should l1Iobilize one joint at a
tlme. The joint should be stabilized as ncar one articulating
FollOWing an ankle sprain. accumulated scar tissue is pre­ surface as possible. whi.le moving the other segmcnt wilh a
'il!ali ng gliding mo­ venting full plantar nexion. How can joint mobilization be firm, confident g.rasp.
e in whalever diree­ used to help regain full ROM?
l~ restriction. The
dHn g glidcs is deter­ Contraindications for Mobilization
e c ribed previously. Techniques of mobilization and manipulalion should not
lac y and the convex
I.ndications for Mobilization
be used haphazardly. These techniques should generally
Ie convex segment In Maitland's system. grades I and II are used primarily for not be used in cases of inOammatory arthritis, malignancy,
to the restriction of trcalment of pain, and grades III and IV are used for treat­ bone disease. neurological involvement. bone fracture,
-l). If the convex ar­ ing stiffness. Pain musl be lreated first and stiffness sec­ congenital bone derormities. and vascular disorders of the
~ con cave surface is ond. J S Painful condit,ions should be treated on a daily vertebral artery. Again, manipulation should be performed
284 PART THREE ThcTooJs of Rehabilitation

the articulating SLI

Grade'
.... packed position. A~
tions within th
maximally impron:

~
Grade" ... Grade "'
-. . CLINICAL DEClSI

A physician has dI
BP
PL AL
(Beginning
(Point of (Anatomical hockey player witt
point in range
limitation) limit) and impinging on
of motion)
help relieve pain

Figure 14·7 KaJtenborn's grades of traction. PL = point of limitation; ......................................­

AL = anatomical limit.

I
I

~ I ~I~""
X
""
\ I ~ Traction
~--
1 ~
X \
II
I" I
l "d I); ~ ,~ I) I /: I.,~:.=.:.:~
Stationary-~ ~ ~ Stationary~ i
I

Figure 14·8 Traction vs. glides. Traction should be perpendicular to the treatment
plane. while glides are parallel to the treatment plane.
only by those athletic trainers specifically trained in the
procedure. because some special knowledge and judgment
are required for effective treatment. 2 ~
JOINT TRACTION TECHNIQUES
Traction is a technique involVing pulling on one articulat·
ing segment to produce some separation of the two joint
surfaces. Although mobilization glides are done parallel to
the treatment plane. traction is performed perpendicular
to the treatment plane (see Figure 14·4). Like mobilization
techniques, traction can be used either to decrease pain or
to reduce joint hypomobilityJ O
Kaltenborn has proposed a system using traction com·
bined with mobilization as a means of redUCing pain or mo­
bilizing hypomobile jointsY As discussed earlier. all joints
have a certain amount of joint play or looseness.
Kaltcnborn referred to this looseness as slack. Some degree
of slack is necessary for normal joint motion. Kaltenborn's
three traction grades are defined as follows ll (Figure 14-7):
Grade I traction (loosen). Traction that neutralizes
pressure in the joint without actual separation of
figure 14·9 Tra
ogether.
the joint surfaces. The purpose is to produce pain
relief by reducing the compressive forces of artic·
ular surfaces during mobilization and is used with
all mobilization grades.
Grade II traction (tighten or "take up the slack"). Trac­
tion that effectively separates the articulating sur­
faces and takes up the slack or eliminates play in
the joint capsule. Grade II is used in initial treat­
ment to determine joint sensitivity.
Grade 1lI traction (stretch). Traction that involves ac­
tual stretching of the soft tissue surrounding the
joint to increase mobility in a hypomobi'le joint.
Grade I traction should be used in the initiallreatment to
reduce the chance 01'a painful reaction. It is recommended
that 10-second inLermiUent grades I aod II traction be
used. distracting the joint surfaces up to a grade III trac­
tion and then releasing distraction untillhe joint returns
to its resting position.
Figure 14·11 1
Kaltenborn emphasizes that grade III traction should
ular glides at the 5
be used in conjunction with mobilization glides to treat
gers to mobilize l.b
joint hypomobilityll (Figure 14-8). Grade III traction
ele vation .
stretches the joint capsule and increases the space between
 CHAPTER 14 Joint Mobilization and Traction Tcchniquc~ in Rehabilitation 285

the articulating surfaces, placing the joint in a loose­
packed position. Applying grade 1lI and grade IV oscilla­
tions within the athlete's pain limitations should
maximally improve joint mobility (Figure 14-9).
CLINICAL DECISION MAKING Exercise 14-6
A physician has diagno ed disc pathology in a field
hockey player with low back pain. The disc is protruding
and impinging on the spLoal cord. How could traction
help relieve pain for this athlete?
MOBILIZATION AND TRACTION
TECHNIQUES
Throughout Chapters 18 to 25. photographs are used to
show appropriate joint mobilization and traction tech­
niques for each joint. These figures should be used to de­
termine appropriate hand positioning. stabillzation (S) and
the correct direction for gliding (G), tTaction (T). and/ or ro­
tation (R). The information presented in this chapter
should be used as a reference base for appropriately incor­
porating joint mobilization and traction techniques into
the rehabilitation program (Figures 14-10 to 14-73).

Figure 14-9 Traction and mobilization should be used Figure 14-10 Posterior and superior claVicular glides.
together. v\Then posterior or superior clavicular glides are done at
· to produce pain the sternoclavicular joint. use the thumbs to glide the
in e forces of artic­ clavicle. Posterior glides are used to increase clavicular re­
n and is used with traction, and superior glides increase c1m!icular retrac­
tion and clavicular depression.
me slack"). Trac­
tle rticulating sur­
eliminates play in
ed in initial treat­
\ ilY.
that involves ac­
e urrounding the
I} lX)mobile joint.

ini tiClltrealment to
I. H is recommended
an d II traction be
1.0 Cl grade III tmc­
ltil the joint returns

~ill traction should Figure 14-11 Inferior clavicular glides . In:Ferior clavie­ Figure 14-12 Posterior c1avicu lar glides. Posterior
ILlar glides at the sternoclavicular joint use the index fin­ clavicular glides done at the acromioclavicular (AC) joint
Hion glides to treat
gers to mobilize the clavicle, whieh increases clavicular apply posterior pressure on the clavicle while stabilizing
Grade [If traction
elevation. the scapula with the opposite hand. They increase mobil­
the space between ity of the AC joint.
286 PART THREE The Tools of Rehabilitation

Figure 14-13 Anterior/posterior glenohumeral glides. Figure 14-14 Posterior humeral glides. Posterior f igure 14-17
Anterior/posterior glenohumeral glides are done with humeral glides use one hand to stabilize the humerus at h umeral glides th
one hand stabilizing the scapula. and the other gliding the elbow and tbe other to glide the humeral head. They Lh e elbow resting ~
the humeral head. They initiate motion in the painful increase nexion and medial rotation. lizes the scapula . a
shoulder. in feriorly. T hese gli

Hgure 14-15 Anterior humeral glides. In anterior
humeral glides the patient is prone. One hand stabilizes
the humerus at the elbow. and the other glides the
humeral bead. They increase extension and laieral
rotation.
Figure 14-16 Posierior humeral glides. Posterior figure 14-19
humeral glides may also be done with the shoulder at 90 \Iedial and lateral
degrees. With the patient in supine position . o ne hand abducted at 90 dCI!
stabilizes the scapula underneath wh ile the patient's el­ rotation in a prog!'i
bow is secured at the athletic traiDer's should er. Glides lOlerance.
are directed downward througb tbe humerus. They in­
crease horizontal adduction.
 CHAPTER 14 Joint Mobilization and Traction Techniques in Rehabilitation 287

:Ie . Poslerior Figure 14-17 Inferior humeral glides. For inferior
:e the humerus at humeral glides the patient is in the sitting position with
meral head. They the elbow resting on the treatment table. One hand stabi­
lizes the scapula. and the other glides the humeral head
inferiorly. These glides increase shouJder abduction.
Figure 14-18 Lateral glenohumeral joint traction. Lat­
eral glenohumeral joint traction is used for initial testing
of joint mobility and for decreasing pain. One hand stabi­
Hzes the elbow while the other applies lateral traction at
the upper humerus.

de . Posterior Figure 14-19 ",ledial and lateral rotation oscillations. Figure 14-20 General scapular glides. General scapu­
the s houlder at 9() \Iedial and latera l rotation oscillations with the shoulder lar gl'ides may be done in all directions. applying pressure
lion . one hand abducted at 90 degrees can increase medial and lateral at either the medial. inferior. lateral. or superior border of
. th e patient's el­ rota tion in a progressive manner according to patienL the scapula. Scapular glides increase general scapulotho­
_h uLtier. elides tolerance. rucic mobility.
merus. They in­
288 PART THREE The Tools of Rehabilitation
figure 14-21 Inferior humeroulnar glides. Inferior
humeroulnar glides increase elbow flexion and extension.
They arc performed using the body weight to stabilize
proximally with the hand grasping the ulna and gliding
inferiorly.
Figure 14-23 Proximal anterior/posterior radial
glides. Proximal anterior/posterior radial glides use the
thumbs and index fingers to glide the radial head. Ante­
rior glides increase flexion. while posterior glides increase
e.xtension.
Figure 14-22 Humeroradial inferior glides. Humerora­
dial inferior glides increase the joint space and improve extension. Valgus
flexion and extension . On e hand stabilizes the humerus lever arm.
above the elbow; the other grasps the distal forearm and
glides the radius inferiorly.
Figure 14-27 R
carpal joint p()sl e~
Figure 14-24 Dista.l anterior/ posterior radial glides.
Distal anterior/ posterior radial glides are done with one
hand stabilizing the ulna and tbe other gliding tbe radius.
These glides increase pronation.
Figure 14-29
carpal joLnt radii:
 CHAPTER 14 Joint Mobilization and Traction Techniques in Rehabilitation 289

Figure 14-26 Rad iocarpa l joint a nteri or glides. Radio­

Figure 14-25 Meuia 1and lateral ulnar oscillations. carpal joint anterior glides increase wrist extension.
," kuial and lateral ulnar oscillations increase fl ex ion and
extension. Valgus and varus forces are used with a short
lever arm.

Figure 14-27 Radiocarpal joint posterior glides. Rauio­ Figure 14-28 Radiocarpal joint ulnar glides. Radio­
carpal joint posterior gliues increase wrist flexion . carpal jOint ulnar gliues increase radial deviation.

r radial glides.

e done with one

r gliding the radiu s.

Figure 14-29 Radiocarpal joint radial glides. Radio­ Figure 14-30 Carpometacarpal joint anterior/ poste­
carpal joint rauial glides increase ulnar deviation . rior glides. Carpometacarpal joint anterior/ posterior
glides increase mobility or the hand.
290 PART THREE The Tools of Rehabilitation

Figure 14-31 "leLacarpophalangeal joint

anterior/ posterior glides. In metacarpophalangeal joint
anterior or posterior gJides. the proximal segment, in this
case the metacarpal. is stabilized and the distal segment is
mobilized. Anterior glides increase fl exion of the MP Figure 14-32 Cervical vertebrae rotation oscillations. Figure 14- 35
joint. Posterior glides increase extension. Cervical vertebrae rotation oscillations are done with one racie vertebra l fac et
hand supporting the weight of the head and the other ro­ hand underneath Lh
tating the head in the direction of the restriction. These the weight of th e b~
oscillations treat pain or stiffness when there is some re­ rib cage to rotate an
sistance in the same direction as the rotation. lion of the thorac ic
movement with t hi
joint.

Figure 14-33 Cervical vertebrae side bending. Cervical

vertebrae sidebending may be used to treat paint or stin~ Figure 14-34 Unilateral cervical facet anterior/ poste­
ness with resistance when sidebel1ding the neck rior glides. Unilateral cervical facet anterior/ posterior Figure 14-37 Lu
glides are done using pressure from the thumbs over indi­ era l distra ction iner
vidual facets. They increase rotation or flexion of the process and increa
neck toward the side where the technique is llsed. foramen. This posi
flexing th e athlete'
gapping in the ap pr
the upper trunk to I
position . Then I1ngl
separate individual
ducing paIn in th e I
comp ression of n SI
 CII/\PTER 14 )oinl.\o!obilization und Tracti on Techniques in Rehabilitation 291

Figure 14-36 Anterior/posterior lumbar vertebral

glidcs. In the lumba r region. a nterior/posterior lumbar
Figure 14-35 Thoracic vertebra l facet rotations. Tho­
vertebral glides may be acco mplished at individual scg­
arc done lVith one racic verlebral facct rolations arc accompli shed wilh one
men ts using prcssurc on the spinous proccss through thc
an d the other ro­ hand un derneat h the palien! providing stabilization an d
pisiform in the h'lIld. These decrease pain or increase mo­
Triction . T h ese ,he weight of the body pressing downward throu gh the
bility of individual lumbar vertebrae.
rib cagc to rotatc an individual thora cic vcrtebrac. Rota ­
Lio n . iion of the thoracic vertebrae ,is minimal. and most of th e
movemcnt with this mobilization in volvcs th e rib fa cet
joint.

Figure 14-37 Lumbar lat eral distrac ti on. Lumbar lat­ Figure 14-38 Lumbar ve r tebral rotations. LUl1lbur
eral dislraction increases the space betwee n tr ansverse vertebral rot ations decrc<1sc pain and incrcasc mobility in
proccss and in crcases the opcning of th e intcrvertc bra l lumbar verlebrae. These rotations should be don e in a
fI ramen . This position is ac hieved by ly ing over a support, sideJying position.
lcx ing the athle tc's upper knee to a po in t where there is
a pping in the appropriate spinal segment. then ro tclting
he upper trunk to place the seg menl in a close-packed
sition. Then fmger and forear m pressure are used to
..e parclte individual spaces. This pressure is u sed for re­
ducing pain in t he lumber verte brae associated with some
ompression of a spinal segment.
292 PART THREE The Tools of Reh abilitation

Figure 14-43 An
rior innominate rou
Figure 14-39 Lateral lumber rotations. Lateral lumbar Figure 14-40 Anterior sacral glides. Anterior sacral
le nding tbe hip. a pp
rotations may be done with the patient in supine position. glides decrease pain and redu ce muscle guarding around
lh igh. and stabiLizin
In this position, one hand must stabilize the upper trunk, the sacroiliac joint.
This technique is on
wbiJe the other produces rotation.
u nilateral innom im

Hgure 14-41 Superior/ inferior sacral glides. Supe­
rior/inferior sacral glides decrease pain and reduce mus­
de guarding around the sacroiliac joint..
Hgure 14-42 Anterior innominate rotation. An ante­ Figure 14-45
rior innominate rotation in a sidelying position is accom­ posterior innomi
plished by extending the leg on the affected side then degrees stabilizes
stabilizing with one hand on the front of the thigh while a nteriorly throu gh
the other applies pressure ant eriorly over the posterosu­
perior i'liac spine to' produce an anterior rotation, This
techn ique will correct a unilateral posterior rotation.
 CHAPTEl{ l4
figure 14-43 Anterior innominate rotation. An ante­
rior innominate rotation may also be accomplished by ex­
\ nterior sacral lending the hip. app~ying upward force on the upper
gua rding around thigh . and stabilizing over the posterosuper ior iliac spine.
This technique is once again used to correct a posterior
u nilateral innominate rotation.
Figure 14-45 Posterior innominate rotation. Another
posilion is accom­ ;xJsterior innominate rotation with the hip fl exed at 90
side then degrees stabilizes th e kn ee and rotates the innominate
of the thigh while n teriorly through upward pressure on the ischium.
er Lhc postcrosu­
r rotation. This
Joint Mobilization and Traction Techniques in Rehabilitation 293
Figure 14-44 Posterior innominate rotation . A poste­
rior innominate rotation with th e patient in sidelying
position is don e by llexing the hip. stabiliZing the antero­
superior iliac spine. and applying pressure to the ischium
in an anterior direction.
Figure 14-46 Posterior innominate rotation self­
mobilization (supin e). Posterior innomina te rotation may
be easily accomplished using self-mobilization. In a
supine position the patient grasps behind th e flex ed knee
and gently roc ks the innominate in a posterior direction .
294 PART THREE The Tools of Rehabilitation
Figure 14-47 Posterior rotalion self-mobilization
(standing). Tn a standing position the patient can perform
a posterior rotation self-mobilization by pulling on the
knee and rocking forward.
Figure 14-49 Femoral traction. femoral traction with
the hip at 0 degrees reduces pain and increases hip mobil­
ity. Tnferior femoral glides in this position should be used
to increase Oexion and abduction.
Figure 14-48 Lateral hip traction. Since the hip is a Figure 14-5
very strong. stable joint. it may be necessary to use body lient supine. i
weighL to produce effective joint mobilization or traction. biltzing un deJ
An example of this would be in lateral hip traction. One applied thro
strap should be used to secw"e the patient to the treat­ glides are u
ment table. A second strap is secured around the patient's
thigh and around the therapist's hips. Lateral traction is
applied to the femur by leaning back away from the pa­
tient. This technique is used to reduce pain and increase
hip mobility.
.igure l.,l-:
emoral rot
II and are
hile inler
Figure 14-50 Inferior femoral glides. fnferior femoral
glides at 90 degrees of hlp Oexion may also be used to in­
crease abduction and l1exion.
 CHAPTER 14 Joint Mobilization and Traction Techniques in Rehabilitation 295

Figure 14-51 Posterior femoral glides. With the pa­ Figure 14-52 Anterior femoral glides. Anterior
tient supioe. a posterior femoral glide can be done by sta­ femoral glides iocrease extension and are accomplished
ion or traction. bilizing uoderneath the pelvis and using the body weight by using some support to stabilize under the pelvis and
traction. One applied through the femur to glide posteriorly. Posterior applying an anterior glide posteriorly on the femur.
to the treat­ glides are used to increase hip flexion ,
rou nd the .patient·~
Laleraltraction is
~'ay from the pa­
pain and tncrease

figure 14-53 Medial femoral rotations. Medial Figure 14-54 Lateral femoral rotation . Lateral femoral
fe moral rotations may be used for increasing medial rota­ rotation is done by stabiliZing a bent knee in the figure 4
tion and are done by stabilizing the opposite innominate position and applying rotational force to the isc hium.
': :hile internally rotating the hip through the flexed knee. This technique increases lateral femoral rotation .

c .Inferior femoral
aI 'o be used to io­
296 PARTTIlREE The Tools of Rehabilitation

Figure 14-55 Anterior tibial glides. Anterior tibial
glides are appropriate for the patient lacking full exten­
sion. Anterior glides should be done in prone position
with the felllur stabilized. Pressure is applied to the poste­
rior tibia to glide anteriorly.
Figure 14-59
Figure 14-56 Posterior femoral glides. Posterior
joint traction rcd
femoral glides are appropriate for the patient lacking full
clone with the pa
extension. Posterior femoral glides should be done in
grees. The elbol\
supine position with the tibia stabilized. Pressure is ap­
is applied throug
plied to the anterior femur to glide posteriorly.

Figure 14-57 Posterior tibial glides. Posterior tibial Figure 14-58 Patellar glides. Superior patellar glides Figure 14-61
glides increase flexion. With the patient in supine posi­ increase knee extension. Inferior glides increase knee the I1bula. Ante
tion, stabilize the femur. and glide the tibia posteriorly. flexion. Medial glides stretch the lateral retinaculum. Lat­ be clone proxima
eral glides stretch tight medial structures. head and rcdu c~
With the knee sL
an d glide it ante
 CHAPTER 14 Joint Mobilization and Traction Techniques in Rehtlbililation
Figure 14-59 Tibiofemoral jOin t tracLlon. Tibiolemoral
· Posterior jOint traction reduces pain and hypomobilily. It may be
'ent lacking full
done with the patient prone and the knee nexed at 90 de­
d be done in grees. The elbow should stabilize the thigh while traction
Pressure is Clp­
is applied through the tibia.
a rty.
Figure 14-61 Proximal anterior and poslerior glides of
the fibula . Anterior aod posterior glides of the fibula may
be done proximally. They increase mobility of the fibular
head and reduce pain. The femur should be sWbilized.
Wit h the knee slightly nexed. gmsp the head of the femur.
and glide it a nteriorly and posterio rly.
297
figure 14-60 Alternative techniques for tibiofemOl-al
jOint traction. In very large indiv id uals an alternative
tec hnique for tibiofemoral joint truction lISes body weight
of the athletic trainer to distract the joint once again for
reducing pain and hypomobility.
figure 14-62 Distal anterior and posterior !1hular
glides . Anterior and posterior glides of the fibulu may be
done distally. The tibia should be stabilized. and the fibu­
'Iar malleolus is mobilized in an anterior or posterior
direction.
298 PART TllREE The Tools of Rl!habilitulion

Figure 14-64 Ta locrural joint traction. Talocrura l figure 14-67

Figure 14-63 Posterior tibial glides. Posterior tiblal u
jOint traction is performed using the patient's body action reduces pai
glides increase pla ntar11exion. T he foot should be stabi­
weight to stabilize the lower leg and applying traction to
lized. and pressure on lhe anterior tibi a produces a poste­ The lower leg is stab
the midtarsal porti on of the foo l. Traction reduces pai n pplied by grasping
rior glide.
and in creases dorsiflexion and pla ntarflcxion .

Figure 14-69 A
Figure 14-65 Anterior ta lor glides. Pl a ntarrtexion may Figure 14-66 Posterior ta lor glides. Posterior ta la r gl ides. Anterior/pq
also be increased by using a n anterior talar glide. \Vith gl ides may be used for increasing dorsiflexion. \Vith the
used for in creasi n ~
the patient prone the tibia is stabilized on the table. an d patient supin e the tibia is stabilized on the table. and pres­
neus should be stal
pressure is applied to th e posterior aspect of the talus to sure is applied to the anterior aspect of the talus to glide it
glide it a nteriorly. posteriorly.
 CHAPTER 1. 4 Joint Mobilizution und Traction Techniques in Rehabilitation 299

n. 'l'alocrural Figure 14-67 Subtalor joint traction . Subtalar joint Figure 14~ 68 Subtalor joint medial and lateral glides.
ient's body
traction reduces pain and increases inversion and eversion. Subtalar joint medial and laLeral glides increase eversion
lying tracLion to The lower leg is stabilized on the table. and traction is and inversion. The tcdus must be stabilized while the cal­
on reduces pain
applied by grasping the posterior aspect of the calcaneus. caneus is mobilized medially to increase Inversion and
laterally to Increase eversion.

Figure 14-69 Anterior/ posterior ca lcaneocuboid Figure 14-70 Anterior/ posterior cuboid metatarsal
~ P teriol' talar glides. Anterior/ posterior calcaneocuboid glides may be glides. Anterior/ posterior cuboidmetatarsal glides are
e.·d on. With the
u cd for increasing adduction and abduction. The calca­ done with one hand stabiliZing the cuboid and the other
th e table. and pres­
neus should be stabilized while the cuboid is mobilized. gliding the base of the I1fth metatarsal. They are Llsed for
the talus to glide it
increasing mobility of the nrth metatarsal.
300 PART THREE The Tools or Rehabilitation

6. The convex-cq
joint surface is
face, gliding \~
rolling motion j
ing on a stati o~
in an opposite
7. The resting pol
and the !igan~
maximum amc
8. The treatment
ning rrom the ~
the center of th

Figure 14-71 Anterior /posterior carpometacarpal Figure 14-72 Anterior/ posterior talonavicular glides. References
glides. f\nterior/ posterior carpometacarpal glides de­ Anterior/ posterior talonavicular glides also increase ad­
crease hypomobility of the metacarpals. duction and abduction. One hand stabilizes the talus 1.
while the other mobilizes the navicular bone.

2. Basmajian. J.. an
ill rehaiJilitation:
Livingstone.
3. Conroy, D. E.. an:
bilization as a ~
primary shaul
thopaedic mId Spq
4. Cookson, J. 197
II. The spine. Jo
lion 59 :259.
5. Cookson. J.. and
An overview: 1.1
icaJ Therapy As:
6. Cyriilx. J. 1996· 1
icine. London: B
7. Donatelli. R.. i
Figure 14-73 Anterior/ posterior metacarpopha­ mobilization on
langeal glides. With anterior/posterior metacarpopha­
langeal glides. the anterior glides increase extension. and 8.
po~terior glides increase Oexion. Mobilizations are accom­
plished by isolating individual segments. 9.
randomized co ,
lizilti on on aeu!
Sl( 4): 984-94.
lO . Grimsb),. O. ]9
Summary
\vo"~book. Vags~
Jl . /;-lOUIS. M. 1989.
12 . Hsu. A. Too L. Hj
1. Mobilization and traction techniques increase joint 3. Accessory motions are movements of one articulating 2002. Characl
mobility or decrease pain by restoring accessory move­ joint surrace relative to another. directed lmnsll
ments to the joint. 4. Norma l accessory compon ent motions must occur for joint. Archives
360-66.
2. Physiologica l movements result from an active muscle full-range physiological movement to take place.
13. Kaltenborn , F.. (
contraction that moves an extremity through tradi­ 5. Accessory motions are also referred to as joint
mobilization 1,( :
tional cardinal planes. arthrokinematics, which include spin , roil, and glide.
 CHAPTER 14 Joint Mobilization and Traction Techniq ues in Rehabilitation
6. The convex-concave r u le states that if the concave
joint surface is moving on the stationary convex sur­
face, gliding will occur in the same direction as the
r olling motion, and that if the convex surface is mov­
ing on a stationary concave surface, gliding will occur
in an opposite directio n to rolling.
7. The resting position is one in which the joint capsule
and the ligaments are most relaxed, allowing for a
maximum amount of joint play.
S. The treatment plane falls perpendicular to a line run­
ning from the axis of rotation in the convex surface to
the center of the concave articular surface.
o n avicular glides. References
, a lso increase au­
ilizes the lalus 1. Barak, T.. E. Rosen. and R. Sofer. 1990. Mobility: Passive or­
- bo ne. thopedic manual therapy. In Orthopedic and sports physical
therapy. edited by J. Gould and G. Davies. St. Louis: Mosby.
2. Basmajian, J.. and S. Ban erjee. 1996. Clinical decision making
in rehabilitation: E[!lcaey and outcomes. Philadelphia: ChurchiU­
Livingstone.
3. Conroy. D. E.. and K. W. Hayes. 1998. The effect of jOint mo­
bilization as a oomponent of comprehensive treatment for
primary shoulder impingement syndrome. Joumal of Or­
thopaedic and Sports Physical Therapy 28(1): 3-14.
4. Cookson. J. 1979. Orthopedic manual therapy: An overview:
II. The spine. Journal of the American Physical Therapy Associa­
tion 59:259.
5. Cookson. J.. and B. Kent. 1979. Orthopedic manual therapy:
An overview: I. The extremities. Journal of the American Phys­
ical Therapy Association 59:13fi.
6. Cyriax, J. 1996. Cyriax's illustrated manual of orthopaedic med­
icirze. London: Butterworth-Heinemann Medical.
7. Donatelli. R.. and H. Owens-Burkhart. 1981. Effects of im­
mobilization OIl the extensj bility of periarticular connective
tissue. Journal of Orthopaedic and Sports Physical Therapy 3:67.
8. Edmond. S. 1993. Manipulation and mobilizatiol1: Extremity
and spinal techniques. St. Louis: Mosby.
9. Green. T.. K. Refshauge. J. Crosbie. and R. Adams. 2001. A
randomized controlled trial of a passive accessory joint mobi­
Hzation on acute ank'l e inversion sprains. Physical Therapy
81(4): 984-94.
10. Grimsby. O. 1981. Fundamentals of manual therapy: A course
lVorkbook. Vagsbygd. Norway: Sorlandets Fysikalske Institutt.
11. HoUis, M. 1989. Practical exercise. Oxford: Blackwell Scientific.
12. Hsu. A. T.. L. Ho. ]. H. Chang. G. L. Chang. and T. Hedman.
lor one articulating 2002. Characterization of tissue resistance during a dorsally
directed translational mobilization of the glenohumeral
,don s must occur rur jOint. Archives of Physical Medicine and RehabilitaUon 83(3):
360-66.
I LO take place.
L 3. Ka1tenborn. P.. O. Evjenth, and B. Kaltenborn. 1999. Manual
:"ferred to as joint mobilization of the joints: The Kaltenborn method of joint exami­
pin, roll, and glide.
301
9. Maitland has proposed a series of fIVe graded move­
ments or o scil\a ~ ions in the range 0[' motion to treat
pain and smrness.
] 0. Kaltenborn llses three grades of traction to reduce
pain and stiffness.
11. Kaltenborn emphasizes thai traction should be used
in conjunction with mobilb,ation glides to treat joint
hypomobility.
nation and treatment: The extremities. Minneapolis: Orthopaedic
Physical Therapy Products.
14. Kisner. C., and 1. Colby. 1997. Therapeutic exercise: FOllluia­
tions and techniques. Philadelphia: F. i\. Davis.
15. MacConaill. M., and J. Basmajian. 1969. lvluscles and
movements: A basis{or kinesiolollY. Baltimore: Williams & Wilkins.
16. Maigne. R. 1976. Orthopedic l1ledicine. Springfield, 11: Charles
C.Thomas.
17. Maitland. G. 1991. Extremity IIulI/jpululion London: Butterworth.
18. Maitland. G. 2000. \lertebrail1l(!lIipulation. 'London: Butterworth.
19. Menncll. J. 1991. The musculoskeletal system: Dijfcrcl1tial diag­
nosis (rolll symptoms al1d physical silins. New York: Aspen.
20. Nygard. R. 199.3. Manipulation: Definition, types, applica­
tion. In Rational manual therapies. edited by]. Basmajia n and
R. Nyberg. Baltimore: Williams & Wilkins.
21. Paris. S. 1979. The spine: Course 110tebook. Atlanta: Institute
Press.
22. Paris. S. 1979. Mobilization of the spine. Physical Therapy
59:988.
23. Saunders. D. 1994. Evaluation. trcatl/Wllt (//ul prcvcntion of /IlUSetl­
10skeleLaI disorders. Bloomington, MN: Educational Opportunities.
24. Schiotz, E., andJ. Cyriax.1978. Manipulatioll past mzdprcsent.
London: Heinemann Medical Books.
25. Stoddard. A. 1980. Manllal of osteopathic practice. London:
Hulchinson Ross.
26. Stone.]. A. 1998. Joint mobilization. Athletic Thernpy Today
4(6): 59-60.
27. Taniqawa. M. 1972. Comparison of the hold-relax procedure
and passive mobilization on increasing muscle length. Physi­
cal Therapy )2(7): 725-3).
28. Wadsworth, C. 1988. Mal1ual exmnillatiol1 mzd treatmel1t of the
spine and extremities. Baltimore: William & Wilkins.
29. Zohn. D., and J. :"fennell. 1987. Musculoskeletal pain: Diagno­
sis and physical treatmcl1t. Boston: LilLIe. Brown.
30. Zusman, M. 198 S. Reappraisal of a proposed neurophysio­
logical mechanism for the relief or joint pain with pRssive
joint movements. Ph.'lsiotizcmpy Practice 1:61-70.
302 PART THREE The Tools of Rehabilitation

SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES

C ,H AI

14-1 Once the athlete has progressed through the acute 14-4 Most manipulations performed by a chiropractor
stage. exercises and active and passive stretching
can be accompanied by joint mobilizations. Mobi­
are grade V. They take the joint to the end range of
motion and then apply a quick. small-amplitude
PNI
lization of the knee joint involves gliding the con­
cave tibia anteriorly on the femur.
14-2 In addition to exercises and possibly friction mas­
thrust that forces the joint just beyond the point of
limitation. Grade V manipulations should be per­
formed only by those speciJ1cally trained in this
Md
sage. she would benefit from joint mobilization to
break down the scar tissue. If plantar flexion is lim­
technique. Laws and practice acts relative to the
use of manipulations vary conSiderably from state
in I
ited. the talus should be glided anteriorly to stretch to state. William E
the anterior capsule. To address her ankle instabil­ 14-5 Grade IV mobilization can be used. The talus
ity she can be provided with a brace. taping. and ex­ should be forced anteriorly until movement is re­
ercises to increase stability. Exercises should also stricted. Small-amplitude movements are then
target the muscles responsible for ankle inversion made at this end range causing structural changes
and eversion. in the scar tissue.
14-3 If the athlete is restricted in extension. and lateral 14-6 Traction applied to the spine increases space in be­
rotation due to tightness in the anterior capsule is tween the vertebrae. The increased space reduces
causing the restriction. then the humeral head the pressure and compressive forces on the disc.
StL
should be glided anteriorly on the glenoid to stretch
To become more fa
the restriction.
necessary to desigr
tic rehabilitation JlI
/die Training E dl/c~
l'roJlcicncirs'Then:
www.mhhe.coID D
cises in the new La
simulates the atbJ
ID\lw.mhhc. coID ei
visit our Ilealth an
www.mhhe.com .~

techniqu
• Identifv t
PNF re~ iI;
• Demonstri ,

ening and
 CHAPTE R 15
by a chiropractor
lO the end range of
•. small-amplitude
PNF and Other Soft-Tissue
leyond the point of
lOS should be per' M:olbillization Techniques
lly trained in this
lets relative to the
iderab'ly from state
in Rehabilitatli10n

William E. Prentice
~ used. The talus
iI m ovement is re­
ements are then
str uctural changes

:reases space in be­

ilSed space reduces
rces on the disc. Study Resources • Describe PNF patterns for the upper
To become more familiar wilh the knowledge and skills and lower extremity, for the upper and
necessary to design. implement. and document therapeu­
lower trunk. and for the neck.
tic rehabUi tation programs as identitled in the _;A]~1 Ath­
letic Tmining Edumtional Competencies and Clinical • Discuss the concept of muscle energy
Projlciel1cies' Therapeutic Exercise content area, visit
technique and explain how it is similar
www.mhhe.com/prenticelle. Also refer to the lab exer­
cises in the new Laboratory Manual and to eSims, which to PNF.
simulates the athletic training certification exam, at
www.mh he.com/esims. For more online study resources,
• Compare and contrast the soft tissue
visit our Health and Human Performance website at mobilization techniques including
www.mhh e.com/hhp. strain-counterstrain, positional re­
lease, active release technique, and
After Completion of This
massage therapy.
Chapter, the Student Should

Be Able to Do the Following:

• Explain the neurophysiological basis of
PNF techniques.
• Discuss the rationale for use of the
techniques.
• Identify the basic principles of using
PNF in rehabilitation.
• Demonstrate the various PNF strength­
ening and stretching techniques.
ollowing injury, soft tissue loses some of its ability to
F tolerate the demands of functional loading, A major
part of the management of soft-tissue dysfunction lies
in promoting soft-tissue adaptation to restore the tissue's
ability to cope with functional loading,21 Specil1c soft­
tissue mobilization involves specific, graded, and progressive
application of force using physiological. accessory, or com­
bined techniques either to promote collagen synthesis, ori­
entation. and bonding in the early stages of the healing
process or to promote changes in the viscoelastic response of
the tissue in the later stages of healing, Soft-tissue mobiliza­
tion should be applied in combination with rehabilitation
regimes to restore the kinetic control of the tissue, 21

303
304 PART THREE The Tools of Rehabilitation

A variety of manual therapy techniques used in injury
rehabilitation could be classified as soft-tissue mobilization .
Stretching techniques for musculotendinous structures. my­
ofas cia I release, and stretching for tight neural structures
were discussed in Chapter 6. This chapter will include dis­
cussions of proprioceptive neuromuscular facilitation (PNF),
muscle energy, and the strain-counterslrain , positional re­
lease, active release, and sports massage techniques.
PROPRIOCEPTIVE
NEUROMUSCULAR FACILITATION
Proprioceptive neuromuscular facilitation (PNF) is
an approach to therapeutic exercise based on the princi­
ples of functional human anatomy and neurophysiology. 7
ft uses proprioceptive, cutaneous, and auditory input to
produce functional improvement in motor output and can
be a vital element in the rehabilitation process of many
sport-related injuries. 22 These techniques have long been
recommended for increasing strength. flexibility, and
range of motion. 6.1 ;.20.22.2 7.13.44.4 i It is apparent that PNF
techniques are also useful for enhancing neuromuscular
control. 45 This discussion should guide the athletic trainer
using the principles and techniques of PNF as a compo­
nent of a rehabilitation program.
muscles would be aided by facilitation, and muscle spastic­ Stretching a gi\
ity would be decreased by inhibition. IS quency of impulse!'
S'herrington attributed the impulses transmitted from muscle spindle, \\'h
the peripheral stretch receptors via the afferent system as frequency of molOl
being the strongest innuence on the alpha motor neu­ muscle. thus reflex:.
rons. 40 Therefore the athletic trainer should be able to development of cf­
modify the input from the peripheral receptors and thus vates the Golgi tcnc
influence the excitability of' the alpha motor neurons. The carried back to tbe
discharge of motor neurons can be facilitated by periph­ hibitoty effect on
eral stimulation, which causes afferent impulses to make muscles and cause
contact with excitatory neurons and results in increased 'fwo neurophj'
muscle tone or strength of voluntary contraction. Motor
faciLitalion and inh
neurons can also be inhibited by peripheral stimulation, The first. autogen
which causes afferent impulses to make contact with in­ mediated by affercr
hibitory neurons, resulting in muscle relaxation al1d al­ on the alpha mol Ol
lowing for stretching of the muscle. 40 To indicate any lllg it to relax. Whe
technique in which input from peripheral receptors is used .;upplying that ml
to facilitate or inhibit, Pi\TF should be used . IS hibitory impulses fl
The principles and techniques of PNF described here tinued for a slight ly
are based primarily on the neurophysiological mecha­
nisms involving the stretch reflex. The stretch reflex in­
volves two types of receptors: (1) muscle spindles, which
are sensitive to a change in length, as well as the rate of
change in length of the muscle fiber; and (2) Golgi tendon
organs, which det ect changes in tension (Figure 1 5-1).

THE NEUROPHYSIOLOGICAL
Dorsol
BASIS OF PNF
The therapeutic techniques of PNF were first used in the
treatment of patients with paralysis and neuromuscular
disorders. Most of the principles underlying modern ther­
apeutic exercise techniques can be attributed to the work
of Sherrington,40 who first defined the concepts of facilita­
tion and inhibition.
An impulse traveling down the corticospinal tract or an Gomma efferent fiber
~causes reflex
afferent impulse traveling up from peripheral receptors in relaxation
the muscle causes an impulse volley. which results in the ,- - \ -Alpha motorneuron
discharge of a limited number of speCific motor neurons, as .1 causes .r eflex
well as the discharge of additional surrounding (anatomi­ contraction

cally close) motor neurons in the subl.iminal fringe area . An

impulse causing the recruitment and discharge of addi­
tional motor neurons within the subliminal fringe is said to
be facilitatory. Any stimulus that causes motor neurons to
drop out of the disc harge zone and away from the sublimi­
nal fringe is said to be inhibitory. 26 Facilitation results in in­
creased excitability, and inhibition results in decreased Figure 15-1 Diagrammatic representation of the
excitability of motor neurons.4 ~ Thus the fun ction of weak stretch reflex. 'figUi
 CHAPTER 15 PNF and Other Soft-Tissue \o!obilization Techniques in Rehabilitation 305

b d muscle spastic­ Stretching a given muscle causes an increase in the fre­ signals from the Golgi tendon organs eventually override

l transmitted from
. arferen t system as
quency of impulses transmilled to the spinall cord from the
muscle spindle, which in turn produces an increase in the
frequency of motor ner ve impulses returning to that same
the excitatory impulses and therefore cause relaxation. Be­
cause inhibitory motor neurons receive impulses from the
Golgi tendon organs while the muscle spindle creates an
alpha motor neu­ muscle, thus reflexively resisling Lhe stretch. However, the initial reflex excitation leading to contraction, the Golgi
h ould be abre to development of excessive tension within the muscle acti­ tendon organs apparently send inhibitory impuolses that
receptors and thus vates the Colgi tendon organs, whose sensory impulses are last for the duration of increased tension (resulting from
otor neurons. The carried back to the spinal cord . These impulses have an in­ either passive stretch or active contraction) and eventually
iUtated by periph­ hibitory effecl on the motor impulses returning to the dominate the weaker impulses from the muscle spindle.
l impulses to make muscles and cause that muscle to rclax,9 This inhibition seems to protectlhe muscle against injury
suits in increased Two neurophysiological phenomena help to explain from reflex contractions resulting from excessive stretch.
facilitalion and inhibition of the neuromuscular systems. The second mechanism. reciprocal inhibition. deals
The ftrst, autogenic inh.ibition. is defmed as inhibition with the relationships of the agonist and antagonist mus­
mediated by afferent fibers from a stretched muscle acting cles (Figure 15-2). The muscles that contract to produce
on the alpha motor neurons supplying that muscle. caus­ joint motion are referred to as agonists. and the resulting
To indicate any ing it to relax. 'vVhen a muscle is stretched, motor neurons movement is called an agonistic pattern. The muscles that
:ral receplors is used supplying that muscle receive both excitatory and in­ stretch to allow the agonist pattern to occur are referred to
.;edl .
hibitory impulses from the receptors. If the stretch ,is con­ as antagonists. Movement that occurs directly opposite to
P :F described here tinued for a slightly extended period of lime. the inhibitory the agonist pattern is called the antagonist pattern.
l} iological mecha­
tJe tretch reflex in-
Ie spindles, which Dorsal
we ll as Lhe raLe of
od 2) Corgi tendon
n (Figure 15-1).

"'IITla efferent fiber

ses reflex
otion
no motorneuron
ses reflex
action

m ation of the
Figure 15-2 Diagrammatic representation of reciprocal inhibition.
306 PART THREE The Tools of Rehabilitation

VVhen motor ncurons of the agonist muscle receive ex­ The brain recognizes only gross joint movement and 4 . Manual contact '
citatory impu Iscs from afferent nerves, the motor neurons not individual muscle acllon. Moreover, the strcngth of a for influenCing eli
that supply the antagonist muscles are inhibited by affer­ muscle contraction is directly proportional to the activated maximal respoill
ent impulses. l Thus contraction or extended stretch of the motor units. Therefore. to increase the strength of a mus­ affected by presS!
agonist muscle must elicit relaxation or inhibit the antag­ cle, the maximulll number of motor units must be stimu­ be firm and confi
onist. Likewise. a quick stretch of thc antagonist muscle lated to strengthen the remaining muscle f1bers. 2o.]4 This curily. The m{lUD
facilitates a contraction of the agonist. For facilitating or "irradiation," or overflow effect. can occur when the touches the atW{
inhibiting motion, PNF relics heavily on the actions of stronger muscle groups help the weakcr groups in com­ weH as the appro
these agonist and antagonist muscle groups, pleting a particular movement. This cooperation leads to relaxation. lS A II
/\ final point of clarification should bc made regarding the rehabilitation goal of return to optimal function. 3.14 by the hand O\'er
autogenic and reciprocal inhibition. The motor neurons of 'fhe following principles of PNF should be applied to reach tate a movement
the spinal cord always receive a combination of inhibitory that ultimate goal. 5, Proper mechanil
and excitatory impulses from the afferent nerves. Whether letic trainer are I
these motor neurons will be excited or inhibited depends sistance. The alb
00 the ratio of these incoming impulses, CLINICAL DECISION MAKING Exercise 15-1 pOSition that is il
Several different. approach es to therapeutic exercise in the diagonal r
based on the principles of facilitation and inhibition have A breaststroker Is having trouble regaining strength aJter be bent and clo.
becn proposed. £\l1Iong these are the Bobath method,~ recovering from a hamstring strain. Whal call the ath­ tion of resistan t~
Brunnstrom method, ' Rood method, I ; and the Knott and lelic trainer do to help her:' propriately thrOl
Voss method, H which they called proprioceptive neuro­ 6. The amount of I
muscular facilitation. L\lthough each of these Lechniques maximal res pan
is important and useful. the PNF approach of Knott and motion. The a p,
Voss probably makes the most explicit use of propriocep­ Basic Principles of PNF large extent on I
tive stimulation. 24 may also chan:
Margret Knott, in her te}..1 on PNF,24 emphasized the im­
range of moti or
portance of the priJ1Ciples rather than specific techniqucs
plied with te ch
Rationale for Use in a rehabilitation program. These principles are the basis of
tions to restriet
PNf that must be superimposed on any speciflc technique.
/\s a positive approach to injury rehabilitation. PNF is also be used in
The principles of PNF are based on sound neurophysiolog­
aimed at what the patient can do physically within the lim­ full range of me
ical and kinesiologi c principles and clinical expcrience,)~
itations of the injury. It is perhaps best used to decrease de­ 7. Rotational m ar c
Application of the follOWing prinCiples can help promote a
ficiencies in strength, llexibility, and neuromuscular the PNF patterlll
desired response in the patient being trea ted.
coordination in response to demands that are placed on possible witho u
the neuromuscular system. Tbc emphasis is on selective 1. The paticnt must be taught the p r--.'. f patterns regard­ 8. Normal timin g i
rceducation of individual motor elements through devel­ ing the sequential movements from starting position that occurs in ~
opment of neuromuscular control, jOint stability, and co­ to terminal posiUon. The athktic trainer has to keep coordinated m
ordinated mobility. Each movement is learned and then instructions brief and simple. It is sometimes helpful the pa tterns shu
reinforced through repetition in an appropriately demand­ for the athletic trainer to passively move the patient components shd
ing and intense rehabilitaUve program. J ~ through the desired movement pattern to demon­ halfway throug
The body tends to respond to the demands placed on it. strate precisely what is to be done. The patterns plish this, appr
The prinCiples of PNP attempt to provide a maximal re­ should be used along with the techniques to increase LLmed with rn a
sponse for increasing strength. llexibility. and coordina­ the effects of the treatment. be used with m ~
tton. These principles should be applied with consideration 2. When learn ing the patterns, the patient is often
ance from the a~
of their appropriateness in achieving a particular goal. helped by looking at th e moving limb. Thts visual
9, Timing for emp
That continued activity during a rehabilitation program is stimulus offers the patient feedback for directional
contractions. Tb
essential for maintaining or improving strength or flexibil­ and pOSitional control.
sistance. at sped
ity is well accepted . Therefore an intense program should 3. Verbal cues are used to coordinate voluntary effort terns of faciJjta tl
offer the greatest potential for recovery.) S with reflex responses. Commands should be ,fIrm and the weaker COITll
T11c PNF approach is holistic, integrating sensory. mo" simple. Commands most commonly used with PNF stronger compo!
tor, and psychological aspects of a rehabilitation program. It techniques are "Push " and "PulL" which ask for an weaker componi
incorporates reflex activities from the spinal levels and up­ isotonic contraction; "Hold ," which asks for an iso­ j O. Spccillc joints n'
ward. either inhibiting or facilita ting them as appropriate. metric or stabilizing contraction; and "Rela x." approximation.

tnt movement and
~r. the strength of a
n a l to the activated
• trength of a mus­
IJlits must be stimu-
Ie !lbers. 20 ·24 'l'his
p occur when the
ocr groups in com­
operation leads to
ptimal function. 3.14
. be applied to reach
Exercise 15-1
"Ig strength after
.It can the ath­
emphasized the im­
peciftc techniqu e
'iples are the basis or
_ pecirtc technique.
d neurophysiolog­
3
. inica l experience.
.:an help promote <1
aledo
:r patterns regard­
starting position
rain er has to keep
meLimes helpful
move the patient
lern to demon­
The patterns
I:)niq ues to increase
. - fo r directional
\~untary effort
ho uld: be !lrm and
00. Specific joints may be facilitated by using traction or
and "Relax."
CHAPTER 15 P and Other Soft-Tissue ,Vlobilization Techniques in Rehabilitation
4. ManLlal contact with appropriate pressure is essential
for influencing dlrection of motion and facilitating a
maximal response. because reflex responses are greatly
affected by pressure receptors . .\{anual contact should
be firm and con!ldcnt to give the patient a feeling of se­
curity. The manner in which the athletic trainer
touches the athlete influences athlete conlldence as
well as the appropriateness of the motor response or
relaxation. 1R A movement response may be facilitated
by the hand over the muscle being contracted to facili­
tate a movement or a stabilizing contraction.
S. Proper mechanics and body pOSitioning of the ath­
letic trainer are essen Lial in applying pressure and re­
sistance. The athletic trainer should stand in a
position that is in line with the direction of movement
in the diagonal movement pattern. The 'knees should
be bent and close to the patient such that the direc­
tion of resistance can easily be applied or altered ap­
propriately throughout the range.
6. The amount of resistance given should facilitate a
maximal response that allows smooth. coordinated
motion. The appropriate resistance depends to a
large extent on the capabilities of the patient. It
may also change at different poinfs throughout the
range of motion. Maximal resistance may be ap­
plied with techniques that use isometric contrac­
tions to restrict motion to a speCific point; it may
also be used in isotonic contractions throughout a
fuB range of movement.
7. Rotational movement is a crit'ical component in all of
the PNF patterns because maximal contraction is im­
possible without it.
H. ormal timing is the sequence of muscle contraction
that occurs in any normal motor activity resulting in
coordinated movement. H The distal movements of
the patterns should occur firSt. The distal movement
components should be completed no later than
halfway through the tOlal PNJ: pattern. To accom­
plish this. appropriate verba! commands should be
timed with manual commands. Normal timing may
be llsed with maximal resistance or without resist­
ance from the athletic trainer.
9. Timing for emphasis is used primarily with isotonic
contractions. This principle superimposes maximal re­
sistance. at specific points in the range. upon t he pat­
Lerns of facilitation. allOWing overflow or irradiation to
the weaker components of a movement pattern. The
stronger components are emphasized to facilitate the
weal<er components of a movement pattern.
approximation. Traction spreads apart the joint arlic­
307
ulations. and approximation presses them together.
Both techniques stimulate the joint proprioceptors.
Traction increases the muscular response. promotes
movement, assists isotonic contrac tions. and is used
with most flexion antigravity movements. Traction
must be maintained throughout the pattern. j\pproxi­
mation increases the muscula r response. promotes
stability. assists ,i sometric contractions. and is used
most with extension (gravity-assisled) movements .
Approximation may be quick or gradual and may be
repeated during a pattern .
] 1. Giving a quick stretch to the muscle before musclc
contraction facilitates a muscle to respond with
greater force through the mechanisms of the stretch
reflex. It is most effective ,if all the components of a
movement are stretched simultaneollsly. However.
this quick stretch can be contraindicated in many or­
thopedic conditlons because the extensibility limits of
a damaged musculotendinous unit or joint structure
might be exceeded . exacerbating the injury.
CLINICAL DECISION MAKING Exercise 15-2
A baseball player has had shoulder surgery to correct an
anterior instability. He Is having difficulty regain ing
strength throughout a full range of movement rollowing
the surgery. How can PNF strengthening be beneficial to
someone who has a loss of ROM due to pain ?
TECHNIQUES OF PNF
Each of tbe principles described above shou1ld be applied to
the speCific techniqucs of PNF. These techniques may be
used in a rehabilitation program either to strengthen or fa­
cilitate a particular agonistic muscle group or to stretch or
il1hibit the antagonistic group. LY The choice of a specific
technique depends on the delkits of a particular patient. 31
Specific techniques or combinations of technlques should
be selected on the basis of the patient's problem .2
CLINICAL DECISION MAKING Exercise 15-3
or
Weakness following Immobilization because a radial
fracture leaves a fencer with we(lk wrl °t musculature. She
is having trouble initialing wrist exten. Ion . What P
technique might Lhe athletic trainer employ to incre!! e
strength?
308 PART THREE The Tools of Rehabilitation

Strengthening Techniques. The following tech­ Rhythmic stabilization. Rh)1thmic stabilization Slow-reversal
niques are most appropriately used for the development of uses an isometric contraction of the agonist. followed by relax technique beg
muscular strength. and endurance. as well as for reestab­ an isometric contraction of the antagonist to produce co­ agonist. which ofte[
lishing neuromuscuIar control. contraction and stability of the two opposing muscle pattern. followed b)'
R'lythmic initiation. The rhythmic initiation tech­ groups. The command given is always "Hold ," and move­ nist (muscle that \\i
nique involves a progression of initial passive. then active­ ment is resisted in each direction. Rhythmic stabilization During the relax ph
assistive. followed by active movement against resistance results in an increase in the holding power to a point where the agonists are C(J
through the agonist pattern. Movement is slow. goes the position cannot be broken. Holding should emphasize direction of the agl
through the available range of motion . and avoids activa­ co-contraction of agonists and antagonists. antagonist. The t
tion of a quick stretch. It is used for patients who are unable hold-relax. is useful
to initiate movement and who have a limited range of mo­ tbe primary :limiting
CLINICAL DECISION MAKING Exercise 15-4 Because the goa '
tion because of increased tone. It may also be used to teach
the patient a movement pattern. injuries is restorari(
A Lcnnis player is compla ining that when he serves. it feels
Repeated contraction. Repeated contraction is stricted range of ffiI
like his shoulder "pops out" jusL after he hits the ball 011
uscl'ul when a patient has weakness either at a specific ometimes combin,
the follow-through. How can PNF IcchnJques be lIsed to goal. 29 Figure 15- 3
point or thmughoutthe entire range. It is used to correct
help thIs tennis player increase stability In his shoulder?
imbalances that occur within the range by repeating the which the athletic 11
wcakest portion of the total range. The patient moves iso­ Treating SpeeiJ
tonically against maximal resistance repeatedly unti.l fa­ PNF strengthening
tigue is evidenced in the weaker components of the CLINICAL DECISION MAKING Exercise 15-5 ful in a variety of di
motion. When fatigu e of the weak components becomes hoice of the most e
apparent. a stretch at that point in the range should facil­ A wrestler Is recovering (rom a shoulder dislocation. He will be dictated by tb
itate the weaker muscles and result in a smoother. more wants to know why the athletic trai ner is using a man­ the capabilities an d
coordinated motion. Again . quick stretch may be con­ ual PNl' strengthening program instead of just letting There are some ad
traindicated with some musculoskeletal injuries. The him go 10 the weight room and work out on an exercise general.
alTIoun t of resistance to motion given by the athletic mach ine. What possible rationale mighllhe athletic Relative to streD
trainer should be modified to accommodate the strength trainer give La the wrestler as to why PN[l may be a more encumbered by the I
of the muscle group. The patient is commanded to push by usefullechnique; eise machines. alLh~
using the agonist concentrically and eccentrically hines have been
throughout the range. motion and thus \
Slow reversal. Slow reversal involves an isotonic Stretching Techniques The following techniques With the PNf pat
contraction of the agonist followed immediately by an should be used to ,i ncrease range of motion. rclaxation . planes simultaneo
isotonic contraction of the antagonist. The initial con­ and inhibition. ru nctional movem
traction of the agonist muscle group facilitates the suc­ Contract-relax is a stretching technique tbat moves applied by the ath le
ceeding contraction of the antagonist muscles. The the body part passively into the agonist pattern. The pa­ (ered at different pG
slow-reversal technique can be used for developing active tient is instructed to push by contracting the antagonist meet patient capa b~
range of motion of the agonists and normal reCiprocal (muscle that wil'! be stretched) isotonica'lly against the rc­ lO concentrate on til
timing bet ween the antagonists and agonists. which is sistance of the athletic trainer. The patient then relaxes the of motion or throu ~
critical for normal coordinated motion. l4 The patient antagonist while the lherapist moves the part passively of several strengthf
should be commanded to push against maximal resist­ through as much range as possible to the point where lim­ rentIy within the Sill
ance by using the antagonist and then to pull by using itation is again felL This contract-relax technique is bene­ useful in the e ar l~
the agonist. The initial agonistic push facilitates the suc­ ficial when range of motion is l.imited by muscle tightness. lete is having di m
ceeding antagonist contraction . Hold-relax. Hold-relax is very similar to the contract­ lfee arc. Passive
Slow-re,'ersal-'lOld. Slow-reversal-hold is an iso­ relax technique. It begins with an isometric contraction of maintain a full ran
tonic contraction of the agonist followed immediately by the antagonist (muscle that. will be stretched) against resist­ ove through the a
an iwmetric contraction. with a hold command given at ance. followed by a concentric contraction of the agonist should be used to
the end of each active movement. The direction of the pat­ muscle combined with Ught pressure from the athletic 'Iow-reversal-hold
tern is reversed by using the same sequence of contraction trainer to produce maximal stretch of the antagonist. This pecific poin ts in th
with no re.laxation before shifting to the antagonistic pat­ technique is appropriate when there is muscle tension on strengthening.
tern. This technique can be especially useful in developing one side of a joint and may be used with ejther the agonist or RhythmiC stabil
strength at a specific point in the range or motion. antagonist. neuromuscular con
 CHAPTER 15 PNF and Other Soft-Tissue Mobilization Techniq ues in Rchabi litalion 309

mmie stabilization Slow-reversal-hold-relax. Siow-reversal-hold­

19ooist. followed by relax technique begins with an isotonic contraction of the
Jni t to produce co­ agonist, which often limits range of motion in the agonist
:> opposing muscle pattern, followed by an isometric contraction of the antago­
. "Hold," and move­ nist (muscle that will be stretched) during the push phase .
Jt hrnic stabili%ation During the relax phase, the antagonists are relaxed while
\\ er to a point where the agonists are contracting, causing movement in the
g hould emphasize direction of the agonist pattern and thus stretching the
oi t . antagonist. The technique, like the contract-relax and
hold-relax, is useful for increasing range of motion when
the primary limiting factor is the antagonistic muscle group.
Exercise 15-4 Because the goal of rehabilitation in most sport-related
injuries is restoration of strength through a full, nonre­
be serves, it feels stricted range of motion, several of these techniques are
the ball on sometimes combined in sequence to accomplish this Figure 15-3 PNF stretching technique.
ues be used to goa1. 29 Figure 15-3 shows a PNF stretching technique in
his shoulder? which the athletic trainer is stretching t'he injured athlete.
Treating Specific Problems with PNF Techniques. quires co-contraction of opposing muscle groups and is
PNF strengthening and stretching techniques can be use­ useful in creating a balance in the exist.ing force couples.
Exercise 15-5 ful in a variety of different conditions. To some extent the
.::hoice of the most effective technique for a given situation CLINICAL DECISION MAKING Exercise 15-6
di ·Iocation. He
will be dictated by the state of the existing condition and by
using a man­
the capabilities and limitations of the individual athlete.4 8 A maUfemale athletic trainer is attempting to do a D2
r just letting
There are some advantages to using PNF techniques in lower-extremlly PNF strengthen ing pattern on a 300­
on an exercise
general. pound offensive tackle. now can the at.hletic trainer en­
I he athletic
Relative to strengthening, the PNF techniques are not sure that proper resistance is applied when performing
:r may be a more
ncumbered by the design constraints of commercial exer­ PNF strengthening even when the athlete is qUite strong:
cise machines, although some of the newer exercise ma­
chines have been designed to accommodate triplanar
motion and thus will allow for PNF patterned motion."
lowing techniqucs With the PNF patterns, movement can oCCur in three PN F Patterns
molion, relaxation. planes Simultaneously, thus more closely resembling a
fu nctional movement pattern. The amount of resistance The Pt\Tf patterns are concerned with gross movement as
. 'hnique that moves applied by the athletiC trainer can be easily adjusted and al­ opposed to specit1c muscle actions. The techniques identi­
. 1 pattern. The pa­ tered at different points through the range of motion to fied previously can be superimposed on any of the PNF
rting the antagonist meet patient: capabilities. The athletic trainer can choose patterns. The techniques of P!\;F are composed of both ro­
- ally against the rc­ to concentrate on the strengthening through entire range tational and diagonal exercise patterns that are similar to
en t then relaxes the of motion or through a very specific range. Combinations the motions required in most sports and in normal daily
the parl passively of several strengthening techniques can 'be used concur­ activities.
he point where lim­ rently within the same PNF pattern. 30 Rhythmic initiation The exercise patterns have three component move­
technique is bene­ i useful in the early stages of rehabilitation when the ath­ ments: flexion-extension, abduction-adduction. and internal­
y muscle lightness. lete is having difficulty moving actively through a pain­ external rotation. Human movement is patternt-xl and rarely
Uar to the contract­ free arc. Passive movement can allow the athlete to involves straight motion because all muscles are spiral in na­
etric contraction oJ maintain a full range while using an active contraction to ture and Lie in diagonal directions.
~c hed) against resist­ move through the available pain-free range. Slow reversal The PNF patterns described by Knott and VOSS24 in­
ction of the agonist should be used to help improve muscular endurance. volve distinct diagonal and rotational movements of the
re [rom the athletic low-reversal-hold is used to correct existing weakness at upper extremity. lower extremity. upper trunk. lower
the antagonist. Thi, specific points in the range of motion through ·isometric trunk. and neck. The exercise pattern is initiated with the
musclc tension on rreogthening. muscle groups in the lengthened or stretched position. The
~ eilher the agonist or RhythmiC stabilization is used to achieve stability and muscle group is then contracted. moving the body part
neuromuscular control about a joint. s This technique re- through the range of motion to a shortened position.
310 PART THREE The Tools of Rehabilitation

01 FLEXION 02 FLEXION
Shoulder-Flex. Shoulder-Flex.
Add. Abd.
Ext. Rot. Ext. Rot.
Forearm-Sup. Forearm-Sup.
Wrist-Radial Flex. Wrist-Radial Ext.
Fingers-Flex. Shoulder flexion Fingers-Ext.
External rotation

Shoulder adduction
Shoulder abduction
Wrist flexion
Wrist extension
Fing er flexion
Finger extension

Shoulder extension
Internal rotation
02 EXTENSION
0/2
Wrist pronation o
01 EXTENSION
Shoulder-Ext. Shoulder-Ext.
Add. Abd.
Int. Rot. Int. Rot.
Forearm-Pron. Forearm-Pron. Fe
Wrist-Ulnar Ext. Wrist-Ulnar Ext.
Fingers-Flex.
Fingers-Ext. Tc
Figure 15-4 PNF patterns of the upper extremity.
Fi

The upper and lower extremities all have two separate
patterns of diagonal movement for each part of the body,
which are referred to as the diagonal 1 (01) and diagonal
2 (1)2) patterns. These diagonal patterns are subdivided
into 01 moving into flexion, 01 moving into extension. 02
moving into flexion, and 02 moving into extension. Fig­
ures 15-4 and 15-5 diagram the PNF patterns for the up­
per and lower extremities respectively. The patterns are
named according to the proximal pivots at either the
shoulder or the hip (for example. the glenohumeral joint or
femoralacetabular joint).
Tables 15-1 and 15-2 describe specific movements in
the 01 and 02 patterns for the upper extremities. Figures
15-6 through 15-13 show starting and terminal positions
for each of the diagonal paHerns in the upper extremity.
Tables 1 5-3 and 15-4 describe specific movements in
the 01 and D2 patterns for the lower extremities. Figures
15-14 through 15-21 show the starting and terminal
pOSitions for each of the diagonal patterns in the lower
extremity.
Table 15-5 describes the rotational movement of the
upper trunk moving into extension (also called chopping)
and moving into flexion (also called lifting). Figures 15-22
and 15-23 show the startling and terminal positions of the • TAB LE 15 "
upper-extremity chopping pattern moving into flexion to
the right. Figures 15-24 and 15-25 show the starting and
terminal positions for the upper-extremity lifting pattern
moving into extension to the right.
Table 1 5-6 describes rotational movement of the lower Body Part
extremities moving into positions of nexion and extension.
Figures 15-26 and 15-27 show the lower-extremity pat­ ' houlder
tern moving into flexion to the left. Figures 15-28 and
15-29 show the lower-extremity pattern moving into ex­
tension to the left. 'capula
The neck patterns -involve simply flexion and rotation
to one side (Figures 15-30 and 15- 31) with extension and
rotation to the opposite side (Figures 15-32 and 15-33). Forearm
The patient should follow the direction of the movement Wrist
with their eyes. Finger and thumb
The principles and techniques of Pl\TF, when used ap­
propriately with specific patterns, can be an extremely effec­ Hand position for
tive tool for rehabilitation of sport-related injuries. 4b They athletic trainer"
can be used to strengthen weak muscles or muscle groups
and to improve the range of motion about an injured joint. Verbal command
Specinc techniques selected for use should depend on indi­
vidual patient needs and may be modified accordingly.1 1,1 4 "For athl ete' s ri ght aJ1j
 CHAPTER 15 PNP and Other Soft-Tissue Ivlobilization Techniques in Rehabilitation 311

ON Dl FLEXION D2 IFLEXION
lex. Hip-Flex. Hip-Flex.
d. Add. Abd.
t. Rot. Ext. Rot . Int. Rot .
,po Ank.-Dorsi. Foot-Dorsi.
~I Ext. Inver. Ever.
Toes-Ext. Hip flexion Toes-Ext.
Foot dorsiflexion
Toe extension

Hip adduction Hip abduction

External rototion Internal rotation

Foot inversion Foot eversion

Hip extension

Foot plantar flexion

02 EXTENSION Toe ,flexion

D~

~:N
1
EXTENSION
Hip-Ext. Hip-Ext.
Add . Abd.
~ Rot. 'Ext. Rot. Int. Rot.
'OIl . Foot-Plont . Flex. Foot-Plant. Flex.
r Ext. Inver. Ever.
Toes-Flex. Toes-Flex.
Figure 15-5 PNF patterns of the lower extremity.

nnin al positions of the • TA B LEiS -1 D 1 Upper-Extremity Movement Patterns

mov ing in to flexion to
how the starting and Moving ,into Flexion Moving into Extension
emity lifting pattern
Starting Position Terminal Position Starting Position Terminal Position
\'ement of the lower Body Part (Figure 15-6) (Figure 15-7) (Figure 15-8) (Figure 15-9)
nex ion and extension.

lo wer-extremity pat­
~houlder Extended Flexed Flexed Extended
. Figures 15-28 and
Abducted Adducted Adducted Abducted
ncrn moving into ex­ Internally rotated Externally rotated Externally rotated Internally rotated
Scapula Dep ressed Flexed Elevated Depressed
_. flexion and rotation Retracted Protracted Protracted Retracted
311 wit h extension an d Downwardly rotated Upwardly rotated Upwardly rotated Downwardly rotated
1 5-32 and 15-33). Forearm Pronated Supinated Supinated Pronated
:11on of the movement ', \lrist Ulnar extended Radially flexed Radially flexed Ulnar extended
finger and thumb Extended Flexed Flexed Extended
Pl\E when used ap­ Abducted Adducted Adducted Abducted
.... be an extremely effec­ Hand position for Left and inside of volar surface of hand
Left hand on back of elbow on humerus

related injuries. 4 6 The} ilthletic trainer' Right hand underneath arm in cubital
Right hand on dorsum of hand

les or muscle group. fossa of elbow

about an injured joint. Verbal command Pull

Push

should depend on indi­

lllilled accordingly. ll . H "For athlete's right arm.
312 PART THREE The Tools of Rehabilitation

• TABLE 15·2 D2 Upper-Extremity Movement Patterns

Moving into Flexion Moving into Extension

Starting Position Terminal Position Starting Position Terminal Position

Body Part (Figure 15·10) (Figure 15··11) (Figure 15·12) (Figure 15·13)

Shoulder Extended Flexed Flexed Extended

Abducted Adducted Adducted Abducted
Internally rotated Externally ro tated Externally rotated Internally rotated
Scapula Depressed Flexed Elevated Depressed
Retracted Protracled Protracted Retracted
Downwardly rolated Upwardly rotated Upwardly rotated Downwardly rotated
Forearm Pronated Supinated Supinated Pronated
Wrist Ulnar flexed Radially extended Radiany flexed Ulnar flexed
Finger and thumb Flexed Extended Extended Flexed
figure 15·8 0 1
Adducted Abducled Abducted Adducted
moving into extensl
Hand position for Left hand on back of humerus
Left hand on volar surface of humerus

athletic trainer' Right hand on dorsum of hand

Right hand on cubital fossa of elbow

Verbal command Push

Pull

'Por athlcll" s right arm.

Figure 15-6 D1 upper-extremity movement pattern Figure 15-7 D1 upper-extremity movement pattern
moving into flexion. Starting position. moving into flexion . Terminal position.

111 0vi11g into exl efJ

 CHAPTER 15 PNP and Other Soft-Tissue Mobilization Techniques in Rehabilitation 313

dension

'erminal Position
(Figure 15-13l

. ~e nded
bd ucted
lc rna lly rotated
Jepressed
tracted
k>wnwardly rotated
Iron ated

Figure 1 5-8 Dlupper-extremity movement pattern Figure 15-9 OJ upper-extremity movement pallern
moving into extension. Starting position. moving into extension. Terminal position.

Figure 15-10 D2 upper-exlremity movement pattern figure IS-II 02 upper-extremity movement pattern
rnoving into flexion. Starling position. moving into flexion . Termina l position .

Figure IS- 12 02 upper-extremity movemen t pattern Figure 15-13 02 upper-extremity movement pattern
'1loving into extension. Starling position. moving into extension. Terminal position.
314 PART THREE The Tools of Rehabilitation

• TABLE 15-3 01 Lower-Extremity Movement Patterns

Moving into Flexion Moving into Extension

Starting Position Terminal Position Starting Position Terminal Position

Body Part (Figure 15-14) (Figure 15-15) (IFigure 15-16) (Figure 15-17)

Hip Extended Flexed Flexed Extended

Abducted Adducted Adducted Abducted
Internally rolated Externally rotated Externally rotated InLernalily rotated
Knee Extended Flexed Flexed Extended
Position of tibia Externally rotated Internally rotated Internally rotat(j(j External'ly rotated
Ankle and foot Plantar flexed Dorsiflexed Dorsiflexed Plantar llexed
Everted Inverted Inverted Everted
Toes Flexed Extended Extended Flexed
Hand position for Right hand on dorsimedial surface of loot
Right hand on lateralplantar surface of foot

Figure 15-14 D:
athlelic trainer' Lc!'l hand on anteromedialthigh near patella
Left hand on posteriolateral thigh
moving into llexjon
near popliteal crease

Verbal command Pull Push

"For athlete's right leg,

• TABLE 15-4 02 Lower-Extremity Movement Patterns

Moving into Flexion Moving into Extension

Starting Position Terminal Position Starting Position Terminal Position

Body Part (Figure 15-18) (Figure 15-19) (Figure 15-20) (Figure 15-21)

Hip Extended Flexed Flexed Extended

Adducted Abducted Abducted Adducled
Externally rotated Internally rotated Internally rotated l~'(lernally rOlated Fi gure 1 5 -1 6 J)
Knee Extended Flexed Flexed Extended moving into exten
Position of tibia Externally rotated Internally rotated Internally rotated [xlerna1ly rotated
Ankle and foot Plantar flexed Dorsillexed Dorsiflexed Plantar flexed
Inverted Everted Everted Inverted
Toes Flexed Exlended Extended Flexed
Hand position for Right hand on dorsilateral surface of fool
Righ t. hand on medial plantar surface of foot

athletic trainer' Left hand on anterolateral thigh near patella

Lefl hand on posleriomedial thigh near

popliteal crease

Verbal command Pull

Push

'For athlete's right leg,

mo\'ing into nexiOLl.

 CH;\PTER 15 P\ F ilnd Other Soft-Tissue Mobilization Tec hniques in Rehabilitation 315

(tension

erminal Position
Figure 15-17)

-ro ally rotaLed

nta r flexed
rted
ed
",r urfa ce o[ root
figure 15-14 01 lower-extremity movement piltlern Figure 15-15 01 lower-extremity movement pallcrn
moving into flexion. Starling position. moving into flexion . Terminal position.

Figure 15-16 01 lower-extremity movement pattern Figure 15-17 011owcr-cxtremity movement pattern
lOving into extension. Starting position. moving into extension . Terminal position .

Fi gure 15-18 02 lower-extremity movement pattern Figure 15-19 02 lower-ex tremity movement pattern
oving into flexion. Starting position. moving into fle xion . Terminal position.
316 PART THREE The Tools of Rehabiliwlion

• TABLE 15 ·

Body Part

Right upper
extremity

Left upper
extremity (left
hand grasps
right forearm)
Trunk
Figure 15-20 D2 lower-extremity movemen t pattern Figure 15-21 02 lower-extremity movement pattern
moving into extension. Starting position. moving into exte nsion. Terminal position.
Head

Hand position of
ath leUc trainer
Verbal co mmand

'Athlete's rolation i' t

• TABLE 15 ·

Body Part
Figure 15-22 Upper-trunk pattern moving into exten­ Figure 15-23 Upper-trunk p8ttern moving into exten­
sion or chopping. Slarling position. sion or chopping. Terminal position. Right hip

Left hip

:\nkles
Toes
Hand posiLion of
a thl etic trainer

\'erbal command

·.'>"tb l ete·~ rotation is Ii

-,". thleks rOlation is ,I
Figure 15-24 lJpper-trunk patlern moving inl o flexion Figure 15-25 Upper-trunk pall ern moving into flexion
or lifting. Starting position. or liftin g. Terminal position.
 CHAPTER 15 PNF and Other Soft-Tissue Mobilization Techniques in Rehabilitation 317

• TABLE 15-5 Upper-Trunk Movement Patterns

Moving into Flexion (Chopping)* Moving into _Extension (Lifting)*

Starting Position Terminal Position Starting Position Terminal Position

Body Part (Figure 15-22) (Figure 15-23) (Figure 15-24) (Figure 15-25)

Right upper Flexed Extended Extended Flexed

extremity Adducted Abducted Adducted Abducted
Internally rotated Externally rotated Internally rotated Externally rotated
Left upper Flexed Extended Extended Flexed
extremity (left Abducted Adducted Abducted Adducted
hand grasps Externally rotated Internally rotated Externally rotated Internally rotated
right forearm)
Trunk Rotated and extended Rotated and flexed Rotated and flexed Rotated and extended
to left to right to left todght
Head Rotated and extended Rotated and flexed Rotated and flexed Rotated and extended
to left to right to left to right
Hand position of Left hand on right anterolateral surface of forehead Right hand on dorsum of right hand
ath l etic trainer Right hand on dorsum of right hand Left hand on posteriolateral surface of head
Verbal command Pull down Push liP

•Athlete's rotation is to the right.

• TAB LEiS- 6 Lower Trunk Movement Patterns

Moving into Flexion* Moving into Extension t

Starting Position Terminal Position Starting Position Terminal Position

Body Part (Figure 15-26) (Figure 15-27) (Figure 15-28) (Figure 15-29)
m 'ling into ex ten­
Right hip Extended Flexed Flexed Extended
Abducted Adducted Adducted Abducted
Externally rotated Internally rOlated Internally rotated Externally rotated
Left hip Extended Flexed Flexed Extended
Adducted Abducled Abducted Adducted
Internally rotated Externally rotated Externally rotated Inlernally rotated
Ankles Plantar flexed Dorsiflexed Dorsit1exed Plantar flexed
I
Toes Flexed Extended Extended Flexed
Hand position of Right hand on dorsum of feet Right hand on plantar surface of foot
a thletic trainer Left hand on anterolateral surface of left knee Left hand on posteriolateral surface of
right knee
l,'erbal command Pull up and in Push down and out

·..\thlete's rotation is to the lefl in nexion,

'_-\ thlete's rotation is to the right in extension,
1 moving into flexion
318 PAHT THREE The Tools of Rehabililation

Figure 15-26 l.ower- trunk pattern moving in to flexion Figure 15-27 Lower-trunk patlem moving into flexio n
to the lefl. Starling posiLion . to the left. Terminal position. Figure 15-32
Starting position .

Figure 15-28 Lower-trunk pattern moving into exten­ Figure 15-29 Lower-trunk pattern mov ing into exten­
sion to the left. Star ling position. sion to the left. Terminal position .
Figure 15-33
Terminal position.

MUSCLE EI
\! uscle energy is a
Hliun of th e P
iJke th e PNF tech

'ng the stretch refl

Lie energy techni
muscle in a specifJ
of intensity again
plied by the atW
Figure 15-30 Neck flexion and rotation to the left. Figure 15-31 Neck fl exion and rotalion to the left. Ter­ orrective illtrill sfi
Starting position. minal position. musc ul ar contra,
 CHAPTER 15 pf\p and Other Soft-Tissue Mobilization Techniques in Rehabilitation
Figure 15-32 Neck extension and rotation to the right.
Starting position.
moving into exten­
Figure 15-33 Neck extension and rotation to the right.
Terminal position.
M USCLE ENERGY TECHNIQUES
\l uscle energy is a manual therapy technique that ·is a vari­
ation of th PNF contract-relax and hold-relax techniques.
li ke the P . techniques, the muscle energy techniques are
oa sed on the same neurophysiological mechanisms involv­
mg th e stretch reflex discussed earlier in this chapter. Mus­
de energy techniques involve a voluntary contraction of a
m uscle in a speCifically controlled direction at varied levels
r intensity against a distinctly executed counterforce ap­
plied by the athletic trainer. 1043 The paLicnt provides the
.alion to the left. Ter- .:: rrective intrinsic forces and controls the intensity of the
muscular contractions while the athletic trainer controls
319
the preCISIOn and localization of the procedure.l~ The
amount of patient effort can vary from a minim<ll muscle
twitch to a maximal muscle contraction. 20
Five components <Ire necess<lry for muscle energy
techniques to be effective: 1o
1. Active muscle contraction by the patient
2. A muscle contraction oriented in a speciflc direction
3. Some patient control of contraction intensity
4. Athletic trainer control of joint position
5. Athletic trainer application of appropriate
COLI nterforce
Clinical Applications
It has been proposed that muscles function not only as flex­
ors. extenders. rotators. and side-benders of joints. but
also as restrictors of joint motion. In situations where the
muscle is restricting joint motion. muscle energy tech­
niques use a specific muscle contraction to restore physio­
logical movement to a joinL 18 Any articulation. whether
in the spine or in the extremities. that can be moved byac­
tive muscle contraction can be treated using muscle en­
ergy techniques.)o.lh
Muscle energy techniques can be used to accomplish a
number of treatment goals: 2u
1. Lengthening of a shortened. contracted. or spastic
muscle
2. Strengthening of a weak muscle or muscle group
3. Reduction of localized edema through musclc pumping
4. Mobilization of an articulation with restrictcd mobility
5. Stretching of fascia
Treatment Techniques
Muscle energy techniques can involve four types of muscle
contraction: isometric, concentric isotonic. eccentric iso­
tonic, and isoJytic. An isolytic contraction involves a con­
centric contraction by the patient while the athletic trainer
applies an external force in the opposite direction, over­
powering the contraction and lengthening that muscle. 2H
Isometric and concentric isotonic contractions are
most frequently used in treatment. Isometric contractions
are most often used in treating hypertoni c muscles in the
spinal vertebral column; isotonic contractions are most of­
ten used in the extremities. With both types of contraction
the idea is to inhibit antagonistic muscles producing more
symmetrical muscle tone and balance.
A concentric contraction can also be used to mobilize
a joint against its motion barrier if there is motion restric­
tion. For example, if a knee has a restri ction due to tight-
320 PART THREE Thc Tools of Rehabilitation
Figure 15-.34 Position for isometric muscle energy
tcchnique for tightness of the hamstring muscle.
ness in thc h ams trings that is limiting full extension. the
followi ng isometric m uscle energy technique should be
u.sed (Figure 1 5-34):
1. The athlete should lie prone on the treatment table.
2. The athletic trainer stabilizes the knec with one hand
and grasps the ankle with the other.
3. The athletic trainer fully extends the knee until an ex­
tension barrier is felt.
4 . The athle te is instructed to actively nex the knee us­
ing a minimal s·ustained forc e.
S. Thc athletic trainer provides an eq,ual resistant coun~
terforce fo r 3 to 7 seconds. after which the athlete
completely relaxes.
6. The athletic trai.ner once again extends the knee until
a new extension barrier is feli.
7. This is repeated 3 to S times.
If a strength imbalance exists bet ween the quadriceps
and hamstrings. with weak quadriceps limiting knee ex­
tension. the following concentric isotonic muscle energy
technique may be used:
1. The athlete should lie supine on th e treatment
table.
2. The athletic trainer stabilizes the knee with one hand
and grasps the ankLe wi th the other.
3. The athletic trainer fully nexes the knee.
4. The athllete is instructed to actively extend the knee.
using as much force as possible .
."'). The ath 'l etic trainer proVides a resistant counterforce
that al'lows slow knee extension throughout the avail­
able range.
6. Once the athlete has completely relaxed. the athletic
trainer moves U1e knee back to full nexion and the
athlete repeats the contraction with additional resist­
ance applied through the full range of extension. This
is repeated 3 to S times with increasing resistance on
each repetition.
Figure 15- 3 5
body part is plan',
and then slow ly m
STRAI N·COUNTEIR STRAI N
TECHNII QUE
Straill-counterstrain is an approach to decreasing muscle will gently an d sl!
tension and guarding that may be used to normalize mus­ tender point is no I
cle function. It is a passive technique that places the body for 90 seconds. lb
in a position of greatest comfort. thereby relieving pain.21 turns the neck to
In this technique. the athletic trainer locates "tender point is pressed a~
cant decrease in pi
points" on the athlete 's body that correspond to areas of
The phys iologi
dysfunction in specil1c joints or muscles that are in need of
treatmenL 13 These tender points ar e not located in or just strain-coun terslra
beneath the skin. as are many acupuncture points. but in­ stretch reflex. ! Tht
stead are deeper in muscle. tendon. ligament. or fascia. the section "The
They are characterized by tense. tender. edematous spots When a muscle i
on the body. They are 1 centimeter or less in diameter. with from the muscle SI
the most acute points being 3 millimeters in diameter. al­ muscle in respons
though ,u1ey may be a few cen timeters 'l ong within a mus­ the joint or I11u sclt
cle. There can be multiple points for one specific joint irnstead in a slack ~
dysfunction. Points might be arranged in a chain. and they duced and th e mu'
are oRen found ,in a painless area opposite the site of pain te llsion and pain .­
and/ or weakness. 1 l
The athletic trainer monitors the tension and level of POS I TIO N ~
pain elicited by the tender point while moving the patient
into a position of ease or comfort. This is accomplished by Positional release
markedly shortening the muscle. 43 When this position of counterstrain ted
ease is fClUnd, the tender point is no longer tense or tender. uw two is th e use
When this position ,is maintained for a minimum of 90 sec· enhance the effect
onds. the tension in the tender point and in the correspon­ f-i ke stra in -COL
ding joint or muscle ts reduced or cleared. By slowly llzation technique
pOSition of gre a t e~
returning to a neu,(,ral position. the tender point and the
the position of gre
corresponding joint or muscle remains pain-free with nor·
each jOint with thi
mal tension. For example. with neck pain and/or tension
te nder points. One
headaches. the tender point may be foun d on either the
front or back of the athlete's neck and shoulders. The ath­ w ith the palpatill!
letic traine.r will have the athlete lie on his or her back an d patient is then p ~
 CHAPTER 15 PNF and Other Soft·Tissuc Mobilization 'I't:chniqucs in Rehabilitation 321

nee with onc hand

· nee.

extend the knee.

qa nt counterforce
oughout the avail-

axed. the athletic

nexion and the
additional resist­
of extension. This

Figure 15-35 Strain/coLlnterstrain techniquc. Thc

body part is placcd in a position of comfort for 90 seconds
and then slowly moved back to a natural position .
IN
Figure 15-36 The positiona l release technique places
the mLiscle in a position of comfort with the finger o r
thumb exerting submaximal press ure on a tendon point.

decreasing muscle will gcntly and slowly bend the athlete's neck until that the tcnsion under the palpating finger prodUCing a subjec­
d to normalize mus­ tender point is no longer tcnder. After holding that position tive reduction in tenderness as reported by the patien t.
tha t places the body for 90 seconds. the athlclic trainer gcntly and slowly re­ This specinc position ,js adjusted throughout the 90­
. y re lieving pain. l l turns the !leck to its rcsting position. Whcn that tender second treatment period. It has been suggested that main­
er locates "tender poin l is prcsscd again. th e athlete sho uld notice a signifi­ taining coutact with the tender poin t during the trcatment
rrespond to areas of cant decrease in pain there (rigure 15-35}.43 period exerts a therapeutic cffect. 11 . 12 Th is technique is one
th at are in need of The physiological rationale for the effectiveness of th e of the most effective and most gentle methods fo r the treat­
1 tl ocated in or just strain-counterstrain technique ca n be explaincd by the ment of acute and chronic musculoskeletal dys function .\9
Clure pOints. but in­ slret ch reflex.] The stretch reflex was discussed in detail in (Figure 15-36).
igament. or fascia. the section "The Neurophysiologic Basis of Stretching."
ler. edematous spots When a muscle is placed in a stretched position. impulses ACTIV'E 'RELEASE TECHNIQUE
in diameter. with i'rom the muscle spindles create a reflex contraction of the
, LeT in diameter. al­
muscle in response to stretch . With strain-counterstrain. Active release technique (AH' ) is a relativcly new type of
lo ng within a mus­ the joint or muscle is placed not in a position of stretch but manual thcrapy that has been developed to correct soft­
r one specific joint
instead in a slack position . Thus muscle spindle input is rc­ tissue problems in muscle. tendon. and fascia caused by
lin a chain . and they duced a nd the muscle is relaxed. all owing for a dccrease in the formation of nbrolic adhesions that result from acull.'
ite the site of pain tensio n and pain. I injury. repetitive or overuse injuries. constant pressure. or
te nsion injuries.2 i Whe n a muscle. tendon, fascia. or liga­
, tension and level of POSITIONAL RELEASE THERAPY me nt is torn (strained or sprained) or a nerve is damaged.
moving the patient the tiss ues hcal with adhesions or scar tiss ue formation
. is accomplished by Positional release therapy (PRT) is based on the strain­ rather than the formation or brand nell' tissu .. Scar tissue
hen this pOSition of cou nterstrain technique. The primary ditTerence between is weaker, less elastic, less pliable. and more pain-sensitive
~!l ge r tcnse or tender.
[he t wo is the usc of a facilitating force (compression) to than healthy tissue.
I mi n imum of 90 scc­
enhan ce the effect of the posilioning.1!.l2 Thcse fibrotic adhesions disrupt the norma l muscle
IDd in th e correspon­ Like stra tn-counterstrain . PRT is an osteopathic mobi­ function. which in turn affecls the biomecha nics of the
. cleared. By slowly lization technique in which the body part is moved into a joint complex and can lead to pain and dysfunction. Active
tender point and the posit ion of greatest relaxation .16 The athletic trainer finds release technique provides a way to diagnose and treat the
pain-free with nor­ th e position of greatest comfort a nd muscle relaxation for underlying causes of cumulative trauma disorders that.
pain and / or tension each joint with the help of movement tests and diagnostic left uncorrected . ca n lead to inflammatio n . adhesions, fi­
(o uod on either th e le nder points. Once located, the tender point is maintained brosis, and muscle imba'lances. All of these can res ult in
d sho ulders. Thc ath­ with the palpating finger a t a subthreshold pressure. The weak and tense tissues. decreased circulation, hypoxia.
!l his or her back and pa tient is then passively placed in a position that reduces and symptoms of ,peripheral nerve entrapment. including
322 PART THREE The Tools of Rehabilitation

Conclusive eviden ce
gogenic aid ,in the at
How these clTec
by the specific appro
and how they are aPi
are either reflexive 01
the nervous system
method employed. Ll
of applications. Th rc
induced. Slow. gen
f1eurage may reliel
muscles more rel axe
and motor nerves l~
response. The med
chanical or histol ~
through direct force
Figure 15-37 Active release technique. The muscle is elongated from a shortened position while static pressure is ap­
plied to the tender point. Among the m~
cine are the follO\',iD
1. Ha.f]ilI1JnsSIl(j£'.­
numbness. tingling. burning. and aching. 25 Active release include efi1eural
technique is a deep-tissue technique used for breaking ment, and vib ra
down scar tissue/adhesions and restoring function and
movement. 2 i In the active release technique, the atbleLic
trainer first locates through palpation those adhesions in Summary
the muscle, tendon, or fascia tbat are causing the problem.
Once these are located, the athletic trainer traps the af­
•

fected muscle by applying pressure or tension with the 1. !\ variety of l1i

thumb or finger over these lesions in the direction of the classified as
fibers. Then the athlete is asked to actively move the body stretching tech
part such thaltbe musculature is elongated from a short­ tures. l11yofas("
ened position while the athletic trainer continues to apply structures, ma<
tension to the lesion (Figure] 5-37). This should be re­ counterstrain.
peated three to five times per treatment session. By break­ techniques.
ing up the adhesions, the technique improves the athlete's 2. The PNF tec hl
condition by softening and stretching the scar tissue, re­ strength and 11
sulting in increased range of motion. increased strength, Figure 15-38 Massage can be an extremely effective neurophysiolo
and improved circulation. which optimizes healing. Treat­ soft-tissue mobilization technique. 3. The motor new
ments telld to be uncomfortable during the movement combination a
phases as the scar tissue or adhesions tear apart. 25 This is from the affertl
temporary and subsides almost immediately after the rons will be exC'
(Figure 15-38). Over the years many claims have been
treatment. An important part of active release technique the two typcs 01
made relalive to the therapeutic bendits of massage in the
is for the athlete to heed the athletic trainer's recommen­ -t. The PNF lcd },
athletic population. but few are based on well-controlled.
dations regarding activity modification, stretching, and that may be 5
well-designed studies. Athletic trainers have used massage
exercise. techniques.
to increase f1exibility and coordination as well as to in­
crease pain threshold; to decrease neuromuscular ex­ 'i. The PNF stre n
SPORTS MASSAGE citability in the muscle being massaged: to stimulate con traction. sit
circulation . thus improving energy transport to the mus­ mic stabilizu ti Q
Mns5a!{e is a mechanical stimulation of the tissues by cle: to facilitate healing and restore joint mobility; and to re­ h. The PNF stretcl
means of rhythmically applied pressure and stretching l l move lactic acid, thus alleviating muscle cramps. l2 hold-relax, am
 CHAPTER 15 PNf and Other Soft-Tissue :viobilization Techniques in Rehabilitation
Conclusive evidence of the e[llcacy of massage as an er­
gogenic aid in the athletic population is lacking.
How these effects can be accomplished is determined
by the specific approaches used with massage techniques
and how they are applied. Generally the effects of massage
are either rejlexive or mechanical. The effect of massage on
the nervous system will differ greatly according to the
method employed. the pressure exerted. and the duration
of applications. Through the reflex mechanism. sedation is
induced. Slow. gentle. rhythmical. and superfiCial ef­
fleurage may relieve tension and soothe. rendering the
muscles more relaxed. This indicates an effect on sensory
and motor nerves locally and some central nervous system
response. The mechanical approach seeks to make me­
chanical or histological changes in myoJ'ascial structures
through direct force applied superficially.l2
Among the massage techniques used in sports medi­
cine are the following: 32
l. Hoffa massage. The classic form of massage. Strokes
include effleurage. petrissage. percussion or tapote­
ment. and vibration.
Summary
l. A variety of manual therapy techniques could be
classified as soft-tissue mobilization. These include
stretching techniques for musculotendinous struc­
tures. myofaseial release. stretching for tight neural
structures, massage. PNF, muscle energy. and strain­
counterstrain. positional release, and active release
techniques.
2. The PNF techniques may be used to increase both
strength and range of motion and are based on the
neurophysiology of the stretch reflex.
3. The motor neurons of the spinal cord always receive a
combination of inhibitory and excitatory impulses
from the afferent nerves. Whether these motor neu­
claims have been rons will be excited or inhibited depends on the ratio of
of massage in the the two types of incoming impulses .
on well-controlled. 4. The PNf techniques emphasize specific prinCiples
have used massage that may be super·i mposed on any of the speCific
as wefl as to in­ techniques.
uromuscular ex­ 5. The PNF strengthening techniques include repeated
aged: to stimulate contraction. slow-reversal. slow-reversal-hold. rhyth­
lIl5port to the mus­ mic stabilization. and rhythmic initiation.
l mo bility; and to re- 6. The PNF stretching techniques include contract-relax.
muscle cramps.)2 hold-relax. and slow-reversal-hold-relax.
323
2. Friction massage. Used to increase the inflammatory
response. particularly in cases of chronic tendinitis or
tenosynovitis.
3. AcupresslIre. Massage of acupuncture and trigger
points. sed to reduce pain and irritation in
anatomical areas known to be associated with spe­
dnc points.
4. Connective tisslIe massage. A stroking technique used
on layers of connective tissue. A relatively new form
of treatment in this country. primarily affecting circu­
latory pathologies.
5. M!Jo,{tlscial release. Used for the purpose of relieving
soft tissue from the abnormal grip of light fascia.
6. Rolfing. A system devised to correct incfficien t struc­
ture by balanCing the body within a gravitational field
through a technique involving manual soft-tissue
manipulation.
7. Trager. Attempts to establish neuromuscular control
so that more normal movement patterns can be rou­
tinely performed.
7. The techniques of PNF are rotational and diagonal
movements in the upper extremity. lower extremity.
upper trunk. and the head and neck.
8. Muscle energy techniques involve a olu n tary con­
traction of a muscle in a speCifically con troLled direc­
tion at varied levels of intensity against a distinctly
executed counterforce applied by th e athletic trainer.
9. Strain-counterstrain is a passive technique that places a
body part in a position of greatest comfort to decrease
muscle tension and guarding. and to relIeve pain.
10. Positional release therapy is similar to strain­
counterstrain. Pressure is maintained on a tender
point with the body part in a position of comfort for
90 seconds.
11. Aclive release technique is a deep-tissue technique
used for breaking down scar tissue and adhesions and
restoring function and movement.
12. Massage is the mechanical stimulation of tissue by
means of rhythmically applied pressure and stretch­
ing. It allows the athletic trainer. as a health care
provider. to help a patient overcome pain and relax
through the application of the therapeutic massage
techniques.
324 PAR'l!' THREE The Tools of Rehabilitation

37. Rood. M. 1954.

References physical therapy.
38. Saliba. v.. G. Jom
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SOLUTIONS 1
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hot or cold water immersion and m odified proprioceptive 28. Mitchell, F. 1993. Elem en ts of muscle energy lechnique. In
molor parre
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length. jOllmal oj Athletic TminiIJ!/36(1): J 6-19. berg. Baltimore : 'lVi/iiams & Wilkins. may help h
9. Carter, A M.. S. J. Kinzey, L. F. Chitwood, and j. L. Cole. 2000. 29. Osternig, L.. R. Robertson. R. Troxel cl HI. 1990. Differential kick.
Proprioceplive neuromu sc ula r fa cilitation decreases muscle respouses to proprioceplive neuromu sc ular facilitation 1.5-2 The athleti .
activity during the stretch renex in selected posterior thigh stret.ch lechniques. MedicillC alld Selellce ill Sports 111111 Exercise courage ID(
muscles. Journol of Sport RehalJilitatioIl9(4 ): 269-78. 22:106-11. strengtheni
10. Chaitlo\\', L. 2001. Muscle ellerflY teclmiques. Philaclelphia : 30. Osternig, L.. R. Robert son, H. l'n,xel. and P. H'll1sen. 1987. coordinati(J
Churchill Livingstone. Mu scle activation during proprioceptive neuromuscular fa­ 1'i-3 The rhyth
11. Chaitlow, L. 1996. Positional release techniques (adl'alJced soJt cililalion (PNF) slretching techniques ... slretch-relax iSR), slrength b}
tissue techniques), Philadelphia: Churchill LiVingstone. contract-relax (CR) and agonist contract-relax (/\CR). Amer­
passively. T
12. Chaitlow, L. 1998. Positional release techniques in the treat­ icml JOllnwl oj PlJy,~icuJ Medicine 66( 0): 29R- 107.
assislive aJ:
ment of mU5c1e and joint dysfunction. Clinical Hullel.in oj My­ 31. Prentice, W. 199 3. Proprioceptivc /"'lIrolllllsw /ar lacilitl1ti(J/l
oJascial Thempy3 (1): 25- 35. [VideotapeJ. SL LOQis: Mosby, movement
13. Cookson, J. 1979. Orthopedic mannal therapy: An overview: 32. Prentice. W. 2003. Sports mussagc. [n Therapeutic modalities 15-4 Rhythmic
II. The spint'o Journal oJ the American Physical Therapy Associa­ in sports lIIedicilleand athleUc traillilli!. edited by W. F'renticc. 51. strength at
tion 59:259. Louis: McGraw-HilI. conlracti o(
14. Cookson, J.. and B. Kellt.1979 . Orthopedic manual therapy: 33. Prentice, W. 1983, A comparison of sta tic slrelching and the joint. P
An overview: I. The extremities. Journal oj the Americall Phys­ PNF stretching for improving hip joint f1e xibilily. AIIlleUe
ical Tl1cmpy Associatioll 59:136. Tmillillg 18(1 ): 56-59.
15 . Cornelius, W.. and A. Jackson. 1984. The effects of cryother­ 34. Prentice, W. 1988. 1\ manual resistance technique for
apy and PNF on hip extension flexibility. Athletic Traininq strengthening tibial rotation. Athlctie Training 23(3):
19( 3): 184. 230-33.
16. D'Ambrogio, K.. and G. Roth. 1996. Positional release therapy: 35. Prentice, w., and E. Kooima. 1986. The usc of proprioccptive
Assessment alld treatlllerit oj l1l11sculoskelel.ll/ dysJullction, St. neuromuscular facilitation techniqu es in thc rehabilitalion
Louis: Mosby/Year Book. of sport-relaled injuries. 11th/elic Traillill!l21 :26- 31.
17. Engle, R. , and G. Canner. 1989. Proprioceptive neuromuscu­ 36. Roberts. B, L. 1997. Soft tissue manipulation: Neuromuscu­
lar facilitation (PNF) and modit1ed procedures for anterior lar and muscle energy techniques. Jouma/ of Nelll'OsciellCl'
cruciate ligament (ACL) instability. Jou rllal oj OrtilOpaedic and Sursillg 29(2): 123- 27.
Sports Physical Therapy 11(6): 230-36.
 CHAPTER 15 PNF and Other Soft-Tissue Mobilization Techniques in RehabLlitation 325

37 . Rood. M. 1954. Neurophysiologic reactions as a basis of 44. Stone. J. A. 2UOO. Prevention and rehabiLitation: Propriocep­
physical th erapy. Physical Therapy Review 34:444. tive neuromuscular facilitation. Athletic Therapy Today 5( il) :
38. Saliba. V. G. Johnson. and C. Wardlaw. 1993. Proprioceptive 38-39.
,medicine. Baltimore:: neuromuscular facilitation. In Rationalmllllilal therapies. edited 45. Surburg. P. . and J. Schrader. 1997. Proprioceptive neuromus­
by). BHsmajian and R. Nyberg. Baltimore: Williams ,'I;. Wilkins. cular facilitation techniques in sports med icine: A reassess­
.ing with proprioce:p­ 39. Schiowitz. S. 199U. Facilitated positian al release. JOllrnal oj ment. Jou rnal oj Athletic Trainirlg 32(1): l4-39 .
'11 alld COl!(litiollillil the American Osteopathic Association 90(2): 145-46. 151-55. 4 6. Surberg. P. 1954. Neuromuscular facilitaUon techniq ues in
.J:O. Sherrington. C. 1947. The inteyrative action of tlze llerl'OIlS sys­ sports medicine. Physical Therapy Review 34:444 .
Blackwell Scientific. ten!. New Haven: Yale Cniversity Press. 47. Taniqawa. M. 1972 . Comparison of the hold-relax procedure
"ilization in the man­ 41 . Spernoga. S. G.. T L. Uhl. B. L. Arnold. and B. M. Gansneder. and passive mobilization on increasing muscle l('ngth. Pilysi­
Therapy 3( 1): 2- 1 1. 2001. Duration of maintained hamstring nexibility after a cal Therapy 52(7): 725-35.
lahilitation. JO"r/1ll1 of one-lime, modified hold-relax stre tching protocol. Journal oj 48 . Worrell. 'to T. Smith. and J. Winegardner. 1994. Effect of
, ;-) : 41 ll- 31. Athletic Training 36( I): 44-48. hamstring stretch ing on hamstring muscle performance.
• OJ: Jones Strain­ 4 2. Slone. J. 2000. Muscle energy technique. Athletic Therapy To­ Journal oj Orthopaedic and Sports Physical Therapy 20(3):
day 5(5): 25. 154-59.
4 3. Stone. J. 2000. Strain-counterstrain. Athletic Thera py Today
'f "" " roll ll/sCIIlarJ;'­ 49. Zohn. D.. and J. Mennell. 198 7. MlIsCtllo.~kelctal pain: Diagno­
: Harper & Ro\\,. 5(6): 30. sis and physical treatmellt. Boston : Little. Brown.
carpal tunn el <lI1d
Jicll1c 9(1): 6.
lio n of spinal mo­
--l ~ 1 .
SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES

teral dfe ·ts of pro­

teclmlqu es on hip
. PhysiC(lI Themp!!
mer" techniqLle. In
~ma jian and R. y-
al. 99U. DilTcrcntiai
u ·u lar f"cilitat ion.
n SPM/s lIlId l'xcn'is,
d P. llans<;n. 19 8/.
neuromu sc ular fa­
. . stretch-relax (SR ).
ik.1.-reIClx (ACR). tUllcr·
. _9 - 1U7.
..,,0I1/,CII1ar jil!:ilitatioll
T1re rapI'lItic lllOr/alitie
dited by W. Prentice. 51
ta lie str etching and
nl l1exibility. IIthlelil
] 5-1 A breaststroke kick involves multiplanar move­
ments. Because PNF is used to strengthen gross
motor patterns instead of specil1c muscle actions . it 15-5 The movements required fo r s port are not single­
may help her regain strength and control in her
kick.
] 5-2 'J'he athletic trainer can apply reSistance and en­
courage movement within the pain-free ROM. Th is
strengthening technique will he'l p prevent loss of
coordination due to inactivity.
1 5-.3 'fhe rhythmic initial,i on technique promotes
strength by ftrst introdUCing the movement patlern
passively. The athlete will slowly progress to active
assistive and then resistive exercises through the
movement pattern.
1 5-4 Rhythmic slabiHzation can be used to facilitate
strength an d stability at a joint by stimulating co­
con trac ti on of the opposing muscles that support
the joint. PNF strengthening using the Dl and D2
patterns wi.ll encourage control in the player's over­
head serve.
plane movements. PNF strengthening is m ore func­
tional and is not limited by the design constraints of
an exercise machine. Also. f'NF technique allows
the athletic tra in er to adjust the amount of manual
resistance througho ut the range of moNon accord­
ing to the ath le te 's capabiH ties .
15-6 Proper body a nd hand positioning will maximize
the a thl etic trainer's ability to provide sufl1cienl re­
sista nce. The a thl e ti c trainer sh o uld stand in a po­
sition that is in lin e with the direction of movement
in the diagonal I11O\Temenl pattern. The knees
should be bent and th e stance close to the athlete.
so that th e directio n a nd amount of resistance can
easily be applied or a ltered appropriately through­
out the range of movement.

anee tech nique for

lie Trai lling 2 3(3 1:

use of proprioceptiv
in the rehabi litation
, 9 21:26- 3 l.
rlt.t!ation: eurom uscu­
urtllll oj Neuroscieltc<
 CHAPTER 16

Aquatic Therapy in Rehabilitation

r-:.. . -w
Barbara Hoogenboom ~
Nancy Lomax

figure 16-1 Examp

quatic environment.
Study Resources • Identify and describe techniques of
To become more familiar with the knowledge and skills aquatic therapy for the upper extrem­ Water healing le
necessary to design . implement. and document therapeu­
ity, lower extremity. and trunk. through bistory as eal
tic rehabilitation programs as identified in the ;\ 'fl.TA fitl!­
the late nineteenth cer
leLic Training EducaLio lla] Compclrll(ics alUl Clillical • Select and utilize various equipment ercise types of aq uatic
ProjlCiCllcics'Therapell.lic E.xercise conteut area, visit
for aquatic therapy. development of tbe Hl
www.mhhe.com/pren1.icel l c. i\lso refer to the lab exer­
tiation of present-d ar
cises in the new Laboratory Manual and to eSims. which • Incorporate sport-specific movements aqua tic therapy to hi'
simulates the athletic training certification exam, at
w\\'w.mhhe .co m /e si!Jl~. For more on line study resources,
and exercises performed in the aquatic clin ical setting. ' Loern
environmen t into rehabilitation. in 1924 and stimula
visit om I [ealth and Human Performance website at
nly recently, howe\ _
wIl'w.mhhe.comJhhp.
• Understand and describe the necessity therapeutic exercise n
Aquatic therapy'
After Completion of This
for transition from the aquatic environ­
decreases joint coml
Chapter, the Student Should
ment to the (land) playing environment. weightlessness expe .
Be Able to Do the Following:
pain and eliminate 0:
rive muscular guan o.
• Explain the principles of buoyancy and la r spasm and pa in _
specific gravity and the role they have daily functional acth~
in the aquatic environment. therapy is to teach ill
n recent years. widespread interest has developed in the
• Identify and describe the three major
resistive forces at work in the aquatic
I area of aquatic therapy. It has rapidly become a popular
rehabilItation technique among athletic trainers. This
newfound interest has sparked numerous research efforts to
ity for improving rn
Then, along with ot~
ments, aquatic therd
lete's recovery ch ain.
environment. evaluate the effectiveness of aquatic therapy as a therapeu·
tic modality. Current research shows aquaUc therapy to be
• Apply the principles of buoyancy and benefiCial in the treatment of everything [rom orthopedlc PHYSICAL .,
resistive forces to exercise prescription injuries to spinal cord damage, chronic pain, cerebral palsy, RESISTIVE ~
multiple sclerosis, and many other conditions, making it
and progression. The ath letic trainer
useflll in a variety of settings. 2.;. 31 It is also gaining accept­
ance as a preventative maintenance tool to facilitate overall properties of the \\'a
• Contrast the advantages and disadvan­
fitness, cross-training, and sport-specific skills for healthy apy program. Land
tages of aquatic therapy in relation to athletes1 7.1~ (Figure 16-1). Movement skills, conditioning. aquatic exercise. b
traditional land exercises. and strength can all be enhanced by aquatic therapyI6.37.42 lhe major force gO\'e

326


tion
Figure 16-1 Example of sport-specific training ,in the
aquatic environment.
Water healing techniques have been traced back
Ih rough history as early as 2400 B.C .. but it was not until
Ihe late nineteenth century that more traditional water ex­
ercise types of aquatic therapy came into existence. 3.20 The
development of the Hubbard tank in J 920 sparked the ini­
ialion of present-day therapeutic use of water by allowing
. movements aquatic therapy to be conducted in a highly controlled,
n the aquatic linical setting. 7 Loeman and Roen took this a step farther
itation. 1924 and stimulated interest in actual pool therapy.
Only recently, however, has water come into its own as a
he necessity lherapeutic exercise medium,33
Aquatic therapy is believed to be beneficial because it
latie environ­
decreases joint compression forces. T.he perception of
environment. weightlessness experienced in the water seems to decrease
pain and eliminate or drastically reduce the body's protec­
tive muscular guarding, This results in decreased muscu­
lar spasm and pain that can carryover into the patient's
daily functional acLiviLiesY·4<lThe primary goal of aquatic
therapy is to teach the athlete how to use water as a modal­
[ has developed in th~ ity for improving movement. strength, and fitness.-') 4 -7
dh' become a popular
Then , along with other therapeutic modalities and treat­
ILhletic trainers. Thb me nts, aquatic -therapy can become one link in the ath­
us research efforts to
lete's recovery chain, 1
hera py as a therapeu­
aquatic therapy to Jxo
hing from orthopedic PHYSICAL PROPERTIES AND
pain. cerebral pals~. RESISTIVE FORCES
:.-onci.itions, making -.
- also gaining accept­ The athletic trainer mllst understand several physical
001 to facilitate overaE properLies of the water before designing ao aquatic ther­
rifi skiHs [or heallh. apy program, Land exercise cannot always be converted to
It ki lls, conditioning. aquatic exercise, because buoyancy rather than gravity is
iquatic therapy.16. 3,.L the major force governing movement. A thorough under-
CHAPTER 16 Aquatic Therapy in Rehabilitation 327
o t Grn";'Y
· · ···· B"~~"~y~ r '· 'V~ ·/~~· '~~·
Figure 16-2 The buoyant force ,
standing of buoyancy, specific gravity, the resistive forces
of the water, and their relationships must be the ground­
work of any aquatics program. The program must also be
specific and individualized to the athlete's particular in­
jury and sport if it is to be successful.
Buoyancy
Buoyancy is one of the primary forces involved in aquatic
therapy. All objects, on land or in the water, are subjected
to the downward pull of the earth's gravity. In the water,
however, this force is counteracted to some degree by the
upward buoyant force, According to Archimedes' Princi­
ple. any object submerged or lloating in water is buoyed
upward by a counterforce thal helps support the sub­
merged or partially submerged object against the down­
ward pull of gravity. In other words, tbe buoyant force
assists motion toward the water's surface and resists mo­
tion away from the surface. 2 1. 42 Because of this buoyant
force, a person entering the water experiences an apparent
loss of weight. 14 The weight loss experienced is nearly
equal to the weight of the liquid that is displaced when the
object enters the water (Figure 16-2).
For example, a 100-pound lndividual. when almost
completely submerged. displaces a volume of water that
weighs nearly 93 pounds: ther,efore that person feels as
though she or he weighs less than 5 pounds. This sensa­
tion occurs because, when partially submerged, the ,indi­
vidual only bears the weight of the part of the body that is
above the water. With immersion to the level of the sev­
enth cervical vertebra, both males and females only bear
approximately 6 to 10 percent of their total body weight
(TEW). The percentages increase to 25 to 31 percentTBW
for females and 30 to 3 7 percent TBW for males at the
Xiphisternal level and 40 to 31 percent TBW for females
328 PART THREE The Tools of Rehabilitation
• TABLE 16·1 Weight-Bearing
Percentages
Percentage of Weight Bearing
Body Level Male Female
C7 8%
Xiphisternal 28%
ASIS 47%
and 50 to 56 percent TBW for males at the anterosuperior
iliac spine (ASIS) level 21 (Table 16-1). The percentages dif­
fer for males and females due to the differences in centers
of gravity. Males carry a higher percenta.ge of tlleir weight
in the upper body. whereas females carry a higher per­
centage of their weight in the lower body. The center of
gravity on land corresponds with a ccnter of buoyancy in
the water.33 Also. variations of build and body type only
minimally effect weight bearing values. Due to the de­
creased percentage of weight bearing each jOint that is be­
low the water is decompressed. This allows ambulation
and vigorous exercise to be performed with little impact
and drastically reduced friction between joint articular
surfaces.
CLINICAL DECISION MAKING Exercise 16-1
A 35-year-old male sustained 3 right rotator cuff tear
while playing softball. Three weeks ago he hud a surgical
repair of a lear of less than 2 centimeters and has now
been referred for rehabilltation. He is active and plays soft­
ball, golf, and tenniS. At what point could he begin to pur­
ticipa\e in all aquatic program during his rehabilitation?
Specific Gravity
Buoyancy is partially dependent on body weight. However.
the weight of different parts of the body is not constant.
Therefore, the buoyant values of different body parts wiU
vary. Buoyant values can be determincd by several factors .
The ratio of bone weight to muscle weight, the amou nt
and distribution of fat. and the depth and expansion of the
chest all playa role. Together. these factors determine the
specific gravity of the individual body part. On the average.
humans have a specific gravity slightly less than that at
water. Any object with a specifk gravity less than that of
water will Ooat. A speeific gravity greater than that of wa­
ter will cause the object to sink. However, as with buoyant
values, the specific gravi ty of all body parts is not uniform.
Therefore, even with a total-body speCific gravity of less
than the specific gravity of water. the individual might not
noat horizontally in the water. Additionally. the lungs,
when 1111ed with air, can further decrease the speCific grav­
ity of the chest area. This allows the head and chest to 110at
8%
higher in the water than the heavier, denser extremities.
35 %
Many athletes tend to have a low percent body fat (specifk
54%
gravity greater than water) and are "sinkers." Therefore,
compensation with Ootation devices at the extremities ana
trunk might be necessary for some athletes. 4 .42
Resistive Forces
Water has 12 times the resistance of air. 19 Therefore. when
an object moves in the water. several resistive forces are at
work that must be considered. Forces must be considered
for their potential benefits and precautions. These forces
include the cohesive force. the bow force, aod the drag
force.
Cohesive Force. There is a slight bat easily over­
come cohesive force that runs in a parallel direction to the
water surface. This resistance is formed by the water mole­
cules loosely binding together. creating a surface tension.
Surface tension can be seen in still water. because the wa­
ter remains motionless with the cohesive force intact un­
less disturbed.
Bow Force. A second force is the bow force. or the
force that is generated at the front of the object during
movement. ''''hen the object moves. the bow force causes
an increase in the water pressure at the front of the object
and a decrease in the water pressure at the rear of the ob­
ject. This pressure change causes a movemeot of water
.oeily of the object. 1
from the high-pressure area in the front to the low-pres­
ercises should be pc
sure area behind the object. As the water enters the low­
poSition possible in
pressure area, it swirls into the low-pressure zone and
ment (Figure 16-5 1.
forms eddies. or small whirlpoolt urblllences. 11 These ed­
On the other h ~
dies impede Dow by neating a backward force, or dra g,
urbulent situation ,
force (Figure 16-3).
.Irag) exists. In a turi;
Drag Force. This third force, the Ouid drag force. is
.he veloeit)' squa.red.
very important in aquatic therapy. The bow force. and
""lovemeot 2 Limes. th
therefore also the drag force, on an object call be controlled
increased 4 times.
by changing the shape of the object or the speed of its
istance progressh
movement (Figllre 16-4).
·.derable turbu lence
Frictional resistance can be decreased by making the
""lovement is incrc
object more streamlined. This change minimizes the sur­
,"arder to keep th e m
face area at the front of the object. Less surface area causes
•~e ase resistance is 1
less bow force and less of a change in pressure between th
ing increased drag.
front and rear of the object, reSUlting in less drag force. In
. a limb through th e
a streamlined Oow, the resistance is proportional to the ve­
 CHAPTER 16 Aquatic Therapy in Rehabilitation 329

.:r. as with buoyant

rts is not uniform.
inc gravity of less
.dividual might not
·on ally. the lungs. Force
the specitlc grav­
d a nd chest to t10at
enser extremities.
t body fat (specific
. - rs ." Therefore.
Movement

Figure 16-3 The bow force.

Therefore. when

:•
Force Drag force

Movement

e bow force cau Figure 16-4 Drag force.

e front of the object
1 th e rear of the ob·
ovement of water
I city of the object. Therefore, to assist a weak athlete. ex­ that increases surface area, the athletic trainer can modify
or to the !ow-pr -­
rcises should be performed slowly in the most streamlined the athlete's workout intensity to match strength increases
"ater en ters the 10\\­
position possible in order to decrease resistance to move­ (Figure 16-6).
-pressure zone anu
ment (Figure 16-5). Drag force must also be considered when portions of a
lences .11 These
On the other hand. if the object is not streamlined, a limb or joint must be protected after injury or surgery. For
mrd force . or dra"
urbulent situation (also referred to as pressure or form example, when working with an athlete with an aClltely
drag) exists. In a turbulent situation. drag is a function of injured MCL or ACL of the knee. resistance mllst not be
e fl uid drag forc e.
.be velocity squared. Therefore by increasing the speed of placed distal to the knee. due to the increased torque that
The bow force. a
movement 2 times, the resistance the object must overcome occurs due to drag forces.
eet can be contrall
- increased 4 times. 14 This provides a method to increase Quantification of resistive forces that occur during
r the speed of i
resis tance progressively during aquatic rehabilitation. Con­ aquatic exercise has been a challenge. Poyhonen et al . ex­
lderable turbulence can be generated when the speed of amined knee l1exion and extension in the aquatic envi­
:novement is increased, causing the muscles to work ronment using an anatomic model in barefoot and
arder to keep the movement going. Another method to in­ hydroboot wearing conditions . They found th at the high­
surface area caUStc
.Tease resistance is to change directions of movement. cre­ est drag forces and drag coefficients occurred during early
pressure bet.ween
tin g increased drag. Finally. by simply changLng the shape extension from a t1excd position (150 t.o '1 40 degrees of
~ in less drag forc .
a limb through the addition of rehabilitation equipment l1exion) while wearing the hydroboot (making the foot less
oportional to th \ - '
330 PARTTHREE The Tools of Rehabilitation

..
..
Force ..
..
..

• Movement

Figure 16-5 StreClmlined movement. This creates less drag force and less
turbu lence.

Force
• figure 16-7 Deep
~

• • TABLE 16­

• Indications for U:

• Movement
-wel ling/peripheral

creased range of I
Figure 16-6 Turbulent flow.
Decreased strength

Decreased bala nce. I

streamlined), and th a t fasLer velocity was associated with
higher drag forc es. 36
Through careful use of Archimedes' Principle, a gradual
increase in the percentage of weight bea ring can be under­
taken. Initially, the athlete would begin non-weight-bearing
in the deep end of the pool. !\ wet vest or similar buoyancy
device might be used to help the athlete remain aOoat It)r the
desired exercises (Figure 16-7). Other commercia l equip­
ment available for use in the aquatic environment will be dis­
cussed in the section "FacUities an d Equipment"
On ce therapy has progressed, the athlete could be
moved to neck-deep wClter to begin ligh t weight bearing.
Gradual increases in the percentage of weight beari ng are \'cight-bearing re
accomplished by systematically moving the athlete to
shallower water. Even when in waist-deep water. both .."ardiovascular deco
male and female athletes are only bearing approximately onditioning due 1
50 percent of their TEW. By placing a sinkable bench or ~a i t deviations
chair in the shallow water. step-ups can be in itiCl ted under Difficulty or pain \\"j
partial-weight-bearing conditions long before th e a thl ete
is capable of performing the same exercise in full weight
bearing on land. Thus the advantages of low weight bear­ -ompik-d and lllodi l1ec
ing are coupled with the proprioceptive benellts of closed­ \'el/ Uon. edited b)' \\ .
kinetic-chain exercise, making aquatic therapy an IBoston: Jones & Bar
.-\lhlete," Journal of (
excellent [uncUonal reh abilitation activity.
 CHAPTER 16 Aquatic Thcrapy in Rehabilitation 331

ADVANTAGES AND BENEFITS OF

AQUATIC REHABILITATION
The addition of an aquatic therapy program can offer
many advantages to an athletc's therapylY.42 Crable 16-2).
The buoyancy of the water allows active exercise whil e
providing a sense of security and causing lillie diseom­
fort,4 0 Uilizing a combinat·ion of the water's buoyancy. re­
sistance. and warmth . the athlete can typically ac hieve
more in the aquatic environment than is possible on
land. 2x Early in the rehabilitation process. aquatic therapy
is useful in restoring range of motion and flexibility. As
normal function is restored. resista nce training and sport­
specific activities can be added.
Fo'llowing an injury. th e aquatic experience provides a
medium where early motion can be performed in a support­
ive environment. The slow-motion effect of moving through
water provides extra time to control movement. which al­
lows th e athlete to experience multiple movement errors
without severe consequences. JR Tbis is especially helpful in
lower-extremity injuries where balance and proprioception
a nd balance are impaired. Geigle et al. demonstrated a posi­
tive relationship between usc of a supplemental aquatic
therapy program and unUatera] tests of balance when treat­

)
19ure 16-7 Deep-water running.
ing athletes with inversion ankle sprains . IS The increased
amount of time to react. combined with a medium in which

)
• TAB LE 16·2 Indications and Benefits of Aquatic Therapy

Indications for Use of Aquatic Therapy Illustration of Benefits

:\\'elling/peripheral edema Assist in edema control. decrease pain. increase mobility as

edema decreases
:kcreased range of motion Earlier initiation of rehabilitation. controlled active m ovements
De teased strength Strength progression from assisted to resisted to functional ;
gradual increase i'n exercise intensity
Decreased balance. proprioception . coordinatio n Earlier return to function in supported. forgiving environmcnt.

~
-eight
slower 1I10Vemel1 ts
bearing ar Weight-bearing restrictions Can partially or completely ul1weightthe lower extremities: rcgu­
mg the athlete t late weight-bearing progrcssions

(-deep water. bot

Cardiovascular deconditioning or potential Gradual increase or cxercise intensity. alternatilic tra ining
. . g approximat l.
econdilioning due to inability to train environment for IOlVer weight-bearing
a sinkable bench
Gait deviations Slower movements. easier assessment and modification of gait
Difficulty or pain with land interventions Increased support. decreased weight-bearing. ass islaJ1ce due to
buoyancy. more relaxed environment
ercise in full weight
of low weight bear­ Comp iled and modif1cd from J. M. Irion . ',\q uatic Ther<lPY," in Bandy W. D. and S<lnders B.: Therapeutic Exercise: TechniquesJor lnler­
\'f benellts of closed­
l'el11ioll. edited by W. D. Bandy and B. Sanders (Baltimore: Lippin cott. Williams & Wilkin s, 200 1): R. Sova, Aquatic Activities Handbook
therapy an (Boston: Jones & Bartlett. 1993); and J. M. Thein and L, Thei n Brody. "Aquatic-Based Rehabilitation <lnd Training [or the Elite
Athlete. " Journal oj Orthopedic and Sports P17ysical l'llerapy 27( 1): 32--41 (19 98).
332 PARTTI-IREE 'l'heTools of Rehabilitation
the fear of falling is removed, assists the athlete's ability to
regain proprioception,
Turbulence functions as a destabi]jzer and as a tactile
sensory stim ulus. The stimulation from the turbulence
genevated during movement provides feedb ack and pertur­
bation challenge that aids in the return of proprioception
and balance. There is also an often overlooked benefit of
edema reduction due to hydrostatic pressure. This would
benefit pain reduction a nd increase range of motion.
By understanding buoyancy and utilizing its princi­
ples. the aquatic environment can provide a gradual tran­
sition from non-weight-bearing to full-weight-bearing
land exercises. This gradual increase in percentage of
weight bearing helps provide a return to smooth, coordi­
nated movements that are pain-free. By utilizing the buoy­
ant lorce 10 decrease apparent weight imd joint
compressive forces, locomotor activities ca n begin much
earlier following fl n injury to the lower extremity. This pro­
vi.des an enormous advflntflge to the athletic population.
The ability to work ou t bard without the fear of reinjury
provides a psychological boost to the athlete. This h elps
keep motivation high and can help speed the athlete's re­
turn to normal functio n .2B Psychologically. aquatic ther­
apy increases confidence. because the athlete experiences
increased success at locomotor. stretching. or strengthen­
ing flctivities in the water. Tension and anXiety arc de­
creased, and athlete morale increases, as does postexercise
vigor.13.H33
CLINICAL DECISION MAKING Exercise 16-2
A collegiate football player slIstained a severe ACLlMCL
and medial meniscus injury to the right knee. The injury
to thc medial meniscus was so severe that it was decmed
l1onrepairable. and the surgeon determined that a staged
surgery (ACL reconstruction first. later a meniscal allo­
graft) would best serve the athlete, The MeL is allowed to
heal without surgica l intervention. Despite well-designed
and well-executed rehabilitation after the ACL rt~con­
structiol1, it is likely that after the meniscal transplant a
clinical "regression" in strength , ROM. and function will
OCCLlr due to post-operative restrictions. What rehabilita­
tion techniques can the athletic trainer utilize to maxi­
mize the rehabilitation after the meniscal allograft during
the requisite non weigh t-bearing and partial weighl­
bearing phases?
Muscular strengthening and reeducation can also be
accomplished through aquatic therapy. 34.42 Progressive
structed in how to
resistance exercises can be increased in extremely small in ­
while eXercising in \
crements by using combinations of different resistive
Not only does tl
forces. The intensity of exercise ca n be controlled by ma­
tion. but the aqu atil
nipulating the !low of water (turbulence). the body's posi­
't ory deconditioni ng
tion or throug h the addition of exercise equipment. This
dynamics as a res ul
allows individuals with minimal muscle contrflction capa­
actually function s []
bilities to do work an d see improvement. The aquatic envi­
tic pressure enhanc
ronment can also provide a challenging resistive workout
stroke volume and c
to an athlete nearing full recovery.42 Additionally, the wa­
maintain cardiac Oli
ter serves as an accommodating resistance medium. This
Ulations and an in,
allows the muscles to be maximaHy stressed through the
means that the In
full range of motion available. One drawback to this. how­
normal maxima! <
ever. is that strength gains depend largely on the effort ex­
cise. 1 >.32 Due to the
erted by the ath lete. which is not easily quantil1ed.
it has been suggeSll
In another study. P6yh6nen et a!. n studicd the bio­
fise prescription i
mechanical flnd hydrodynamiC characteristics of the
gests the use of 1
thcrape utic exercise 01 kn ee flexion and extension using
controlling exercise
kincmatic and electTomyographic analyses in !lowing
use target heart rat€
and still water. They found that the flowing properties of
pen sates for the hye
water modified the agonist/antagonist neuromuscular
ra nge 10 percent Ie
function of the quadriceps and hamstrings in terms of
exercise. Actual trai
early reduction of quadriceps activity and concurrent in­
the aquatic environ
creased activation of the ha mstrings. They also found
heart rates establi!
that flowing water (turbule nce) causes additional resist­
(Table 16-3). Regar
ance when mov,i ng the limb opposite th e flow. They con­
mccessful use of c
c1udc that when prescribing aquatic exercise, the
monitoring of the c
turbulen ce of the water mllst be considcred in terms of
munication betweel
both resistance and alterations of neuromuscular re­
cruitment of muscles. -
CLINICAL DECIS
SLrength gains through aquatic exercises arc also
brought abou t by the increased energy needs of the body
working in an aquatic environment. Studies have shown A hJgh school
that aquatic exercise requires a higher en ergy expenditure
than the same exercise performed on land .9 .l3.1 4 A2 The
ath letc not only has to perform the activity but must also
maintain a level of buoyancy and overcome the resistive
pclltive season bu
forces of the water. For example, the energy cost for water
mJght the athletic
running is four times greater than the energy cost lor run ­
ning the same distance on land.l l.1u r, allow her to main
compete?
A simulated run in either shallow or deep water as­
sisted by a tether or flotation devices can be an effective
meons of alternate fitness training (cross-training) for the
injured flthlcte. It should be noted that a study of shal·low­ DISADVANl
water running (xiphoid level) and deep-water running (us­
ing an aqua jogger), at the same rate of perceived exertion. REHABILlT;
fou n d a signilkant difference of 10 beats/ minute in heart
Disadvantage
rate, with shallow-water running demonstrating a greater
heart rate. The authors of this study point out that aquatic
with any thera ~
:\ 5
rehabilitation professionals should not prescribe shallow­
disadvantages. The
water working heart rates from heart rate values obtaincd
habilitation pooL if
during decp-wa ter exercise. l7 All at hletes should be in­
 CHAPTER 16 Aquatic Therapy in Rehabilitation 333

structed in how to accurately monitor their heart rate • TABLE 16-3 Karvonen Formula for
vhile exercising in water, whether deep or shallow. 9 Water Exercise
different resistin.>
Not only does the athlete benefit from early interven­
'ontrolled by ma­
tio n. but the aquatic exercise helps prevent cardiorespira­ 220

'I. t he body's posi­

tory deconditioning through alterations in cardiovasculcj[ - age

uipment. This ynamics as a result of hydrostatic forces, 1>.2341 The heart Maximal heart rate

actually functions more efllciently in the water. Hydrosta­ Maximal 'heart rate

tic pressure enhances venous return. leading to a greater - Resting 'heart rate

oke volume and a reduction in the heart rate needed to Reserve heart rate

maintain cardiac output. 4 J There is also a decrease in ven­

til ations and an increase in central blood volume. This
m ea ns that the injured athlete can maintain a near­ Heart rate reserve Heart rate reserve

normal maxima l aerobic capacity with aquatic exer­ X 0.50 (intensity level) X O.H 5 (in tensity level)

cise. j ' .. l l Due to the hydrostatic effects on heart efficiency, + Resting henrt rate + Resting heart rilte
qu a ntified . l has been suggested that an environment-specific exer­ Minimum working Maximum working
, studied the bi
' ise prescription is necessary. 2 7,41.4 5 Some research sug­ heart rate heart rate
n eristics of t h ,
gests the use of perceived exertion as a method for (land-based exercise) (land· basco exercise)

~ ~

'ontrolling exercise intensity. Other research continues to

u e target heart rate values as with land exercise, but com­
pe nsates for the hydrostatic changes by setting the target Minimum working Maximum working
ra nge] 0 percent lower than would be expected for land heart rate heart rate
exercise. Actual training heart rate should be calculated in (land-based exercise) (land-based exercise)
h e aquatic environment rather th an relying on working - 1 7 bea ts per min ute - 1 7 beats per minute
. T hey also fou o .... heart rales established during land-based exercise 39 ,42 Minimum working Maximum working
_ addition al re s .­
Table 16- 3). Regardless of the method used. the keys to heart rate for aquatic heart rate for aquatic
the flow. They con ­
successful use of aquatic therapy are supervision and exercise exercise
atic exercise. lh "Donitoring of the athlete during activity and good com­
ide red in term munication between nthlete and athletic trainer.
Target work zone for aquatic exercise
CLINICAL DECISION MAKING Exercise 16-3
Adapted from R. Sova, Aquatic Activities [Jal/(lbook (Bos ton: Jones
A high school cross-country runner sustained a small & Bartlelt. 1993 ). p. j5.
ludies have shOl\
second-metatarsal stres reactlonJfracture during the
energy expenditur
la ndY' 13, 14.42 T short 3-month season in response to increased volume
and in tensity of tralnlng. She has been cleared by her can be very high. Also, qualified pool attendants must be
'\i ty but must al presen t. and the sports therapist involved in the treatment
physician to finish out the remaIning 3 weeks of the com­
rc me the resislh must be trained in aq u atic safety and therapy proce­
petitive season bulls only allowed to run In meets. What
ergy cost for wal dures. 1 1. 26
might the athletic trainer sugge t for alternate training to
energy cost for r un­ An athlete who requires high levels of stabilization will
allow her to maintain aerobic function and enable her to
compete? be more challenging to work wi th. beca llse stabiliza tion in
the wateris considerably more difficult than on land. Ther­
moreg ulation issues exist for the athlete who exercises in
an aquatic environment. Because th e athlete cannot al­
DISADVANTAGES OF AQUATIC ways choose the temperature of the pool. the elTects of wa­
REHABILITATION ter temperature must be noted for both cool and warm or
hot pool tempera tures. Water temperatures greater than
Disadvantages body temperature cause increases in core body tempera­
onstrating a greal,
ture greater than in a land environment, due to differences
int out that aqu a -\s with any therapeutic modality. aquatic therapy has its in thermoregulation. Water temperatures less than body
l prescribe shall .:i adva ntages. The cost of 'building and maintaining a re­ temperature will decrease core temperatures in athletes
rate va Iues obtain a biliLation pool. if there is n o access to an existing facility, faster and more than in the general population, due to the
le tes should be '
334 PART THREE The Tools of Rehabilitation
• TABLE 16·4 Contraindications for
Aquatic Therapy
Untreated infectious disease (patient has a fever/
tempera ture)
Open wounds or unhealed surgical incisions
Contagious skin diseases
Serious cardiac conditions
Seizure disorders (uncontrolled)
Excessive fear of water
Allergy to pool chemicals
Compiled and modit1ed from J. M.lrion. 'I\quatic Therapy," Ther­
apeutic Exercise: Teclmiques Jor Intervention, edited by W. D.
Bandy and B. Sanders (Baltimore: Lippincott. Williams &
Wilkins. 2001); R. Soya. Aquatic Activities Handbook (Boston:
Jones & Bartlett. 1993 ): and J. M. Thein and L. Thein Brody.
'I\q uatic-Based Rehabilita tion and Training for the Elite Ath­
lete." Jouma} oj Orthopedic and Sports Physical Therapy 27(1):
32-41 (1998).
low body fat of many athletes. and cause shivering. 9 An­
other disadvantage of aquatic exercise uti.[jzed for cross­
training is that training in water does not allow the athlete
to improve or maintain their tolera]lce to heat while on
land.
Contraindications and Precautions
The presence of any open wounds or sores on the patient
is a contraindication to aquatic therapy. as are contagious
skin diseases. This restriction is obvious for health reasons
to reduce the chance of infection of the patient or of oth­
ers who use the pooI.24.25.31.39 Because of this risk. all sur­
gical wounds must be completely healed or adequateJy
protected using a wa terproof barrier before the ath'rete en­
ters the pool. An excessive fear of the water would also be
a reason to keep an athlete out of an aquatic exercise pro­
gram. Fever. urinary tract infections, aUergies to the poo.]
chemicals. cardiac problems, and uncontrolled seizures
are also contraindications (Tables 16-4 and 16-5). Use
caution (or waterproof barrier) with medica'l equipment
access sites such as an insulin pump.
FACILITIES AND EQUIPMENT
When considering an existing facility or when planning to
build one, certain characteristics of the pool should be
taken into consideration. The pool should not be smaller
than 10 feet by 12 feet. It can be in-ground or above­
ground as long as access for the athlete is well planned.
• TABLE 16·5 Precautions for the Use
of Aquatic Therapy
Recently healed wound or incision, incisions covered by
moisture-proof barrier
Altered peripheraJ sensation
Respiratory dysfunction (asthma)
Seizure disorders controlled with medications
Fear of water
Compiled and modilled from J. M. Irion. ':l\quaticTherapy." Tiler­
apeutic Exercise: TechniquesJor Intervention, edited by W. D.
Bandy and B. Sanders (Baltimore: Lippincott. Williams &
Wilkins, 2(01): R. Soya. Aquatic Activities Handbook (Boston:
Jones & Bartlett. 1993); and f. M. Thein and L. Thein Brody.
'/\quatic-Based Rehabilitation and Training for the Ellie Ath­
figure 16·8 The
lete." Joumal oj OrtllOpedic alld Sports PllysimJ Th erapy 2 7( 1):
u ollable water fl m\
32-41 (1998).
al lzed prescriptive e'
many as three patie
Both a shallow area (2)0; feet) and a deep area (5 + feet)
should be present to allow standing exercise and swim­
ming or nonstanding exercise. 7 The pool bottom should be
flat and the depth gradations clearly marked . Water tem­
perature will vary depending 011 the activity. For the ath­
lete, recommended pool temperature should be 2 6 to 28°C
(79-82 OF) but may depend on the available facility.41
Some prefabricated pools come with an in-water
treadmill or current-producing device (Figures 16-8 to
16-10). These devices can be benefic.jal but are not es­
sential to treatment. An aquatic program will benel1t
from variety of types of equipmel1t to allow increasing
levels of resistance and assistance. and also to motivate
the athlete. Catalog companies and sporling goods stores
are good resources for obtaining equipment. There are
many styles and variations available in regard to equip­
ment: the athletic trainer will need to select equipment
Figure 16-10 ell
depending on the needs of the program. Creative use of
actual sport equipment (baseball bats, tennis racquets.
golf dubs. etc.) (Figures 16-1. 16-15.16-20) to incorpo­ wimwear that co
rate sport-specil1c activities will challenge the athlete. an d upper trun k/u~
Use of mask and snorkel will allow options for prone ac­ of profeSSionalism i
tivities/swimming (Figures 16-18 . 16-32). Instruction in another imporlaJ!
the proper use of the mask and snorkel is essential for the .\·ell as athlete. Prol
athlete's comfort and safety. Equipment aids for aquatic prevents injuries. at
therapy, or so called "pool toys." are limited only by the
imagination of the sports therapist. 21 What is important AQUATIC TI
is to stimulate the athlete's interest in therapy and to keep
in mind what goals are to be accomplished. _.quatic techniqu
The clothing of the athletic trainer is an important ave assistive mOve
consideration. Secondary to the close proximity of the ath­ strengthening an
letic trainer to the athlete with some treatments. wearing lected based on seH
 CHAPTER 16 f\quatic Therapy in Rehabilitation 335

IS for the Use

, Therapy

tl ions covered by

\cations

qua tic Therapy," Tlzer­

edited by W. D.
olt , Williams &
Handbook (Boston:
rod L. Thein Brody,
for the Elite Ath­
'cal Therap!I 2 7( 1): Figure 16-8 The SwimEx pool. This pool's even , con­
trollable water flow allows for the application of individu­
alized prescriptive cxercise and therapeutic programs. As Figure 16-9 Custom pool with treadmill,
many as three patients can be treated Simultaneously,
deep area (5+ fect i
exercise and swim­
pol bottom should be
marked, Water tem­
activity, For the ath­
ho uld be 26 to 28 or
rai lablc facility.42
with an in-water
ce (Figures 16-8 tl1
... i I but are not es­

rting goods stor

uipment. There ar
in regard to eq ui p­
-
o select equipmen Figure 16-11 Sports equipment for use in aquatic
Figure 16-10 Custom pool environment. environment.
, Creative use
. tennis racquet
- .16 -20) to incorpo­ ~ imwear that covers portions of the lower extremities

aJlenge the ath lete aIld upper trunk/upper extremities is an important aspect Type of injury/surgery
pti.ons ror prol1e a - r professionalism in the aquatic environment. Footwear Treatment protocols, ,if appropriate
6 -32), Instruction in another important consideration, for athletic trainer as Results/muscle imba la nces found in evaluation
el i ' essentia l for th ~ \'ell as athlete, Proper aquatic footwear provides stability, Goals/expected return to activities as stated by the
ent aids for aquat i.: prevents injuries, and matntains good foot position, athlete
limited only by the Aquatic programs are des igned similar to land-based
\ \ hat is importa AQUATIC TECHNIQUES programs, with the following components:
th erapy and to ke p
pH bed, -\quatic techniques and activities can be designed to be ac­ Warm-up
er is an importan tive assistive movements and can be progressed to work on Strengthening/ mobility activities
proximity of the at h­ trengthening and eccentric control. Activities are se­ Endurance/ cardiovascular activities
t treatments, wearin ", ected based on several factors: Cool-down/stretching
336 PART THREE The Tools of Rehabilitation
Figure 16-12 Prone kayak movement using mask and
snorkel. Challenges the upper extremities and promotes
stabi1ization of the trunk.
Figure 16-14 Prone hip abduction / adduction with
manual resistance by athletic trainer. Note use of mask
and snorkel. allowing athlete to maintain proper trunk
and head/neck position .
With these general considerations in mind, the follow­
ing sections provide examples of aquatic exercises for the
upper c.:dremity, trunk, and lower extremity in a three­
phase rehabilitation progression.
The Upper Extremity
The goal of rehabilitation is to restore function by
restoring motion and rbythm of movement of all joints
of the upper extremity. Aquatic therapy may be used for
treatment of the shoulder complex, elbow. wrist, and
Figure 16-13 Sport-specific training using buoyancy Figurel6-15 JmeI
cuffs around a bat for resistance. te appropriate noat
hand as one of the modalities to accomplish goals along
with a land-based program. The following sections de­
scribe a rehabilitation progression for shoulder complex
dysfunction.
Initial Level. The athlete can be started at chest­
deep water to allow for support of the scapular/thoracic
area. Vlalking forward, backward, and sideways will allem'
for warm-up, working on natural arm swing, and restora­
tion of normal scapulolhoracic moLions, rotation. and
rhythm. [nitiatioll of activities to work on glenohumeral
motions can be started at the wall (athlete with back
against the wall); having the athlete in neck- or shoulder­
deep water gives the athlete physical cues as to posture and
quality of movement. The primary goal during the carly
Igure 16-16 Ran;
phase is for the athletic trainer and athlete to be aware of
n.
the amount of movement available without compensatory
shoulder elevation. The other options for positions durin g
early treatment are supine and prone. The athlete wi ll terns (nexion/e\
need flotation equipment for cervical, lumbar. and lower­ uction) in pain- f.-e
extremity support in order to have good positioning when Intermediate ~
supine (Figure 1 6-1 5). ed to challen ge.
Supine activities include stretching, mobilization . and lion through the
range of motion. Stabili:t.ing the scapula with one han d. , area of the eXlr
the athletic trainer can work on glenohumeral motion r arm will incre.
with the athlete (Figure 16-16). The athlete can iniLiate "a thl ete progre
active movement in shoulder abduction and extension. ding position b
Prone activity can be done depending on an athlete' he 90-degree an~
comfort in water and use of mask and snorkel. Flotation waler. It is impor
support around the pelvis aHows the athlete to concentrate - position of th e
on movement. The athlete is able to perform pendulum-type d substitution patl.l
movements. PNF diagonal. and straight-plane movemen: idties while stan
 CHAPTER 16 Aquatic Therapy in Reh abilitation 337

using buoyancy Figure 16-15 Jntcrnal Clnd external rotation in supine. Figure 16-17 Other pool equipment: underwater step.
, lote appropriate noatation support for the athlete. mask and snorkel , kickboard , and tubing.

The athlete will be able to progress with scapular stabi­

pliSh goals along lization from standing to supine and prone positions .
low ing sections de­ Supine and prone positioning can allow for more func­
houlder complex tional movement patterns and core stabilization of the
scapular muscles. Flotation assistance [rom equipment as
well as use of mask and snorkel will allow [or proper cervi­
capular/ thoracic cal and spine positioning during prone activities (Figure
ideways will al[o\\­ ] 6-1 7). Activities such as PNF diagonal patterns can be
swing, and restora­ performed with resistance in the paLn-free range. A'lternate
s. rotation. an d shoulder llex1ion, "kayaking" type motion (Figure J 6-12),
on glenohumeral and horizontal shoulder abduction/adduction can all be
ta thlele with back performed USing various types of equipment or manual re­
sistance provided by the athletic trainer. Supine positioning
as to posture an d allows for work on shoulder extension at varying degre s of
during the early abduction (Figure 16-18) and activities to work on internal
Figure 16-16 Range of motion with scapular stabiliza­
lete to be aware of and external rotation (see Figure 16-15). The land-based
lion.
thout compensatoD program and aquatic program should be coordinated to en­
fo r positions durin g sure continued improvement of strength, endurance, and
The ath lete ~ ILl patterns (f1exilln!extcnsion and horizontal abduction! function. The goal of treatment in the intermediate-level
adduction) in pain-free range. activities is development of strength and eccentric eonltrol
Int.ermediate Level. The program can be pro­ throughout increasing ranges of motion.
gressed to challenge strength by using equipment to resist Final Level. The goal of this level of treatment is
molion through the pain-rree range. Increasing the sur­ high-level. functional strengthening and training. Equally
fa ce area of the extremity or increasing the length of the important is the transition from the aquatic environment
lever arm will increase the difficulty of the activity. As to the land environment. lltilizing sport equipment in
the athlete progresses into this phase, the limitations of the treatment wHi keep the athlete motivated and working to­
and extension.
standing position becomes apparent. The athlete can work ward the goal of returning back to sport. Increasing the re­
nding on an athlete' _
to the 90-degree angle but not overhead without exiting sistance by using elastic or notation attachments will keep
ind snorkel. Flotation
the water. It is important lor the athlete to maintain a neu­ it challenging (Figure 16-13). As in the intermediate level.
thlete to concentrate
tral position of the spine and pelvic area to avoid injury the athlete needs to be involved in a strengthening and
fo rm pendulum-type
a nd substitution patterns when performing strengthening training program on land. This will ensure transition to
ghl-plane movement
etivities while standing. the act.ual playing environment.
338 PART THREE The Tools of Rehabilitation

Figure 16-18 Supine shoulder extension can be done Figure 16-19 Flotation equipment. Figure 16-21 Tn
at multiple angles. posterior forces.

CLINICAL DECISION MAKING Exercise 16-4

A] 7-year-old high school baseball pilcher bas un der­

gone an ulnar collateral Ugament repair of his domin ant
(right) elbow that used an autogenollb graft. According lo
the post-operalive protoco\' resistive exercises at the el­
bow mllSl be avoided for the next 4 weeks and a motion­
limiting el bow brace must be worn during all activities for
5 weeks after surgery. How mlght aquatic exercises be
used for this patient after the fifth weeki Are there any
precautions th at mllst be observed;

Figure 1'6-20 Equipment used for resistance or

f1oataLion. Figure 16-23 Ch,
Spine Dysfunction cul ar control and ba
.;ingle-Iimb stancc. l
The unloadjng characteristic of the water a,llow$ the ath­ If dealing with radicular (sciatica) type symptoms, th e
lete ease of movement and some potential relief of symp­ athlete will benel1! from deep-water traction. Flotation
tom ~ . The athlete will need to be shown how to obtain and support of the upper body and trunk and placement of ll sed to mimic push
maintain the neutral spine pOSition in the water even if light weights on the ankles will allow for gentLe distrac­ ures 16-21 and 1 f
they have been ,i nstructed on land. This is the basis of tion in the lumbar spine (Figures 16-19 and 16-20). The extremity or 101\'cr­
treatment in land and water al1d wHI be progressed in level athlete can hang to perform small pedaling motions as il' ta nce or lunge po
of dif'ficulty. Activities of the trunk, upper extremities, and bicycJ.ing. 29 and stabilization of ;
lower ex tremities all challenge trunk stability, strength, Working onnormaoJizing the gait pattern and develop­ 16-23).
and total body balance and neuromuscular control. ing the abillity to weight bear equally on the right and left The athlete's abil
Initial Level. The athlete is instructed in neutral legs can be done in any depth of water that is comfortable deep-water acti v,Jiie
spine posi Uol1 in a partial squat position with back against to the athlete. lncorporating gentle stretching and rota­ position whil e bri O!
the waH. Use of the pool wall provides [he athlete with a tion movements to increase pelvic mobility can be done in to tucking and rolli!
mechanism to monitor their ability to maintain the neu­ the pain-free motion. ) 6- 26). Activities Cat
tral position with activities. Upper- and lower-extremity Intermediate Level. At this level the athllete is pro­ rotation directions w
actil'ities can be progressed to incorporate the athlete's gressed away from the wall, and equipment is used to chal­ Activities in a SL
ability to stabilize without increasing symptoms. lenge the athlete's ability to stabilize. Kickboards can be trunk mobility an d I
 CHAPTER 16 AquilticTherapy in Rchubilitation 339

Figure 16-21 Trunk stabilization against anterior/ Figure 16-22 Trunk sLabilization against oblique/
posterior forces. diagonal forces.

figure 16-23 Challenging lower-extremity neUromus­ Figure 16-24 Tuck-and-roll exercise, extended
cular control and balance as well as trunk control in position.
single-limb stance, utililling upper-extremity resistance.
type ymptoms, tht

lrac tion. notalio

a nd placement
llsed to mimic pushing, puUing. and lifting motions (Fig­ ity using Bad Ragaz techniques (Figure 16-27)17 Activi­
\ ~ r gentle distra ­ ures 16-21 and 16-22). Equipment that rcsists upper­ ties in pronc position will allow I'or challenges to maintain
- 19 a nd 16-20). The
extrcmity or lower-cxtremity movemcnts in a Single-leg the ncutral spine position, and thc athlete may need nota­
.:Ialing motions as if
stancc or lunge position challengcs the athlete's balance tion equipment to accomplish that goal. The use of the
and stabilization of abdominal and pelviC muscles (Figure mask and snorkel will al1o\\l for better positioning of the
pattern and develo ­ 16-23). spine whilc pcrforming thc activities (see Figure 16-12). It
on the right and left The athlete's ability to stabilizc can be challenged using is important to monitor and teach thc athletc the neutral
. that is comfortable decp-watcr activities that require maintaining a vcrtical spine position with each new position that is introduced in
, tretching and rota­ position while bringing knees to chcst and progressing treatment program . The athletc should be ablc to maintain
bili ty can be done Ln to tucking and rolling typc movcmcnts (Figurcs 16-24 to the neulral spinc position while performing single knee to
16-26). Activities can be created to work on the diagonal and chest, opposite UE/ LE flexion / extension (kayak),
\-cl lhe athlete is pro­ rotation directions while maintaining the neutral position. Final Level. Depending on the athletic trainer's
pment is used tochal­ Activities in a supine position can work on incrcasing level of knowledge of the athlete's sport. it may be neccs­
e. Kickboards can be lrunk mobility and then progress to work on trunk stabil- sary to question the athlete more thoroughly on specifics
340 PART THREE The Tools of Rehabilitation
Figure 16-15 Tuck-and-roll exercise, tuck position .
Figure 16-17 Bad Ragaz technique for oblique trunk
stabilizaLion.
of the sport. The athletic trainer needs to be creative with
the usc of aquatic equipment and use equipment specific
to the athlete's sport to challenge for a higher level of
trunk stabilization. It is important to integrate movement
paHerns that arc the opposite of the ones the athlete nor­
mally performs in her or his sport. (For example, if a gym­
nast or ice skater predominantly turns or rotates in one
direction, have tbem practice turns in the opposite direc­
tion.) The water does allow the athlete an aJternate envi­
ronmentto train in. and this should be encouraged for the
seri ous athlete to avoid overuse type of conditions that can
occur. Especially in this phase. the athlete needs to be inte­
grated back into training on land. as the water environ­
ment does not allow for normal speeds and forces during
sport-specific activities.
Figure 16-16 Tuck-anel-roll exercise, pike position. Figure 16-18 Am
against tubing resisti
Lowe....Extremity Injuries
Aquatic therapy is a common modality for rehabilitation of
many injuries of the lower extremity because of the prop­
erties of unloading and hydrostatic pressure. At an early
phase of healing, the athlete may need to use a notation
belt, vest, exercise bars, noodles. etc. to give some support.
depending on pain and how long they have been non­
weight bearing. The aquatic environment allows for lim­
ited weight bearing and restoration of gait by calculating
the percentage of weight bearing allowed and weight of
the athlete and then placing the athlete in an appropriate
depth 01 water.
Initial Level. The expected goals at this level are re­ Figure 16-30
turn of normal motion and early strengthening of affected and extension, us in~
and unaffected muscles. The restoration of normal a nd by athletic trainer g
lunctional gait pattern is also desired. Performing back­
ward and sideways walking adds a functional dimension
to the program along with the traditional forward walk­ Deep-water aClii
ing. RalJge-of-motion activities may involve active motions cross-training op ~
of the hip. knee, and ankle. Utilizing cuffs, noodles, or kick­ athlete initially ma ­
boards under the foot will assist with increasing motioo. but can progress to
Exercises for strengthening noninvolved joints such as when able. For the ~
hips or ankles can be done with the athlete who has had a ing secondary to l ~
knee injury. However, it is important to remember that re­ workout along w it~
sistance may need to be placed above the injured knee to joints. Activities ell
decrease torque forces on the knee. It is import.ant to inte­ count.ry skiing. an
grate conditioning and balance activities within this initial [Figure 16-29).
phase. Standing activities are to be performed with atten­ The athletic traj
tion to maintaining the spine in a neutral position as well formed in the supin
as to challenging balance and neuromuscular control in supported with notai
the lower extremity (Figure 16-23). t10at evenly. The [ fa

Figure 16-28 Athletes running forward and backward
against tubing resistance.
Figure 16-30 SUpi:1C alternating hip and knee flexion
a nd extension, using Bad Ragaz technique. Hand contact
by athleLic trainer give the athlete cues for movement.
Deep-water activities will allow for conditioning and
ross-training opportunities (Figures 16-7. 16-11). The
a thlete initially may need more assistance with flotation
inc reasing motioL but can progress to decreasing the amount of flotation
\ed joints such a< when able. For the athlete who must be non-weight bear­
lete who has had c ing secondary to the injury. the deep water al:fows for a
workout along wilh maintaining strength in uninvolved
joints. Activities can involrre running. bicycling, cross­
important to inte­ country skiing. and in corporating sport-specific activities
within this initial (Figure 16-29).
a r med with atten­ The athletic trainer can also incorporate activities per­
(Tal posiUon as well formed in the supine position . The athlete will need to be
uscular control in supported with flotation eq uipment that will allow them to
float evenly. The trainer can stabilize the athlete at the feet
CHAPTER 16 Aqualic'l'herapy in Rehabilitation 341
Figure 16-29 Supported single-lower-extremity run­
ning movement. Note the appropriate support of the ath­
lete with buoyancy belts l and upper-extremity bell and
lower-extremity bell under the stationary LE. Also chal­
lenges trunk stabilization.
and have the athlete work on active hip and knee flexion
and extension to work on increasing range of motion at
the affected joint (Figure 16-30). Resistance of hip abduc­
tion and adduction can be performed in a supine position.
Again. attention must be paid to the location of applied
force. Resistance of the uninvolved leg movement will also
allow for strengthening of the injured extremity.
Intermediate Level. Depending on the injury or
surgery. the athlete wiUI progress to the intermediate level
quickly. The activities can be progressed by usc of weights
or flotation cuffs to increase difficulty. As in the initial
level, resistance may need to be placed more proximally
with ACL injuries/ surgeries and ligament injuries. Per­
forming circuits of straight-plane and diagonal patterns
with both lower extremities can be progressed by perform­
ing with upper-extremity support on the wall and pro­
gressing to no support. The athlete cao stand on an
uneven surface, such as a noodle or cuff. to challenge bal­
ance and stabilization. Eccentric activities can be per­
formed in shallow water with the athlete standing on a
noodle or kick board for single-'leg reverse squats, and uti­
Hzing a noodle, kickboard, or exercise bar for bilateral
reverse-squat motions in deep water (Figure 16-31) and
progressing to a Single-leg reverse squat.
Performing deep-water tether running or sprinting
forward and backward for increasing periods of time will
allow for overHll conditioning. The athlete can progress to
running in shallower water when allowed b5r injury or sur­
gery (Figure 16-32).
Supine activities can be continued with emphasis on
strengthening and stabilization of the trunk. pelvis, and
342 PART THREE The Tools of Rehabilitation
~~
Figure 16-31 Reverse squat, bilateral.
Figure 16-32 Athlete running against tether.
lower extremities. Placement of the athletic trainer's re­
sistance will depend on the athlete's strength, ability to
stabilize, and how much time has elapsed since surgery or
injury. Increasing the number of repetitions and/ or speed
of movement will provide more resistance and work on fa­
tiguing muscle groups. The prone position will provide in­
creased challenges to the athlete to perform hip abduction
and adduction along with hip and knee flexion and exten­
sion . The athlete can use the mask and snorkellor flotation
equipment to help with positioning while in the prone po­
sition (see Figure 16-14).
Sport-specific activities can be integrated into the pro­
gram. Practicing movement patterns needed for sport. the
athlete can start at chest depth and progress to shallow
water. As with spine rehabilitation. there is benefit from
practicing opposite movement patterns such as turns and
j.umps. Jumping program and activities can be initiated
wben appropriate.
Final Level. In the finalleveI. the athlete is involved athletic trainer sh Oll
with a high-level strengthening and training program. other. with knees slil
The aquatic program can be used to complement the land to compensate for thl
program. The athlete can continue to practice sport­
specific activities in varying levels of water. Decreasing the
use of flotation equipment can increase the difficulty of
Burdenko Met
deep-water activity. Using buoyancy cuffs on the ankles The Burdenko Melh
without using a flotation belt will challenge the athlete's healing modality. A
ability to stabilize and perform running il) deep water. En­ nents of dynamic he,
durance training in an aquatic environment is a good al­ in jury assessmen ts a
ternative for the healthy athlete's conditioning programs with the athlete in a
and may help prevent further injuries. As with the upper the injured athlete b
extremity, this phase also requires integration of aquatic­ a nd blood-flow an d D
and land-based exercises to successfully transition the ath­ activity. j Six essemiaJ
lete to full participation in sport on land. and maintaining the
lion. flexibility. endUJ
advocates the present
CLINICAL DECISION MAKING Exercise 16-5
tivities in the previOl
:ombination of wateo
A 20-year-old female collegiate basketball player was in­
center of buoyan c~ ;:
jured and sustalned left ACL tear. She had a surgical re­
formation on th iS (.
pair utilizing the hamstring graft. How soon can she
Readings" at ,he end
begin with actlvllies In tbe aquatic environment. and
what would be the goals of early intervention?
Halliwick Mett
The Halliwick Metho
SPECIAL TECHNIQUES L1als with physical dis
ntrol in waler. De\
Bad Ragaz Ring Method rick Method or con
ra mme,"s Portions
Bad Ragaz technique originated in the thermal pools of Bad restore an athlete's b
Ragaz, Switzerland, in the 1930s but continues to evolve sist in developin g s
through the years to working on muscle reeducation . halleoge the athlete
strengthening, spinal traction/elongation. relaxation. and hange in the direc
tone inhibition. 17 The properties of water-including buoy­ maintains a single-l
ancy, turbulence, hydrostatic pressure, and surface ten­ another athlete r uns
sion-provide dynamic environmentai forces during cor an increased chi
activities. The proprioceptive neuromuscular facilitation ca n change direction:
(PNF) patterns (see Chapter] 5) add a three-dimensional as­ echnique is availablf
pect to this method. Movement of the athlete's body through at the end of this eha:
the water provides the resistance. lO The turbulent drag pro­
duced from movement is in direct relation to the athlete's
speed of movement. The athletic trainer provides the move­
ment when the athlete works on isometric (stabilization) pat­
terns, but the athletic trainer is in the stable/ fixed position
when isokinetic or isotonic activities are being performed by
the athlete'7 (Figures 16-27 and 16-28).
Awareness of body mechanics and prevention of in­
jury are important to the athletic trainer when performing
resistive activities. The trainer should stand in waist-deep
water and wear aqua shoes for traction and stability. The
 CHAPTER 16 Aquatic Therapy in Rehabilitation 343

athlete is involved athletic trainer should stand with one foot in front of the
ining program. other. with knees slightly bent and shou lder-width apart,
plement the land to compensate for the long lever arm force of the athlete.
o practice sport­
er. Decreasing the Burdenko Method
the dif[1culty of
s on the ankles The Burdenko Method utilizes motion as the principle
eDge the athlete's healing modality. According to Burdenko,; the compo­
~lents of dynamic healing include: patterns of movement,
injury assessments and rehabilitation exercises that occur
·tioning programs with lhe athlete in a standing pOSition. the psychology of
with the upper the injured athlete benefiting from pain-free movement,
a tion of aquatic­ a nd blood-now and neural stimu lation being enhanced by
tran sition the ath- activity. ; Six essential qualities are necessary for perfecting
a nd maintaining the art of movement: balance. coordina­
Figure 16-33 Balance and neuromuscular contro'!
tion, nexibility, endurance. speed. and strength. Burdenko restoration technique for trunk and single :lower extrem­
advocates the presentation of these qualities in exercise ac­ ity. This exercise demonstrates the use of the principle of
Exercise 16-5 ti vities in the previously stated order. This method uses a turbulence. generated in the Halliwick technique to cha l­
ombination of water and land exercise and challenges tbe lenge the stability of th e athlete.
"enter of buoyancy and the center of gravity. For further
su rgica I re­
nfo rmation on this technique, see the section "Suggested
can she Readings" at the end of this chapter.
ment. Elnd

...................................
Halliwick Method
The Halliwick Method is commonly used to teach individ­

Jals with physical disabilities to swim and to learn balance
Aqnatic rehabilitation should not be the exclusive treat­
.::onLrol in water. Developed by James McMillan, the Halli­
i ck Method or concept is 'based on a ;' Ten Point Pro­
fers many positive psychological and physiological effects
J amme." 8 Portions of the technique can be used to
during the early rehabilitation phase of injury. JU.4l How­
"e tore an athlete 's balance. Use of turbulence forces can
ever, in subsequent phases of rehabilitation, it is typical to
sist in devefoping strategies for maintaining balance or
use combinations or land- and water-based training proto­
hallenge the athlete La main Lain a stable posture during a
cols Lo achieve rehabilitation goals. Because humans func­
. relaxation. aI hange in the direction of force. For example, the athlete
-incl uding bu }­ aintains a single-leg stance while the athletic trainer or
" nd surface ten­ other ath lete runs around the athlete (Figure 16-33).
tal forces duri n:­ r-or an increased cha llenge, those providing turbulence
u uJar facilitalior change directions. More ,i nformallon on the Halliwick
h nique is available in the "Suggested Readings" section
the end of this chapter.
CLINICAL DECISION MAKING Exercise 16-6
12-year-old femal e involved In high-level gymna tics
has complaints of low ba ck pain Wltb 5- to 6-bour train­
mg sessions 5 Lo 6 days per week. She Is dJagno ed with
grade 1 spondJyolisthesis at L4-S. Wha t Is a key principle
or position that she needs to be taughl. a nd how can
aquatic activities complement your land program?
CONCLUSIONS
ment option for the ath lete. The aquatic environment of­
tion in a "gravity environment," transition from waler to
land is necessary for rull rehabilitation of the athlete.
Sport-specific training (SST) can occur in waLer, but it is
difficult to reproduce in water the eccentric movements
and sport-specific movements with normal speed and force
as they occur on land .
The therapeutic exercise domain competencies (both
cognitive and psychomotor) of athletic training refer to
treatment of ath letes using a variety of techniques in­
cluding aquatic therapy. This chapter provides informa­
tion regarding indications and benefits as well as
contraindications and precautions to help the athletic
trainer incorporate aquatic exercise into a rehabilitation
program . Add ition ally, examples of therapeutic exercise
and progressions are emphasized to allow the athletic
trainer to use judgment. ski lls, and creativity when pre­
scribing and modi.fying exercise programs that include
the use or aquatic therapy.
344 PART THREE The Tools of Rehabilitation

Summary ~3. Hertler, L., M. Pro

1992. Water runniJ
gen consumption a
Science in Sports and
]. The buoyant force counteracts the force of gravity as it 6, Application of the principle of buoyancy allows for
.:: ... Hurley, R.. and C. TI
assists motion toward the waler's surface and resists progression of exercises, apy. Clinical Mmlllg
motion away from the surface. 7, Upper- and lower-extremity activities require and 15. Irion, J. M. 2001 .
2. Because of dUTerences in the specific gravity of the challenge trunk and core stability, Techniques for inu
body. the head and chest tend to Iloat higher in the wa­ 8, The special techniques exclusive to the aquatic envi­ B. Sanders. BaJUmo
ter than the heavier. denser extremities. making com­ ronment can be used to complement traditional reha­ 26 . Kolb, M, E, 195 7. r
pensation with flotation devices necessary. bilitation exercises, Therapy Review 2711
3. The three forces that oppose movement in the water are 9, Aquatic therapy can help stimulate interest and moti­ 27. Koszuta, L. E. 19 89
the cohesive force. the bow force. and the drag force. vation in the athlete, helping to supplement tradi­ cise the wave of Li
17(4): 203- 6.
4. Aquatic therapy allows for fine gradations of exercise. tional exercise and return the athlete to normal
18. Levin, S. 1991. i\ql
increased control over the percentage of weight bear­ function and competition,
cine 19( I 0): 11 9-21
ing. increased range of motion and strength, de­ 10. It is typical to use a combination or land- and water­ 29, McNamara, C, and
creased pain, and increased confidence. based protocols to achieve rehabilitation goals, musculoskeletal COl
S. Pool size and depth, water temperature, and specillc tion, edited by R_ 4
pool equipment will vary depending on resources Philadelphia: Lippir
available to the athletic trainer. 30 . McWaters, j. G. 1 q
Sports Medicine T.:pd
31. Meyer, R.l. 1990. Pr
Clinical KineSiology 4
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346 PART THREE The Tools of Rehabilitation

SOLUTIONS TO CLINICAL DECISION MIAKING EXERCISES CHAF

Fun
,
16-1 This individual can begin initial activities when ac­ for elbow and shoulder musculature. being very
tive assistive motion is allowed. Activities in this cautious about valgus forces thai might occur at
phase might include shoulder elevation (nexion and the elbow due to drag forces that could occur dur­
abduction) while standing in shoulder-deep water
utilizing the assistance of buoyancy. He will be able
to beneOt from strengthening and stabilization ac­
ing upper-extremity adduction and internal rota­
tion motions aga,i nst water resistance, Exercises
could be progressed appropriate,!y to inc'lude exer­
Fun
,
tivities when he progresses to being able to do resis­ cise directed at development of endurance. power. ~Iichael M4
tive activities. See Figures] 6-16 and] 6- J 9. He will and sport-specit1c movements (pitching).
also benellt from sport-speeil1c training like that 16-5 She could begin as soon as incisions are healed. or
demonstrated in Figures 16-1 and 16-20. sooner if a moisture-barrier dressing is used, Goals
] 6-2 It is important in this example to honor the pre­ would be these:
scribed weight-bearing restrictions imposed after 1. To control and decrease swelling because of
surgery. The aquatic environment is an excellent the property of hydrostatic pressure
choice for implementation of early rehabilitation 2. To restore gait pattern ,in an un l oaded environ­
after sufTicient incisional healing or adequate ment StU(
coverage with a moisture-proof dressing. This en­ 3. To normalize motion in the left knee To become more ram
vironment is ideal for maintaining or improving 4, To normalize neuromuscular control necessary to design.
range of motion and strength without ful[! weight 5, To initiate and maintain her conditioning level tic rehabilitation pre)
bearing. Also. the aquatic environment offers the with deep-water activities leUc Training EdllcQli
possibility of gradual weight-bearing progression Awareness of gralt vulnerability occurring at 4 to Proficiencies'Thera pc
and restoration of balance. neuromuscular con­ 8 weeks after surgery must be integrated into the www,mhhc.com fpre
trol. and function. An example of closed-chain program, Examples of exercises that could be used cises in the new 1&
neuromuscular retraining is shown in Figure for improving neuromuscular control arc shown in simulates the alhleL
16-23. rigure 16-3 3 shows an example using the Figures 16-21. 16-23. 16-30. and 16-33 (Hall i­ www.mhhe.com/es1 ·
HaIHwick technique. wick Method), Examples of rehabilitatjon for range visit our Health and
16-3 The athletic t,r ainer should recommend an alter­ of motion and strengthening (after the graft wWj\',mhhc.comJl:!h
nate environment for maintenance of aerobic vulnerability stage) are shown in Figures 16-27.
fLinction. The aquatic environment is ideal for 16-28. andl6- 30.
cross-training applications that decrease or elimi­ 16-6 She needs to be taught neutrall position and core
nate weight bearing in the lower extremities. Excel­ strengthening, Activities that are specit1c to gym­ Aftere
lent choices·[night include deep-water running and nastics and the events she participates in can be Chapter,
sport-spednc lower-extremity strengthening in a practiced and challenged in the aquatic environ­ Be Able 1
diminished weight-bearing application (chest-deep ment. fntegrali"ng activities utilizing opposile­
water). See Figures 16-7.16-11. and 16-30. movement patterns can assist in developing core • Develop the
16-4 Initially the aquatic environment is ideal for devel­ stabilization. See Figures 16-18. 1 6-21 to 16-27 progreSSion.
oping range of motion for elbow ncxion and exten­ (Bad Ragaz technique). and 16-33 (HalLiwick tech­
sion. ft can also be used for light resistance training nique) for core stabilization activities. • Identify the
progression
• Recognize h
progressiom
habilitation
Describe th~
associated \'
progression
 CHAPTER 17
.ulature, being very
lh t might occur at
bat could occur dur­
Functional Progressions and
Functional Testing in Rehabilitation
Michael McGee

Study Resources • Identify an d de cribe the psychologi­

To become more familiar with the knowledge and skills cal benefits associated with a func­
necessary to design . implement. and document therapeu­
tional progression .
lie rehabilitation progra ms as iden tified in the J~ATA l'lth­
Ietic Training EdllClltional Competencies and Clinical • Generalize the disadvantages associ­
ity occurring at 4 t Projiciencies"['h era peutic Exercise co ntent area . visit
inlegrated into the ated with a functional progression.
wlVw.mhhe.com/ prenticcll C. A'lso refer to the 'lab exer­
lhat could be used cises in the new Laboratory Ma nual and to eSims. which • Incorporate the components of a func­
simulates the athlelic [ra ining certification exam. at
wWIV.mhhe.com /e~ . For more online study resources.
tional progression.
ab ilitalion for range visit our Health and Human Performance website at
ng (after the gnu • Develop a functlonal progression for an
www.mhhe.com/hho.
'Il in Figures 16-2; athlete.

aJ position and cort • Analyze various functional tests.

are specific to gym­ After Completion of This

ticipates in can Ix Chapter, the Student Should

• DeSign a functional test for an athlete.
Lhe aquatic enviro . Be Able to Do the Following:

u tilizing OppOSil ·
l in developing corr
• Develop the concept of a functional
n the athletic community, injuries and subsequent dis­
1 . 16-21 to 16-2­
6- 3 (Halliwick te r-
progression.
• Identify the goals of a functional
progression.
I ability frequently occur. Disabilities can be described as
restrictive 'intluences that "disease and injury exert
upon neuromotor performances." I ; Thus. in an effort to
reduce the lasting effects of injury, the athletic trainer
should direct rehabilitCltion towClrd improving neuromus­
• Recognize how and when functional cular coordination and agility. and not simply toward in­
progressions should be used in the re­ creasing strength and endurance. ff rehabilitation is
habilitation process. directed toward regaining range of motion. tlexibility.
strength. and endurClnce. and perhaps primClrily towClrd
• Describe the physical benefits increasing neuromuscular coordination and agility. a full
associated with a functional return to activity is possible. However. if the program sim­
ply provides a means for redUCing signs and symptoms as­
progression.
sociated with the injury. the athlete will not return to a safe
and effective level of activity. l As a result, rehabilitation of

347
348 PART THREE The Tools of Rehabilitation

athletic injuries needs to focus on retu_m to preinjury ac­ of the entire program. The goals of the functional progres­
strengthened dynam
tivity levels. 21> sion generally include a restoration of (1) joint range of
encountered io COllI
Function refers to patterns of motion that use multiple motion, (2) strength, (3) proprioception, (4) agility, and
joints acting with various axes and in multiple planes. 19Tra_ (5) confidence. Achieving these goals allows the athLete to
ditionaJ rehabilitation techniques, although vital to the re­ reach the desired level of activity safely and effectively. 24 Endurance
turn 01 funciton, often stress single joints in single planes of Functional progressions provide both physical and
:\'Iuscular and carcU<
motion. To complement traditional rehabilitation, the ath­ psychological benefits to the injured athlete. The physical
enhanced with a ru
letic trainer can use functional rehabilitation techniques. benefits include improvements in muscular strength and
necessary for long-dl
Functional rehabilitation, along with traditional methods, endurance, mobility and flexibility, cardiorespiratory en­
ing or in the repealt
will ready the athlete for activity and competition more suc­ durance, and neuromuscular coordination, along with an
participation. The rl
cessfully than if either method is employed alone. increase in the functional stability of an injured joint. Psy­
muscular enduran ce
chologically, the progression can reduce the feelings of
ual activities and the
THE ROLE OF FUNCTIONAL anxiety, apprehension, and deprivation commonly ob­
tivity. The progress
served in tbe <
i njured athlete.
PROGRESSIONIS IN improving muscular
ing more than one pI
REHABILITATION Improving Functional Stability can be improved lhn
Athletic trainers must adapt rehabilitation to the sport­ volved in the progre
Functional stability is provided by (1) passive restraints on ness levels imprO\I
specific demands of each individual sport and playing posi­ the ligaments, (2) joint geometry, (3) active restraints gen­
tion. But rehabilitation programs in a clinical setting
erated by musdes, and (4) joint compressive forces that oc­
cannot predict the ability of the injured part to endure the cur with activity and force the joint together.2~ Stability is Flexibility
demands of full competition on the playing field. For exam­ maintained by the neuromuscular control mechanisms
ple, the complex factors surrounding a solid tackle in com­ With injury, tissues'
involved in proprioception and kinesthesia (as discussed in immobilization. Thi:s
petition play cannot be produced in the clinical selting. Chapter 5). Functional stability cannol always be deter­
The role of the functional progression is to improve and functional progressil
mined by examining the athlete in the clinic. Therefore, a controiJed ra nge.
complete the clinical rehabilitation process. l2 A functional the functional progression can be used to evaluate func­
progression is a succession of activities that simulate ac­ enough to allow the;
tional stability both objectively and subjectively. Can the length. This imprm (
tual motor and sport skills, enabling the athlete to acquire or athlete complete all tasks with 00 adverse affects? Does
reacquire the skills needed to perform athletic endeavors the athlete. Stren gth
the athlete appear to perform at the same level, or close to the injured body par
safely and effectively. The athletic trainer takes the activities the same level, as prior to injury? Performance during a
involved in a given sport and breaks them down into indi­ motion. Tissues als
functional task can be evaluated for improvement. and tresses, so tissues ot
vidual components. In this way the athlete concentrates on functional testing can be incorporated to provide an objec­
individual parts of the game or activity in a con trolled envi­ witb the function al
tive measure of ability. I 7 The athlete can also give impor­
ronment before combining them together in an uncon­ tant feedback regarding function, pain, and stability while
trolled environment as would exist during fuJI competition. performing the functional tasks. Muscle Relax;
The functional progression places stresses and forces on
each body system in a well-planned, positivc, and progres­ Relaxation involv,
sivc fashion, ultimately improving the athlete's overaH abil­ Muscular Strength tension. The fun eti
ity to meet the demands of daily activities as well as sport ual to recognize t' .
Increased strength is a physicall benefit of the functional
competition. The functional progression is essential in the re­ move it by conscio
progression. Strength is the ability of the muscle to pro­
habilitation process, because tissues not placed under Tbe total body rei
duce tension or apply force maximally against resistance.
performance-level stresses do not adapt to the sudden return jured area, helpin g
This occurs statically or dynamically, in relation to the
of such stresses with the resumption of full activity. Thus, the inhibit the joint's ful
imposed demands. Strength increases are possible U' the
functional progression is integrated into the normal rehabil­ load imposed on a muscle exceeds that muscle's
itation scheme, as one component of exercise therapy, rather Motor Skills
anatomic capabilities during exercise. This is commonl)'
than replacing traditional rehabilitation altogetherY referred to as the overload principle and is possible due to
Coordination , agili tj
increased eflkiency in motor unit recruitment and mus­
of normal functio n .
BENEFITS OF USING cle J1ber hypertrophy.20 To see these improvements, the
the most opportu ne
FUNCTIONAL PROGRESS liONS muscle must be worked to the point of fatigue with either
sity.20 An athlele I1i
high or low resistance. The functional progression will
skills to trans form 51
IJsing a functional progression in a rehabilitation program develop strength using the SAID (specific adaptation to im­
rull-speed performa~
will help the athlete and the athletic trainer reach the goals posed demands) prinCiple. The muscles involved will be
injured athlete. If t!
 CHAPTER 17 Functional Progressions and Functional Testing in Rehabilitation 349

. functional progres­ strengthened dynamically, under stresses similar to those their coordination and agility, their performance is ham­
f il ) joint range of pered and can in itself lead to further injury. Repetition and
encountered in competition.
~on. (4) agility, and
practice are important to learning motor skills. Regular
allows the athlete to motions that are conSCiously controlled develop into auto­
and effectively. 2~ Endurance
matic reactions via motor learning. This is possible due to
both physical and 1Iuscular and cardiorespiratory endurance can both be the constant repetition and reinforcement of a particular
th lete. The physical enhanced with a functional progression . Endurance is skUl.l , In order to acquire these "automatic reactions," one
- ular strength and necessary for long-duration activity. whether in daily liv­ needs an intact and functional neuromuscular system. Be­
diorespiratory en­ ing or in the repeated motor functions found with sport cause this system is disturbed by injury, decreases in perfor­
falion, along.with an participation. The functional progression wUl enhance mance will occur, increasing the potential for injury. The
~ LI1Jured )omt. Psy­
muscwlar endurance through the repetition of the individ­ functional progression can be used to minimize the loss of
uce the feelings of ual activities and their combination into one general ac­ normal neuromuscular control by providing exercises that
lion commonly ob- tivity. The progression provides an environment for stress proprioception, motor-skill integration, and proper
improving muscular strength and endurance without us­ timing. The functional progression is indicated for improve­
ing more than one program. Cardiorespiratory endurance ment in agility and skill because of the constant repetition
can be improved through the repetition of movements in­ of sport-specific motor skills. use of sensory cues. and pro­
volved in the progression in the same way as regular fit­ gressive increases in activity levels. Proprioception can be
passive restraints on (Jess levels improve with continuous exercise. enhanced by stimulating the intra-articular and intramus­
live restraints gen­ cular mechanoreceptors. These are all components of. or
ive forces that oc­ general principles for. enhancing neuromuscular coordi­
ether. 1 9 Stability is Flexibility
nation. 20 The practice variations used with functional pro­
-on trol mechanis[ill With injury. tissues will shorten or tighten in response to gressions allow the athlete to relearn the various aspects of
ia (as discussed iG immobilization. This can inhibit proper function. With a their sport that they might encounter in competition.
Ol always be deter­ functional progression. the injured area is stressed within RehabUitative exercise programs must stress neuro­
e clinic. Therefore a controlled range. This stress should be significant muscular coordinalioJ.l and agility. Increases in strength.
to evaluate fu oc­ enough to allow the tissue to elongate and return to proper endurance. and nexibility are unquestionably necessary
ubjecti\lely. Can th le ngth. This improved mobility and nexibility is crucial to for a safe and effective return to play, but without the neu­
,. ese affects? Doe! the athlete. Strength and endurance do not mean much if romusclliar coordination to integrate these aspects into
the injured body part cannot move through a fu ll range of proper function. little performance enhancement can oc­
motion. Tissues also become stronger with consistent cur. For this reason, functiona ll progressions should be­
im provement. an _tresses, so tissues other than muscle can also be improved come an integral part of the long-term rehabilitation stage
to provide an obja. · I'ith the functional progression. 2o so that injured athletes can maximize their ability to re­
a n also give im por­ turn to competition at their preinjury level.
. and stability who
Muscle Relaxation
Relaxation involves the concerted effort to reduce muscle PSYCHOLOGICAL AND SOCIAL
ension. The functional progression can teach an individ­ CONSIDERATIONS
....a l to recognize this tension and eventually control or re­
efil of the functio n move it by consciously relaxing the muscles after exercise. Functiona.l progressions can also provide psychological
r t he muscle to pr - The total body relaxation that can ensue relaxes the in­ benefits to the athlete. Anxiety, apprehension, and feelings
I) against resistanc ured area, helping to relieve the muscle guarding that can of deprivation are all common emotions found with in­
Iy. in relation to in hibit the joint's full range of motion. 2fl juries. The functional progression can aid the rehabilita­
are possible if t tion process and facilitate the return to play by
eeds that muscl~ diminishing these emotions. Chapter 4 discusses the psy­
e. This is common Motor Skills chological aspecls of the rehabilitati\le process in more de­
and is possible due tail. This chapter will focus on the specU1c contributions of
Loordination , agility. and motor skUls are complex aspects
cruitment and ill u. the functional progression.
f normal function defined as appropriate contractions at
improvements.
.he most opportune time and with the appropriate inten­
of fatigue with eith
·ty.20 An athlete needs coordination, agility, and motor
nal progression \ Anxiety
ilills to transform strength. nexibility, and endurance into
rifie adaptation to l
.J.lI-speed performance. This is especially important for an Uncertainty about the future is a reason many athletes
les involved will -
jured athlete. If the athlete does not regain or improve give for their feelings of anxiety. Athletes experience this
350 PART THREE The Tools of Rehabilitation

insecurity because they have olilly a vague uo_d erstanding Each sucCess builds on past success, allowing the athlete to propria tely, each deci
of the severity of their injury and the lengtb of time it will feel in control as they return to full activity. individual results an
take for them to fully recover. I? The progression can lessen Figure 1 7- 1 provides a list of the physical and psycho­ t ime fa ctors. ,24
anxiety because the athlete is gradually placed into more logical benefits of functional progressions. Several fa ctors m
demanding situations that allow the athlete to experience effective ret Ll rn to pl.
success and not be concerned as much with failure in the ions. First. what aJ1
future. COMPONENTS OF A FUNCTIONAL thlete's return to aJ
xpecta tlol1s for his (]
PROGRESSION
Deprivation the total disability or
Functional progressions can begin early post-injury. In parameters of physi
The athlete might experience feelings of deprivation after general. the early focus of phase 1 in the progression is on tota l well-being or
losing direct contact with his team and coaches for an ex­ restoration of joinL range of motion. muscular strength. significant factor. 3~
tended period of time. The functional progression can limit and muscle endurance. The next phase of the progression
such feelings of depriva tion . because the athlete can exer­ focuses on incorporating proprioception and agility exer­ Activity Consi
cise during regu lar team practice times at the practice site. cises into the program. These two phases can be two sepa­
By engaging in an activity that can be completed during rate phases or, as is often the case. they may overlap. By ercise can be vie
practice. the athlete remains close in proximity and so­ including proprioception and agility exercises into the pro­ perspective, exercise
cially feels little loss il1 team cohesion . I? gram, the injured area is positively stressed to improve the motor skill~s. From ll:
neurovascular, neurosensory, and kinetic functions. 2l the training and cor
Apprehension The functional progression should allow for planned It is well accepted ( hi
sequential activities that challenge the athlete while al­ if appropriate aCl h";
Apprehension is often listed as an obstacle to performance lowing for success. The success will give the athlete confi­ train and condition
and many times serves as a precursor to reinjury.17 Func­ dence in his or her ability to complete tasks and motivate these activities. four
tiona l progressions enable athletes to adapt to the imposed the athlete to attain the next goal. Neglecting to plan and in dividuality of the
deman ds of their sports in a controlled environ ment, help­ use a simple progression cao lead to feinjury. pain, effu­ be addressed. Secon
ing to restore confidence. thus decreasing apprehension . sion, tendinitis, or a plateau in performance. To plan ap- negative; no increa'
Third, an orderly pt
nd fou rth, th e PI"Ol
FUNCTIONAL PROGRESSIONS ony.211 Steps to mi ni!

1. Vary exercise le
PHYSICAL BENEFITS PSYCHOLOGICAL/SOCIAL
1. Alter the progra
BENEFITS
3. Mainlain fi rn e:
pl ay.
1. Strength 1 . Decreased anxiety
2 _ Endurance 2 . Decreased deprivation
3. Mobility and 3. Decreased apprehension
flexibility -
4. Relaxation
5. Coordination!
skill and agility
6. Assessment of
functional stability

./

SAFE/EFFECTM
RETURN TO PlAY

Figure 17-1 PhYSical and psychological benefits of using functional progressions.

 CHAPTER 17 Functional Progressions and Functional Testing in Rehabilitation 351

)\\'in g the athlete to propriately, each deCision for an athlete should be based on 4. Set achievable goals. reevaluate, and modjfy regu­
'\'ity. individual results and performance rather than solely on larly.
hysical and psycho­ lime factors, 24 5. Use clinical. home, and on-field programs to vary the
Several factors must be addressed to provide a safe and activity. I I
effective return to play with the use of functional progres­
Athletes are continually exposed to situations that
sions, F,irst, what are the physician's expectations for the
make reinjury likely, so every effort should be made to un­
JNCTIONAL athlete's return to activity? Second, what are the athlete's
derstand and incorporate the inherent demands of the
expectations for his or her return to activity? Third, what is
sport into the rehabilitation program. The athletic trainer
the total disability of the athlete? And fourth, what are the
can emphasize the importance of sport-specific activities
.arly post-injury. In parameters of phYSical fitness for this athlete? Keeping the
to enhance the ath'lete's return to activHy rather than sim­
e progression is total well-being of the injured athlete in perspective is a
ply concentrating on traditional rehabilitation methods
mu cular strengt h. Significant factor. H
involving only weight machines and analgesics.
of the progressi n
The components of fitness are listed in Figure 17-2.
n nd agility ex r­ Activity Considerations There are two distinct components in this model. The
ca n be two sepa'
physicall fitness items used ,in more traditional rehabilita­
. may overlap. B, Exercise can be viewed from two perspectives. From one
tion programs should be merged with the athletic fitness
r i es into the pro­ perspective, exercise ,is a Single activity involving simple
items of functiona l progressions to maximize the athlete's
:d to improve th motor skills. From the second perspective, exercise involves
chance to regain preinjury t1tness levels.
c functions. 24 the training and condition,ing effect of repetitive activity.' >
The components of a functional progression should
. allow for plann It is well accepted that preinjury status can be regained only
aim to incorporate all the factors listed in Figure 17-2 un­
atb lete whUe a . if appropriate activities of sufficient intensity are used to
der athletic fitness items.
the athlete co nf · train and condit,ion the athlete. To provide the athlete with
k. and moliva these activities, four principles must be observed. First, the
li ng to plan an individuality of the athlete, the sport, and the injury must
-injury. pain, efli ' be addressed. Second, the actjvities should be positive, not
D'ESIGNING A FUNCTIONAL
Mlance. To plan al'" negative; no increased signs and symptoms should occur. PROGRESSION
Third, an orderly progressive program should be utilized.
Athletic trainers sbould consider all C1spects of an C1thlete's
.\nd fourth, the program should be varied to avoid monot­
situation when designing a functional progreSsion. There
ony. 20 Steps to minimize monotony include these:
is no "cookbook" method that meets the needs of all C1th­
I. Vary exercise techniques used. letes. Athletic trainers should use their creativity when it
2. Alter Lhe program at regular intervals. comes to devleoping progressions for the athlete. As previ­
3. Maintain [1tness base to avoid reinjury with return to ously mentioned, functional progressions may stClrt early
p'lay. in the rehabill itation process and then culminate in a fuH

Athletic fitness:
Functional progressions

Complete fitness

Flexibility Physical fitness:

Body composition Traditional rehabilitation
Muscular strength and training/conditioning
Muscular endurance
Cardiorespiratory endurance

Figure 17-2 Combining components of physical fitness with compo­

ions . nents of athletic fitness in functional progressions.
352 PART THREE The Tools of Rehabilitation

return to participation. The following guidelines are sug­ functional progression occurs when the skill can be com­ When contemp
gestions for designing functional progressions that can pleted at functional speed with high repetitions and no as­ battery of tests. lh
meet the needs of various injury situations. sociated increase in pain or effusion or decrease in range of testis) chosen. Valid
As with any rehabilitation program, the athlete's cur­ motion. The athletic trainer and the athlete should realize, A test should mea51
rent sCate should be evaluated first. This step may include however, that setbacks will occur and are common. Some­ ity) and should con
a review of the athlete's medical history, physician notes times it takes two steps forward and one step back to bility) regardless of
and/ or rehabilitatioo protocols, a physical exam or injury achieve the needed level of improvement. considered before re
evaluation, diagnostic testing, and functional testing. include a subjecti\'e
Once the status of the athlete is established, planning for on functional tests. f
Full Return to Play toms, other recagn
proper progression may occur. The planning will involve
reviewing the expectations of the athlete and the physi­ Deciding whether an ath'lete is ready to return to play at special tests. etc.1.
cian. What are the rehabilitation goals and parameters? At full participation is a difficult task. The decision requires a tional testing shouJ(j
this point the athletic trainer must determine whether the complete evaluation of the athlete's condition , including and bilateral fun ctie
injury situation. the athlete's goals, and the physician's ex­ objective observations and subjective evaluation. The ath­ the athJete is compe:
pectations will work together. If not, the athletic trainer letic trainer should feel that the athlete is ready both phys­ considerations shou
must work to bring the three together. The athletic trainer ically and mentally before allOWing a return to play. s athlete, appropria....
will also need to understand the demands of the sport and Return to activity should not be attempted too soon , in or­ Functional t
the position played by the athlete. The athlete, coaches, derto avoid added stress to the injury, which can slow heal­ trainer does not ha\
and other athletic trainers may serve as valuable resources ing and result in a long, painful recovery or reinjury. 7 The line values for COlI
for successful completion of this step. following are criteria for allOWing a full return to activity: cannot complete th
A complete analysis of the demands that will be placed play. However. what
1. Physician 's release plete the testis) bm
on the athlete and the iojured body part once return to
2 . Free of pain comparison ?The at
play is achieved must be completed. All of the tasks in­
3. No swelling decision based on tb
volved in the acti.vity should be ranked on a continuum
4. Normal ROM preinjury data are
from simple to difficult Simple tasks may involve isolated
5. Normal strength (in reference to contralateral limb) make an objective,
joints, assisted techniques, or low-impact activities,
6 . Appropriate functional testing completed 'w ith no ad­ complete a sprint le
whereas difficult tasks often group simple tasks together
verse reactions preinjury time was
into one activity and involve higher-impact activity­
related skills. Primary concerns should include the inten­ cent functional. \\11
tion of the activity, what activities should be included, and trainer might be UQ
FUNCTIONAL TESTING tional level. Of cOQ
the order in which the activities should occur. to For exam­
ple, if throwing a baseball is the purpose, the progression Functional testing involves having the athlete perform cer­ compa.re to the mei
can be broken into an ordered sequence like this: tain tasks appropriate to his or her stage in the rehabilita­ team members to a'
tion process in order to isolate and address speCific deilcits. ods that will aid in
1. Grip the ball symmetry and errOl
As a result the athletic trainer is able to determine the ath­
2. Stance formula
lete's current functional level and set functional goals.27
3. Backswing of the upper limb
According to Harter, functional testing is an indirect meas­ (ipsilateral lill
4. Forward swing of the upper limb
ure of muscular strength and power. Function is "quanti­ IimJj
5. Release of the ball
fied" using maxima,l performance of an aclivityl4 Harter
6. Follow-through 10 An 85 pereent ol
describes three purposes of functional testing as follows:
It is imperative that the athletic trainer assesses the for limb symmetry
1. Determine risk of injury due to limb asymmetry culate the number
athlete periodically throughout the progression pri.or to
2 . Provide objective measure of progress during a treat­ testing time frame. B
moving to the next level in the progression. Assessment of
ment or rehabilitation program Stork Stand for the a
present functional status of the injury should serve as a
3. Measure the ability of the individual to tolerate forces. 14 the number of er rQ
guide to a safe progression 2 0 The assessment should be
based on traditional assessment methods, such as goniom­ Functional testing can provide the athletic trainer with score for the contral'
etry, along with knowledge of the healing process and the objective data for review. Traditional rehabilitation pro­ Functional teslli
athlete's response to activity, functional testing, aod sub­ grams and improvements in strength and range of motion trainers and should!
jective evaluation. Aggressive activities that lead to pain, do not always correlate with functional ability.l H Func­ derstand. Cost em
effusion, or athlete anxiety can be replaced with less­ tional testing should have a better correlation with func­ mands are importan
aggressive activities. Achieving a certain skm level in a tional ability. to use.

e kill can be com­
eritions and no as­
:ecrease in range of
ete should realize,
re common. Some­
one step back to
11.
.0 return to play at
decision requires a
oodition, including
,·aluation. The ath­
is ready both phys­
a relurn to play.s
~ed too soon. in or­
,hich can slow h eal­
~ or reinjury. i The
relurn to activity:
nrralaterallimb)
Dpleted with no ad­
••
•alhlete perform cer·
3ge in the rehabilita·
:ire . s pecific defici ts.
~o determine the at h·
~ functional goais. ­
c formula
~ i an indirect mea~·
Fu nction is "quan\1­
an activity. 14 Hartt"
II testing as follows:
mb asymmetry
gress during a treaj·
Ial to tolerate forces .! .
e ath letic trainer with
al rehabilitation pro­
Ian d range of mo riol!
ional abilityY Func·
rrelation with fn nc·
CHAPTER 17 Functional Progressions and Functional Testing in Rehabilitation
When contemplating the use of a functional test or
battery of tests, the athletic trainer must evaluate the
test(s) chosen. Validity and reliability must be considered.
A test should measure what it intends to measure (valid­
ity) and should consistently provide similar results (re!la­
bility) regardless of the evaluator. Other factors must be
considered before releasing an athlete to ,full activity. These
include a subjective eva'luation of the injury, performance
on functional tests, presence or absence of signs and symp­
toms, other recognized clinical tests (isokinetic testing.
special tests, etc.), and the physician's approval. FU llc­
tional testing should attempt to look at unilateral function
and bilateral function in an attempt to determine whether
the athlete is compensating with the uninjured !lmb. Other
considerations should include the stage of healing for the
athlete, appropriate rest time, and self-evaluation. 27
Functional testing might be limited H the athletic
trainer does not have normative values or preinjury base­
,]inc values for comparison. Obviously, an athlete who
cannot complete the test(s) is not ready for a return to
play. However, what happens to the athlete who can com­
plete the test(s) but has no preinjury data available for
comparison? The athletic trainer has to make a subjective
decision based on the test result. If the normative data or
preinjury data are available, the athletic trainer can
make an objective decision. If a soccer player is able to
complete a sprint test with a mean of 20 seconds but her
preinjury time was 17 seconds, then she is only 85 per­
cent functional. Without the preinjury data, the athletic
trainer might be unable to determine the athlete's func­
tional level. Of cour se, the athletic trainer can always
compare to the mean functional 'level of the uninjured
team members to aid in the decision making. Other meth­
ods that wiII aid in objective decision making include limb
symmetry and error scores. Limb symmetry refers to the
(ipSilateral Hmb/contralaterallimb) (100) =
limb symmetry percentage
An 85 percent or better goal is the recognized standard
for limb symmetry scores. '1.11.27 Error scores typically cal­
culate the number of times an error is made during the
testing time frame. Bernier describes an error test with the
Stork Stand ,for the ankle. Over the 20-second time frame,
the number of errors is recorded and compared to the
score for the contralaterallimb. s
Functional testing should be an easy task for athle1cic
lrainers and should be equally simple for athletes to un­
:Ierstand. Cost efficiency, time demands, and space de­
mands are important concepts when conSidering the tests
to use.
353
CLINICAL DECISION MAKING Exercise 17-1
A soccer Illidfielder is recovering from a grade 2 MeL
sprain and bas been cleared for sport·specific training.
What types of activities could you use for this athlete?
EXAMPLES OF FUNCTIONAL
PROGRESS!IONS AND TESTING
The Upper Extremity
Functional activities that will enhance the healing and
per{ormance of the upper extremity migh t incl ude PNF
patterns. swimming motions, c1osed-kinetic-chain activi­
ties, and using pulley machines or rubber tubing to simu­
late sport activity. K Functional rehabilitation ['or the
shoulder joint needs to focus on proprioception and neu­
romuscular control. M:yers and Lephart report that four
"facets of functiona l rehabilitation must be addressed:
awareness of proprioception, dynamic stabilization
restoration, preparatory and reactive muscle facilitation.
and replication of functional activities ... lS Activities that
promote awareness of proprioception are described as activ­
Ities that promote restoration of interrupted afferen t path­
ways while facilitating compensatory afferent pa th ways.
This improvement in afferent pathways will result in a re­
turn of kinesthesia and joint position sense at an early
stage in the rehabilitat,ion process. Dynamic stabilization in­
volves training the muscular and tendinous structures to
work together as "force-couples." The muscles of the
glenohumeral joint along with the scapular stabilizers
work together using co-contraction as a way 01 providing
stability to the upper extremity. Preparatory and reactive
muscle facilitation involves stressing the upper extremity
with unexpected forces. These activities will allow the ath­
lete to improve both muscle slifrness a Dd muscle rellex ac­
tion. Finally,functionaI activities that mimic actual sport or
activity participation should be in cluded. l ~
Numerous activities can promote joint posil,ioll sensc.
Isokinetic exercise, proprioception testing devices, go­
niometry, and electromagnetiC motion analysis are all re­
ported by Myers and Lephart 2S as potential means for
achieving this goal. Athletes can practice reproducing
joint positions with visual cues and progress to using no
external cues. Activities can be passive, where the athlete
allempts to recognize certain joint positions when pas­
sively moved by the athletic trainer, or active in nature,
where the athlete attempts to actively reproduce a specific
354 PART THREE The Tools of Rehabilitation
position. The athlete can also attempt to reproduce specific
motion paths in an attempt to increase the functional com­
ponent of the activity. All activities need to stress the joint
at both the end range of motion and midrange of motion.
The end-range motion wUl stress the capsul'o ligamentous
a fferents; the midrange motion will stress the musculo­
tendinous mechanoreceptors. Attention to full range of
motion \.vill maximize the functional training for complete
joint position sense. l8
Kinesthesia training can use activities similar to those
for joint position sense. To stress kinesthetic awareness. the
athletic trainer needs to remove external visual and audi­
tory cues. During motion, the athlete ·is instructed to signal
when they first notice joint motion. The athletic trainer
notes what degree of error occurs before the athlete senses
the motion2~
Dynamic stability stresses the training of the force­
couples provided by the scapular stabilizers and the
muscles of the glenohumeral joint. Closed-kinetic­
chain anivities arc believed to enhance co activation of
these force couples. Common examples of activities
would include push-ups and variations on the push-up,
slide board activities, weight-shifting activities, and
press-ups.l 8
The athletic trainer can improve the athlete's muscle
preparation and reaction skills by incorporating rhythmic
stabilization activities into the program along with the
closed-kineLic-chain activities discussed above. Rhythmic
stabilization helps the athlete prepare for motion, thus im­
proving muscle stiffness, while also training for muscle re­
action. Simple rhythmic stabilization activities are
discussed in Chapter 15. Plyometric training is an excel­
lent alternative activity to include for training the muscle
for reaction and preparation. Finally, functional activities
that stress sport-specific skiUs should be included in the
progression. Pi'<"F pallerns can be used as an early alterna­
tive to sport-specific activity to simulate the sport motions
with less stress.l~
King advocates that upper-extremity rehabilitation
should focus on the glenohumeral joint, the scapulotho­
racic articu lation, and the core. An effort should be made
to coordinate the rehabilitation process and incorporate
activities that stress glenohumeral improvements along
with scapular and core stability. The quadruped position
allows the athlete to work the muscles that connect the
!.funk and scapula in both a concentric and an eccentric
manner. 19 This idea is consistent with Myers and Lephart's
plan for improving dynamic stability and muscle readi­
ness. King suggests using activities that usc a quadruped
position with stable and unstable surfaces along with
movement paLlerns. 19
Although many sport-specific skills for the upper ex­ .TAB LE 17-]
tremity are completed in the open kinetic chain, closed­
kineUc-chain activities are imporLant factors for proper Fu nctional acth"
function. Athletic trainers should work to incorporate _ Ru bber tubin g e"
these activities into the rehabilitation process as a part or Swi mming
the funcitonal progression. Open-kinetic-chain sport­ Push-ups
specific activities are important as well. A functional pro­ 'port drills:
gression for the throwing shoulder should include the • Tnte rval tbrO\\ [
following steps. First the athlete must be instructed in 4 5 fl phase
and complete a proper warm-up. During the warm-up. Step 1:
the athlete should practice the throwing motion at a slow ')
velocity and with low stress. The activity can then
progress through increasingly difficult stages as indi­ .
l_
~"
cated in Table 17-1 and in more detail in Chapter 19.
Table 17-2 provides an example of a functional progres­
sion for hitting a golf ball, and Table 17-3 provides a
program for return to hitting a tennis ball. Any upper­
extremity injury can benefit from one of these programs
'peat steps] and ~
or can be exercised in similar fashion using any sport
hieved. See Cb apt
equipment needed for that sport. 1
CLINICAL DECISION MAKING Exercise 17-2
• TABLE 17-~
A volleyba ll player has chronic impingement syndrome
due to poor scapular stabilization . What types of fUll(,­
tiona l activities would help this athlete?
Week 1
-.
The shoulder joint serves as a template for upper­
extremity rehabilitation and functional progressions.
Many of the activities for the shoulder are eqnally effective
for rehabilitation of the elbow, wrist, and hand. Other
actvities that can be used for upper-extremity rehabilita­ \\ eek 2
tion may focus more on the elbow or wrist/hand. An ex­
cellent example of functional elbow rehabilitation can b 1
found with Uhl, Gould, and Ceick's work with a football
lineman. The progression started with simulated lineman
drills for the upper extremity in the pool. The athlete then
progressed to proprioception and endurance work using a
basketball bounced against a wall and progressed to a
Week 3
medicine ball thrown against a plyoback .35
There are many ways to functionally test an athlete. 1
The most common and often the simplest ways include 1
timed performance. For the upper extremity, a throwing 1
velocity test is often used. This can be accomplished two ]
ways. depending on the athletic trainer's budget and the .1
availability of complex testing tools.
Week 4
1. Test velocity in a controLled environ ment. preferably
indoors to decrease effects of the weather. Re
 CHAPTER 17 Functional Progressions and Functional Testing in Rehabilitation 355

for the upper ex­ • TA Bt E 1 7 -1 Upper-Extremity Progression for Throwing

lic chain. closed­
~ctors for proper 1. Functional activity can begin early with assisted PNF techniques
'k to incorporate 2. Rubber tubing exercises simulating PI F pallerns and/or sport motions
ocess as a part of 3, Swimming
e tic-chain sport­ 4. Push-ups
.\ functional pro­ ). Sport drills:
loult! include the • Interval throwing program
be instructed in 45 ft phase

g the warm-up. Step 1: 1. vVarm-up throwing Step 2: 1. Warm-up throwing

g motion at a slow 2. 2'i throws 2. 25 throws

iCl ivity can then 3. ,test 10 minutes 3. 15 minule rest
t -tages as indi- 4. Warm-up throwing 4. Warm-up throwing
Iii in Chapter 19. 5. 25 throws 5. 25 throws
6. Rest 10 minutes
7. "Varm-up throwing
8. 25 throws
f these programs
Repeat steps 1 and 2 ror flO, 90. 120. 150. and 180 reet. unli I rull throwing [rom the mound or respeclive position is
using any sport
achieved. See Chapter 19 for a more detailed program.

Exercise 17-2
• TAIB LE 17-2 Interval Golf Rehabilitation Program

Day 1 Day 2 Day 3

Week 1
5 min chipping/ putting 5 min chipping/ putting 5 min chipping/ putting
5 min rest 5 min rest 5 min rest
plate for upper­
5 min chipping 5 min chipping 5 min chipping
n a l progressions.
5 min rest 5 min rcst
equally effective
5 min chipping 5 min chipping
nd hand. Other
lremily rehabilita­ Week 2
wrist/ hand. An ex­
habilitation can be 10 min chipping 10 min chipping 10 min short iron
rk with a football 10 min rest 10 min rest 10 min rest
10 min short iron 10 min short iron 10 min short iron
10 min rest 10 min rest
nce work using a 10 min short iron 10 min short iron
progressed to a Week 3
'k .35
lally test an athlete. 10 min short iron 10 min short iron 10 min short iron
plest ways include 10 min rest 10 min rest 10 min rest
em ily. a throwing 10 min long iron 10 min long iron 10 min long iron
accomplished two J 0 min rest 10 min rest 10 min rest
er' . budget and the 10 min long iron 10 min long iron 10 min long iron

Week 4
n ment. preferably
\'eather. Repeat week 3. day 2 Play 9 holes Play 18 holes
356 PART THREE The Tools of Rehabilitatjon

• TABLE 17-3 Interval Tennis Program 2. Set up a standa

3. Have the ath letJ
Day 1 Day 2 Day 3 4. Measure a max
miles per hour 1
WeekI radar gun (C.\O
36 inches hi gh
12 FH 15FH 15 FH
5. Compute the ID
8BH 8BH lOBH
the pretest valu
10 min rest 10 min rest 10 min rest
13FH 15 FH 15 FH Many athletic
7BH 7BH lOBH equipment. A secon
veloCity would be
Week 2 radar gun. In th is
25FH 30FH 30FH topwatch to lime tJ
15BH 20BH 25BH begins liming as tI
10 min rest 10 mln rest 10 min rest when the catcher r
25FH 30FH 30FH throws should be c(
15 BH 20BH 1513H The flrst method \\;
10 Overheads (OH) method can be usee
Other uppcr-ex1
Week 3 "inetic-chain Uppei
an be used for an
30FH 30FH 30FH
readiness for sport.
25 BH 25BH 30BH
sets up a course
100H 150H 150H
the ground parallel
10 min rest 10 min rest 10 mln rest
(ete assumes a push
30FH 30FH 30FH
priate tape strips.
25BH 25BH 150H
al ternately reac h HI
100H 150H 10 min rest
The athlete should (
30FH
The mean value i
30BH
d ard 1: 3 work:resl
150H
fo r 45 seconds in b
Week 4 score can be the tOI
ouches divided by I
30FH 30FH 30FH
30BH 30BH 30BH
lOOH 100H 100H
10 min rest 10 min rest 10 min rest
Play 3 games Play set Play 1 .:; sets
lOFH lOFH lOFH
lOBH lOBH ]OBH
SOH SOH 30H

FH = Forehand
BH = Backhand
OH = Overhead
 CHAPTER 17 Functional Progressions and Functional Testing in Rehabilitation
2. Set up a standard pitching distance (60 feet 6 inches).
3. Have the athlete use a windup motion.
3 4. Measure a maximum of five throws- measured in
miles per hour with a ca ibrated ,rvlagnum X ban
radar gun (CMI Corporation . Owensburg. KY) placed
36 inches high and to the right of the catcher.
5. Compute the mean of the five throws and compare to
the pretest value.
Many athletic trainers do not have access to such
equipment. A second way to test the upper extremity using
velocity wou'ld be to use a similar setup but minus the
radar gun. In this situation the athletic trainer needs a
stopwatch to time the night of the ball. The athletic trainer
begins timing as the ath'lete releases the ball and stops
when the catcher receives the ball. Again. a mean of five
throws should be computed to help decrease testing error.
The first method will be the most accurate. but the second
method can be used as an effective testing tool.
ds (OH)
Other upper-extremity tests are possible. The closed­
kinetic-chain upper-extremity stability test (CKC UE ST)
can be used for an objective measure of upper extremity
readiness for sport. In the CKC (JE ST the athletic trainer
sets up a course using two strips of athletic tape placcd on
the ground parallel to each other 36 inches apart. The ath­
lete assumes a push-up position with hands on the appro­
priate tape strips. The athlete then has 15 seconds to
alternately reach across and touch the opposite tape strip.
The athlete should complete 3 trials with a maximal effort.
The mean value is calculated as the athlete's score. A stan­
dard 1:3 work:rest ratio is used allowing the athlete to rest
for 45 seconds in between each trial. Assessment of the
core can be the total number of touches. the number of
touches divided by body weight to normalize ~he data, or
determining a power score by multiplying the mean score
by 68 percent of the athlete's body weight (weight of arms,
head. and trunk) then dividing by 15 seconds. Goldbeck
and Davies found that th e CKC DE ST has a test-retest reli­
LS ability of 0.922 and a coefficient of stability of 0.859, in­
dicating that the test is a reliable evaluation tool. 12
Dh.1 et al. used sport-specific testing to determine the
readiness for return of the football lineman. The athlete
completed up-down drills, drive-blocking on a dummy
15 X 4 yards). blocking drill with a butt roll to both the
right and the left, and fmally a snap-pass protection drill
against an opponent. Both athletic trainer and athlete sat­
isfaction and no report of pain indicated successful com­
pletion.) 5 This is a great example of how the athletic
training staff used sport-specific tasks to determine the
fu nctional level of the athlete.
357
To funclionally test the upper extremity. the key con­
cept is to focus on the sport demand for the athlete. Careful
attention should focus on the skill involved with the sport.
Does the athlete perform a primarily open-kinetic-chain
skill. or is the skill performed in a closed kinelic chain ? A
gymnast might need more closed-kinetic-chaj n tcsting
than a tennis player. Similarly. the athletic trainer will not
test a volleyball player using a pitching test. The athletic
trainer will have to consult with the coach and determine
what the athlete needs to do, and from this devise a test
battery. For the volleyball player, a serving test wouJd obvi­
ously be better than the pitching test.
CLINICAL DECISION MAKING Exercise 17-3
A gymnast has a recurrent anterior dislocation of the
glenohumeral joint. Sbe bas excellent muscular strength
in both the glenohumeral muscles and the scapular mus­
cles. She has had no problem regaining full range of mo­
tion. She is extremely worried that the shoulder will
dislocate again. Because strength and range of motion
are normal for this athlete. what type of rehabilitation ac­
tivities should the athlete concentrate on to help improve
ber dynamic stability?
The Lower Extremity
The lower extremity follows the same basic pattern, with
different exercises. The activities used should proVide runc­
tional stress to the injured limb. An example of a func­
tional progression for the lower extremity is found in Table
17-4. The lower extremity can be tested in many ways;
sprint times. agility run times, jumping or hopping
heights/distances. co-contraction tests. carioca runs. and
shuttle runs. The following are brief introductions to a va­
riety of these tests.
Sprint Tests. The sprint tcst is exactly what the
name implies:
1. A set distance is measured.
2. The athlete then runs the distance with a time per
run recorded.
3. Three to 5 sprints should be completed and the mean
computed.
4. Pretest and posttest means are compared.
Agility Tests. AgJility runs involve the same premise.
The run is timed. and a mean ,is taken for five runs. The dif­
ference is the course. Rather than concentrating on
358 PART THREE The Tools of Rehabilitation

• TABLE 17·4 Lower-Extremity Functional Progression

1. Functional activily can begin early in the rehabilitalion process with:

• Assisted proprioceptive neuromuscular facilitation (PNF) techniques A

• Cycling
• Non-weigbt-bearing (NWB) BAPS board or tilt board exercises
• Partial-weigbt-bearing (PWB) BAPS board or lilt board exercises
• Full-weighl-bearing (FWB) BAPS board or tilt board exercise (Figure 17-3)
• Walking

Normal

Heel

Figure 17-3
Toe

Sidestep/shuJne slides (Figure 17-4)

2. Lunges:
• 90° Pivot (Figure] 7-5)
• lS0° Pivot (Figure 17-6)
3. Slep-ups:
• Forward slep-up. 50-75% max speed (Figure 17-7 A)
• Lateral step-up, 50-75% max speed (Figure 17-78) A
4. Jogging:
• Straight-aways on track ; jog in turns (goal = 2 miles)
• Complete oval of track (goal= 2-4 miles)
• 100 yd-"S" course 75-100'};, max speed with gradual increase in number of curves (Figure 17-S)
• 100 yd-"S" course 75-100% max speed with gradual decrease in size of "S" to lit .5-10 yd (Figure 17-9)
• 100 yd-"Z" course 75-100% max speed with gradual increase in number of "Zs"(Figure ] 7-10)
• Sidestep/shuffle slides
5. Lunges:
Figure 17-4
, • 90° Pivot with weight or increased speed

• 180° Pivot with weight or increased speed

6. Sprints:
• 10 yd X 10

·20yd X 10

• 40 yd X 10
• Acceleration/deceleration: 50 yd X 10 (Figure 17-11)
• "W" sprints X 10 (Figure 17-12 )
7. Box runs: (Figure 17-13) End
• 5 yd clockwise/counterclockwise X 10
S. Carioca: (Figure 17-14)
• 30 yd X 5 right lead-off; 30 yd X 5 left lead-off
9. Jumping: (Figure 17-15)
• Rope
• Lines
• Boxes, balls, etc.
10. Hopping: (Figure 17-1S)
• Two feet
• One foot
• Alternate Figure 17-5 90-d~
11. Cutting, jumping, hopping on command with the lefl foot. Ian
12 . Sport drills used for preseason or inseason practice fronl. lhen steps ~
foot. then back laten
on the right foot. til
 A B

Figure 17-3 Board exercises. A, Tilt board exercise. B. BAPS board exercise.

A B

1 7-8)
Figure 17-9)
--10)

Figure 17-4 ShufOe slides. A, Starting position. B. Finish position.

90-degree lunge

18D-degree pivot
R

'~32
J

End

Begin R

Figure 17-5 90-degree pivot. The athlete pushes off
with the left foot, landing on the right foot directly in
front. then steps immediately laterally landing on the left
foot. then back laterally in the opposite direction la nding
on the righ t foot, then backward onto the left foot.
Figure 17-6 1 RO-degree pivot. The athlete pushes off
the right foot, pivoting on the left, thus rotating the body
180 degrees , landing on the right foot. Then pushing orf
the right foot, the body pivots on the left foot 180 degrees
in the other direction , landing on the right foot.

359
A [' _.' '!lW -•.-,,­ - [ - ~ B

Figure 17-7 SLep-ups. The aLhlete sleps A, forward or B, laterally onto a step.

"5" curve course

Figure 17-8 S Curve. The athlete runs a set distance in a curving S pnLtern Figure 17-12 "\\
ruther than sLraight ahead. Lo the fu-st marker.
sprints forward Lo th
Figure "8" course

"Z" course (zigzag)

Figure 1 7-10 "Z" course. The athlete runs a zigzag

Figure 17-9 Figure 8. The athlete walks, jogs, or runs course to emphasize sharp cutting motions and quick
a figure 8 pattern around cones or markers. controlled directional changes.
 CHAPTER 17 Functional Progressions and Functional Testing in Rehabilitation 361

Acceleration/deceleration course

B Accelerate Decelerate Accelerate Decelerate

I
Start 10 yards 20 yards

Figure 17-11 Acceleralion/ deceleration. The athlete accelerates to a maximum.

then decelerates almost to a stop. then repeats this within a relatively short distance.

Box run course

1 Begin --"""'~P' 2

"W" sprint course

5
End

Figure 17-12 "W" sprints. The athlete sprints forward

t4
3

Figure 17-13 Box runs. Running both clockwise a nd

to the fIrst marker. then backpedals to the second. then counterclockwise. the athlete runs around four markers
sprints forward to the third. and so on. set in a box shape. concentrating on abrupt directiona l
c hangesatea c hcorn e~

Carioca step

Figure 17-14 Carioca. The athlete sidesteps onto the

right foot. then steps across with the left foot in front of
the right, then steps back onto the right root, th en the
left foot steps across in back of the right, then back onto
the right, and so on.
[tete runs a zigzag
lotions and quick
362 PART THREE The 'fools of Rehabilitation
Figure 17-15 Timed exercise. The athlete jumps side to
side over a ball or other obstacle in a limcd exercise.
stmight-ahead molion. the agility run incorporates
changes of dircction. acccleration/dccc:lcralion, and quick
starts and stops. for example, a simple figure eight can be
set up with cones and the athlete is instructed to travel the
cones as fast as possible while being limed for performance.
Gross et al. described a figme-eight course that was 5 by
10 meters. Each subject in their study was instructed to
complete three trips around the llgurc eight while being
timed. Two trials were conducted, and the best lime was
recorded. ll Anderson and Foreman point out that no
standard in the literatme dictates testing procedures for
the l1gure eight. 2 A standard procedure should be devel­
oped by each athletic trainer or each institution to ensure
the validity and reliabibty of the test.
Box runs arc also benef,ici8l as agility runs, because
they emphasize pivoling and change of direction. The ath­
lete is instructed to travel around four cones <lrranged in a
box formation. OJ'he time to complete the box is recorded.
Again, variations are prominent. with single laps versus
multiple laps and the use of multiplc movements (run, car­
ioca, back pedal. etc). The BarroVl' zigzag run is a variation
of the box run using nve cones. ]'he four cones of the box
arc set8s usu81, and the fifth cone is set in the center of the
box. The box course is 16 feet by 10 feet. The athlete trav­
els around the cones as shown in Figme 1 7-16. 2
ussbaum reports that the use of sprinting, cutting ma­
neuvers, figure-eight runs, and backpedaling drills are all ex­
cellent means for assessing the functional perforrmmce of the
lower eJ.iremity. )0 Jt is beneficial to use agility runs beGlUse
the level of dif!1cully can be changed. Early in the rcllabilita­
tion process, large Ilgure eights that arc more circular in
shape can be used to provide functional data with low stress
to the injury. As the injury heals, the Ilgure eight can be
lighter to provide greater stressed to the injured body part.
-,•
I
10 It
Stop Start
1•
Figure 17-16 Barrow Zigzag Run test. The athlete es­ Figure] 7-17 Co<
sentially runs a figure 8 with sharp turns at the corners. in a sidestep or sh uJTh
semicircle, using surg
Vertical Jump. The vertical jump test can also be Timed hop
used to evaluate the lower extTemity.4 In this test, the ath­
lete has chalked llngertips and jumps to touch a piece of pa­
per (of a different color than the chalk). Three to llve jumps
6 meters n I"'"
should be attempted and the mean height recorded (meas­
ured from llngertips standing to the cnalk mark).2.6.l3 Vari­
ations in the test also exist. Anderson and Foreman t<
mention alterations that include "bilateral vs. single leg
jump, countermovement vs. static squat start, approach
steps vs. stationary start, and use of the upper extremities
A II t<
for propulsion vs. restricted use of the upper extremities. ,,2
Many more-expensive testing devices are available that
measure time differentials, force, and height.
Co-contraction Semicircular Test. The co­
contraction semioircular test involves securing the athlete in
t<
~
a 48-inch resistance strap (TheraBand) that is attached to the
wall 60 inches above the floor (see Figure 17-17). The strap ,is
then stretched to twice its recoil length and the athlete com­
Figure 17-18 Hor
pletes five 180-degree sernicirdes, with a radius of 96 inches,
required to cover a 6­
around a tape line. The athlete is instructed to use a forward­ onds. B, The single he
facing lateral shuffle step. If the athlete starts on the left, she tance covered in a sin
or he vvill travel around the semicircle until reaching the right of the injured leg COlT
boundary. This semicircle counts as one repet,ilion. The ath­
lete must complete five repetitions in the shortest amount of
time possible. Three ,trials can be used, and the mean time is metry.2.26.29 The mOl
calculaled. This test is designed to provide a dynamic pivot sing1le-Ieg hop for disl
shift for the ACL-insufflcient knee. 0.21.22.23.26 hop for distance, and
Hopping Tests. Hopping tests are also found in the single-leg hop for di.sl.
literature (Figure 17-18). Booher et al. and Worrell et al. to hop as far as possil
report that hopping tests might not be sensitive enough to The timed hopping t
evaluate the functional abilities of athletes. 6 .3 ? However, the athlete to hop a di!
hopping tests are noted in the literature and are used for distance measures the
clinical determination of function. Noyes et al. used a va­ three consecutive h o~
riety of hop tests to determine lower-extremity limb sym- distance measures th l
 CHAPTER 17 Functional Progressions Hnd Functional Testing in Rehabilitation 363

secutive hops while crossing over a strip 15 centimeters

wide. 1.5.6.9.1 K.2 6.29.l7
Carioca Test. Carioca runs can be limed to meas­
ure improvement in function (see figure 17-14). The
carioca run involves a lateral grapevine ur crossover
step over a total distance or flO feet. First. choose which
direction (0 face and maintain the stance. The athlete
will then carioca 40 reel. change direction without
turning around. and return to the starling position. f he
time to complete the 80-root course is recorded. Three
trials should be used and the mean Lime calcu­
lated. 21 .22.2l.26
Shuttle Runs. Shuttle run s can involve many differ­
ent drills. The most common requires the athlete to com­
. The athlete es­ Figure 17-17 Co-contraction test. The athlete moves plete rour 20-root spints. for a toLal of 1;0 feet.
- at the corners. in a sidesLep or shufne fashion around the periphery of a incorporating three direcLion changes. It is common to
semicircle. using surgical tubing ror resistance.
take three trials. and the mean s\)ouJd be caleu­
lated .21.12.2J.2b Another common shullle run is the line
) test can also be Timed hop Single hop for distance drill, sometimes called "suicide sprints" or "death warmed

,
this test. the ath­ over." The course is set with markers at various dist,mces
ouch a piece of pa­ 6 meters , 6 meters from the starting line. The athlete is instructed to sprint
hree to nve jumps and touch the first marker and then return to tbe starti n g
hl recorded (meas­ position. '1' he athlete then continues the course, touching
k mark).1.6.11 Vari- each marker and returns to the sLarLing position. A total
IOn and Foreman time is recorded. ~ This test is vcry flexible and can be used
leTal vs. single leg on baske tball, volleyball, or tennis courts, as well as root­
at start. approach A B ball, soccer, or other playing l1elds.
~ u pper extremities Balance Tests. Balance is an importan t component
pper extremilies,"2 of any motor skill activity. FollOWing injury. many athletes
are available that exhibit deficits in proprioception. which translate into a
~ig h l.
loss of balance. i\ simple single-leg balance test is a valid
Test. The co­ test. The athlete is instructed to stand on one leg, and tim­
:uring the athlete in ing begins. Timing stops when the ath l etl' alters his or her
la l is attached to the ,position in order to maintain balance. This test can be
·1 t -1 7). The strap i~ modified to include eyes open or closed to elim.inute visual
md the athlete com­ cues. Also, changes in surface can be made that require
Figure 17-18 Hop tests . A, In the timed hop test. lime
radius of 96 inches. greater bala nce. Instead of testing on a floor surrace. the
required to cover a 6-meter distance is measured in sec­
led to use a forward­ athletic tra iner might choose to use a foam surface or a
onds. B, The single hop ror distance test measures the dis­
. arts on the left, she tance covered in a single hop. Both tests use a percentage minitrampoline.2. 5.1h The a t hletic trainer can also incorpo­
f reaching the right or the injured leg compared to the uninjured leg. rate sport skills into a balance test (see Chapter 8).
Subjective Evaluation. Subjective evaluations or

~
repe tition. The ath­

,t
U6
hortest amoLlnt of
d t.he mean lime IS
e a dynamiC pivot

e also round in the

metry.2.2u.29 The more common hopping tests are the
Single-leg hop for distance, the timed hop test, the triple
hop for distance. and the crossover hop for distance. The
single-leg hop for distance requires the athlete to atLempt
~. an d Worrell et a1. to hop as far as possible while landing on the same limb.
r sensitive enough to The timed hopping test measures the amount time it takes
fbl etes.6.37 However. the athlete to hop a distance or 6 meters . The triple hop ror
lJre and are used ro dista nce measures the distance traveled by the athlete wi th
yes et al. used a va­ three consecutive hops. And finally the crossover hop for
;tremity limb sym­ distance measures the distance traveled using three con­
perrormance have been correlated wilh functional perror­
mance testing to determine predictive capabilities. Wilk
et al. round strong correlations beLwcen subjective sco res
and knee extension peak torques, knee extension acceler­
ation. and fUl1ctionaltcsting: however. no sign ificant rela­
tionship was noted with hamstring function.il> This is in
contrast to Shelbourne's research. which showed a poor
relationship between subjective evaluation. runctional
tests . and knee strength. Shelbourne concluded that
knee strength was a good measure of ability.31 Subjective
questionnaires or numeric scales might or might not be
364 PART THREE The Tools of Rehabilitation

benellcial in the funcitonal assessment of athletes. based
on th e correlations. 1\ low subjective score might indicate
that the athlete is apprehensive, which should serve as a
warning sign of psychological unreadiness to return to
play. The athletic trainer should determine whether subjec­
tive evaluation is useful with respect to the given athlete.
Obviously. budget considerations and availability of
equipment will determine the types of tests the athletic
trainer can use. but simple timed sprints can indicate im­
proved performance just as well as the more complicated
tests that involve expensive equipmenl.I. 2 1.2 2 .2 J
CLINICAL DECISION MAKING Exercise 17-4
What type of funcitonal testing could you use for a foot­
ball receiver who has sustained a secon d-degree acromio­
clavicular sprain? What criteria for a return to play would
you use?
This progre
tive. CFP! index was determined for males and females that
nths. cou pled
can be used in accurately assessing functional perfor­
es to increase
mance based on the results of only two of the tests-the
m hs the progre.
carioca test and the co-contraction test. 2"
._-:am including the
Using stepwise regression techniques, the following
Ru nning for Ii­
prediction equations were established:
Lu nges-90
Males: 1.09(xI) + 1.415(x 1 ) + 8.305 = CFP! pr ints-"\\~
Females: 1.26(x l ) + 1.303(X2) + 8.158 = CFPT :\cceleration
(Where XI = co-contraction score in seconds. h uflle slides
and X2 = carioca score in seconds) arioca
Ball work-T
The athletic trainer can test any individual using these
two tests (co-contraction and carioca) and determine their
individual CFP!. The CFPI value for that individual can be
compared to the mean normative CFPI indices of 31.551 for e-on-one: scrirr
males and 36.402 for females. If baseline preinjury testing full game ); full a.:
was done, then the preinjury CFPI can be compared to the
postinjury CFPI to determine how the athlete is progressing
in their rehabi'litation program. The CFPI provides a reliable CLINICAL DEC
I
objective criteria for functional performance Lesting.

Acute in Oamm.rr. .
CAROLINA FUNCTIONAL Applying Functional Progressions
PERFORMANCE INDEX (CFPI) to a Specific Sport Case
The CFP! has been developed to help the athletic trainer The following is an example of how a functional progres­
evaluate lower-extremity functional performance. The sion may be applied to a specUk sport-related injury:
CFPI evaluates the athlete's existing functional perfor­ Subject: 20-year-ol'd female soccer player
mance capability. McGee and FultreJ] evaluated 200 colle­ History: Sustained anterior cruciate J,igament (I\CL) rup­
giate athletes and nonathletes using a battery of tests that ture of left knee while performing a cutting motion in
included the co-contraction test, carioca test, shutt.le run practice. I\CL reconstruction using an inLra-articular
test. and one-legged timed hopping test. Table 17-5 shows patellar tendon graft was performed.
the mean and standard deviation for each of these tests for Rehabilitation for first 2 months was conducted botb Summary
males and for females. From this series of tests. a norma­ at home and in clinical setting. Emphasis of program
concentraLed on increasing range of motion (ROM) and
decreasing pain and swelling, with some minor considera­
• TABLE 17-5 CFPI Mean Index and tions to improving strength. romuscular
Performance Test Means I\t 2 months postsurgery. the rehabilitation protocol
durance. an d
conSisLed of emphasizing general physical Iltness. .::!. The role of the
Males Females strengthening via traditional rehabiliLation means and
Means/standard Means/standard strength testing, as well as improving ROM.
deviation deviation At approximately 3 months postsurgery a functiona :
progression was initiated. The progression included the
CFPI 31.55112.867 36.402/ 3.489 loJ]owing activities an average of three times per week:
Carioca 7.81211.188 8.899/1.124 Walking
Co-contraction 11.188/1.391 13.218/ 1.736 Proprioceptive neuromuscular facilitation techniques­ nenLs, allowin",
test using lower extremity D1, 02 patterns difficult.
One-legged hop 4 .953 / 0 .53 5.746/0.63 Jogging on track with walking of curves 5. Functional pr
test Jogging full track therapy tech n iq
Shuttle run 7.596/0.654 8.539/0.69 Running on track with jogging of curves long-term re ba
Running full track
 CHAPTER 17 Functional Progressions and Functional Testing in Rehabilitation 365

This progression occupied the majority of the next 2

~sand females that CLINICAL DECISION MAKING Exercise 17-6
months, coupled with traditional rehabilitation tech­
functional perfor­ niques to increase strength and maintain ROM, At 4
o of the tests-tILe A male athlete has a CFPr 0[,41,00 ['ollowing an ACL re­
months the progression intensified to a 5-day-a-week pro­
.!b construction. AI what percentage of the norm Is the ath­
gram including the following:
ues, the following lete? What decision wou ld you make about bis return to
Running for fitness-2 to 3 miles three times per week
play? What type of activitie may help this athlete im­
Lunges-90 degree, pivot, 180 degree
prove hls score?
,,305 = CPP] Spr,i nts-"W," (riangle, 6 second, 20 yd, 40 yd, 120 yd
' .158=CPPI Acceleration/ deceleration runs (see Figure 17-11)
'e in seconds. Shu me slides progressing to shufl1e run
~conds)
Carioca CONCLUSION
Ball work-Turn /stop the pass; turn / mark opponent;
iividual using these mark/ steal/shoot the ball; two-touch and shoot; one­ Once the athlete can safcly and effectively perform all spe­
IlDd determine their touch and shoot; volley and shoot; passing; pass/ cific tasks leading up (0 the motor skill, they can return to
ill individual can bc knock/ move; coerver drills; light drill work at practice; activity. For example, an athlete might progress from cy­
ndices of 31,551 for one-on-one; scrimmage (begin with short period, progress cling, to walking, to jogging, to running, before returning
n e preinjury testing to full game); full active partiCipation. to sprinting activities and competition in the 4X 400 relay,
be compared to the The athletic trainer must note that these are only ex­
Ilhlete is progressing amples, No one program will benefit every athlete and
PI provides a reliable CLINICAL DECISION MAKING Exercise 17-5 every condition. AthletiC trainers should use these actiVI­
:ance testing, ties. along with others they develop, to help maximize the
An athlete had surgery 1 weeks ago for an ACL rupture, athlete's recovery, By proViding athletes with every option
Acute inflammation is controlled. and he is clear to begin available in rehabilitation, the athletic trainer can return
'assions the next phase of rehabilitation, The physician prefers an the athlete to participation at preinjury status, The prein­
accelerated protocol for the athlete. What types of func­ jury status achieved with the functional progression not
tional acllvilies could you suggest for the athlete? only can return the athletc to competition, but also can en­
I functional progres­

sure a safer, more effectivc return to play,

-related injury:

ayer

ligament (ACL) rup­

~ cutting motion in

: an intra-articular

was conducted both

Summary
nphasis of program

- motion (ROM) and

me minor considera­ 1. Complete rehabiHtation should strive to improve neu­ 6, Functional progressions allow for improvements in
romuscular coordinalion and agility, strength, en­ strength. endurance, mobilitylflcxibility, relaxation,
h bilitation protocol
durance, and flexibility, coordination/ agility/skUI. and assessment of func­
r,1 physical fitness.
2, The role of the functional progressions is to improve tional s(abili ty.
lilitation means and
and complete the traditional rehabilitation process by 7. Functional progression can benefit the athlete psycho­
. RO M.
providing sport-specifIc exercise, logically and socially by decreasing the athlete's feel­

~
rgery a functional 3. The functional progression is a sequence of activities ings of anxiety, deprivation, and apprehension,
sion included the thal Simulate sport activity, The progression will begin 8, Components of a functional progression that should
e times per week: easy and progress to full sport participation. be addressed include deve'lopment, choice of activity,
4, Each sportaclivity can be diVided into smaller compo­ implementation, and termination.
- 'tation techniques­ nents, allowing the athlete to progress from easy to 9. Many functional tests exist and should be adminis­
~ ns difficult. tered when deciding whether to return an athlete to
'urves
5. Functional progressions are highly effective exercise competition.
therapy techniques that should be incorporated in the
urves
long-term rehabilitation stage,
366 PART THREE T h e Tools of Rehabilitation
References
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tonic. and isokinetic con centric and eccentric quadriceps a n d
hamstring fp rcc and three components of athletic perfor­
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14:3 .
2. Anderson, M. A.. (I ndT. L. Foreman. 19 96. Return to compe­
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13. Gross, M. T.. ). R. Everts. and S. E. Roberson. 1994. Effect of
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35. UhI,T. L.. M. Gou ld
ter posterolatera l di
ball player: A case
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63(4 ): 14-19. 36 . Wilk. K. E.. W. T. Rl
18. KeskuJa . D. R., J. B. Dunc.an, and V. L. Davis. 1996. Functionall 199 4. The re.Iatioru
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oj Athlel.ic Tmilling 31 (2): 105-10. SOLUTIONS TO
19. King, M. A. 200n. Functional stability for the upper quarter.
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21. Lcphart, S. 199 2. Relationship between selected physi ca l
rection chang
characteristics and functional capa city in the an terior cruci­
1 7-2 Closed-kinetic
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tion and kine
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dosed-kineti
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 CHAPTER 17 Functional Progressions and Functional Testing in Rehabilitation 367

J. H. Geick. 2000. Rehabilitation af­

J 5. Uhl. T. L.. M. Gould, and netic testing. and functional testing in the ACL-rcconstruelcd
tcr posterolateral dislocation of the elbow in a collegiate foot­ knee. Journal oj Orthopaedic and Sports Physical Therapy 20(2):
ball player: A case report. Journal of At/JIetic Training 35(1 ): 60-71.
108-10. 37 . Worrell, T. W. L. D. Booher. and K. M. Hench. 1994. Closed
IrtS Physical TlJerapy
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,'15. 1996. Functional
~ as essment. Journal
SOLUTIONS TO CLINICAL PECISI'ON MAK'ING EXERCISES
'or the upper Quarter.

lie exercise foundati ollS
~n selected physical
in the Hnterior cruci­
JQ./ of Orthopaedic and
17-1 Agility runs would be the most beneficial for this ing would be necessary in order to evaluate all as­
athlete to allow for improvement in speed and di­ pects of the athlete's position . Criteria for return:
rection change. no pain, full ROM, bilaterally equal strength,
17-2 Closed-kinetic-chain (CKC) activities that stress successful completion of functional test, self­
coactivation of the core, scapular stabilizers, and evaluation, and physician's release.

Itional rehabilita Llon rotator cuff muscles would help the athlete correct 17-5 Although it is early in the rehabilitation process,

operlic Clinics of ;\ 'Ot'rh
~ aI. 1991. Functional
:iate ligament-insulTi­
](1:44- 50.
lClional re habilitation
'IIpl Today 6(6): 12-8.
. (If spo rts injurie s miff
Belfus.
nal restinll of mil/ell'S
'liorwl Performance In­
rrersily of I orth Car-
the strength deficits with the scapular stabilizers.
Once improvements are noted with the CKC activi­
ties. sport-specit1c open-kinetic-chain activities
would be indicated.
17-3 The athlete is probably deficient in her propriocep­
tion and kinesthetic awareness. Upper-extremity
closed-kinetic-chain activities, rhythmic stabiliza­
tion. and PNF diagonal patterns may benefit this
athlete. tinuation of his strengthening program, will help
: 7-4 Sport-specific and posi lion-specific testing would
be indicated . Open- and c1osed-kinetic-chain test­
functional activities could beg,i n. Closed-kinetic­
chain activities such as minisquats could be initi­
ated safely. Gait training and functional activities in
the pool could also benefit t h e athlete in this stage.
17-6 The athlete is at approximately 75 percent of func­
tion. Based on this score. the athlete would con­
tin ue his rehabilitation program and not return to
full participation. Agility training. along with con­
the athlete reach his goals.

billt lio n of the knee.

'11e r Ie of lhe sensori­

Ier. /o ur/lal of Athlet ic

199 1. Abnormal limb

p te 'Ls afler anterior
ur/lal of Sports Mcdi­

ly in athletes with an­

TiCilIl Journal oj SfJorr~

p.. el al. 1986. t\ perfor­

I and evaluate anteri r
.urnal of Sports IVIl'di ­
 CHAPTER 18
Acror
Rehabili,tation of Shoulder Injuries

Rob Schneider Greater

William E. Prentice
Sicip

Lessel

Study Resources • Administer exercises that may be used

To become more familiar wilh the knowledge and skills to reestablish neuromuscular control.
necessary 10 design. implement. and document therapeu­
tic rehabilitation programs as identified in the .\"ATA Ath­ • Relate biomechanical principles to the
letic Training Educational Competencies mill Clinical rehabilitation of various shoulder Figure 18-1 Skeleli
Proficicncies' Therapeutic Exercise content area. visit
inj uries/pathologies.
wlVw.mhhe.com/prenticel] e. Also reft:r to tbe lab exer­
cises in the new Laboratory Manual and to eSims. which
joint (Figure IS-I ). D
• Discuss criteria for progression of the of the shoulder compJ
simulates the athletic training ce.rtification exam, at
w\vw.mhhe.com /esims. for more online study resources .
rehabilitation program for different rour articulations if m
visit our Health and Human Performance website at shoulder injuries/pathologies.
lVww.mhhe.com/hhp. SternoclaviculCl
• Describe and explain the rationale for
various treatment techniques in the The clavicle articulat.
After Completion of This
num to form the Slt'!
Chapter, the Student Should
management of shoulder injuries. ;kcletal connection bi
Be Able to Do the Following:
tr unk. The sternal ar1
sternum. causing the
• Review the functional anatomy and ,ternum. A fibroc ar
biomechanics associated with normal FUNCTIONAL ANATOMY Lhe two articulating
function of the shoulder joint complex. AND BIOMECHANICS rber against the m
any displacement 1I~
• Differentiate th e various rehabilitative The anatomy of the shoulder joint complex allows for lhat the clavicle mo~~
strengthening techniques for the tremendous range of motion. This wide range of motion of oves separately onJ
the shoU!lder complex prm.1mal permits precise pOSitioning {Q move up and dom
shoulder, including both open- and of the hand distally. to allow both gross and skilled move­ nation . and in rotati
closed-kinetic-chain isotonic, plyomet­ ments. However. the high degree of mobility requires some The sternoclavi
ric, isokinetic, and PNF exercises. compromise in stability. which in turn increases the vul­ of its bony arrangem
nerability of the shoulder joint to injury. particularly in dy­ ligaments that tend t
• Compare the various techniques namic overhead athletic activities. downward and tOI'van
for regaining range of motion includ­ The shoulder girdle complex is composed of three The main ligament
bones-the scapula. the clavicle. and the h umerus-which which prevents up\\'-a
ing stretching exercises and joint are connected either to one another or to the axial skeleton posterior sternocla\'ii
mobilizations. or trunk via the glenohumeral joint. the acromioclavicular displacement of tbe
joint. the sternoclavicular joint. and the scapulothorasic prevents lateral displ'

368

 CHAPTER 18 Rehabilitation of Shoulder Injuries 369

• • Acromioclavicular joint
"Juries
Acromion ---I.eW""'>'

Greater tuberosity

Bicipital groove

I\~~""'---:J?' Scapulothoracic
Lesser tuberosity articulation

It may be used
cular control.
in iples to the
boulder Figure 18-1 Skeletal anatomy of the shoulder complex.

joint (Figure 18-1). Dynamic movement and stabilization
ression of the or the shoulder complex require integrated function of all
r different four articulations if normal motion is to occur.
ies.
Sternoclavicular Joint CSC joint)
~ rationale for
Liques in the The clavicle articulates with the manubrium of the ster­
num to form the sternoclav·i cular joint, the only direct
:or injuries. skeletal connection between the upper ext.remity and the
trunk. The sternal articulating surface is larger than the
'ternum, causing the clavicle to rise much higher than the
sternum. A fibrocartilaginous disk is interposed between
MY the two articulating surfaces. It functions as a shock ab­
sorber against the medial forces and also helps to prevent
any displacement upward. The articular disk is placed so
complex allows for that the clavicle moves on the disk, and the disk, in turn.
fide range of motion of moves separately on the sternum . The clavicle is permitted
. precise positioning 10 move up and down. forward and backward, in combi­
o and skilled move­ nation, and in rotation .
obility requires some The sternoclavicular jOint ·is extremely weak because
n increases the vul­ of its bony arrangement. but it is held securely by strong
_'. particularly in dy­ ligaments tbat tend to pull the sternal end of the clavicle
downward and toward the sternum. in effect anchoring it.
composed of thra' The main ligaments are the anterior sternoclavicular,
the humerus-which vhich prevents upward displacement of the clavicle; the
r to the axial skeleto(1 posterior sternoclavicular, which also prevents upward
the acromioclavicular displacement of the clavicle; the interclavicular, which
[he scapulothora ic prevents lateral displacement of the clavicle; and the cos-
toclavicular. which prevents lateral and upward displace­
ment of the clavicle. l
It should also be noted that for the scapula to abduct
and upward rotate throughout 180 degrees of humeral
abduction, clavicular movement must occur at both the
sternoclavicular and acromioclavicular joints. The c1av,i­
cle must elevate approximately 40 degrees to allow up­
ward scapular rotation. i6
Acromioclavicular Joint CAC joint)
The acromioclavicular joint is a gliding articulation of the
lateral end of tbe clavicle with the acromion process. This
is a rather weak joint. A fibrocartilaginous disk separates
the two articulating surfaces. A thin. fibrous capsule sur­
rounds the joint.
The acromioclavicular ligament consists of anterior.
posterior. superior, and inferior portions. In addition to the
acromioclavicular ligament, the coracoclavicular liga­
ment joins the coracoid process and the clavicle and helps
to maintain the position of the clavicle relative to the
acromion. The coracoclavicular ligament is further di­
vided into the trapezoid ligament, which prevents overr id­
ing of the clavicle on the acromion. and the conoid
ligament, which limits upward movement of the clavicle
on the acromion. As the arm moves into an elevated posi­
tion, there is a posterior rotation of the clavicle on its long
axis. which permits the scapula to continue rotating thus
370 PARTTHREE TheToobofRchabilitation

REHAB I LITATION PLAN

T HERMAL-ASSISTED CAPSULAR SHRINKAGE OF THE
In this phase. str'
G LENOHUMERAL JOINT
and IR and ER resist
exercises are initial
INJURV SITUATION A 27-year-old male baseball player returns to the throwing rolation of his baseball club after having
stabilization drills c
elbow surgery 5 months earlier. Three weeks after returning. he starts complaining of posterior shoulder pain. After 3
ROM goals are ach ie\
months of using ice and NSAID therapy, he begins to have dimculty with his velocity and con­
low the body). an d lao
trol of his pitches. The athlete is diagnosed by an orthopedist with posterior impingement sec­
II' symptoms of pai n
ondary to mu,l tidirectional instability of the glenohumeral joint.
justed accordingly.
--

SIGNS AND SYMPTOMS The athlete complains of posterior cuff pain whenever he externally
PHASE T
rotales. He has 165 degrees of external rotation and 3 S degrees of inlernal rotation. Hori­

GOALS: improl'e Slr

zontal adduction of the humerus is only 15 degrees. Tenderness is present along the posterior

Estimated Length of 1
glenohumeral joinlline. He also has a positive apprehension sign and relocaUon test. The ath­

The criteria used to

lete is evaluated for other factors that have stressed the throwing motion. Evaluation revealed

at least 80 percent
an extremely tight hip nexibility pallern: bilateral hip nexion of 70 degrees, hip internal rota­

wblished ROM an d sb
tion of 15 degrees bilaterally, and hip external rotation of 50 degrees bilaterally.

ball into Lhe Plyobac

MANAGEMENT PLAN The athlete underwent thermal-assisted capsular shrinkage to address
At week 16. th e a
his instability and was rehabilitated with the goal of returning to play in 9 to 12 mouths.
on separate days pri
tOIllS appear, the athl
PHASE ONE PROTECTIOi\ PHASE
PHASE F
GOALS: Allow soft-tissue healing. diminish pain and innammation, initiate protected motion. retard muscle atrophy.
Estimated Length of Time (ELT): Day 1 to Week 6 GOALS: Complete_.
lo'or the firsl2 weeks the athlete uses a sling full time for 7 to 10 days. sleeping with it for the full 2 weeks. Exercises include Estimated Length of 1
hand' and wrist range of motion and actil'e cervical spine range of motion. During this phase. cryotherapy is used before Usually by week 2~ th
and after treatments. Passive and active assisted range of motion for the glenohumeral joint is cautiously performed in a a.nd type of pitch are
restricted range of motion. Shoulder rotation is done in the scapular plane; external rotation (ER) is to neutral and inter­ wiH progress to gam e­
nal rotation (IR) is allowed to 2:; or 30 degrees for the rlrsl week. Moist heat can be used prior to therapy after 10 days. At gressing if he can ill
2 weeks. ROM is progressed ca uliously: nexion is allowed to 90 degrees, ER to 2:; degrees, IR to 45 degrees in the scapular CRITERIA FOR R£1
plane. Passive ROM is performed by the athletic trainer and active-assisted ROM by the athlete. l.
During this phase. ROM is progressed based on the end feel the athletic trainer gets when evaluating the athlete. '''lith 2. No pain or Lender
a hare! end feel. the athletic trainer mal' choose to be more aggressive: a soft end feel dictates slower progression. Range 01 3. Satisfactory m
motion is not the main focus of this phase. By weeks:; and n the athletic trainer should be able to progress to 160 degrees 4. Satisfactory c1i ni
01' elevation. 7:; to 80 degrees of ER. and 60 to 6:; degrees of IR. Rotation should be progressed out of the safe zone to 90 D1SCl'SSION QUES
degrees of elevation. ROM of the athlete's hips is also addressed during th ,is phase. Aggressive stretching and core stabil­ 1. What other fa ct
ity exercises may be started to maintaiu an increased slate of nexibiIity of the pitcher's total rotational capabilities. 2.
Shoulder strengthening begins early in this phase with rhythmiC stabiliza[jon. scapular stabilizing exercises. isometric 3.
exercises for the rotator cuff muscles. and PNF control exercises in a restricted range of motion. By the end of this phase. 4.
exercises for the external rotators and scapular stabilizers should move to unweighted isotonic exercises. '.
ery speed and powcr j
P HAS E i W0 fNTERMEDIATE PIIASE
GOALS: Restore full range of molion. restore functional range of motion. normalize arthrokinemaUcs, improve dy­
namic stability. improve muscular strength.
Estimated Length of Time (ELl): \>Veeks 7 to 12
During this phase the athlete's ROM is progressed to fuIly functionaf by 8 weeks: nexion to 180 degrees, 90 to 100 degrees
of ER at 90 degrees of abduction, and nO to nS degrees of IR. Aggressive stretching Illay be used during this phase if lhe
goal is not met by 8 weeks. This may include jOint mobilization and capsular stretching techniques. From week 9 ,[0 week
12, the athletic trainer begins to gradually progress ROM exercises to a position functional for this pitcher.
 CHAPTER 18 RehabilitaLion of Shoulder Injuries 371

R E H A B I LIT A T ION P LAN (CONT'D.J

In this phase. strengthening exercises include progressive resistive exercise (PRE) in au' planes of shoulder motion
and IR and ER resisted exercises at the 90/90 positions. Resistance progresses from isotonic to plyometric. Plyometric
exercises are initiated with two-handed drills progressing to single-handed plyometric throwing acLivi.Lies . Rhythmic
,all club after having stabilization drills continue to be progressed with increasing diff1culty. Aggressive strengthening may be initiated if
loulder pain. After .3 ROM goals are achieved. vVeight room aclivities, including push-ups, bench press (without allowing the arm to drop be­
low the body), and latissimus pull-downs in front of body, may begin. Exercises should be performed asymptomatically.
If symptoms of pain or illstabiliEy occur. a thorough evaluation of the athlete should be performed and the program ad­
justed accordingly.

PHASE THREE ;\I)V/\NCEI) ACTIVITY ,\:\1) STREi\CTIIEl\I!\i(;

GOALS: Improve strength. power. and endurance; enhance neuromuscular contra\; functional activities.

Estimated Length of Time (ELT): Weeks 12 to 20

The criteria used to allow the athlete to progress to this phase are full ROM , no pain or tenderness. and muscular strength

at least 80 percent of the contralateral side. All strengthening exercises are progressed. The athlete should maintain es­

tablished ROM and should continue stretching exercises. Throwing-specific exercises are initiated. including throwing a

ball into the Plyoback.

At week 16. the athletic trainer will initiate a formal interval-throwing program. Each step is performed at least 2 times
on separate days prior to advancing. Throwing should be performed without pain or any increasing symptoms. [f symp­
lOms appear, the ath'lcte will be regressed to the previous step and remain there until syalptom-free.

PHASE FOUR RETld{~ TO !-'l ILt /\(,TI"ITY

ard muscle atrophy.
GOALS: Complete elimination of pain and full return to activity.

I:Cks. Exercises inelu Estimated Length of Time (ELT): Weeks 20 to 30

Usually by week 22 the athlete will begin throwing off the pitcher'S mound. In this phase the number of throws. intensity.

'herapy is used bcfor ­

a nd type of pitch are progressed gradually to increase the stress at the glenohumeral joint. By 6 to 7 months the athlete

Iliously performed in
lO neutral and inter­
will progress to galne-type situations and return to competition. The athlete will begin by limiting his pitch count and pro­

gressing if he can ma,i ntain his pain and symptom-free status. Full return may take as long as 9 to 12 months.

L"fOPY after 10 days . .

jegrees in the scapula; CRI'l'ERlA FOR RETURNING TO COMPETITIVE PITCHING

1. Full functional ROM

2. 1\0 pain or tenderness
alin g the athlete. V\'il
progrcssion. Range 3. Satisfactory muscular strength

-l. Satisfactory clinical exam

og ress to 160 degr

lof the safe zone to . orSCUSSION QUESTIONS:

_ching and core stab I . What other factors may affect the pitcher's ability to generate velocity of the baseball when he throws the ball?

na l capabilities. ) Can the athktic trainer truly simulate the demands of pitching during the rehabilitation process?

3. Should the athlete be allowed to take NSAIDs during the rehabilitation progression?

,; . What muscles generate the greatest amounts of torque during the athlete's throwing motion?

- What other areas 0(' the thrower's body should be targeted for strengthening, to ensure that he will recover his deliv­

ry speed and power?

~' . 90 to 100 deg e

during this phase if
. . ' From week 9 to \\
pitcher.
372 PART THR HE The Tools of Rehabilitation
allowing full elevation. The clavicle must rotate approxi­
mately 50 degrees for full elevation to occur: otherwise el­
evation wou ld be limited to approximately 110 degrees. ,6
Coracoacromial Arch. The coracoacromial liga­
ment connects the coracoid to the acromion. This liga­
ment, along with the acromion and the coracoid, forms
the coracoacromial arch over the glenohumeral joint. In
the subacromial space between the coracoacromial arch
superiorly and the humeral head inferiorly. lies the
supraspinatus tendon, the long head of the biceps tendon.
and the subacromial bursa. Each of these structures is
subject to irritation and in flammation resulting either
from excessive humerall head translation or from impinge­
ment during repeated overhead activities. In asympto­
matic individuals the optimal subacromial space appears
to be about 9 to 10 mm .; 7
Glenohumeral Joint
The glenobumeral joint is an enarthrodial, or ball-and­
socket. synovial joint in which the round head of the
humerus articulates with the shallow glenoid cavity of the
scapula. The cavity is deepened slightly by a fibrocartilagi­
nous rim cal.lcdlhe glenoid labrum . The humeral head is
larger than the glenoid, and at any point during elevation
only 25 to 30 percent of the humeral head is in contact
with tbe glenoid . 1M The glenohumeral joint is maintained
by both static and dynamic reslraints. Position is main­
tained statically by the glenoid labrum and the capsular
ligaments, and dynamically by the deltoid and rotator cuff
muscles.
Surrounding the articulation is a loose, articular cap­
sule that is attached to the labrum. This capsule is strongly
reinforced by the superior, middle, and inferior gleno­
humeral ligaments and by the tough coracohumeralliga­
ment, which attaches to the coracoid process and to the
greater tuberosity or the humerus. 52
The long tendon of the biceps muscle passes superiorly
across the head of the humerus and then t.hrough the
bicipital groove. In the anatomical position the long head
of the biceps moves in close relationship with the
humerus. 'I'he transverse humeral ligament maintains the
long head of the biceps tendon within the bicipital groove
by passing over it from the lesser and the greater tuberosi­
ties, converting the bicipital groove into a canal.
Scapulothoracic Joint
The scnpulothoracic joint is not a true joint. but the move­
ment of the scapula on the wall of the thoracic cage is crit­
ical to shoulder joint molion . Contraction of the scapular Suprospin
musdes that attach the scapuJa to the axial skeleton is es­
sential in stabilizing the scapula. thus providing a base Oll
which a highly mobile joint can function . IS
Stability 'in the Shoulder Joint
Maintaining stability. while the four articulations of the s...bscopuloris
shoulder complex collectively allow l'or a high degree of
mobility. is critical Lo normal function of the shoulder
joint. Instability is very often the cause of many of the spe­
cific injuries to the shoulder that will be discussed later in
this chapter. In the glenohumeral joint, the rounded
humeral head articulates with a relatively Oat glenoid on .gure 18-2 Tr
the scapula. During movement of the shoulder joint. it. i
essential to maintain the positioning of the humeral head
relative to the glenoid,. Likewise it is also critical for the gle­
noid to adjust its pOSition relative to the moving humeraJ
head while Simultaneously maintaining a stable base. Th e to the glenoid.
glenohumeral joint is inherently unstable, and stability de­ ce couple invol\"e
pends on the coordinated and s)7nchronous function of g in opposite diIa
both dynamiC and static stabilizers. 4h ese force cou pl
The Dynamic Stabilizers of the Glenohumeral glenohumeral
Joint. The muscles that cross the glenohumeral joint umerus. If an im"
produce motion and function to establish dynamic stabil­ mponents thaL
ity to compensate for a bony and ligamentous arrange­ nohumeralmecb
ment that allows for a great deal 01 mobility. Movements at
the glenohumeral joint include Oexion. extension. abduc­
lion , adduction. circumduction, and rotation.
The musc:Ies acting on the glenohumeral' joint may be pinatus, teres
classified into two groups. 'rhe first group consists of mus­ presses and com
des that originate on the axial skeleton and attach to the ead movements.
humerus; these include the latissimus dorsi and the pec­ In the coronal
toralis major. The second group orig,i natcs on the scapul a ,\'een the deltoid
and attaches to the humerus; these include the deltoid. the Figure 18-3). With
teres major, the coracobrachialis, the subscapularis, th ~e deltoid produc
supraspinatus, the inkaspinatus. and the teres minor.
These muscles constitute the short rotator muscles whos
tendons insert into the articular capsule and serve as rein­
forCing structures. The biceps and triceps muscles attach
on the glenoid and affect elbow motion.
The muscles of the rolator cuff, the subscapularis, in­ The supraspinatu s Co
fraspinatus, supraspinatus. and teres minor along with th!: glenOid and ctlong \\'
long head of the biceps function to provide dynamic stabil­ ;h is stable bctse. Dyn
ity to control the pOSition and prevent excessive displace­ .:n joint compressio
ment or translation of the humeral head relative to the su praspinatus an d .
pOSition of the glenoid.8.43. 73 traction of the inferi
Stabilization of the humeral head occurs through CG­ The long head of
contraction of the rotator cuff muscles. This creates a se­ dynamic stability by
ries of force couples that act to compress the humeral head h umerus during eI
 CHAPTER 18 Rehabilitation of Shoulder Injuries 373

jon of the scapular

axial skeleton is e ­
providing a base 00
l
In .

Dint Infraspinatus
ilIticulations of the­ Subscapularis

Jr a high degree
on of the should r
,of many of the spc­
ile discussed later in
joint. the rounded
J\"e ly flat glenoid on Figure 18-2 Transverse plane force couples.
figure 18-3 Coronal plane force couples.
h oulder joint, it is
Jf the humeral head
;0 critical for the gle­
be moving humeral
Ilg a stable base. The­ into the glenoid . minimizing humeral head translation. A Static Stabilizers. The primary static stabilizers of
&hIe. and stability d ­ j(Jrce couple involves the action of two opposing forces act­ the glenohumeral joint are the glenohumeral ligaments.
If no us function f ing in opposite directions to impose rotation about an axis. the posterior capsule. and the glenoid labrum.
These force couples can establish dynamic equilibrium of The glenohumeral ligaments appear to produce a ma­
he Glenohumeral the glenohumeral joint regardless of the position of the jor restraint in shoulder flexion. extension. and rotation.
glenohumeral joint humerus. II" an imbalance exists between the muscular The anterior glenohumeral ligament is tight when the
.Iisb dynamic slabil­ components that create these force couples. abnormal shoulder is in extension. abduction. and/or external rota­
,amentous arran ge­ glenohumeral mechanics occur. tion. The posterior glenohumeral ligament is tight in Ilex­
ility. Movement at In the transverse plan a force couple exists between the ion and external rotation. The inferior glenohumeral
fl. xtension. abduc­
subscapulariS anteriorly and the infraspinatus and teres ligament is tight when the shoulder is abducted, extended.
minor posteriorly (Figure 18-2). Co-contraction of the in­ and /or externally rotated. The middle glenohumeral. liga­
rOlation.
lumcra ! joint may b fraspinatus, teres minor. and subscapularis muscles both menl is tight when in flexion and external rotation. Addi­
IUp consists of mus­ depresses and compresses the humeral head during over­ tionally. the middle glenohumeral ligament and the
o and attach to thl' head movements. subscapularis tendon limit laterall rotation from 45 to 75
do rsi and the pec­ In the coronal plane. there is a critical force couple be­ degrees of abduction and are important anterior stabiliz­
tween the deltoid and the inferior rotator cuff muscles ers of the glenohumeral joint. 3 The inferior glenohumeral

~
al es on the scapula
lude the deltoid. the (Figure 18-3). With the arm fully adducted. contraction of
. ubscapularis. th the deltoid produces a vertical force in a superior direction
causing an upward translation of the humeral head rela­
tive to the glenoid. Co-contraction of the inferior rotator
Ie and serve as rein­ cuff muscles produces bolh a compressive force and a
c ps muscles attac h downward translation of the humerus that counterbal­
ances the force of the deltoid. stabilizing the humeral head.
e subscapularis. il~­ The supraspinatus compresses the humeral head into the
m or along with the glenoid and along with the deltoid initiates abduction on
\-ide dynamic stabii­ this stable base, Dynamic stability iscreated by an increase
t excessive displace­
in joint compression forces from contraction of the
head relative to th supraspinatus and by humeral head depression from con­
traction of the inferior rotator cuff muscles. 8 . 16 .4 I .i3
d occurs through co­ The long head of the biceps tendon also contributes to
es. This creates a se­ dynamic stability by limiting superior translation of the
~s the humeral head
humerus during elbow flexion and supination.
ligament is a primary check against both anterior and pos­
terior dislocation of the humeral head and is the most im­
portant stabilizing structure of the shoulder in the
overhead athlete. I
The tendons of the rotator cuff muscles blend into the
glenohumeral joint capsule at their insertions about the
humeral head (Figure 18-4). As these muscles contract.
tension is produced. dynamically tightening the capsule
and helping to cent.er the humeral head ,in the glenoid
(ossa. This creates both static and dynamiC control of
humeral head movement.
The posterior capsule is tight when the shoulder is in
flexion. abduction. internal rotation. or in any combina­
tion of these. The superior and middle segment of the pos­
terior capsule has the greatest tension while the shoulder
is internally rotated.
 374 PA RT THREE The Tools of Rehabilitation
Superior glenohumerol
ligament
Intraspinatus Subscopularis
Middle glenohumeral
ligament
Teres minor
Posterior axi lIary
pouch af the inferior
glenohumeral
ligoment
Superior bond of inferior
glenohumeralligoment
Figure 18-4 Rotator cuff tendon s blend into the jOint
capsule.
The bones and artlcnlar surfaces within the shoulder
are positioned to contribute to static stability. The glenoid
labrum, which is lightly attached to the bottom half of the
glenoid and loosely attached at the top, increases the gle­
noid depth approxi mately two times, enhancing gleno­
humeral stability.·j I The scapula faces 30 degrees
anteriorly to the chest wall and is tilted upward 3 degrees
to enable easier movement on the anterior frontal plane
and movemen ts above the shoulder. 2R The glenoid is til ted
upward 5 degrees to help control inferior instability.44
Scapular Stability and Mobility. Like the gleno­
hnmera'l muscles. the scapular muscles playa critical role
in normal function of the shoulder. The scapular muscles
produce movement of ~he scapula on the thorax and help
to dynamically position the glenoid relative to the moving
humerus. They include the levator scapula and upper
trapezius. which elevate the scapulo; the middle trapezius
and rhomboids . which adduct the scapula; the lower
trapezius. which adducts and depresses the scapula; the
pectoralis minor, which depresses the scapula; and the ser­
ra tus anterior. which abdu cts and upward rotates the
scapula. Collectively they function to maintain a consis­
lentleogth-tension relationship with the glenohumeral
muscles.37. 3s.4R
The only attachment of the scapula to the thorax is
through th ese muscles. The muscle stabilizers must fix the
pOSition of the scapula on the thorax. providing a stable
base for the rotator cuff to perform its intended lunction
on the humerus. It has been suggested that the serratus
anterior moves the scapula while the other scapular mus­
cles fUll ction to provide scapular stability. 17.38The scapular
muscles act isometrically. concentricaUy. or eccentrically.
depending on th e movement desired and whether tht tching Ex ,
movem ent is speeding up or slowing down. 44
Scapulohumeral rhythm. Scapulohumerat rhythm
is the movement of the scapula relative to the movement
the humerus throughout a full range of abduction. As lht:
humerus elevates to 30 degrees, there is no movement of the
scapula. Tbis is referred to as the setting phase during whicp
a stable base is being established on the thoracic wall. Frorr
30 to 90 degrees. th e scapula abducts and upward rotal,
1 degree for every 2 degrees of humeral elevation. Fro!'"
90 degrees to full abduction. the scapula abducts and UJ)­
ward rotates 1 degree for each 1 degree of humeral ele\'a ­
tion . [I' normal scapulohumeral rhythm is compromisee
normal shoulder jOint funclioll in moving to a fully elevat,
position cannot occur, and adaptive compensatory motio
can predispose the athlete to injury."
Plane of the scapula. The concept of the plan e
the scapula refers tolhe angle of the scapula in its resti ll",
position, usually 35 to 45 degrees anterior Lo the fro nta
plane toward the sagillal pla ne. When the limb is po'
ti oned in the plane of the scapula, th e mechanical axis
the glenohumerall joint is in line with the mechanical aJ
of the scapula. The glen ohumeral joint capsule is lax, a
the deltoid and supraspinatus muscles arc optimally p
tioned to elevate the humerus. Movement of the hum er
in this plane is less restricted than in the frontal or sagi U
planes. because the glenohumeral capsule is nott wisted.­
Because the rotator cuff muscles originate on the scap...
and attach to th e humerus. repositiolling the humer
into the plane of the scapula increa ses the length of the
muscles, improving th e length-tension relationship. Th i­
likely to increase muscle force. 2 1 [t b as been recommen
that many strengthening exerci ses for the shoulder jo'
complex be done in the scapul a r plane. 22. , B.I'!
CLINICAL DECISION MAKING Exercise 18-1
A varsity ice hockey player suffers a grade 1 acromioclav­
icular (AC) separation after being checked into the boards
during a bockey game. The athlete presents with the chief
complaint of pain and the inability to abduct his affected
arm. The physician was not able to see any widening of
the AC loint with a weighted X ray. The athlete is referred
to the athletic trainer for conservative management of
his Injury. What can th.c athletic trainer do to ensure th at
the athlete's injury will hea l and not lead to further dys­
function of the shoulder complex?
 CHAPTER 18 Rehabilitation of Shoulder Injuril's 375

and whether the Stretching Exercises

wn:H
humeral rhythm
lO the movement of
abduction. As the
movementof the
phase during which
thoracic wall. From
and upward rotates
ral elevation. From
ula abducls and up­
of humeral eleva­
is compromised.
g to a fully elevated
pensatory motions

'ept of the plane of

Figure 18-7 Sawing. The athllete moves the arm forwa rd
ap ula in its resUn_ and backward as if performing a sawing molion. This tech­
terior to the frontal nique is useful as a general stretch in the early stages oj' re­
n the limb is po i­ habilitation when motion above 90 degrees is restricted.
mechanical axis r
e mechanical axi
t capsule is lax. an
, are opLimally po -i­
entof the hum eru ~
e fron tal or sagill a
ule is not twisted. ­
nate on the scapul
ning the hU!11cru
the length of tho. Figure 18-5 Static hanging. Hanging from a chinning
relationship. Thi ' oa r is a good general stretch for th e musculature in the
been recommend ,houlder complex.
r the shoulder joir
.:!.JS.79

Exercise 18-1

de 1 acromioclav­
into the boards
'nlS with the chief

Figure 18-6 Cadman's circumduction exercise. The

.. .............................. th lete holds a dumbbell in the hand and moves it in a
_ rc ular pattern, reversing direction periodically. This
hniqu e is useful as a general stretch in the early stages
rehabilitation when motion above 90 degrees is re­
ricted.
Figure 18-8 Wall climbing. The athlete uses the fin­
gers to "walk" the hand up a wall. This tcchniquc is use­
ful when attempting to regain full-range elevHtion. ROM
should be restricted to a pain-free arc.
376 PART THREE The Tools of Rehabilitation

Figure lS-10 Wall/corner strclch.Used to stretch the

pectoralis major and minor. nnterior deltoid. and coraco­
brachialis. and the anterior joint capsule.

Figure IS-9 Rope and pulley exercise. This exercise

may be used as an active-assislive exercise when trying to
regain full overhead motion. ROM should be restricted to
a pain-free arc.
A

L ---...._~_ ,

Figure IS-I I Shoulder extensor stretch using an L­ Figure] S-12 Shoulder flexors stretch using an L-bar.
bar. [jsed to stretch the latissimus dorsi. teres major and Used to stretch the anterior deltoid. coracobrachialis. pec­ B
minor. posterior deltoid. and triceps muscles. and the in­ toralis major. and biceps muscles and the anterior joint
ferior joint capsule. capsule.

Figure IS-14 ShOll

latissimus dorSi. teres
A, 0 degrees, B, 90 d
 CHAPTER 18 Rehabilitat ion oj' Shoulder Injuries 377

Figure 18-13 Shoulder adductors stretch using an L­

bar. Used to stretch th e latissimus dorsi. teres major and
minor. pecl()rali~ major and minor. posterior deltoid. and
B
triceps muscles. and the inferior joint capsule.

Figure 18-15 Shoulder lateral rot"alors stretch using

an L-bar. Used to stretch the infraspinatus, teres minor.
and posterior deltoid muscles , and th e post.erior joint
capsule. This stTetch should be done at A. 90 degrees.
B. 1 3 degrees. C. 135 degrees.

lch using an Ir bar.

w racobrachialis. pee­ B
d the anterior joint c

figure 18-14 Shoulder medial rotators stretch using an L-bar. sed to stretch the subscapularis pectoralis major,
iatissimus dorsi, teres major. and anterior deILoid muscles, and the anterior joint capsule. This stretch should be done at
A, 0 degrees. B. 90 degrees, a nd C, 135 degrees.
378 PART THREE The Tools of Rehabilitation

REHABIUTAl
FOR THE SH~
Strengthening

Figure] 8-17 Horizonal abductors stretch . Used to

Figure 18-16 Horizontal adductors stretch using an 1­ stretch the posterior deltoid. infraspinatus. teres minor.
bar. Used to stretch the pectoralis major. anterior deltoid. rhomboids. and middle trapezius muscles, and the poste­
and long head of the bic(~ ps muscles. and the anterior rior capsule. This position might be uncomfortable for
joint capsule. athletes with shoulder impingement syndrome.

Figure 18-21 Ber_

-oralis major. an teri
~ iy the coracobracrn.
d lh the feet on the
.md helps to isolate

Figure 18-19 Inferior capsule stretch. Self-stretch

done with the arm in the fuHy devated overhead position.
Figure 18-18 Anterior capsule stretch. Self-stretch us­ This pos.ition might be uncomfortable It)[ athletes with
ing the wall. shoulder impingement syndrome.

figure 18-23
the pectoralis
toid , coracobrachia
Figure 18-20 A, Isometric medial rotation . and B, isometric lateral rotation, are useful in the early stages of a sho ul­
der rehabilitation program when full ROM isotonic exercise is likely to exacerbate a problem. The towel under the arm is
used to help establish neuromuscular control and help facilitate scapular stability.
 CHAPTER 18 Rchabilit<ltion of Shoulder rnjurie~ 379

REHABILITATION TECHN IQUES

FOR THE SHOULDER
Strengthening Techniques

:tretch. Used to

Figure 18-21 Bench prl:!ss . Used to strengthenlhe pec­

toralis major. anterior deltoid. and triceps ; and secondar­
ily the coracobrachia lis muscles. Performing this exercise
with thc feet on the bench serves to flatten the low back
Hnd helps to isolate these muscles.

Figure 18-22 incline bench press. Uscd to SLrengthen

the pectoralis major (upper IIbers ). triceps. middle and
anterior deltoid; and secondarily the coracobrachialis.
upper trapezius. and levator scapula muscles.

teh . Self-sLretch
oncrhead position.
f r athletes with

Figure 18-2 3 Decline bench press. Used to strengthen Figure 18-24 i\llililary press. Used to strenglhenthe
the pectoralis major (lower fibers). triceps. anterior del­ middle deltoid. upper trapezius. levator scapula.
lOid. coracobrachiaLls. and latissimus dorsi muscles. and tri ceps.
380 PART THREE The Tools of Rehabilitation

Figure 18-29
ed to strengthen
ondarily th e
slightly flexed.
Figure 18-26 Shoulder flexion. Used to strengthen pri­
a nding with
marily the anterior deltoid. and coracobrachialis: and
secondarily the middle deltoid. pectoralis major. and bi­
ceps brachii muscles. Note thalthe thumb should point
upward.

Figure 18-25 Lat pull-downs. Used to strengthen pri­

marily the latissimus dorsi. teres major. and pectoralis mi­
nor: and secondarily the biceps muscles. This exercise
may be done by pulling the bar down in front of the head
or behind the neck. Pulling the bar down behind the neck
requires contraction of the rhomboids and middle trapez­
ius. Pull-ups done on a chinning bar can also be used as
an alternative strengthening technique.
Figure 18-31
rsi. and tere
Figure 18-27 Shoulder extension. Used to strengthen
' he r lying supine
primarily the latissimus dorsi. teres major. and posterior
10 degrees. and
deltoid: and secondarily the teres minor and the long
head of the triceps muscles. Note that the thumb shou ld
point downward. IvJay be done standing using a dumbbeL
or lying prone using surgica l tubing.

~ Figure 18-28 Shoulder abduction to 90 degrees . Used A

to strengthen primari'ly the middle delLoid and figure 18-32 Sb
supraspinatus; and secondarily the anterior and posterior arily the posterior
deltoid and serratus anterior muscles. Note that the du mbbell or standi
thumb is in a neutral position. [) degrees and 13 j
 CHAPTER IS Rehabilitation of Shoulder Injuries 381

Figure 18-30 Reverse nys (shoulder horizontal <lbduc­

f igure 18-29 Flys (shouldcr horizontal adduction).
'eel to strengthen primarily the pectoralis major; and
condarily the anterior deltoid. Notc that the elbow may
be slighlIy nexed. May be done in a supine position or
la nding with surgical tubing or wall pulleys behind.
tion) . Uscd to strengthen primarily the posterior deltoid;
and secondarily the infraspinatus. teres minor. rhom­
boids. and middle trapezius muscles. May be done lying
prone using either dumbbells or tubing. Note that with
the thumb pointed upward the middle tr<lpezius is more
active. and with the thumb painted downward the rhom­
boids <lre more active.

A B c
Figure 18-31 Shoulder medi<ll rotation. Used to strengthen primarily the subscapularis. pectoralis major. l<ltissimus
dorsi. and teres major; aod secondarily the anterior deltoid. This exercise may be done isometrically or isotonically. ei­
cr lying supine using a dumbbell or standing using tubing. Strengthening should be done with the arm fully adducted
at () degrees. and also ill 90 degrees and 13 5 degrccs of abduclion.

A B c
Figure 18-32 Shoulder lateral rotation. Used to sLrengthen primarily the infraspinatus and teres minor; and second­
and posLerior arily the posterior deltoid musclcs . This C'xercise may be done isometrically or isotonkally. eithcr lying prone uSing a
lhat the ' umbbell or standing using tUbing. Strengthening should be done with the arm fully <ldducted at 0 degrees. and also in
9 0 degrees and 13 5 degrees of abduction.
382 PART THR EE The Tools of Rehabilitation

f igure 18-37 Be<­

Figure 18-33 Scaption . Used to strengthen primarily
the supraspinatus in the plane of the scapula; and sec­
ondarily the anterior and middle deltoid muscles. This
exercise should be done standing with the arm horizoD­
tally adduCLed to 45 de grees and the thumb pointing
downward.
-na rily the midd l
"lg in a bent-over
Figure 18-34 Alternative supr8spinatus exercise. Used nch.
to strengthen primarily the supraspinatus; and secondar­
ily the posterior deltoid. Tn the prone position with the
arm abducted to 100 degrees. the arm is horizonta ll y ab­
ducted in extreme lateral rotation. Note thut the thumb
shou ld pOint upward.

f 1\ Figure 1 8-39 Pu~

cise. includin g A. n ..,

Figure 18-36 Superman. Used to strengthen primarily

Figure 18-35 Shoulder shrugs . Used to sLrengthen pri­ the inferior trapezius: and secondarily th e middle trapez­
mClrily the upper trapezius and the levator scapu la; and ius. May be done lying prone using eithe r d umbbells or

)
secondarily the rhomboids. tubing. Note that the rhumb is in a neutra l position.
 CHAPTER 18 Rehabilitation of Shoulder Injuries 383

Figure 18-.3 7 Bent-over rows. Used to strengthen pri­ Figure 18-38 Rhomboids exercise. Used to st rengthen
marily the middle trapezius and rhomboids. Done stand­ primarily the rhomboids: and secondarily th e inferior
ing in a bent-over position with one knee supported on a trapezius. Should be done lying prone with manual resist­
at us exerci.se. Used bench. ance applied at the elbow.
lUS : and secondar­
'ilton with the
1 is horiwntally ab­
e that the thumb

A B

Figure 18-39 Push-ups with a plus. Used Lo strengthen the serratus anterior. There are several variations to this exer­
cise. including A. regular push-ups. B. weight-loaded push-ups with a plus.

Figure 18-40 Scapular strengthening using a Body

Blade. Holding an osci llating Body Blade with both
hands. the athlete moves rrom a fully adducted position in
rront or the body to a fully elevated overhead position.
384 PAR'I' THREE The Tools of Rehabilitation

Closed Kinetic Chain Exercises Plyometric

Igure 18-45
A ·engthen the
etch of the
otraction of th

A
B

Figure 18-41 Push-ups. May be done with A, weight Figure 18-42 Seated push-up. Done sitting on the end
supported on feel. or B, modified to support weight on the of a table. Place hands on the table and lift weight up­
knees. ward off of the table isotonically.

Figure 18-44 Stair Climber with feet on chair. An ad­

vanced c1osed-kinetic-ehain strengthening exercise tha t
Figure 18-43 Biodcx upper-extremity closed-chain de­ places the hands on the foot plates of a Stair Climber wit h
vice . One of the only isokinetic c1osed-kinetic-cham exer­ the l'eet supported on a chair. Requires substantial upper­
cise devices currently al'ailable. body strength.
 CHAPTER 18 Rehabilitation of Shoulder Injuries 385

Plyometric Exercises

Figure 18-45 Surgica l tubing. For example, to

strengthen the medial rotators. use a quick eccentric
stretch of the medial rotators to facilitate a concentric
contraction of those muscles.

A B

itling on the end

Ilft weight up­

c D

on chair. An ad­
ng exercise that Figure 18-46 Plyoback. The athlete sho uld catch the ball, decelerate it. then imm ediately accelerate ill
a Stair Cl imber with th e opposite direction. A. Single-arm toss. B, Two-arm toss with trunk rotation. C, Two-ann overhead toss.
substanLial upper- D. Single-arm toss on unstable surface.
386 PART THREE The Tools of Rehabilitation

E I ~ '\,. ~ '\l ~ F

Figure 18-46 continued E. Kneeling single-arm toss. F. Kneeling two-arm toss. The weight of the
plyoball should be increa sed as rapidly as can be tolerated. 7l

Figure 18-51 PUc

<;l a nds behind the (I'
\\ all. The athlete dl:
orf the wall immedi
Figure 18-47 Seated single-arm weighted-ball throw.
The athlete should be seated with the a rm abducted to 90
deg rees and the elbow supported on a table. The sports PNF Strengthe
therapist tosses the ball to the hand. creating an overload Figure 18-48 Push-ups with a clap. The athlete
in lateral roiation that forces th e athlete to dynamically pushes off the ground, claps his hands. a nd catches his
stabilize in that position. weight as he decelerates.

,-~ .~ A

____ I!'_
Figure 1849 Push-ups on boxes. When performing a
plyometric push-up on boxes, the athlete can stretch the
~.-=--- , ~=­
Figure 18-50 Shuttle 2000.1. The exe rcise machine
anterior muscles, which facilitates a concentric con trac­ can be used for plyometric exercises in either the upper or
tion. the lower extremity.
 CHAI'TER 18 Rehabilitation 0(' Shoulder In juries 387

Isokinetic Exercises

figure 18-52 [so kin etic medial/lateral rotation. Wh en

using an isokinetic device for strengthening the shoulder.
the athlete should be set LIp such that strengthe ning can
be clone in a scapular plane.l l

Figure 18-51 Push into wall. The athl etic trainer

stands behind the athlete and pushes him toward the
wall. The athleLe decel erates the forces and then pushes
of!' the wall immediately.

PNF Strengthening Techniques

A B

'xercise machine
either the upper or Figure 18-53 Rhythmic contraction. Using either a Dl or D2 pattern. A, The athlete uses an isometric co-contraction to
maintain a specifIc position within the ROM. B, The athletic trainer repeatedly changes the direction of passive pressure.
388 PART THREE The Tools of Rehabilitation

A
Figure 18-54 PNF technique for scapula. As the ath­
lele moves through either a 01 or a D2 pattern . the ath­
lelic trainer applies resislance at the appropriate scapular
border.

Figure 18-57 PNF using a Body Blade. Tn a standing

position. the athlete moves an oscillating Body Blade
through a 02 pattern.

Figure 18-55 The athlete can use resistance from tub­

ing lhrough a PNF movement pattern.
Figure 18-59
kneeling in a four­
lrainer can apply ran
lwo- and lhree-point
maint.ain neurom U'

Figure 18-56 PNF using both manual resistance and

surgical tubing. Rhythmic stabilization can be performed Figure 18-58 Surgical tubing may be altached lo a
as the alhlete isometrically holds a specific position in the tennis racket as the athlete practices an overhead serve
ROM with surgical tubing and force applied by the ath­ technique. This is useful as a functional progression
letic trainer. technique.
 CHAPTER 18 Rehabilitation of Shoulder fnjuries 389

Exercises to Reestablish
Neuromuscular Control

A B

c D

Figure 18-59 Weight shifting on a stable surface may be done A. standing with hands supporting weight on table. B.
kneeli ng in a four-point position, C. kneeling in a three-point position. D, kneeling in a two-point position. The ath letic
trainer can apply random directional pressure to which the athlete must respond to maintain a static position. In the
t wo- and three-point positions. the arm that is supported in a c1osed-kinelic-chain is using shoulder force couples to
maintain neuromuscular control.

be attached to a
an overhead serve
nal progression
390 PART THREE The Tools of RehabilitaLion

Figure 18-60 Wcight shifting on a ball. In a push-up

position with wcight supported on a ball. the ath1ctc
shifts weight from side to side and/or forward and back­
ward. Wcight shifting on an unstable surface facilitates
co-contraction of thc muscles involvcu in the force cou­
ples that collectively maintain dynamic stabiility.
Figure 18-61 Wcight shifting on a Fillcr. [n a kneeling
position the athlete shifts weight from s.ide to side using a
Fitter. \"'eight shifting on an unstable surface facilitates
co-con traction of the l1lUscles involved in the force cou­
plcs that collec ~ ivcly maintain dynamic stability.

Figure 18-62 Weigh t shifting on a KAT systcm. In a
knecling position thc athlcte shifts wcig,h t from side to
sidc and/or backward and forward using a KAT. Wcigh t
shifting (In an unstable surface facilitates co-contraction
of the muscles involved in the force couples that collec­
ti\!ely ma,i ntain dynamic stabi'lity.
Figure 18-63 \!\/eigh t shifting on a I3APS board. In a
knceling position vilc athlete shifts weight [rom side to
side and/or backward and forward using a BAPS board.
"Veight shifting on an unstable surface ,facilitates co­
contraction of the muscles involved in the forcc couples
that collectively maintain dynamic stability.

Figure 18-64 Weight shilling on a Swiss ball. With the Figure 18-65 Slide:
feet supported on a chair. the athlete shifts weight from backward motion. B.
side to side and/or backward and forward using a Swiss iateralmotion. The at
ball. Weight shifting on an unstable surface facilitates co­ and/or backward and
contraction of the muscles involved in the force couples Weight shifting on an
that collectively maintain dynamic stability. contraction of th e mu
that collectively m ain
 A
figure 18-65 Slide board exercises. A, Forward and
weight rrom backward motion. B, \lVax-on / wi:lx-orr motion. C, Hands
u ing a Swiss lateral motion . The athlete shirts weight rrom side to side
racilitates co­ a nd/or backward and rOrlvard using a B}\PS board.
the rorce couples \ Veight shifting on an unstable surrace racilitates co­
IbUity. contraction 0[' the muscles involved in the rorce couples
that collectively maintain dynamic stability.
Figure 18-66 Scapular neuromu5cliiar control exer­
cises. The athlete's hand is placed on the table, creatin g a
closed-kinetic c hain. and the athletic trainer applies
pressure to the scapula in a random direction. The ath­
lete moves the scapula isotonically into the direction of
resistance.
Figure 18-67 Swiss ball exercises. The athlete lies in a
prone position on the Swiss ball and m a intains a stable
posi tion.
Figure 18-68 Body Blade exercises. The athlete is in a
three-point kneeling position holding an oscillating Body
Blade in one hand while lVorking on neuromuscular con­
trol in the Weight-bearing shoulder.
 392 PAR'l'THREE The 'j()ols of Rehabilitation
REHABILITATION TECHNIQUES
FOR SPECIFIC INJURIES
Sternoclavicular Joint Sprains
Pathomechanics. Sternoclavicular joint sp rains
a re not commonly seen as at hletic injuries. Al th o ugh
they are ra re. the joint's co mplexity and integra l interac­
tion with the uther joints of the sho ul der co mplex wa r­
rant its discu ssion. The SC join t has multiple axis of
rotati on a nd a rticulates with the m a nubrium with an in­
terposed fi brocarti laginous disc. Patho logy of this joint
ca n incl ud e injury to th e I1brocartilage a nd sprai n s of the
sternoclavicular liga m ents and / or th e costoclavicular
Iigaments. lU
As sta ted earlier in this chapter, th e stern oclavicular
jOi nt is extremely weak because of its bony arran gement.
It is held in place by its strong ligamen ts, which tend to pull
the sternal end of the clavicle downwa rd and toward the
sternum. A sprain o r th ese liga men ts o rt en res ults in either
a subluxing SC joini or a dislocated SC joint. This ca n be
Significant beca use th e joint plays a n integ ral role in
scapu la r motion through th e clavicle's arti c ulation with
the scapula . Co mbined movements at the acromi oclavicu­
lar an d sternoclavic ul ar joints h ave been reported to ac­
co unt for up to ('0 degrees of upward scapular ro ta tion
inherent in glenohumeral a bduction. J
When this joint incurs a n in jury. a res ult cll1 t inl'lam­
matory process occurs. The inflam ma tory process can
ca use an increase in the join t capsul e press ure as well as a
stiffening or the jo int due to th e collage n tissue being pro­
duced for the healing tissu es . The pathogenesis of this in­
flammatory process can ca use an a ltering of th e jOint
mechanics as well as an in crease in pain felt at th e jOin t.
This orten results ad versely on the sho ulder complex. "·l
Injury Mechanism. After motor vehicle a ccident s,
the most cOlllmon source of in juri es to th e sternoclavicu­
lar joint is sport s partici pation. , J The SC joint can be in­
jured by di rec t or indirect forces, res ultin g in spra in s.
dislocations. or physical injuries.)O Direct force injuries a re
usually the res ult of a blo w to the an teromedial aspec t of
th e clav icle an d produce a posterior disloca tion. )O Indirec t
force injuries can occur in many different sporting events.
usually when th e athlete falls and la nds with an out­
stretched arm in either a Jlexed and adducted position or
extended and a ddu cted position of th e upper ex tremity.
The Ilexed positi on causes an anterior lateral compression
force to the adducted arm, producing a posterior disloca­
tion. The ex tended position causes a posterior lateral com­
pression force to the adducted a rm . leading to an a nt eri or
dislocation . Lesser forces can also lead to varying degrees
of sprains to the SC joint. Additionally. there have been re­ COIIUl1Uni cate wi Lh
ports of repetitive microtrauma to this joint in sports such lasting symptoms."
as golf, gymnastics. and rowiJ1g. ;SM When dealing \\
In golf. a n example of mecha nism of injury is during ins tability, the a tble, 1
lIi
th e backswing: For a right-handed golfer, the sternoclav­ socia ted pain wit b
icular jOint is s ubject to m edi a lly directed forc es on the left exercises tha t s tren ~
at the top of the backswing and on the right at the end of men ts. In all of the
the backs wing. When th e right a rm is abducted and fully dress th e role o r
coiled at the end of the backswLng a nd the beginning or movement. A fu ll
the downswing. there is a posterior retraction of th e sho ul­ sh o uld be perform
der complex, resulting in an anterior sternoclavicular join t eleva tion . Exerci
stress. Due to th e repetitive nature of golf, th is can cause rh ombOids, and pu
repetitive ll1icrotrauma leading 10 irritation of the jOint. 10 help eontrol u P\\
Over time the joint may become hypermobile rela tive to its 18-36 through 18­
normal sta ble cond itio n , allowing for degen eration of the be followed while a.
soft tissue aDd fibrocartil ag ino us disc. This often res ults in
a painful syndrome arfecting the mechan ics of th e joint
and musc ular control of the shoulder complex.;~ Similar
examples are found in gymnastics and rowing.
Rehabilitation Concerns. In addressing the reha­
bilitation of an athlete with a sternoclavicular joint injury. ercises and incor
it is important to address the functi on of the joint o n shoul­ a long with the use 0
der complex movement. The sternoclavicular joint acts as ciao. Ultrasound is
th e sole passive a ttachment of th e shoulder complex to the a nd facilitating lhe
axial skeleton. As noted earlier in the chapter. the clavicle should er sling or fig
must elevate approximately 40 degrees to allow upward Lhe joint. Duri.ng lhi
scapular rotatio n . i 6 ,ion, the a thletic trail
In most cases the primary problem reported by th e in­ needs of the athlete '
jured athlete is discomfort aSSOCiated with end-range abilitation to lhe
movement or the shoulder co mplex. It is important to iden­ also con tin ue to \\.
tify the ca use of the pain (i.e.. ligamen tous in stability. disc di orespiratory fitn e.
dege neration. or ligamentous trauma). When the pa in
In cases where there is ligamentous in stability as well trolled. the athlete sh
as disc degeneration, the reha bilitation should focu s on increase or stress to
strengthening the muscles a ttached to the clavicle in a ri me to begin low-go
range that does not put further stress on the joint. Muscles ises for the muscles
such as the pecto ralis minor, sternal fibers of the pectoralis th is phase are best d
major, and upper trapezIus are strengthened to h elp con­ s the athlete's tol
trol the moti on of th e claVicle during motion of th e sho ul­ range of m otion ca.n
der complex. Exercises include incline bench, should er Iso importa nt to ad
shru gs. and the seated press-up, in a limited range of mo­ tb e athlete's range 0
tion (Figures 18-22. 18-35 , 18-42). In addition to ad­ o restoring th e no n!
dreSSing the dynamic supports of th e sternoclavicular plex during shoulder
joint. th e athletic train er should employ the appropriate As the athlete
modalities necessary to control pain and the inflammatory
process. It is also noteworthy. in cases where disl ocation or corporate spo rt-specl
subluxa tion has occ urred. to consider the structures in gram . Examples of
close proXimity to the sternoclavicular jOint. In lhe case of go lfer (Figures 18- ­ -
a posterior di sloca tion, signs of Circulatory vessel compro­ :hair, [or the gynm a
mise nerve tissue impingement, a nd difficulty swallowing -h in e for the rower.
 CHAPTER 18 Rehabilitation of Shoulder Injuries 393

may be seen. It is important to avoid these symptoms and Criteria for Returning to FuU Activity. The ath­
l varying degrees
communicate with the athlete's physician regarding any lete may return to full activity when (1) the rehabilitation
lhere have been re­
lasting symptoms. hi program has been progressed to the appropriate time and
joint in sports such
When dealing with ligamentous trauma that lacks stress for the specific demands of the ath'l ete's sport, (2) the
instability, the athletic trainer should also address the as­ athlete shows improved strength in the muscles used to
of injury is during
sociated pain with the appropriate modalities and utilize protect the sternoclavicular joint when compared to the
lfer. the sternoclav­
exercises that strengthen muscle with clavicular attach­ uninjured side. and (3) the athlete no longer has associ­
ed forces on the left
ments. In all of the above scenarios, it is important to ad­ ated pain with movements of the shoulder complex that
! right at the end of
dress the role of the SC joint on shoulder complex will inevitably occur wHh the demands of their sport.
abducted and fully
movement. A full evaluation of the shoulder complex
Id the beginning of
should be performed to address issues related to scapular Acromioclavicular Joint Sprains
'action of the shoul­
elevation. Exercises such as Superman, bent-over row,
ernoclavicular joint
rhomboids, and push-ups with a plus should be included Pathomechanics. The acromioclavicular joint is
golf. this can cause
to help control upward rotation of the scapula (Figures composed of a bony articulation between the clavicle and
itation of the joint.
18-36 through 18-39). Appropriate progression should the scapula. The soft tissues included in the joint are the
mobile relative to its
be followed while addressing the heal\ing stages for the hyaline cartilage coating the ends of the bony articula­
degeneration 0[' the
appropriate tissues. tions, a fibrocartilaginous disc between the two bones. the
This often results in
Rehabilitation Progression. In the initial stages of acromioclavicular ligaments. and the costoclavicular liga­
:b nics of the joint
rehabilitation. the primary goal is Lo minimize pain and in­ ments. There have been two conflicting papers regarding
,S
- complex. Similar
Oammation associated with shoulder complex motion. the motion available at the joint. Codman reported little
I rowing.
The athletic trainer should limit activ·ities to midrange ex­ movement at the joint, whereas Inman reported exactly
idd ressing the reha­
ercises and incorporate the use of therapeutic modalities the opposite. 13 .29 Multiple authors have reported degener­
a\'icular joint injury.
along with the use of NSAID intervention from the physi­ ative changes at the AC joint by age 40 in the average
[)f the joint on shoul­
cian. Ultrasound is often useful for increasing blood flow healthyadult. ls .b2
i\ ic ular joint acts as
and faci·litating the process of healing. Occasionally a The acromioclavicular joint provides the bridge be­
ulder complex to the
shoulder sling or figure 8 strap can help minimize stress at tween the clavicle and the scapula. When an inj ury occurs
ch apter. the clavicle
the joint. During this phase of the rehabilitation progres­ to the joint, all soft tissue should be considered in the reha­
to allow upward
sion. the athletic trainer should idenUfy the sport-specific bilitation process. An elaborate grading system h as been
needs of the athlete in order to tailor the later phases of re­ reported to categor,ize injuries based on the soft tissue that
D reported by the in­
habilitation to the athlete's demands. The athlete should is involved in the inj ury 60 (Table 18-1). Through evalua­
ted with end-range
also continue to work on exercises that maintain car­ tion by X-ray, the athlete's injury should be categorized in
.' important to iden­
diorespiratory fitness. order to provide the athletic trainer with a guideline for re­
DlO US instability. disc
When the pain and inl1ammation have been con­ habilitation.
II.
trolled, the athlete should gradually engage in a controlled Injury Mechanism. Type lor type II acromioclavic­
II instability as well
increase of stress to the tissues of the joint. This is a good ular joint sprains are most commonly seen in athletics due
jon should focus on
time to begin low-grade joint mobilizations resisted exer­ to a direct fall on the point of the shoulder with the arm at
I to the clavicle in a
cises for the muscles attaching to the clavicle. Exercises in the side in an adducted position or falling on an out­
o n the joint. ivlusclcs
this phase are best done in the midrange to minimize pain. stretched arm. The injury mechanism for type III and type
be rs of the pectoralis
As the athlete's tolerance increases, the resistance and IV sprains usually involves a direct impact that forces the
gt hened to help con­
range of motion can be increased. During this phase it is acromion process downward. backward, and inward while
motion of the shoul­
also important to address any limitations there might be in the clavicle is pushed down against the rib cage. The impact
'ne bench. shoulder
the athlete's range of motion. Emphasis should be placed can produce a number of injuries: (1) fracture of the clavi­
limited range of mo­
on restoring the norma'j mechanics of the shoulder com­ cle; (2) AC joint sprain; (3) AC and coracoclavicular joint
l. In addition to ad­
plex during shoulder movements. sprain: or (4) a combination of the previous injury with
the sternoclavicular
As the athlete begins to enter the pain-free stages of concomitant muscle tearing of the deltoid and trapezius at
ploy the appropriate
the progression, the athletic trainer should gradually in­ their clavicular attachments. 3 Another possible mecha­
~nd the inflammatory
corporate sport-speCific demands into the exercise pro­ nism for injury to the acromioclavicular joint is repetitive
where dislocation or
gram. Examples of this are PNF with rubber tubing, for the compression of the joint often seen in weightlifting.M
er the structures in
golfer (Figures 18-55, 18-56) ; Stair Climber with feet on Rehabilitation Concerns. Management of acromi­
~ joint. In the case of
chair. for the gymnast (Figure l' 8-44); and rowing ma­ oclavicular injuries is dependent on the type of injury? l Age,
Ila tory vessel compro­
chine for the rower. level of play. and the demand on the athlete can also ,factor
difficulty swaHolVing
394 PART THREE The Tools of Rehabilitation

• TAB L E 18-1 Acromioclavicular Sprain Classification qure for the im

Ie to remove

Type I
ses to encourage ,­
• Sprain of the acromioclavicular ligaments
p prevent rclat
• Acromioclavicular ligament intact
_ .nohumeral mec
Coracoclavicular ligament. deltoid and trapezius muscles intact
Type II. The tr
Typefl gieal. Because
~ pl ete disrupttoo
• Acromioclavicular joint disrupted with tearing of the acromioclavicular ligament .:nmobilization pia.
• Coracoclavicular ligament sprained e athletes. ThC't:1.
• Deltoid and trapezius muscles intact .::unobilization. Som_
Type III ys, others have
ns the upper
• Acromioclavicular ligament disrupted is debate is fu el
• Acromioclavicular joint displaced and the shoulder complex displaced inferiorly rakes the hody to
• Coracoclavicular ligament disrupted with a coracoclavicular interspace 25 to 100 percent greater than the normal fl from the inj ur~:
shoulder ed too early shO\'
• Deltoid and trapezius muscles usually detached from distal end of the clavicle =~n than the stron"
heal the soft tissu
Type IV ered prior Lo begi::
• Acromioclavicular ligaments disrupted with the acromioclaricular joint displaced and the clavicle anatomically dis­ eavy lifting and L
placed posteriorly through the trapezius muscle to 12 weeks.
• Coracoclavicular ligaments disrupted with wider interspace Type III. Man:.
• Deltoid and trapezius muscles detached 1Jerative approach:
t a sling is adequa.;.
Type V rt ably. l Use of this ~
'lOrted to have liIm
• Acromioclavicular and coracoclavicular ligaments disrupted
<'Suits without supp
• Acromioclavicular joint dislocated and gross displacement between the clavicle and the scapula
·lents. whereas Dol;:
• Deltoid and trapezius muscles detached from distal end of the clavicle
eks of immobiliza.:..
Type VI Operative man
mmarized wi th th
• Acromioclavicular and coracoclavicular ligaments disrupted
• Distal clavicle inferior to the acromion or the coracoid process 1. Stabilization of
• Deltoid and trapezius muscles detached from distal end of the clavicle 2. Resection of disla
3. Transarlicular a
:1:. Use of coracocla\"
acromioclavicula:
into the management of this injury. Most physician~ prefer to lar fibers of the pectoralis major should also be done. Other
handle type I and type II injuries conservatively. but some au­ muscles that help restore the proper mechanics to the shoul­ Taft et al. fou nd
thors have suggested that type I and type IT injuries can cause der complex should also be done. fix ation. They fou nd I
further problems to the athlete later in life. S.15 These injuries Type I. Treatment for the type I injury consists of icc fIX ation had a higher
might require surgi.cal excision of the distal 2 cm of the clav­ to relieve pain and a slmg to support the extremity for sev­ those managed wi th.
icle. The athletic trainer should consider when developing a eral days. The amount of time in the sling usually depends Type IV, V, and 1
treatment plan (l) the stability of the AC joint; (2) the on the patient's ability to tolerate pain and begin carrying quire open reduction
amount of time the athlete was immobilized; (3) pain. as a their involved extremity with the appropriate posture. The ccdures are designe
guide for the type of exercises being used; and (4) the sort: tis­ athletic trainer can have the athlete begin active assisted clavicle to the scapuJ:
sue that was involved in the injury. Rehabilitation of these in­ range of motion immediate'ly and then incorporate iso­ injury is longer and
juries should focus on strengthening the deltoid and metric exercises to the muscles with clavicular attach­ longer. After immobi
trapezius muscles. Additional strengthening of the clavicu- ments. This will help restore the appropriate carrying those prev,iously disCI

posture for the involved upper extremity. When the athlete
..................................
is able to remove the sling. the athletic trainer should in­ itation progression, the athletic trainer should be con­
crease the exercise program to incorporate PRE exercises
for the muscles with cla\licular attachments and add exer­
cises to encourage appropriate scapular motion. This will
help prevent related shoulder discomfort due to poor
glenohumeral mechanics after return to activity.
Type II. The treatment for type II injuries is also non­
surgical. Because this type of injury to the AC joint involves
complete disruption of the acromioclavicular ligaments,
immobilization plays a greater role in the treatment of
these athletes. There is no consensus as to the duration of
immobilization. Some authors have recommended 7 to 14
days. others have suggested using a sling that not only sup­
ports the upper extremity but depresses the clavicle.1M
This debate is fueled by disagreements regarding the time
it takes the body to produce collagen and bridge the gap
than the normal left from the injury. It has been reported that tissue mobi­
lized too early shows a greater amount of type III colla­
gen than the stronger type I collagen. 34 The time needed
to heal the soft tissues involved in this injury must be con­
sidered prior to beginning exercises that stress the injury.
an atomically dis­ Heavy .lifting and contact sports should be avoided for
8 to 12 weeks.
Type III. Many authors have recommended a non­
operathTe approach for this type of injury, most agreeing
that a sling is adequate for allowing the athlete to rest com­
fortably.3 Use of this nonoperative technique has been re­
ported to have limited success. Cox reported improved
results without support of the arm in 62 percent of his pa­
tients, whereas only 25 percent had relief after 3 to 6
weeks of immobilization and a sling. I ,
Operative management of this type of injury can be
summarized with the following options:
l. Stabilization of clavicle to coracoid with a screw
1. Resection of distal clavicle
.... .............................. ..... .
3. Transarticular acromioclavicular fixation with pins down into 4 phases of rehabi1itation with the goal of re­
-±. Use of coracoclavicular ligament as a substitute
acromioclavicular ligament
lid also be done. OLhe~
hanics to the shou!­ Taft et al. found superior results with coracoclavicular
fixation. They found that patients with acromioclavicular
I injury consists of ice tlxation had a higher rate of post-traumatic arthritis than
those managed with a coracoclavicular screw. G7
~
e extremity .ror se\'­
ling usually depends Type rv, V. and VI. Types IV, V. and VI injuries re­
, and begin carrying uire open reduction and internal fixation . Operative pro­
ropriate posture. The cedures are designed to attempt realignment of the
~ begin active assist clavicle to the scapula. The immobilization for this type of
then incorporate is ­ injury is longer and therefore the rehabiHtation time is
~th davicular attach- lo nger. After immobilization, the concerns are similar to
appropriate carrying those previously discussed.
CHAPTER 18 Rehabilitation of Shoulder Injuries 395
Rehabilitation Progression, Ea rly in the rehabil­
cerned with applica tion of cold therapy and pressure for
the first 24 to 48 hoars to control local hemorrhage. Fit­
ting the athlete for a sling is also important to control the
athlete's pain. Time in the sling depends on the severity of
the injury. After the athlete has been seen by a physician
for differential diagnosis, the rehabilitation progression
should be tailored to the type of sprain according to the
diagnosis.
Type I, II, and III sprains should be handled similarly at
first, \Vith the time of progression accelerated with less se­
vere sprains. Exercises should begin with encouraging the
athlete to use the invo'lved extremity for ADL activit,ies and
gentle range-of~motion exercises. Return of normal range
of motion in the athlete's shoulder is the first objective goal.
The athlete can also begin isometric exercises to maintain
or restore muscle function in the shoulder. These exercises
can be started while the athlete is in the sling. Once the
sling is removed, pendulum exercises can be started to en­
courage mO\femenl. In type III sprains the athletic tminer
should bold off doing passive ROM exercises in the end
ranges of shoulder elevation for the first 7 days, The athlete
should have full passive ROM by 2 to 3 weeks. Once the ath­
lete has full active range of motion . a program of progres­
sive resistive exercises should begin. Strengthening of the
deltoid and upper trapezius muscles should be emphasized.
The athletic lrainer should evaluate the athlete's shoulder
mechanics to identify problems with neuromuscular con­
trol and address specific deficiencies as noted. As the athlete
regains strength in the involved extremity, sport-specific ex­
ercises should be incorporated into the rehabilitation pro­
gram. Gradual return to activity s.hould be supervised by
the athlete's coach and athletic trainer.
In th e case of type IV, V, and VI acromioclavicular
sprains a postsurgical progression should be followed . The
sports therapist should design a program that is broken
turning the athlete to his or her activity as qUickly as pos­
sible. 1 Contact with the physician is important to
determine the time frame in which each phase may begin .
Common surgeries for this injury include open reduction
with pin or screw fixation and/or acromioplasly.
The early stage of rehabilitation should be designed
with the goal of reestablishing pain-free range of motion,
preventing muscle atrophy, and decreaSing pain and ,in­
flammation. Range-o(~motion exercises may include Cod­
man's exercises (Figure 18-6). rope and pulley exercises
(Figure 18-9). L-bar exercises (Figures 18-11 to 18-16),
and self capsular stretches (Figures 18-18, 18-19).
Strengthening exercises in this phase may include isomet­
ri cs in all of the card,inal planes and isometrics for medial
396 PART THREE The Tools of Rehabilitation

'o uraged to pre\'

and lateral rotation of the glenohumeral joint at 0 degrees
of elevation (Figure 18-20).
As rehabilitation progresses, the athletic trainer has
the goal of regaining and improving muscle strength, nor­
mali.zing arthrokinematics, and improving neuromuscu­
lar control of the shoulder complex. Prior to advancing to
this phase, the athlete should have full ROM. minimal pain
and tenderness, and a 415 manual muscle test for internal
rotation , external rotation, and flexion. Initiation of iso­
tonic PRE exercises should begin. Shoulder medial and lat­
eral rotation (Figures 18-31, 18-32), shoulder flexion and
abduction to 90 degrees (Figures 18-26, 18-28), scaption
(Figure 18-33). bicep curls, and tricep extensions should
be included. Additionally, a progr<lm of scapular stabiliz­
ing exercises should begin . Exercises should include: Su­
perman exercises (Figure IS-36), rhomboids exercises
(Figure 18-38), shoulder shrugs (Figure IS-35), and
scated push-ups (Figure IS-42). To help normalize
arthrokinematics of the shoulder, complex joint mobiliza­
tion techniques should be used for the glenohumeral,
acromioclavicular, sternoclavicular, and scapulothoracic
joints (see Figures 14-10 to 14-20). To complete this phase
the athlete should begin neuromuscular control exercises
(Figures 18-59 to IS-68). trunk exercises, and a low­
impact aerobic exercise program.
During the advanced strengthening phase of rehabili­
tation. the goals should be to improve strength. power, and
endurance of muscles as well as to improve neuromuscu­
lar control of the shoulder complex, and preparing the
athlete to return to sport-specific activities. Prior to ad­
vancing to this phase. the athletic trainer should use the
criteria of full pain-free range 01 motion. no pain or ten­
derness, and strength of 70 percent compared to the un­
involved shoulder. The emphasis in this phase is on
high-speed strengthening, eccentric exercises, and multi­
planar motions. The athlete should advance to surgical
tubing exercises (Figure 18-45), plyometric exercises
(Figures 18-4() to 18-51), P!'o.TF diagonal strengthening
(Figures 18-53 to 18-58), and isokinetic strengthening ex­
ercises (Figure 18-52).
When the athlete is ready to return to activity, the ath­
letic trainer should progressively increase activities that
prepare the athlete for a fully functional return. An inter­
val program of sport-specific activities should be started.
Exercises from stage III should be continued. The athlete
should progressively increase the time of participation in
sport-specific activities as tolerated. For contact and colli­
sion sport athletes, the AC joint should be protected.
Criteria for Returning to Full Activity. Prior to
returning to full activity the athlete should have full range
of motion and no pain or tenderness. Isokinetic strength
testing should meet the demands of the athlete's sport.
and the athlete should have successfully completed the fi­
ohumeral RO.\ l.
nal phase of the rehabilitation progression.
Jete should begin i!. :
ROM. JOint mo' .
Clavicle Fractures
lete may continu
Pathomechanics. Clavicle fractures are one of the
ks while regainin~
most common fractures in sports. The clavicle acts as a
priate posture \\
strut connecting the upper extremity to the trunk of the
ould begin a streo!;:'
body.19 Forces acting on the clavicle are most likely to
.istance as range
cause a fracture of the bone medial to the attachment of
chieved, the athlet
the coracoclavicular ligaments. 4 Intact acromioclavicular
orrises and contin ue
and coracoclavicular ligaments help keep fractures
r complex muscle
nondisplaced and stabilized.
",able normalneuf1
Injury Mechanism. In athletics. the mechanism
Criteria for Re
for injury often depends on the sport played. The mecha­
,\ ity when the fract ­
nism can be direct or indirect. Fractures can result from a
,ive range of
fall on an outstretched arm, a fall or blow to the point or
.be strength and flel •
the shoulder, or less commonly a direct blow as in stick
mands of their spon
sport~ Hke lacrosse and hockey. 58
Rehabilitation Concerns. Early identification or
the fracture is an important factor in rehabilitation. If sta­
bilization occurs early, with minimal damage andirrita­
Glenohumera1 [
tion to the surrounding structures, the l,ikelihood of an (Surgical vs. He
uncomplicated return to sports is increased. Other factor! Rehabilitation)
influencing the likelihood of complications are injuries to
the acromioclavicuJar. coracoclavicular, and sternoclavic­
ular ligaments. Treatment for clavicle fractures include
approximation of the fracture and immobilization for 6 to
labral fossa. From a
8 weeks. Most commonly a figure-S wrap is used, with the
an t force vector is dir,
invo~ved arm in a sling.
glenOid fossa . crea
When designing a rehabilitation program for an ath­
humeral head by pi\' .
lete who has sustained a clavicle fracture. the athletic
Shoulder dislocaL
trainer should consider the function of the clavicle. The
clavicle acts as a strut offering shoulder girdle stability and
joint necessary for til
allowing the upper extremity to move more freely aboUl
the glenohumeral i
the thorax by positioning the exlrentity away from the
most common ki nd of
body axis. 25 Mobility of the clavicle is therefore very im­
portant to normal shoulder mechanics. Joint mobilization
techniques are statted immediately after the immobiliza­
extremely rare. or d'
tion period in order to restore normal arthrokinematics.
)5 to 90 percent <Ire
The clavicle also serves as an insertion point for the del­
In an anterior gl
toid. upper trapezius. and pectoralis major muscles, ,pro­
the humerus is forced
viding stability and aiding in neuromuscular contra'! of
terior direction past tii
the shoulder complex. II is important to address these mus­
ward to rest under tl
cles with the appropriate exercises in order to restore nor­
that ensues is extensi
mal shoulder mechanics.
tous tissue. possibly ted
Rehabilitation Progression. For the first 6 to 8
muscles. and profuse b~
weeks. the athlete is immobilized in the I1gure 8 brace and
the glenoid I<lbrum mil
sling. If good approximation and healing of the fracture is
ailly slow. and the det a
occurring at 6 weeks, the athlete may begin gentle isomet­
duce a permanent an
ric exercises for the upper extremity. Utilization or the in­
called a Bankart lesiC1
volved extremity below 90 degrees of elevation should be
 CHAPTER 18 Rehabilitation of Shoulder Injuries 397

encouraged to prevent muscle atropby and excessive loss of with anterior dislocation can be found on the posterior lat­
Iy completed the fi­
glenohumeral ROM. After the immobilization period. the eral aspect of the humeral head called a Hill-Sachs lesion.
·ion.
athlete should begin a program to regain full active and pas­ This is caused by compressive forces between th e humeral
sive ROM. JOint mobilization techniques are used to restore head and the glenoid rim while the humeral head rests in
normal arthrokinematics (see Figures 14-10 to 14-12). The the dislocated position. Additional complications can arise
aLhlete may continue to wear the sling for the next 3 to 4 if the head of the humerus comes into contact with and in­
ures are one of the
weeks while regaining the ability Lo carry the arm in an ap­ jures the brachial nerves and vessels. Rotator cuff tears
e clavicle acts as a
propriate posture without the figure 8 brace. The athlete can also arise as a result of the dislocation. The bicepital
to the trunk of the
should begin a strengthening program utilizing progressive tendon might also sublux from its canal as the result of a
are most likely to
resistance as range of motion improves. Once full ROM is rupture of the transverse ligament. b 1
) the aLlachment of
achieved. the athlete should begin resisted diagonal PNF ex­ Posterior dislocations can also result in signil'icant soft­
t acromioclavicular
ercises and continue to increase tbe strength of the shoul­ tissue damage. Tears of the posterior glenoid labrum arc
~I p keep fractures
der complex muscle. including the periscapular muscles. to common in posterior dislocation. J\ fracture of the lesser
enable normal neuromuscular control of the shoulder. tubercle can occur if the subscapularis tendon avulses its
the mechanism
Criteria for Return. The athlete may return to ac­ attachment.
played. The mecha­
tivity when the fracture is clinically united, full active and Glenohumeral dislocation is usually very disabling.
can result [rom a
passive range of motion is achieved. and the athlete has The athlete assumes an obvious disabled posture and the
blow to the poLnt of
the strength and neuromuscular control to meet the de­ deformity itself is obvious. t\ positive sulcus sign is usually
eet blow as ill stick
mands of their sport. present at the lime of the dislocation. and the deformity
can be easily recognized on X-ray. As detailed above. the
rly iden lification oi damage can be extensive to the soft tissue.
Thabilitation. If sta­
Glenohumeral Dislocations/Instabilities Injur}' Mechanism. When discussing the mecha­
damage and ,i rrita­
the likelihood of an
(Surgical vs. Nonsurgical nism of injury for dislocations of the glenohumeral joint.
Rehabilitation) it is necessary to categorize the injury as traumatic or
·eased. Other factor,
atraumatic. and anterior or posterior. An anterior disloca­
3tions are injuries to
Pathomechanics. Dislocations of the gleno­ tion of the glenohumeral joint can result from direct im­
ar. and sternoclavic­
humeral joint involve the temporary displacement of the pact to the posterior or posterolateral aspect of the
fractures include
humeral head from its normal position in the glenoid shoulder. The most common mechanism is forced abduc­
mobilizaLion for 6 [(1
labral fossa. From a 'biomechanical perspective. the result­ tion. external rotation . and extension that forces the
~p is used, with the
ant force vector is directed outside the arc of contact in the humeral head out of the glenOid cavity.45 An arm tackle in
glenoid fossa. creating a dislocating moment of the football or rugby or abnormal forces created in executing a
program for an alh­
humeral head by pivoting about the labral rim. 2o throw can produce a sequence of events resulting in dislo­
ractu re, the athletic
Shoulder dislocations account for up to 50 percent of cation. The injury mechanism for a posterior gleno­
or the clavicle. Th~'
all dislocations. The inherent instability of the shoulder humeral dislocation is usually forced adduction and
er girdle sLability an
jOint necessary for the extreme mobility of this joint makes internal rotation of the shoulder or a fall on an extended

~
more freely abou l
the glenohumeral joint susceptible to dis~ocation. The and internally rotated arm.
ity away [rom tb e
most common kind of dislocation is that occurring anteri­ The two mechanisms described for anterior dislocation
therefore very im­
orly. Posterior dislocations account for only 1 to 4.3 per­ can be categorized as traumatic or atraumatic. The follow­
. Joint mobilization
cent of all shoulder dislocations. Inferior dislocations are ing acronyms have been described to summarize the two
ter the immo'biliza­
extremely rare. or dislocations caused by direct trauma, mechanisms. 36
arthrokinematic . =; to 90 percent are recurring. o>
n point for the del­
In an anterior glenohumeral dislocation, the head of Traumatic Atraumatic
ma jor muscles, pro­
the humerus is forced out of its anterior capsule in an an­ Unidirectional Multidirectional
uscular control terior direction past the glenOid labrum and then down­ Bankart lesion Bilateral involvement
o address these mu ­ ward to rest under the coracoid process. The pathology Surgery required Rehabilitation effective
l order to restore nor- that ensues is extensive, with torn capsular and ligamen­ Inferior capsular shift
lOus tissue. possibly tendonous avulsion of the rotator cuff recommended
muscles, and profuse hemorrhage. A tear or detachment of
figure 8 brace an... the glenoid labrum might also be present. Healing is usu­ The AMBRI group can be characterized by subluxa­
- g of the fracture '
ally slow. and the detached labrum and capsule can pro­ tion or dislocation episodes without trauma. resulting in a
begin gentle isomer­
duce a permanent anterior defect on the glenoid labrum stretched capsuloligamentous complex that lacks end­
'tilizalion of the in' ailed a Bankart lesion. Another defect that can occur range stabilizing ability. Several authors report a high rate
elevation should be
398 Pi\RTTHREE The Tools of Rehabilitation

of recurrence for dislocations, especially those in the nJ!3S
category. h 1
Rehabilitation Concerns. Management of shoul­
der dislocation depends on a number or factors that need
to be identified. Mechanism, chronology, and direction of
instability all need to be considered in the development of
a conservatively managed rehabilitation program. No sin­
gle rehabilitation program is an absolute solution for suc­
cess in the treatment of a shoulder dislocation. The
athl etic trainer should thoroughly evaluale th e injury and
discuss those objective findings with the team physician.
The inHial concern in rehabilitation focus es on maintain­
ing appropriate redu ction of the glenohumeml joint. 'fhe
athlete is immobilized in il reduced pOSition for a period of
time. depending on the type of management used in the re­
duction (surgical vs. nonsurgical). Fo r the purpose of this
section, the discussion will continue with conservative
management in mind . The principles of rehabilitation,
however, remain constant regardless of whether Ihe physi­
program into positions outside the safe zone, accommo­ During phase 1
dating the demands that the athlete will need to meet. Spe­ Th is ,lasts for up to 3 .
cific strengthening should be given to address the muscle_, al of this phase is 1
of the shoulder complex res ponsible for maintaining the crease pain, and retz
axis of rotation. suc h as the supraspinatlls, and rotator motio n exercises cae
cuff muscles. The periscapular muscles should also be ad­ int mobilization t
dressed in order to provide the rotator cuff muscles wit.h h e shoulder m u
their optima:' length-tension relationship for more efficien t .a r ted. The athl ete
usage. In the later stages of rehabilitation, neuromuscul ar and increases to m
control exercises arc incorporated with sport-specific exer­ ds. The proteclh
cises to prepare the athlete for ret urn to activity. l6 apulothoracic exe:'".
Rehabilitation Progression, The first essentialt J OllS of the upper
a successful rehabilitation program is th e removal of the etes should begin, -
athlete from activities that risk reinjury to the gleno­ ower extremity, sue
humeral joint. J\ reasonable time frame for return to activ­ Phase 2 begi ns a
ity is approximately 12 w eeks. with unrestricted activit } the sling. This ph a
coming closer to 20 weeks. This is variable, depending on locuses on full relu
the extent of soft-tissue damage and the type of interven­ gram begins wi th l~
tion chosen by the athlete and physician. Some exercises ~is live ROM (rigu

cian's manage ment is surgical or nonsurgical. Surgical re­ previously used by the athlete might produce undeSired lechniques can a
habilitation should be based on the healing time of tissue forces on noncontractile tissues and need to be modified to reestablish neuro
affected by the surgery. The limitations of moLion in the be performed safely. Push-ups, pull-downs. and the benc h 1 5-13). Exercises \\
early stages of rehabilitation should also be based on sur­ press are performed with th e hands in close and avoidin g begin strength eninb
gical fixation. [I. is extremely important. because of this. the last 10 to 20 degrees of shoulder extension. Pull­ ively. These exerc!
that the athletic trainer and phYSician communicate prior downs and military press performed with wide bars an d a table. progressing
to the start of rehabilitation. After the immobilization pe­ machines a rc kept in front rather than behind the head. \-anc ing from the t,
riod, the rehabilitation program should be focused on Supine fly exercises are limited to - 30 degrees in the coro­ \'ancing to a les
restoring the appropriate ilxis of rotation for the gleno­ nal plane while maintaining glenohumeral internal rota­ 18-63) or Swiss ball
humeral joint, optimi:dng the stabiliZing muscle's lcngth­ tion . See Table 18-2 for fmther modifications depemlcl1l
tension relationship, and restoring proper neuromuscular on directional instability. 1
control to the shoulder complex. In the uninjured shoulder enter phase 3 of th
complex with in tac t capsuloligamentous structures. the • TABLE 18-2 Exercise Modification per f this phase is to r,
glenohumeral joint maintains a tight axis of rotation Direction of Instability cular control. Pr
Within th e glenoid fo ssa. This is accomplished dynill11ically ra nge of motion sh
with complex neuromuscular control of the periscapular Direction Exercises to Be rotator cuff exerc'
muscles , rotator cuff muscles, and intact passive struc­ of Position to Modified or durance. Weight­
tures of the joint. Because the extent of damage in this Instability Avoid Avoided challenging by a ddil
type oj; injury is variable. the exe rcises employed to restore bilization. Scapul ar
these normal mechanics should also vary. h() As the athletic Anterior Combined posilion Fly. pull-down, weight room with gu
trainer helps the athlete regain full range of motion, a safe of external rotation push-up. benc h der to meet the cha U
zone of positioning sho uld be followed. Starting in the and abduction press. military hifting on a Filter
plane of the sca pula is safe. becau se the axis of rotation for press hain strengthenin g
forces acting on the joint fall in the center of this plane. Posterior Combined position Fly. push-up endurance are startl
The I'east, provocative position is somewhere between 20 of in ternal rotation, bench press, from PRE to plyome
and:; 5 degrees of scapular plane abduction. Keeping the horizontal adduction. weight-bearing gical tubing with em~
humerus below :;:; degrees prevents subacromial im­ and flexion exercises gression to multi
pingement, while avoiding full adduction minimizes exces­ Inferior Full elevation, Shrugs, elbow positioning is star ted
sive tension across the supraspinatus/coracohumeral dependent arm curls. military tion tool for this ph ~
and/or capsuloligamentous complex . ;\s range of motion press static to dynamic stab
improves, the athletic trainer should progress the exercise tiangular dynamic eXi

afe zone, Clccommo­ During phase T the athlete is immobilized in a sling.
ill need to meet. Spe­ This lasts for up to 3 wee'ks with first-time dislocations. The
address the muscles goat of this phClse is to limit the inflammatory process, de­
for maintaining th e crease pain. and fetard muscle atrophy. Passive range-of­
pi natus, and rotato r motion exercises can be initiated along with low-grade
hould also be ad­ jOint mobilization techniques to encourage relaxation of
J[ cuff muscles with
the shoulder musculature. Isometric exercises are also
hip fo r more efficient started. The athlete begins with submaximal contractions
lio n , neuromuscular and increases to maximal contractions for as long as 8 sec­
11 p rt-specific exer­ onds. The protective phase is a good time to initiate a
to ac livity. l(, scapulothoracic exercise program. avoiding elevated posi­
The first essential to tions of the upper extremity that put stability at risk. Ath­
lhe removal of th e letes should begin an aerobic tra'i ning regime with the
nju ry to the gleno- lower extremity, such as stationary biking.
for return to activ­ Phase 2 begins after the athlete has been removed from
u nrestricted activit_ the sling. This phase lasts from .3 to 8 weeks postinjury and
.riable. depending on focuses on full return of active range of motion. The pro­
gram begins with the use of an L-bar performing active as­
the type or interven­
ia n . Some exercis sistive ROM (Figures 18-11 to 18-16). Manual therapy
t produce undesir d
techniques can also begin using PNF techniques to help
eed to be modified to reestablish neuromuscular control (Figure 15-6 to
m s, and the bench 15-13). Exercises with the hands on the ground ean help
n cl se and avoiding begin strengthening the scapular stabilizers more aggres­
cr extension. Pu ll­ sivel)'. These exercises should begin on a stable surface like
.. \\1th wide bars ane a table, progressing the amount of weight bearing by ad­
~' ancing from the table to the ground (Figure 18-59). Ad­
an behind the head
degrees in the cor vancing to a less stable surface like a BAPS board (Figure
mera l internal rola­ 18-6.3) or Swiss ball (figure 18-64) will also help reestab­
lications de pender lish neuromuscular control.
At 6 to 12 weeks the athletic trainer sbould gradually
enter phase .3 of the rehabilitation progression. The goal
lodification per of this phase is to restore normal strength and neuromus­
I of Lnstability cular control. Prophylactic stretching is done, as full
range of motion should Cllready be present. Scapular and
Exercises to Be rotator cuff exercises should focus on strength and en­
Modified or durance. vVeight-bearing exercises should be made more
Avoided challenging by adding motion to the demands of the sta­
bi.lization. Scapular exercises should be performed in the
Fly. pull-down. veight room with guidance from t.he athletic trainer in Of­
push-up. ben der to meet the challenge of the athlete's strength. Weight
press. milit ar~ bift.ing on a Fitter (Figure 18-6]) and closed-kinetic­
press chain strengthening on a stair climber (Figure 18-44) for
Fly. push-up en durance are started. Strengthening exercises progress
bench press. from PRE LO plyometric. Rotator cuff exercises using sur­
weigh t-bear in::, gical tubing with emphasis on eccentrics are added. 2 Pro­
exercises "ression to mulliangle exercises and sport-specific
Shrugs, elbow positioning is started. The Body Blade is a good rehabilita­
curls. militar~ rion tool for this phase (Figure 18-68), progressing from
press static to dynamiC stabilization and single-position to mul­
liangular dynamiC exercises.
CHAPn:R 18 Rehabilitation of Shoulder Injuries 399
Phase 4 is the functional progression . Athletes are
gradually returned to their sport with interval Lraining
and progressIve activity increasing the dem'lllds all en­
durance and stability. This can Last as ilong as 20 weeks. de­
pending on the athlete's shoulder strength. lack of pain.
and ability to protect the involved shoulder. The physician
should be consulted prior to full return to activi ty.
Criteria for Return to Acth'ity. 1\.t20 to 2 6 weeks,
the athlete should be ready for return to activity. This deci­
sion shoLlld be based on (1) fuJI pain-free range of mot ion.
(2) normal shoulder strength, (3) pain-free sport-specific
activities, and (4) ability to protect the athlete's shoulder
from reinjury. Some athletic trainers and physiciam like
the athlete to use a protective shoulder harness during
partiCipation.
CLINICAL DECISION MAKING Exercise 18-2
A 40-year-old wrestling coacb suffered an anterior and
inferior dislocation of bis glenohumeral jolnl while at­
tempting to take down an opposing athlete. The joint
needed to be relocated under a nesthesia. X rays showed
no lnjury lo the humeral head. and an MRI was negative
for any other slru tural involvement. The physician's di­
agnOSis was an acuLe dislocation. Whal can the alhlc-lic
trainer recommend to the coach in order to prevent an­
other dislocation?
Multidirectional Instabilities
of the 'Glenohumeral Joint
Pathomechanics. Multidirectional instabilities arc
an inherent risk of the glenohumeral joint. The shoulder
has the greatest range of motion of all the joints in the hu­
man body. The bony restraints are minimal. and the forces
that can be generated in overhead motions of throwing
and other athletIc activities far exceed the strength of the
static restraints of the jOint. Attenuation of [oree is multi­
factorial. with time, distance. and speed determining
forces applied to the joint. Thus stability of the joint must
be evaluated based on the athlete's ability to dynamically
control all of these factors in order to have a stable joint.lfl
cases of multidirectional instability. there are two cate­
gories for pathology: atraumatie and traumatic. The atrau­
malic category includes athletes who have congenitally
loose joints or who have increased the demands on their
shoulder prior to haVing developed the muscular maturity
to meel these demands. When forces are generated althe
400 PART THREE The Tools of Rehabilitation
glenohumeral jOint that the stabilizing muscles are unable
to handle (this occurs most commonly during the deceler­
ation phase of throwing). the humeral head tends to trans­
late anteriorly and inferiorly into the capsuloligamentous
structures. Over time, repetitive microtrauma causes these
structures to stretch. Lephart et al. document the essential
importance of tension in the anterior capsule of the gleno­
humeral joint as a protective mechanism against excessive
strain in these capsuloligamentous structures. 40 They the­
orized that the loss of this protective reflex jOint stabiliza­
tion can increase the potential for continuing shoulder
injury. Increased translation of the humeral head also in­
creases the demand on the posterior structures of the
glenohumeral joint, leading to repetitive microtrauma and
breakdown of those soft tissues . In this type of instability
there will usually be some inferior laxity. leading to a posi­
tive sulcus sign. Although the anterior glenoid labrum is
usually intact during the early stages of this instability.
splitting and partial detachment can develop. 3 The athlete
usually has some pain and clicking when the ann is held
by the side. Any symptoms and signs associated with ante­
rior or posterior recurrent instability may be present.
Injury Mechanism. It is generally believed that the
cause of mulLidirectional instability is excessive joint vol­
ume with laxity of the capsuloligamentous complex. In
the athlete, this laxity might be an inherent condition that
becomes more pronounced with the superimposed trauma
of sport. This type of instability might also occur due to ex­
tensive capsulolabral trauma in patients who do not ap­
pear to have laxity of other joints. 58
Rehabilitation Concerns. The rehabilitation con­
cerns for multidirectional instability are similar to those al­
ready discussed in relation to shoulder instabiHties. The
complexity of this program is increased due to the addition
of inferior instability. The success oJ the program is often
determined by the patieJ1t's tissue status and compli­
ance. nn Additionally, this program emphasizes the anterior
and posterior musculature. These muscles working to­
gether are referred to as force couples and are believed to
be essential stabilizers of the joint. The rehabilitation pro­
gram should also address the neuromuscular control of
these musdes to promote dynamic stability.2n Compliance
is often an extremely important factor in maintaining good
results with this type of instability. The athlete must con­
tinue to do the exercise program even after symptoms have
subsided. If the patient does not, subluxation usually re­
curs. For cases where conservative treatment is not suc­
cessful. Neer recommended an inferior capsular shift
surgical procedure that has proven successful in restoring
joint stability when used in conjunction with a rehabilita­
tion program. 50
Recently. there has been some controversy regarding The first six n'e,
surgical management of multidirectional instability. Ma~y ?fevention of mu
orthopedists are choosing to use thermal-assisted capsular on. soft-tissue hea
shrinkage (TACS). Wilk et al. 80 suggest a postoperative re­ ma tion. During thi!
habilitation program that is based on six factors: (1) type of '0 days and the a!
instability. (2) patient's inflammatory response to surgery. rough day 14. EIb
(3) concomitant surgical procedures, (4) precautions fol­ a nge of motio n i
lowing surgery, (5) gradual rate of progression, and .:.og in the scapular
(6) team approach to treatment. These factors determine 60 degrees of ele\Oi
the type and aggressiveness of the program. First it must ;rees), IR at 90 degr
be determined whether the instability is congenital or ac­ ;eek 6. Extension
quired. Congenital instabilities should be treated more roided.
conservatively. Second, some patients respond to surgery Phase 2 is an in
with excessive scarring and proliferation of collagen -he goals of this phil
ground tissue. Progression should be adjusted weekly ar throkinematics. iII:
based on assessing capsular end feel. The third factor takes "'asic muscul1ar slrt:'C
into account any other procedures performed at the time chieved by week ,
of surgery. Precautions should be followed based on the tis­ ',egrees of ER at the ~
sue healing time of the other procedures. Surgical precau­ mat the 90 /90
tions also should be communicated to the athletic trainer 've stretching ma~
based on the tissues involved , PROM after surgery should "hieved 'by week g, I
be cautious. The authors suggest conservative PROM pro­ essed out of th e s
gression for the first 8 weeks postsurgery. The gradual pro­
gression (factor 5) contrasts to one that moves faster and
then slows down. The speed of progression should be
based on a weekly scheduled assessment of capsular end
feel and progress. Factor 6 ensures a successful rehabUrita­
lion outcome by open and continuous communication be­
tween the athlete, surgeon , and athletic trainer. 80
Rehabilitation Progression. The rehabilitation progressed to tole
program should begin with reestablishing muscle tone n the Plyoback are
and proper scapula thoracic posture. This helps provide a part of this phase f
steady base with appropriate length-tension relationships Phase 3 is th e it
for the anterior and posterior muscles of the shoulder com­ phase, from week IJ
plex acting as force couples. Strengthening of the rotator .Del ude improvemen
cuff muscles in tbe plane of the scapula should progress to {"nha ncement of 0
hIgher resistance. starting at 0 degrees of shoulder eleva­ ma nce of fUl1clio na
tion. As the athlete becomes asymptomatic. the athletic ase should inel u
trainer should incorporate an emphasis on neuromuscu­ r ength at least 80
lar control exercises like PNF. rhythmic stabilization, and (a psular stretch!
weight-bearing activity to establish co-contraction at the Strengthening exer,
glenohumeral joint. Sport-specific training can then be me tric exercises ar
added. first in the rehabilitation setting and then in tbe Figure 18-46). Neu
competitive setting. For successful results, the athlete ,llizalion exercise
might have to continue a program of maintenance for 18-57). In the late ,
neuromuscular control for as long as they wish to be ort program is in
asymptomatic. The final phase. thi
Postsurgical management. 80 For an athlete who fro m week 26 to wee
has undergone TACS surgery. a four-phase rehabilitation ~port participation. 1
may be performed. The program also uses a rule of six ROM, no pain. saUsfi
paradigm. netic testing (Figure j
 CHAPTER 18 Rehabilitation of Shoulder Injuries 401

llroversy regarding The first six weeks is a protective phase; the goals are 'lion. Full return is usually achieved in 7 to 10 months. Re­
~ a l instability. Many prevention of muscle atrophy. initiation of protected mo­ turn is achieved by completing an interval sport progres­
lal-assisted capsular tion. soft-tissue healing. and diminished pain and inflam­ sion.
l a postoperative re­ mation. During this phase a sling is used for the first 7 to Criteria for Returning to Full Activity. The crit.e­
ix factors: (1) type of 10 days and the ath'lete continues to sleep with sling ria for this instability are the same as described for other
res ponse to surgery. through day 14. Elbow and wrist exercises are 'i nitiated. shoulder instabilities. Burkhead and Rockwood reported
(-1) precautions fol­ Range of motion is done actively or actively aSSisted start­ an 80 percent success rate using a conservative approach
f progression. and ing in th e scapular plane (Figure] 8-33). progressing to with athletes who had atraumatic multidirectional insta­
;e factors determine ] 60 degrees of elevation, ER at 90 degrees (75 to 80 de­ bility.IO·6o
og ram . First it must grees). IR at 90 degrees abduction (60 to 65 degrees) by
i~ congenital or ac­ week 6. Extension and cardinal-plane abduction are Shoulder Impingement
lId be treated more avoided.
; respond to surgery Phase 2 is an intermediate phase from week 6 to 12. Pathomechanics. Shoulder impingement sy n­
~ration of collagen The goals of this phase are to restore full ROM. normalize drome was first identified by Dr. Charles Neer.;(l who ob­
be adjusted weekly arthrokinematics. improve dynamic stabil,ity, and restore served that impingement. involves a mechanical
rhe third factor takes basic muscular strength. Full functional ROM should be compression of the supraspinatus tendon, the subacro­
~rformed at the time achieved by week 8 with] 80 degrees of flexion, 90 to 100 mial bursa, and the long head of the biceps tendon. all of
)wed based on the tis­ degrees of ER at the 90/90 position, and 60 to 65 degrees which are located under the coracoacromial arch. This
res. Surgical precau­ of IR at the 90/ 90 position of the upper extremity. Aggres­ syndrome has been described as a continuum during
o the athletic trainer sive stretching may be used if the ROM goals are not which repetitive compression eventually leads to irritation
after surgery should achieved by week 8. From week 9 to week 12, ROM is pro­ and inflammation that progresses to fibrosis and eventu­
lservative PROM pro­ gressed out of the safe zone to achieve full functional ROM. ally to rupture of the rotator cuff. Neer has identified three
~ry. The gradual pro­ During this phase, posterior cuff mobility should be moni­ stages of shoulder impingement:
hat moves faster an d tored and restored to norma!. Isotonic strengthening exer­
ngression should be cises are begun in all planes, scapular stabiliZing exercises STAGE I
nen t of capsular end are started with weights (Figures lS - 34 to 18-38). and dy­
uccessful rehabilita­ namic stabilization exercises for the glenohumeral joint Seen in patients less than 25 years of age with report
IS communication be­ (Figures 18-53 to 18-56). PNF exercises (Figures of repetitive overhead activity
~tic trainer.
80
18-59 to 18-68), and closed-kinetic-chain activities are Localized hemorrhage and edema with tenderness at
The rehabilitation progressed to tolerance. Two-handed plyometric exercises supraspinatus insertion and anterior acromion
l:Jli hing muscle tone on the Plyoback are also used for strengthening in the later Painful arc between 60 and 119 degrees: increased
This helps provide a part of this phase (Figure 18-46). with resistance at 90 degrees
-te n 'ion relationships Phase 3 is the advanced activity and strengthening Muscle tests revealing weakness secondary to pain
of the shoulder com­ phase. from week 12 to week 20. The goal s of this phase Positive Neer or Hawkins-Kennedy impingement signs
b e ning of the rotator include improvement of strength, power, and endurance, (Figures 18-69, 18-70)
ula should progress to enhancement of neuromuscular control, and perfor­ Normal radiographs. typically
ees of shoulder eleva­ mance of functional activities. The criteria to enter this Reversible; usually resolving with rest , activit.y modifi­
btomatic. the athletic phase should li nclude full ROM, no pain. and muscular cation, and rehabilitation program
as is on neuromuscu­ strength at least 80 percent of the contralateral side. 8o
.c stabilization. and Capsular stretching and flexibility are continued. STAGE II
co-con traction at the Strength en ing exercises are progressed with PREs. Plyo­ Seen in patients 25 to 40 years of age with report of
tra ining can then be metric exercises are advanced to Single-arm activities repetitive overhead activity
ting and then in th e (Figure 18-46). Neuromuscular control and dynamic sta­ Many of the same clinical findings as in Stage I
results. the athlet bilization exercises are advanced (Figure 18-53 through Severity of symptoms worse than Stage 1, progressing
n of maintenance for 18-57). In the late weeks of this phase. a formal interval to pain with activity and night pain
as they wish to be sport program is instituted. ao More soft-tissue crepitus or catching at 100 degrees
The final phase, the return to activity phase, is initiated Restriction in passive ROM due to fibrosis
For an athlete wh from week 26 to week 29 and involves gradual return to Possibly radiographs showing osteophytes under
-phase rehabilitatio n ' port participation. The criteria to enter phase 4 are full acromion . degenerative AC joint changes
ilio uses a rule of sL ROM. no pain, satisfactory strength as measured by isoki­ No longer reversible with rest; possibly helped by a
netic testing (Figure 18-52), and a normal clinical evalua- long-term rehabilitatio n program
402 I'1\RT THREE The Tools of Rehabilitation

side" or "outlet" impingement. / .io In outside !mpingcmcm Lcsions on the

there is contact of tbe rotator cuff with the coracoacro­ humeral hea d. 0­
mia] Ligament or the acromion with fray ing, abrasion, in­ Lesions on th e U'
flammation , fibrosis, and degeneration of the superior
surface of the cuff within the subacromial spacc. Thert GROUPIU
might also be evideuce of degenerative processes, includ­
ing spurring, decreased joint space due to fibrotic changes. Found in yo ung

and decreased vascularity. old)

"Inside" or "nonoutlet" impingement is more likely to Positive impingi

occur in the younger overhead athlete. With inside im­ rectional. usual(

pingement the subacromial space appears relatively nor­ Demonstrated ge::

mal. With forced humeral elevation and internal roLation . Humeral head J

the rotator cuff can be impinged on the posterior superior

glenoid labrum and the humeral head. potentially produc­ GROUP IV
ing innammation on the undersurface of the rotator cuff
tendon, posterior superior tcars in the glenoid labrum. and Found in you ng
lesions in the postcrior humeral head (Bankart lesion). old) wUh an te
Figure 18-69 Neer impingement test. matic event b Ul
The mechanical impingement syndrome as originali.y
proposed by Neer has been referred to as primar)7 impinge­ Posterior defect
ment. Jobe and Kvnite have proposcd that an unstable Damage in th
shoulder permits excessive translation of the humeral It has also been
head in an anterior and superior direction, resulLing if: s due to intrinsic t
what has been termed secondary impingement. JI Based .by and partial or .
on th e relationship of shoulder instability 10 shoulder im­ .bin ning, degenera
pingement. Jobe and Kvnitc have proposed an alternative perior migration of
system of classil1cation: 11 ary impingemen t. th
lead to ,full-thickne:
GROUPIA

Found ill recreational athletes more them 35 years of age

with pure mechanical impingement and no instability

lion on the humeru..
Positive impingement signs
[he humerus is addu
Lesions on the superior surface of tbe rotator cuff. pos­
ing out" of the blood
Figure 18-70 Haw kins-Kennedy impingement test. sibly with subacromial spurring
[h is occur repetith~et:
Possibly some arthritic changes in the glenohumeral
wimming stroke. u1l
joint
may lead to partia l or
It is likely that
STAGEID
GROUPIB
mechanical. tTau
Seen in patients older than 40 years of age with history processes collectively !
Found in recreational athletes over 35 who demon­

of chronic tendinitis and prolonged pain Injury Meehan­

strate instability with impingement secondary to mc­

Many of the same clinical fin dings as Stage rr drome occurs wh en

chanical trauma

Tear in rotator cuff usually less than 1 em mial space under th

Positive impingement signs

More limitation in active and passive ROM dynamic and static sUi
L{)sions found on th e undersurface of the rotator culT.

Possibly a prominent capsular laxity with multidirec­ one reason or anotb ,

superior glenoid , and humeral head

tional instability seen on radiograph space, the soft-tissu e ~

Atrophy of infraspinaLLls and supraspinatus due to irritation and infl ~
GROUP II

disuse lIlOst often occurs in rl

Treatment typically surgical following a failed conser­ Found in young overhead alhletcs (less than 3:; years
throWing, swimming.
vative approach old) who demonstrate instability and impingement
vo'lleyball, or durin g
Neer's impingement theory was based primarily on the secondary Lo repe[,itive microtrauma
ongoing disagreemell
treatment of older, nonathletic pntients. The oldcr popuJa­ Positive impingcment signs with excessive anterior
that cause shoulder iii
tion wnI likely exhibit what has been referred to as "out­ translation of humeral head
proposed that mechan:

ltside impingement
lh the coracoacro­
l~i ng. abrasion. in­
n of the superior
omial space. There
~ processes. inc1ud­
to fibrotic changes.
ent is more lcikely to
teo With inside im­
Iellrs relatively nor­
Id internal rota Lion.
e posterior superior
. potentially produc­
e of tbe rotator cu lT
~ enoid labrum. and
B kart lesion).
urrome as originall ~
. primary impinge­
~ th at an unstable
n of the humera;
rection. resulting in
1pingement. J 1 Based
. ' ty to shoulder Ull­
cd an atternati \
'\! than 35 years of a_
m a nd no instab Wr:
me rotator cuff. po!'­
in the glenohume
'er 35 who dem - Injury Mechanism. Shoulder impingement syn­
ot secondary to
less than 35 ye
and lrnpingem
Lesions on the posterior superior glenoid rim, posterior
humeral head, or an terior inferior capsule
Lesions on the undersurface of the rotator cuff
GROUP III
Found in young overhead athletes (less than 35 years
old)
Positive impingement signs with atraumatic multidi­
rectional, usually bilateral. humeral instabilities
Demonstrated generalized laxity in all joints
Humeral head lesions as in Group II but less severe
GROUP IV
Found in young overhead athletes (less than 35 years
old) with anterior instability resulting from a trau­
matic event but without impingement
Posterior defect in the humeral head
Damage in the posterior glenoid labrum
It has also been proposed that wear of the rotator cuff
is due to intrinsic tendon pathology, including tendinopa­
thy and partial or small complete tears with age-related
thinning. degeneration, and weakening. This permits su­
perior migration of the humeral head , leading to second­
ary impingement. thus creating a cycle that can ultimately
lead to full-thickness tears. 72
A ;'critical zone" of vascular insufficiency has been
proposed to exist in the tendon of the supraspinatus,
which is found at about 1 cm proximal to its distal inser­
tion on the humerus. It has been hypothesized that when
the humerus is adducted and internally rotated. a "wring­
g out" of the blood supply occurs in this tendon. Should
Ihis occur repetitively, such as in the recovery phase on a
swimming stroke, ultimately irritation and inflammation
m ay lead to partial or complete rotator cuff tears.;Y
It is likely that some as yet unidentified combination of
mechanical, traumatic. degenerative, and vascular
processes collectively lead to pathology in the rotator cuff.
drome occurs when there is compromise of the subacro­
mial space under the coracoacromial arch. When the
.iynamic and static stabilizers of the shoulder complex for
oe reason or another fail to maintain tbis subacromial
space, the soft-tissue structures are compressed, leading to
italion and inflammation. In athletes, impingement
ost often occurs in repetitive overhead activities such as
hrowing, swimming, serving a tennis ball. or spiking a
Ueyball. or during handstands in gymnastics. There is
ngoing disagreement regarding the specific mechanisms
.hat cause shoulder impingement syndrome. It has been
oposed that mechanical impingement can result from ei-
CHAPTER 18 RehabiJilalion of Shoulder Injuries 403
~.
~. ''-..
('. /,\-"
~;I
,1,-
.'
.
II r
I II III
Figure 18-7l Acromion shapes. Type L flat; type If,
curved; and type III. hooked .
ther structural or functional causes. Structural causes can
be attributed to existing congenital abnormalities or to de­
generative changes under the coracoacromiail arch and
might include the follOWing:
An abnormally shaped acromion (Figure 18-71). Ath­
letes with a type III or hook-shaped acromion are ap­
proximately 70 percent more likely to exhibit signs of
impingement tban those with a flat or slightly curved
acromion. 6
Inherent capsular laxity compromises the ability of the
glenohumeral joint capsule to act as both a static and
a dynamic stabilizer. J 1
OngOing or recurring tendinitis or subacromial bursi­
tis causes a loss of space under the coracoacromial
arch, which can potentially lead to irritation of other.
uninflamed structures, setting up a vicious degenera­
tive cycle. 64
Laxity in the anterior capsule due to recurrent sublux­
ation or dislocation can allow an anterior migration of
the humeral head. which can cause impingement un­
der the coracoid process. 70
Postural malalignmcnts such as a forward head. round
shou'lders, and an increased kyphotiC curve, which
cause the scapular glenoid to be pOSitioned such that
the space under the coracoacromial arch is decreased .
can also contribute to impingement.
Functional causes include adaptive changes that occur
with repetitive overhead activities, altering the normal bio­
mechanical function of the shoulder complex. These in­
clude the following:
Failure of the rotator cuff to dynamically stabi1ize the
humeral head relative to the glenoid, producing exces­
sive translation and inslability. The inferior rotator cuff
muscles (infraspinatus, teres minor, subscapularis)
should act collectively to both depress and compress
404 Pi\RTTHREE The Tools of Rehabilitation

the humeral head. In the overhead or throwing ath­ An injury tbat affects normal arthokinematic motion ~ow ing activities IF
lete, the internal rotators must be capable of produc­ at either the sternoclavicular joint or the acromioclav­ pezius should also
ing humeral rotation on the order of 7.000 degrees per icular joint can also contribute to shoulder impinge­ e in the force COu;
second. 711 Tile subcapularis tends to be stronger than ment. Any l'i mitation in posterior superior clavicular jog scapular stabj
the infraspinatus and teres minor. creating a strength rotation and/or clavicular elevation will prevent nor­ nterior, posten
imbalance in the existing force couple in the transverse mal upward rotation of the scapula during humeral cl~ lions at both lhe
plane. This imbalance produces excessive anterior evation, compromising the subacromial space. ,a\' icular Joint
translation of the humera'l head. Purthermore, weak­ Rehabilitation Concerns. Mana gement of shoul­ lhrokinematic m
ness in the inferior rotator cuff muscles creates an im­ der impingement involves gradually restoring normal bio­ -10 to 14-12 ).
balance in the existing force couple with the deltoid in mechanics to the shoulder joint in an effort to maintai Strengthen i ng
the coronal plane. The deltoid produces excessive supe­ space under the coracoacromial arch during overhead ac­ uscles to provide c
rior translation of the humeral head, decreasing sub­ tivities. 69 The athletic trainer should address the pathomc­ e stresses and st r
acromial space. Weakness in the supraspinatus. which chanics and the adaptive changes that most oflen occur ,d this is also im po
normally functions to compress the humeral head into with overhead activities. -40).
the glenoiu, allows for excessive superior translalion of Overhead activities that involve humeral elevation (ful l Rehabilitation Pr
the hu~meral head. 74 abduction or forward flexion) or a position of humeral flex­ _~abiJitation progra­
Because the tenuons of the rotator cuff blend into the ion, horizontal adduction , and internal rotation arc likely .Tainer is to minimize ;,;
jOint capsule. we rely on tension created in the capsule to increase the pain : 12 The athlete complains of diffu se nt syndrome. This Cl
by contraction of the rotator cuff to both statically and pain around the acromion or glenohumeral joint. Palpa­ ."Dm bination of aem-'
dynamically center the humeral head relative to the tion of the subacromial space increases the pain. . and appropr iate
glenoid. Tightness in the posterior and inferior por­ Exercises sh(JUlld concentrate on strengthening the Initially, the ath
tions of the glenohumeral joint capsule causes an an­ dynamic stabilizers. the rotator cuff muscles that act to ate the athlete's tee.,
terosuperior migration of the humeral head . again both compress and depress the humeral head relative to :t ivity, to rule out f
decreasing the subacromial space. In the overhead the glenoid31.49M (Figures 18-31. 18-32). The inferior :isting performan ce'
athlete. range or motion in internal rotation is usually rotator cuff muscles in particular should be strengthened h letic trainer must
limited by lightness of both the muscles that externally to recreate a balance in the force couple with the deltoid .he activity that ca
rotate and the posterior capsule. There tends to be ex­ in the coronal plane. The supraspinatus should b -ity limitation. how
cessive external rotation. primarily due to laxity in the strengthened to assist in compression of the humeral tead, a baseline 0(
anterior joint capsule. 9 head into the glenoid (Figures 18-33 , 18-34). The exter­ ;hed. The key is to in
The scapular muscles function to dynamically position nal rotators, the infraspinatus and teres minor, are gen­ t'vel of the load on tb
the glenoid relative to the humeral head. maintaining erally weaker concentrically but stronger eccentricalJ:,'
a normal length-tension relationship with the rotator than the internal rotators and should be strengthened to
curf. As the humerus moves into elevation, the scapula recreate a balance in the force couple with the subscapu­ J\·ity. avoiding any ex
should also move so that the glenoid is able to adjust re­ .Iaris in the transverse plane. mpingement position
gardless of the position of the elevating humerus. The external rotators and tbe posterior portion of the o su bside. During lllli
Weakness in the serratus anterior, which elevates, up­ joint capsule are tight and tend to limit internal rotation ete should continue
ward rotates. and abducts the scapula, or weakness in and should be stretched (Figures 18-15, 18-17. 18-] 9). . ardiorespiratory f1 ln
the levator scapula or upper trapezius, which elevate There is excessive external rotation due to laxily in the ~rogometer will hel p t
the scapula, will compromise positioning of the gle­ anterior portion of the joint capsule, and stretching ess and muscular en
noid during humeral elevation, interfering with nor­ should be avoided. There might be some tightness in both Therapeutic mod
mal scapulohumeral rhythm. the inferior and the posterior portions of the jOint cap­ currents and/or heal
It is critical for the scapula to maintain a stable base on sule; this can be decreased by USing posterior and inferior odulate pain. UltTa
which the highly mobile humerus can move. Weak­ glenohumeral jOint mobilizations (Figures 14-13. 14-14. useful for elevating ti
ness in the rhomboids and/ or middle trapezius. which 14-16. ]4-17). flow. and facilitatin g
function eccentrically to decelerate the scapula tn Strengthening of the muscles that abduct, elevate. scribed by the team p
higb-velocity throwing motions. can contribute to and upward rotate the scapula (these include the serra­ gesics. but also for th
scapular hypennobiliiy. Likewise, weakness in the infe­ tus anterior. upper trapezius, and levator scapuJa) should capabilities.
rior trapezius creates an imbalance in the force couple also be incorporated (Figures 18-35. 18-39, 18-40). The Once pain and in na
with the upper trapezius and levator scapula. con­ middle trapezius and rhomboids should be strengthened rcises should concen o
tributing to scapular hypermobility. eccentrically to help decelerate the scapula during stabilizers of the glen(
 CHAPTER 18 Rehabilitation of Shoulder lnjuri 405

nokinematic motion throwing activities (Figures 18-37. 18-38). The inferior rior and posterior portions of the joint capsule. trength­
. or lbe acromiocla\'­ trapezius should also be strengthened to recreate a bal­ ening the scapular muscles that collectively produce nor­
hou lder impingc­ ance in the force couple with the upper trapezius. facili­ mal scapulohumeral rhythm. and maintaining nonna!
r _upe rior clavicular tating scapular stability (Figure 18-36), arthrokinematic motions of the acromioclClvic ular and
wiJI prevent nor- Anterior. posterior. inferior. and superior joint mobi­ sternoclavicular joints.
durin g humeral cl­ lizations at both the sternoclavicular and the acromio­ Strengthening exercises are done to establish n uro­
~ mial space, clavicular joint should be done to assure normal muscular control of the humerus and the scapulCl (Figures
anagement of shoul­ arthrokinemClLic motion at these joints (see Figures 18-59 through 18-65). Strengthening exercises shou ld
-esloring normal bio­ 14-10 to 14-12). progress from isometric pain-free contractions to isotonic
ill effor t to maintain Strengthening of the lower-extremity and trunk full-range pain-free contractions. Humeral control exer­
I during overhead ac­ muscles to provide core stability is essential for reducing cises should be used to strengthen the rotator cuff to re­
dee, s the pat homc­ the stresses and strains placed on the shoulder and arm. strict migration of the humeral head and to regain
hal most ofLen occu r and this is also important for the overheCld athlete (Figure voluntary control of the humeral head positioning
18-40). through rotator cuff stabilization. 77 Scapular control exer­
,umera l elevation (full Rehabilitation Progression. In the early stages of a cises should be used to maintain a normal relationship be­
n of humerlli tlex­ rehabilitation program. the primary gom of the athletic tween the glenohumeral and scapulothorasic joints. 37.38,42
al rot ation are likely trainer is to minimize the pain associated with the impinge­ Closed-kinetic-chain exercises for the shoulder should
.:omplains of diffuse ment syndrome. This can be accomplished by utilizing some be pr,imarily eccentric. They tend to compress the joint,
eral joint. Palpa­ combination of activity modiftcation. therapeutic modali­ providing stability. and are perhaps best used for establish­
lhe pain. ties. and appropriate use of NSAIDs. ing scapular stability and contro\. 43
tre ngLhening th Initially. the athletic trainer should have a coach eVClI­ Gradually. the duration and intensity of the exercise
mu cles Ehat act to uate the athlete's technique in performing the overhead may be progressed within individual patient tolerance lim­
ra l head relative t activity. to rule out faulty performance techniques. Once itations. using increased pain or stiffness as a guide for pro­
1 - 2). The inferior existing performance techniques have been corrected, the gression. eventually progressing to full-range overhead
uld be strengthened athletic trainer must make some decision about limiting activities.
pIe with the deltoid the activity that caused the problem in the first place. Ac­ Criteria for Returning to Full Actil'ity. The a ­
illatus should b ' :ivity limitation. however, does not mean immobilization. lete may return to full activity when (1) the gradual
0(1 of the humeral lnstead. a baseline of tolerable activity should be estab­ gram used to increase the duration and intensity of the
3. 18-34). The exter­ lished. The key is to initially control the frequency and the workout has allowed him or her to complete a n rmal
.' res minor. are geo­ level of the load on the rotator cuff and then to gradually workout without pain; (2) the athlete exhibits 1mPi'
on ger eccentricall~ and systematically increase the .level and the frequency of strength in the appropriate rotator cuff and the apular
d be strengthened to that activity. It might be necessary to initially restrict ac­ muscles; (3) there is no longer CI positive im pin_emeOl
\....ith the subscapu­ tivity. avoiding any exercise that places the shoulder in the sign. drop arm test. or empty can test; and (4) the alhlete
impingement pOSition. to give the intlammation a chance can discontinue use of anti-intlammatory medications
le rior portion of th to subside, During this period of restricted activity, the ath­ without a return of pain.
, mi t internal rotanOi lete should continue to engage in exercises to maintain
-1 5, ]8-17.18-1 9 1. cardiorespiratory fitness. Working on an upper-extremity
d ue to laxity in th e erogometer will help to improve both cardiorespiratory fit­
ule. and stretch ill _ ness and muscular endurance in the shoulder complex. CLINICAL DECISION MAKING Exen:ise 18-3
me tightness in both Therapeutic modalities such as electrical stimulating
io ns of the joint ca currents and/or heat and cold therapy may be used to An ] 8-ycar-old swimmer complains r bilateral.houlder
posterior and inferi r modulate pain. Ultrasound and the diathermies are most pain. She is referred 10 the athlelic trainer \\ilh bilateral
fi gures 14-13. )4- H . useful for elevating tissue temperatures. increasing blooe! rotator cuff tendoDopathy. The at hlete h s positi\'e im­
now. and facilitating the process of healing. NSAIDs pre­ pingement signs and poinltenderness near the insertions
that abduct. elevate
scribed by the team physiCian are useful not only as anal­ of the uprasplnatus tendons, The athlete swims Iwice a
e e include the serra­
gesics. but also for their long-lasting anti-inflammatory day for approximately 3 hours IOlal. he hitS had sboul­
\'ator scapula) shou lo
capabilities. der pain for 3 months and it is gelting progressively
-, 18-39. 18-40), The
Once pain and intlarnmalion have been controlled. ex­ worse. What should the athletic lrdiner recommend to al­
ho uld be strengthenerl
ercises should concentrate on strengthening the dynamic leviate the athlete's symptom..'I";
~ the scapula duri n=­ -tabilizers of the glenohumeral jOint. stretching the infe-
406 PART THREE The Tools of Rehabilitation
Rotator Cuff Tendinitis and Tears
Pathomechanics. Rotator cuff iojury has often
been described as a continuum starting with impingement
of the tendon that, through repetitive compression. even­
tually leads to irritation and inflammalion and eventually
fibrosis of the rotator cuff tendon. This idea began with the
work or Cadman in ] 934 when he identified a critical zone
near the insertion of the supraspinatus tendon. 47 Since
then many researchers in sports medicine have studied
this area and have expanded the information base. leading
to the iden tification of other causative factors. 32 .54 Neer is
also credited with developing a system of classification for
rotator cuff disease. This system seemed to be appropriate
unOI sports medicine professionals began dealing with
overhead athletes as a separate entity due to the accelera­
tion of repeli tive stresses applied to the shou Ider. Disease in
the overhead athlete usually results from failure due to one
or both of these chronic stresses: repetitive tension or com­
pression of the tissue. \'Ve now regard rotator cuff injury in
athletics as an accumulation of microtrauma to both the
stalic and the dynamic stabilizers oJ the s.houlder complex.
In 1993. lVleister and Andrews classified these causative
traumas based on the pathophysiology of events leading to
rotator cuff failure . Their five categories of classification
for modes of failure arc primary compressive. secondary
compressive. primary tensile overload. secondary tensile
overload. and macrotraumatic. 47
Injury Mechanism. Rotator cuCf tendonopathy is a
gradation of tendon failure. so it is important to identify
the causa Live factors . The following claSsification system
helps group inj,ury mechanisms to better aid the athletic
trainer in developing a rehabilitation plan.
Primary compressive disease results from direct
compression of the cuff tissue. This occurs when some­
thing interferes with the gliding of the cuff tendon in the
already tigbt subacromial space. A predisposing factor in
this category is a type 1II hooked acromion process. a com­
mon factor seen in younger athletes with rotator cuff dis­
ease. Other factors in younger athletes include a
congenitally thick coracoacromial ligament and the pres­
ence of an os acromiale. In younger athl.etes. a primary
impingement without one of these associated factors is
rarc. In middle-aged athletes/patients. degenerative
spurring on the undersurface of the acromion process can
cause irritation of the tendon and eventually lead to com­
plete tearing of t.he tendon . These individuals are often
seen because they experience pain during slIch activities
as tennis and golf.
Secondary compressive disease is a primary result
of glenohumeral instability. The high forces generated by
the overhead athlete can cause chronic repetitive trauma paJr of the tendon
to the glenoid labrum and capsuloligamentous structures. lint are performed. ~
leading to subtle instability. Athletes with inherent multi­ 'Ion surgical plan. \\
directional instability, such as swimmers. are also at risk. ased on tissue beaL:
The additional vo'lume created in the glenohumeral cap­ Conservative rru
sule allows for extraneous movement of the humeral head. lation process is Ii
leading to compressive forces in the subacromial space. removing the athl
Primary tensile overload can also cause tendon irri­ Pain should not
tation and failure . The rotator cuff resists horizontal ad­ The athletic trainer
duction. internal rotation, anterior translation of th aid in athlete comk­
humeral head. and distraction forces in the deceleration ,owed during th i
phase of throwing and overhead sports. The repetiti n ' ioo exercises be
high forces generated by eccentric activity in the rotator en don. Attention
cuff while attempting to maintain a central axis of rota­ ar throkinematics l
tion can cause microlrauma to the tendon and eventual l) a result of a comL
lead to tendon failure. This type of mechanism is not asso­ l.retching may be
ciated with previous instability of the joint. Causes for th i. lrengthening of
mechanism often are found when evaluating the athlete'~ ('oncentraling on .
mechanics and taking a complete history during the eval­ joint. Beginning \\
uation. The athJetic trainer might find that the throwin" and lateral rotator"_
athlete had a history of injury to another area of the bod) gressing to isotoniC'
where the muscles are used in the deceleralion phase 0 rience pain (Figun
overhead motion (for example. the right-handed pitche ath lete's arm cao
who sprained his left ankle). houlder muscles.
Secondary tensile disease is often a result of pri­ might need to be a
mary tensile overload. In this case the repetitive irritation h umeral head. SITI
and weakening of the rotator cuff allows for subtle insta­ begin if 90 degret'"
bility. In contrast to secondary compressive disease of the available (Pigur,
tendon. the rotator cuff tendon experiences greater dis­ mengthening of
tractive and tensile forces because the humeral head is al­ start. as the resto
lowed to translate anteriorly. Over time, the increased
tensile force causes fai lure of the tendon.
Macrotraumatic failure occurs as a direct result
one distinct traumatic event. The mechanism for this is of­
ten a fall on an outstretched arm. This is rarely seen in ath­
,letes with normal, healthy rotator cuff tendons. For t.his t
occur. forces generated by tbe fa ll must be greater than the
tensile strength of the tendon . Because the tensile strengt h
of bone is less than that of young healthy tendon. it is rar
to see this in an athlete. It is more common to see a longi­
tudinal tear in the tendon with an avulsion of the greater
tubercle.
Rehabilitation Concerns. '''Ihen designing a re­
habilitation program for rotator cuff tendonopathy. tb
basic concerns remain the same regardless of the extent to
which the tendon is damaged. Instead, rehabilitation Aggressive n
should be based on why and how the tendon has been started in this stage:
damaged. Once the cause of the tendonopathy is identil1ed patterns. starting \\'
and secondary factors are k.nown. a comprehensive pro­ therapist and advan
gram can be designed. If a comprehensive rehabilitation tubing (Figures 18-~
program does not relieve the painful shoulder, surgical re­ used for rhYLhmic st~
 CHAPTER 18 Rehabilitation of Shoulder Injuries 407

Lie repetitive tra Llma pair of the tendon and alteration of the glenohumeral The exercise program shou1ld now progress to free
fm entous structures. joint are performed. Surgical rehabilitation is similar to the weights. and eccentric exercises of the rotator cuff should
with inherent multi­ nonsurgical p'\an. with the time of progression altered be emphasized to meet the demands of the shoulder in
ers. are also at risk. based on tissue healing and tendon histology. overhead activities. Strengthening of the deltoid and up­
· glenohumeral cap­ Conservative management. Stage I of the rehabil­ per trapezius muscles can begin above 90 degrees of eleva­
of the humeral head. itation process is focused on reducing inflammation and tion. Exercises include the military press (Figure 18-24).
~b a eromial space. removing the athlete from the activity that caused pain. shoulder l1exion (Figure 18-20). and reverse l1ys (Figure
cause tendon irri­ Pain should not be a part of the rehabilitation process. 18-30). Push-ups can also be added. It might be necessary
'e ists horizontal ad­ The athletic trainer may employ therapeutic modalities to to restrict range of motion so the body does not go below
translation of th t> aid in athlete comfort. A course of NSAlf)s ,is usually fol­ the elbow, to prevent excessive translation of the gleno­
in the deceleration lowed during this stage of rehabilitation. Range-of-mo­ humeral joint. This author prefers combining this exercise
ports. The repetitive tion exercises begin. avoiding further irritation of the with serratus anterior strengthening in a moditlecl push­
Livity in the rotator tendon. Attention is paid to restoring appropriate up with a plus (Figure 18-39).
c ntral axis of rola­ arthrokinematics to the shoulder complex. If the injury is In the later part of this stage. exercises should
ndon and eventually a result of a compressive disease to the tendon. capsular progress to plyometric strengthening. Surgical tu'bing is
h anism is not asso­ stretching may be done (Figures 18-18. 18-] 9). Active used to allow the athlete to exercise in 90 degrees of ele­
· joint. Causes ('or this strengthening of the glenohumeral joint should begin . vation with the elbow bent to 90 degrees (Figure 18-45).
al uating the athlete's concentrating on the force couples acting around the Plyoball exercises are initiated (Figures 18-46. 18-4 7).
t ry during the eval­ jOint. BegInning with isometric exercises for the medial The weight and distance of the exercises can be altered to
nd that the throwin g, and lateral roLators of the jOint (Figure 18-20). and pro­ increase demands. The Shuttle 2000-1 is an excellent ex­
Ih r area ofthe bod~ gressing to isotonic exercises if the aLhlete does not expe­ ercise to increase eccentnic strength in a plyomeLric fash­
eceleration phase of rience pain (Figures 18- 31.18-32). A LoweI roll under the ion (Figure 18-50).
right-handed pitcher athlete's arm can help initiate co· conLraction of the Stage III of the rehabilitation focuses on sport-specill1c
shoulder muscles. ,i ncreasing joint stability. Exercises activities. With throwing and overhead athljetes. an inter­
often a result of pc'­ might need to be altered to limit translational forces of the val overhead program begins. Total body conditioning. re­
e repetitive irritation bumeral head. Strengthening of the supraspinatus may turn of strength. and ,i ncreased endurance are the
lows for subtle insta­ begin if 90 degrees of elevation in the scapular plane is emphasis. The athleLe should remain pain-free as sport­
ressive disease of the available (F,i gures 18-33. 18-34). Aggressive pain-free specifk activities are advanced and a gradual return Lo
riences greater dis­ strengthening of the periscapular muscles should also sport is achieved.
e h umeral head is a l­ start, as the restoration of normal scapular control will be
· time. the increased essential Lo removal of abnormal stresses of the rotator
do n. cuff tendon in later stages. The athletic trainer might CLINICAL DECISION MAKING Exercise 18-4
as a direct result r wan t to begin with manual resistance. progressing to free­
A 20-year-old ba.-;eball pitcber is complaining of posterior
h anism for tl1is is of­ weight exercises (Figures 18-35 to ] 8-39).
. is rarely seen in ath­ shoulder pain. He is unable to go fully into his cocking
In stage II. the healing process progresses and range
motion of his thrOIV witbout pain . Upon fur ther evalua­
rr tendons. For this to of motion will need to be restored. The athletic trainer
tion. the alhletic trainer fmds that the infraspinatus and
u t be greater than thl' might need Lo be more aggressive in stretching tech­
supra pinatus are weak and painful. The ath lete is re­
~e the tensile strength niques. addressing capsular tightness as it develops. The
ferred to a physician for evaluation. The physician refers
a1thy tendon. it is rar prone-on-elbows position is a good technique for self­
the athlete with anterior instability and secondary im­
mmon to see a longi­ mobilization. This position should be avoided if compres­
pingement. The athlete has tissue breakdown occurring
v-ulsion of the greater sive disease was part 01' the irritation . If pain continues to
on the undersurface of the rotator cuff tendons. In what
be absent. strengLhening gets increasingly aggressive.
order hould the athletic trainer address the athlete's
\' hen designing a re­ lsokinetic exercises at speeds greater than 200 degrees
problem (
uf tcndonopathy. the per second for shoulder medial and lateral rotation may
~dless of the extent to begin (Figure 18-52).
In tead. rehabilitation Aggressive neuromuscular control exercises are
the tendon has been started in this stage: quick reversals during PNF diagonal Postsurgical management. If conservative man­
onopathy is idenlil1ed patterns. starting with manual resistance from the sports agement is insufficient. surgical repair is often indicated.
a comprehensive pro­ therapist and advancing to resistance applied by surgica'i The type of repair done depends on the classification of the
ehensive rehabilitatioI' tubing (Figures 18-55. 18-:;6). A Body Blade may also be injury. Subaoromial decompression has been described by
~ I shoulder. surgical re­ llsed for rhythmic stabinza tion (Figure 18-57). Neer as a method to stimulate tissue healing and increase
408 PART THREE The Tools of Rehabilitation

~ ~- Rehabilitation Progression. The rehabilitation

Adhesive CapS1

~
i\'~ ~---J:' ~. . ,.
progression for conservatively managed rotator cuJT io­
ju..ry should follow along with the progression outlined in Pathomechanin
- - . : .
.'
~
,----.~:~. the section on impingement syndrome. The following pro­ ized by the loss of ill
gression is the author's preference for postsurgical pro­ ..:ause of this arth rolIt
gression . The principles followed for rehabilitation :-riteria used for dia
progression are based on the dynamics of healing tissue. scribed by Jobe ct al.l
Depending on the surgical procedure, the time frame for bumeral motion and
this progression may be altered . A simple way to stage the
~
motion: (2) rcstricterl
,~ ... '
rehabilitation of the postsurgical athlete is by following 90 degrees, depell ding
the rule of six. During the fIrst 6 weeks after the surgery. 50 to 60 percent of n
the goal is to decrease pain. address inflammation . and - to 10 cc vo'lume wi;,:
Figure 18-72 Airplane splint. prevent muscle atrophy. Therapeutic modalities and gentle Id. 3l mher auth ors!:..
ROM are initiated. Jifferel1t areas sun
The second 6-week period (weeks 6 to 12) begins the Travell and Simons e
stage of rehabilitation where full active and passive range ri on could be the Lm
01 motion need to be achieved prior to maturation of the ~ u bscapularis trigger,
the subacromial space. 50 Additional procedures may be healing tissue. Other emphasis is placed on regaining nor­ 'l ammation with nbr,
done as open repairs of the tendon along with a capsular mal static and dynamic joint mechanics. Proprioceptive iight and inelastic.
tightening procedure. One example is a modified Bankart and neuromuscular exercises are used to achieve this goal. Injury Mechanis:
procedure and capsul'olabral reconstruction. 3o In the last 6 weeks (weeks 12 to 18). the repair should ler. we will separalc lh.
Stage I is often begun with some form of immobiliza­ be mature enough to tolerate progression to activities thal mary versus secor.
tion. This does not mean complete lack of movement. In­ prepare the athlete for return to activity. Speed and control capsulitis may bc c(.'~
stead it refers to restricting positions based on the surgical· of resisted exercises are increased. Plyometric training and -pontaneously; it is c
repair. [n open repairs. Ilexion and abduction might be re­ interval progression to sport-specific activities are used . nderlying condit ioI'!
stricted for as long as 4 weeks. When the repair addresses This stage ends with the athlete's return to activity. present.
the capsulolabral complex. the athlete might spend up to 2
weeks in an airplane splint (Figure 18-72).
Criteria for Return to Activity. Return to ful ~ ac­ Primary froze n !or
tivity should be based on these criteria: (1) The ath lete has o;et. The athlete often
Pain control and prevention of muscle atrophy are ad­ full active range of motion. (2) Normal mechanics have , rrictions in his or
dressed in this stage. Shoulder shrugs. isometrics, and joint been restored in the shou,lder complex. (3) The athlete has stiffness with less pa ~
mobilization for pain control can be done. Later in this at least 90 percent strength in the involved shoulder as predispose a patient
stage. active assistive exercises with the L-bar and multian­ compared to the uninvolved side. (4) There is no pain pres­ betes, hypothyroidism
gle isometrics are done in the pain-free range of motion. ent du.riog overhead activity. involvement. 6~ These ;
Stage II collagen and elastin components have begun
demiological studies a
to stabilize. Healing tissue should have a decreased level of
a cteristic person an ti
elastin and an increased level of collagen by OOW. 64 .80 Re­
type of frozen shoulder
gaining full range of motion and increasing the stress to CLINICAL DECISION MAKING Exercise 18-5
Secondary froz en
hea ling tissue for better collagen alignment is important in
the athletic populat i
this stage. Having the athlete hang from an overhead bar A lS-year-old female tennis pLayer has been compLai.n.ing
different underlyin g
(Figure 18-5) or using a rope and pulley system (Figure of shoulder pain that stops her from compLeting ber
listed eight categori
18-9) can help achi.eve desired ROM. matcbes. The athletic trainer finds global scapular stabi­
erC'd in the different
Active range-of-motion exercises are added, progress­ lizer weakness as well as pain and weakness In her rota­
trauma , other soft-li'
ing from no resistance to resistance with surgical tubing. [f tor cuff muscLes. Her physician diagnoses sh ou lder
ioint disorders. bone
a primary repalr has been done to the tendon, reSisted impingement and rotator cuff tendinitis. An MRI re­
trathorack disorder,..
supraspinatus exercises should be avoided until 10 weeks. vealed thickening of tbe supraspinatus and lnfraspinalu"
hogenic disorder ho (T:
The restoration of normal arthrokinematics and tendons. She is in the middLe of her competitive tourna­
Rehabilitation
scapulothoracic rhythm is addressed with exercises em­ ment season and will begin her scbolastlc season In 3
for rehabilitation is p
phasizing neuromuscular control. The athlete can use a months. What course sbould the athLetic trainer recom­
ing to progress the pa
mirror to judge progress. mend to ensure thaI her symptoms subside and she can
activities portion of a
Stage HI remains similar to conservative management. compete successfully again?
exacerbation of til
However. the time frame might lag getting to this stage.
treatment for adhesil'c
 CHAPTER 18 Rehabilitation of Shoulder Injuries 409

rl1e rehabilitation Adhesive Capsulitis (Frozen Shoulder) • TABLE 18-3 Differential Diagnosis
~ rotator cuff in­
of Frozen Shoulder
ression outlined in Pathomechanics. Adhesive capsu]ilis is character­
The following pro­ ized by the loss of molion at thc glenohumeral joint. The Trauma
r postsurgica I pro­ cause of this arthroflbrosis is not well defined. One set of
fo r rehabilitation criteria used for diagnosis of a frozen shoulder was de­ Fractures of the shoulder region
s of healing tissuc. scribed by Jobe et al. in 1996, included: (1) decreased gleno­ Fractures anywhere in the upper extremity
the time frame for humeral motion and loss of synchronous shoulder girdle Misdiagnosed posterior shoulder dislocation
)ie way to stage the motion; (2) restricted elevation (less than] 35 degrees or Hemarthrosis of shoulder secondary to trauma
lete is by following gO degrees, dcpcnding on thc author); (3) cxtcrnal rotation
50 to 60 percent 01 normal; and (4) arthrogram findings of Other Soft-Tissue Disorders about the Shoulder
Ji after the surgery.
inflammation. and 5 to 10 ee volume with obliteration of thc normal axillary Tendinitis of the rotator cuff
.odalities and gentle fold. l ] Other authors have identilled histological changes in Tendinitis of the long head of biceps
different arcas surrrounding the glenohumeral joinL 64 Subacromial bursitis
6 to 12) begins Ihe Travell and Simons explained t hat a re!'lex autonomic reac­ Impingement
e and passive range tion could be the underlYing cause. due to the presence of Suprascapular nerve impingement
1 maturation of the subscapularis trigger pOints. / ] The result is a chronic in­ Thoracic outlet syndrome
rl on regaining nor­ flammation with fibrosis and rotator culT muscles that are
[lies. Proprioceptive tight and inelastic. Joint Disorders
to achicve this goal. InjurJ' Mechanism. For the purposes of this chap­
Degenerative arthritis of the AC joint
I. the repair should ter. we will separate this diagnosis into two categories; pri­
Degenerative arthritis of the glenohumeral joint
ion to activities that mary versus secondary frozen shoutder. Adhesive
Septic arthritis
y. Speed and contro; capsulitis Inay be considercd primary when it dcve'lops
Other painful forms 01' arthritis
)metric training and spontaneously: it is considered secondary when a known
activities are used. underlying condition (e.g .. a fractured humeral bead) is Bone Disorders
ra to activit)'. present.
Return to full ac­ Primary frozen shoulder usual'ly has an insidious on­ Avascular necrosis of the humeral head
I: ( 1) The athlete has set. The athlete often describes a sequence of painful re­ Metastatic cancer
nal mechanics have strictions in his or her shoulder, followed by a gradual Pagel's disease
(.. ( 3) The athlete has stilTness with less pain. Factors that have been found to Primary bone tumor
n \'Olved shoulder as predispose a patient to idiopathic capsulitis include dia­ Hyperparathyroidism
-bere is no pain pres- betes. hypothyroidism. and underilying cardiopulmonary
Cervical Spine Disorders
involvement. 61 These factors were identified through epi­
demiological studies and might have more to do with char­ Cervical spondylosis
acteristic personalities of these patients. It is rare to see this Cervical disc herniation
type of frozen shoulder in the athletic population. Infection
Exercise 18-5
Secondary frozen shoulder is more commonly seen ,in
the athletic population. It has been associated with many Intrathoracic Disorder
, been complainlng
different underlying diagnoses. Rockwood and Matsen DiaphragmatiC irritation
lmpleting her
listed eight categories of conditions that should be consid­ Pancoast tumor
baI scapular stab i­
ered in the differential diagnosis of frozen shoulder: Myocardial infarction
ikness in her rota-
lrauma. other soft-tissue disorders about the shoultder,
shoulder Abdominal Disorder
joint disorders, bone disorders. cervical spine disorders, in­
11 . An MRlre­
trathoracic disorders, abdominal disorders. and psy­
and lnrra'lplnatus Gastric ulcer
chogenic disorder 60 (Table] 8- 3).
IIllpeLitil7e touroa­ Cholecystitis
Rehabilitation Concerns. The primary concern
til: season in 3 Subphrenic abscess
:'or rehabilitation is proper differential diagnosis. Atlempt­
rtIc trainer recom­
:ng to progress the patient into the strength or functional Psychogenic
I ide and she can
activities portion of a rehabilitation program can lead to
exacerbation of the motion restriction. The single best
tceatment for adhesive capsuIttis is prevention. From C. A. Rockwood and F. A. Matsen. 1990. The Shoulda
Philadelphia: W B. Saunders.
4 ,10' PART THREE The Tools of Rehabilitation
Depending on the stage of pathology when interven­
tion is started. the rehabilitation program time frame can
be shortened. In all cases. the goals of rehabilitation are
the same: first relieving the pain in the acute stages of the
disorder. gradually restoring proper arthrokinemalics.
gradually restoring range of motion. and strengthening
the muscles of the shoulder complex.
Rehabilitation Progression. In the acute phase.
Codman's exercises and low-grade joint mobiHzation tech­
niques can be used to relieve pain. This may be accompa­
nied by therapeutic modalities and passive stretching OJ
the upper trapezius and levator scapulae muscles. The ath­
letic trainer may also want to suggest that the patient sleep
with a pillow under the involved arm to preven t internal
rotation dUring sleep.
In the subacute phase. range of motion is more ag­
greSSively addressed. Incorporating PNF tcchniques such
as hold-relax can be helpfu\. Progressive demands should
be placed on the patient with rhythmiC stabilization tech­
niques . Wall climbing (Figure 18-8) and wall/corner
stretches (Figure 18-10) are also good additions to the re­
habilitation program. As ROM returns. the program
should start to address strengthening. Isometric exercises
for the shoulder are often the best way to begin. Progres­
si ve strengthening will continue in the next phase.
The final phase of rehabilitation is a progressive
strengthening of the shoulder complex, Exercises for
maintenance of ROM continue. and a series of strength­
ening exercises should be added. The rehabilitation pro­
gram should be tailored to meet the needs of the patient
based on the dilTerential diagnosis,
Criteria for Return to Activity. The athlete may
return to his or her previous level of activity once the
proper phys iological and arthrokinemalic motion has
been restored to the glenohumeral joint. How long the pa­
tient went untTeated and undiagnosed will affect how long
it takes to reach this point.
Thoracic Outlet Syndrome
Pathomechanics. Thoracic outlet syndrome is the
compression of neU!rovascular structures within the tho­
racic outlet. The thoracic outlet is a cone-shaped passage.
with the greater circumferential opening proximal to the
spine and the narrow end passing into the distal extremity.
On the proximal end. the cone is bordered anteriorly by the
anterior scalene muscles. and posteriorly by the middle
and posterior scalene muscles. Structures traveling
through the thoracic outlet are the brachial plexus. sub­
clavian artery and vein. and axillary vessels. The neu­
rovascular structures pass distally under the clavicle an d
en e stretches a nd \1
subclavius muscle. Beneath the neurovascular bundle i
are used to decrease
the first rib. At the narrow end of the cone. the bundle
on the neurovascu lar
passes under the coracoid process of the scapula and into
,b ould also be re\
the upper extremity through the axilla. The distal end i
m uscles act as a ce
bordered an teriorly by the pectoralis minor and posteriorly
breathing lechn iqu
by the scapula.
muscles.
Based on the anatomy or the thoracic outlet. there are
Rehabilitation
several areas where neurovascular compression can oc­
process begins by de
cur. Therefore. pathology of the thoracic outlet syndrome
lies and symptoms.
is dependent on the structures being compressed.
ues exacerbating lh
Injury Mechanism. In 60 percent of the popula­
athlete can maintair
tion affected by thoracic outlet syndrome. there is no re­
time all erect posturL
port from the patient of an inciting episode. 39 Some of th e
rrengthening exerc'
theories presented by authors regarding the etiology of
reLurn to his or her
thoracic outlet syndrome include twuma. postural com­
maintaining a pain­
ponents. shortening of the pectoralis minor. shortening of
incrcased at regular
the scalencs. and muscle hypertrophy.
free. 1'h is helps build
There are four areas of vulnerability to compressive
ercising on a n
forces: the superior thoracic outlet. where the brachial
backward. can h elp
plexus passes over the first rib: tb e scalene triangle. at the
to sports. it may be
proximal end of the thoracic outlet. where there might be
methods that place
overlapping insertions of the anterior and middle scalen
Criteria for Reo
onW the first rib; the costoclavicular interval, which is the
.\pon ds to the reha
space between the IIrst rib and clavicle where the neu­
pain-free postu re du­
rovascular bundle passes (the space can be nmrowed b}
participatio n ca n be
poor posture. inferior laxity of the glenohumeral joint. or
muscular weaknesc
an exostosis from a fracture of the clavicle); and under the
the athlete fail s to r
coracoid process where the brachial plex us passes and i
n ificant pain and 1\
bordered anteriorly by the pecioraHs minor. 64
l11ight be indieated_
Rehabilitation Concerns. As described. thoraCi c
a natomical bas is for
outlet syndrome is an anatomy-based problem involving
compressive forces applied to the neurovascular bundle.
Conservative management of thoracic outlet syndrome
is moderately successful. resulting in decreased sym p­ CLINICAL DECIS
toms 50 to 90 percent of tbe time. As the first cOllrse ())
treatment. rehabilitation should be based on encourag­
ing the least provocative posture. Leffert advocated a de­
tailed history and evaluation of th e aLhlete's activitie>
amI lifesty le to help identify where and when postural de­
ficiency is occurring. J "
Through a detailed history and evaluation of an ath­
lete's activity. th e athletic trainer can identify the cause 0 ­
compression in the thoracic oullet. The rehabilitation pro­ having to do a 10l
gram should be tailored to encourage good posture puter. The athlete
throughout the athlete's day. Therapeutic exercises should
be used to strengthen posturalmusc!es. such as the rhom­ symptoms occurr­
boids (Figure 1 ~-3~). middle trapezius (Figure 1 ~- 3 7). and with his forehand
upper hapezius (Figure 18-3 .3). Flexibility exercises are recommend to help
also used to increase the space in the thoracic outlet. Sca­
 CHAPTER 11-l Rehabilitation of Shou lder Injuries 411

~ the clavicle and

c ular bundle is
lene stretches and wa'll/corner stretches (Fig ure lS- lO) IBrachial Plexus Injuries
arc used to decrease the inCidence of muscle impinging (Stinger or IBurner)
ooe. the bundle on the neurovasc ular bundle. Proper breathing technique
sca pula and into should also be reviewed lVith th e aLhlete. The scalene Pathomechanics. The brachial plexus begins at
L he dist<ll end is m uscles act as accessory breat hin g muscles. and improper cervical roots c 5 through c8 and thoraciC root n .The ven­
or <l nd posteriorly bre<lt hing technique can lead to lightening of these tral ra mi of these roots arc formed from a dorsal (sensory)
muscles. a nd ventral (motor) rool. The ventral rami join to form the
Rehabilitation Progression. The rehabilitation 'brachial plexus. The ventral rami lie betlveen the anterior
pression can oc­ process begins by detailed evaluation of the athlete's activ,i­ and middle scalene muscles. where they run adjacent to
outlet syndrome ties and symptoms. First. the athlete is removed from activi­ the subclavian artery. The plexus continues distally ,pass­
pressed. ties exacerbating the neurovasc ul ar symptoms until the ing over the fIrst rib. It is deep to the sternocleidomastoid
ol of lhe popul a­ athlete can maintain a symptom-Cree posture. During this muscle in the neck. i l Just caudal to the clavicle and sub­
e. there is nO re­ time an erect posture is encou raged lIsing stretching and clavius muscle. the five ventra l rami unite to form the three
e.J9 Some of the strengthening exercises. Gradually encourage the athlete to trunks of the plexus: superior. middle. inferior. The supe­
g the eLiology 01 return to his or her sport. for short periods or lime. while rior trunk is composed of the c 5 a nd c6 ventra l roots. The
a. postural com­ maintaining a pa in-free posture. The lime of participation is middle trunk is rormed by the c7 root. and the inferior
r. shortening (II increased at regu,l ar intervals if the athlete remains pain­ trunk is formed by cS a nd tl ventra'! roots. After passing
rree. This helps build endurance of the postLU'al muscles. Ex­ under the clavicle. the three trunks divide into three divi­
ly to compressive ercising on an upper-body ergometer. by pedaling sio ns that eventually contribute to the three cords of the
he re the bmchial ba c.k ward. can help build endLU'ance. As the athlete returns brac hial plexus.
De tr iangle. at the to sports. it may be necessary to alter strength ·training The typical picture of a brachi a l plexus injury in sports
here Lhere might be methods that place the athlete in a llexed posture. is th a t of a traction inj ury. This syndrome is commonly re­
:md middle scalene Criteria for Return to Activity. If the athlete re­ ferred to as burner or stinger syndrome. These injuries
1 rva l. which is th e
spollds to the rehabilita tion program and can maintain a usually involve the c5 to c6 nerve roots. The athlete will
Ie where the neu­ pain-free posture during his or her spor t-s pecific activity. co mplain of a sharp. burning pain in the shoulder that ra­
be narrowed b~ participation can be resumed. The athlete should have no diates down the arm into the ha nd . vVeakness in the mus­
oh umeral joinl. or muscular weakness. neurovasc ul ar sy mptoms. or pain . If cles supplied by c5 and c6 (deltoid . biceps. s upraspinatus.
. Ie):. a nd under the
the athlete fails to respond to therapy. and functionally sig­ an d infrasp inatus) accompany the pain . Burning and pain
lexus passes and is nillca nt pain and weakness persist. surgical intervention are often transient. bu t weakness might last a few minutes
ninor. 6~
might be indicated. Surgical procedure depends on the or indefinitely.
de r ibed. thoraci a na tomical basis for the patient's sy mptoms. Clancy et al. have classified brachia l plexus injuries
~ problem involving into three categories. 12 A grade I injury results in a tran­
Jro\' asc u lar bundle. sient loss of motor and sensory functi on. which usually re­
~I outlet syndrome solves completely within minu tes . A grade II ,i njury results
m decreased sym p­ CLINICAL DECISION MAKING Exercise 18-6 in sign ifIca nt motor weakness and sensory loss that might
~ tb e first course of
las t from 6 weeks to 4 month s. EMG evaluation after 2
a cd on encourag­ t\ 19-year-old tennis player has been complaining of weeks will demonstrate abnorm a liLies. Grade III lesions
rt advoca ted a de­ paresthesia in his dominant (right) arm for approximately are characterized by motor and se nsory loss ror at least 1
athlete's activitie_ .3 weeks. He does not remember doing anything that year in duration.
d whe.n post ural de· might have injured his shoulder. but thinks this symptom Injury Mechanism. The structure of the brachial
started shortly after classes began Ihis semester. When plexus is such that it winds its way through the musc u­
al uation of an at h· asked if anything in his normal routine had changed. he loskeletal anatomy of tbe upper extremity as described
! ide ntify the cause revealed that he had changed to a new racquet and was (Cla ncy et al.) identified neck rotatio n. neck lateraillexion.
e reh abilitation pro­ hal'ing to do a lot more 1V0rk with a mouse on a COI11­ sh ould er abduction. shoulder extern al rotation. and si­
uragc good posLur puter. The athlete was seen by a phYSician and diagnosed multaneous scapular and clavicular depression as poten­
. tic exercises shou1 with thoracic outlet syndrome. The athlete also reports ti al mechanislns of injury. 11
. u ch as the rhom· symptoms occurring whenever he strikes a tennis ball During neck rotation and lateraillexion to one side. the
,-(Figure 18-37). a n .... with his forehand stroke. What can the athletic trainer brachial plexus and tbe subclav,i us muscle on the opposite
'Xibility exercises ar~ recommend to help this athlete recover? side arc put on stretch and the clavicle is slightly elevated
. tb oracic ou tLcl. Sea· about its A-P axis. If th e arm is not elevated. the superior
412 PARTTHREE The Tools or Rehabilitation
trunk or the plexus will assume the greatest amount or
tensio n. rr the shoulder is abducted and externally rotated,
the brachial plexus migrates superiorly toward the cora­
coid process and the scapula retracts, putting the pec­
toralis minor on stretch. As the shoulder is moved into rull
abduction, a condition similar to a movable pully is
formed, where the coracoid process of the scapula acts as
the pulley. In rull abduction, most stress falls on the lower
cords of the brachial plexus.~' The addition or clavicular
and scapula depression to the above scenarios would pro­
duce a downward (orce on the pulley system, bringing the
brachial plexus into contact with the clavicle and the cora­
coid process. The portion of the plexus that receives the
greatest amount of tensile stress depends on the position or
the upper extremity during a collision.
Rehabilitation Concerns. Management o[ brachial
plexus injuries begins with the gradual restoration of the
athlete's cervical range of motion. Muscle tightness caused
by the direct trauma, and by reflexive guarding that occurs
because or pain. needs to be addressed. Gentle passive
range-of-motion exercises and stretching ror the upper
trapezius, levator scapulae, and scalene muscles should be
done. The athletic trainer should be careful not to ca use sen­
sory symptoms.
Butler)! advocates using an early intervention with
gentle mobilization or the neural tissues. The goal of early
mobilization is to prevent scarring beLween the nerve and
the bed or within the connective tissue or the nerve itseLr as
the nerve heals. He advocates low tensile loads to avoid the
possibility or irritating a nerve lesion such as axouotmesis
or neurotmesis. More chronic. repetitive injuries may use
the neural tension test positions to do mobilizations with
higher grades.
Strengtheni ng of the involved muscles is also ad­
dressed in the rehabWtation program. Supraspinatus
strengLhel1ing exercises like scaption (Figure 18-31) and
alternative surraspinatus exercises (Figure 18-34) should
be done. Other exercises for involved musculature are
shoulder lateral rotation (Figure 18-32) for the inrraspina­
tus. rorward fl ex ion and abduction to 90 degrees (Figures
18-26 and] 8-28) to strengthen the deltoid, and bicep
curls ror elbow flexion.
The athletic trainer should also work closely with the
athlete's coach to evaluate the athlete's technique and cor­
reeL any alteration in rorm that might be putting the athlete
at risk for burners. Prior to return to activity, the athlete's
equipment should be inspected for proper fitting. and a cer­
vical neck roll should be used to decrease the amount of lat­
eral flexion that occurs during impact. as in tackling.
Rehabilitation Progression. The athlete is re­
moved from activity immediately after the injury. The re­
habilitation progression should begin with the restoration ~nlrations have
of both active and passive range of motion at the neck and [l of LDH- isoe
shoulder. Neural tissue mobilizations utilizing the upper :nigh t be higher in
lin1b tension testing (UL'"IT) positions should begin wit h Travel! and Si
the athlete in the testing positions 1! (see Figure 6-7 A. BI
For the median nerve. the testing position consists
shoulder depression. abduction , external rotation . a
wrist and finger extension. For the radial nerve, the elbO\'
is extended. the rorearm pronated. the glenohumeral join
internally rotated, and the wrist. finger, and thumb flexed
The position for stretching the ulnar nerve consists
shoulder depression. wrist and finger extension, supi na· [eudem
tion or pronation or the forearm . and elbow flexion. Mol' . Primary Ips.
Iizations of distal jOints. Ilke the elbow and wrist. iJ {ssoclated Ir.
large-grade movements should initiate the treatm primary TP~
phase. Progression should include grade 4 and grade ally O\'erloa '
mobili za tions in later phases of recovery.
As the athlete gets return or ROM. strengthening
the neck and shoulder are incorporated into the reh ab,
tation program . Strengthening should progress from PRJ'
type strengthening with free weights to exercises Lh
emphasize power and endurance. Functional progres .
begins with teaching proper technique for sport-sf)'
demands that mimic the position of injury. The progre.
return and proper technique are important to the reha::
itation program, as Lhey address the psychological co m
nent of preparing the ath'iete ror return to sport.
Criteria for Return to Activity. Athletes are
lowed to return to play when they have rull. pai Il­
range of motion. full strength. and no prior episod
that contest. io Additionally, rootball players should Il
cervical neck roll. The athlete's psychological readi
should also be considered prior to return Lo sport. Alb
who are too protective or their neck and shoulder car
pose themselves to further injury.
Myofascial Trigger Points
Pathology. Clinically. a trigger point (TP) is dell
a hyperirritable roci in muscle or rascia that is tender t.
pation and may. upon compression. result ·in referred
or tenderness .in a characteristic ··zone." This zone is di!
rrom myotollles. dermatomes. schlerotomes. or peri
nerve distribution. TPs are identified via palpation .
bands of muscle or discrete nodules or adhesions. Sn
of a taut ba nd will usually initiate a locaitwitcJ1 [esp..'
Physiologically. the definition of a trigger poim
as clear. Muscles with myofascialtrigger points re\
diagnostic abnorm a lities upon EMG examination. R.
laboratory Lcsts show no abnormalities or sign
changes attributable to TPs. Normal serum enzy m
 CHAPTER 18 Rehabilitation of Shoulder Injuries 413

'ith the restoration centrations have been reported with a shift in the distribu­ • TABLE 18·4 Trigger Points
io n at the neck and tion of LDH- isoenzymes. Skin temperature over active TPs of the Shoulder
u tilizing the upper might be higher in a 5 to 10 em diameter.71
· hould begin with Travel! and Simons c1assifyTPs as follows: 7 ]
e Figure 6-7A.B). Posterior shoulder pain
1. Active Tps. Symptomatic at rest with referral pain and
ition consists of
tenderness upon direct compression . Associated Deltoid
nal rotation . and
weakness and contracture are often present. Levator scapulae
'al nerve, the elbow
2. Latent Tps. Pa.in is not present unless direct compres­ Supraspinatus
glenohumeral joint
sion is applied. These might show up on clinical SubscapulariS
· a nd thumb flexed.
exam as stiffness and / or weakness in the region of Teres minor
r nerve consists of
tenderness. Teres major
extension. supina­
3. Primary Tps. Located in speCific muscles. Serratus posterior superior
lbo w !lexion. I'vlobi­
4. Associated Ips. Located within the referral zone of a Triceps
bow and wrist. in
primary TP's muscle or in a muscle that is function­ Trapezius
iate the treatment
.-ade 4 and grade 5 ally overloaded in compensation for a primary TP.
Anterior shoulder pain
:ry. Pathology of a myofascial trigger point is identified
I. strengthening or Infraspinatus
with (1) a history of sudden onset during or shortly after
ed into the rehabili­ an aeu te overload stress or chronic overload of the affected Deltoid
1 progress from PRE­ Scalene
muscle: (2) characteristic patterns of pain in a muscle's re­
· - to exercises that Supraspinatus
ferral zone: (3) weakness and restriction in the end range
tional progressio Pectoralis major
of motion of the affected muscle: (4) a taut. palpable band
,ue for sport-specifi in the affected muscle; (5) focal tenderness to direct com­ Pectoralis minor
. ur ~{. The progress in ' pression, in the band of taut muscle fibers: (6) a local Biceps
lant to the rehabLl­ twitch response elicited by snapping of the tender spot; Coracobrachialis
sychologieal compo­ and (7) reproduction of the patient's pain through pres­
rn (0 sport. sure on the tender spot. Adapted [rom Travell and Simons. 7 1
. Athletes are a i, Injury Mechanism. The most common mecha­
!1m'e full. pain-free nism for myofascial trigger points in the shoulder region is The cyclic nature of TPs requires interruption of the
no prior episodes in acute muscle strain (Table 18-4). The damaged muscle tis­ cycle for successful treatment. Interrupting the shortening
play rs should use a sue causes tearing of the sarcoplasmic reticulum and re­ of the muscle tlbers and prevention of further breakdown
hological readine lease of its slored calcium, with loss of the ability of that of the muscle tissue components should be attempted us­
J.IIll to sporl. Athlete5 portion of the muscle to remove calcium ions. The chronic ing modified hold-relax techniques and post-isometric
and shoulder can e ' , stress of sustained muscle contraction can cause contin­ stretching. Travell and Simons advocate a spray-and­
ued muscle damage. repeating the above cyete of damage. stretch method, where vapocoolant spray is applied and
The combined presence of the normal muscle ATP sup­ passive stretching follows. Theoretically, when the muscle
5 plies and excessive calcium initiate and maintain a sus­ is placed in a stretched position and the skin receptors are
tained muscle band contracture. This produces a region of cooled , a reflexive inhibition of the contracted muscle is fa­
point (TP) is defined as the muscle with an uncontrolled metabolism, to which the cilitated, allOWing for increased passive stretching. 71
ia lhat is tender to pal­ body responds with local vasoconstriction . This region of After a treatment session where passive range of mo­
ullin referred pain increased metabolism and decreased local circulation , tion has been achieved . the muscle must be activated to
e. ~ This zone is distin with muscle fibers passing through that area, causes mus­ stimulate normal actin and myosin crossbridging. Gentle
rolOmes. or peripheral cle shortening independent of local motor unit action po­ active range-of-motion exercises or active assistive exer­
via palpation of tm tentials. This taut band can be palpated in the muscle. cises with the L--bar might be a good activity to use as post­
lIT adhesions. Snappin= Rehabilitation Concerns. The principal mecha­ treatment activity. Normal muscle act.ivity and endurance
oca l twitch response. '" nism of myofascial trigger points is related to muscular must be encouraged after range of motion is restored. A
r a trigger point is n : overload and fatigue, so the primary concern is identifica­ gradual progression of shoulder exercises with an en­
igger points reveal nc tion of the incriminating activity. The athletic trainer durance emphasis should be used.
examination. Routi ne should take a detailed history of the athlete's daily activity Rehabilitation Progression. Treatment progres­
llaLi ties or significan demands, as well as the changing demands 01 his or her sion forTPs should begin with temporary removal from ac­
ill erum enzyme CO D' sport activities. tivities that overload the contracted tissue. The athlete is
414 PART THREE The Tools of Rehabilitation
then treated with myofascial stretching techniques to in­
crease the length of the contracted tissue. Immediate use
of the extended range of motion should be emphasized.
Strengthening exercises are added once the athlete can
maintain the norma'l muscle length without initiating the
return of the contracted myofascial band. As strength and
function of the involved muscles return, the athlete may
gradua'\ly return to his or her sport.
Summary
1. The high degree of mobility in ,t he shoulder complex
requires some compromise in stability, which in turn
increases the vulnerability of the shoulder joint to in­
jury, particularly in dynamic overhead athletic activi­
ties.
2. In rehabiUtation of the sternoclavicular joint. effort
should be directed toward regaining normal clavicular
motion that will allow the scapula to abduct and up­
ward rotate throughout 180 degrees of humeral ab­
duction. The clavicle must elevate approximately 40
degrees to allow upward scapular rotation.
3. ACl'Omi0)clavicular joint sprains a re most commonly
seen in athletes due to a direct fall on the point of the
shoulder with the arm at (he side in an adducted posi­
tion or fa iling on an outstretched arm.
4. Management of acromioclavicular injuries depends
on the type of injury. Types I and II injuries are usually
handled conservatively, focusing 011 strengthen,i ng of
the deltoid, trapezius, and the clavicular fibers of the
pectoralis major. Occasionally AC injuries require sur­
gical excision of the distal portion of the davicle.
5. Treatment for clavicle fractures includes approxima­
tion of the fracture a~ld immobilization for 6 to 8
weeks. using a figure 8 wrap with the involved arm in
a sling. Because mobiliry of the clavicle is important
for normal shoulder mechanics, rehabilitation should
focus on joint mobilization and strengthening of the
deltoid. upper trapezius, and pectoralis major muscles.
6. Following a short immobilization period, rehabilita­
tion for a dislocated shoulder should focus on restoring
the appropriate axis of rotation for the glenohumeral
joint, optimizing the stabilizing muscle's length­
tension relationship, and restoring proper neuromuscu­
lar control of the shoulder complex. Similar rehabilita­
tion strategies are applied in cases of multidirectional
instabiliHes. which can occur as a result of recurrent dis­
location.
7. l\llanagement of shoulder impingement involves grad­
ually restoring normal biomechanics to the shoulder
Criteria for Return to Activity. The athkte mer-­
return to activity in a relatively short period of time if he
she can demonstrate the ability to function without reiOi­
tiating the myofaseial tdgger points and associated ta
bands. Early return without meeting this criterion car­
lead to greater regiol1alization of the symptoms.
joint in an effort to maintain space ul1der the CO r3 ­
coacromial arch during overhead activities. Tech­
niques include strengthening of the rotator cur
muscles, strengthening of the muscles that abduct. el­
evate, and upward rotate th.e scapll'la, and stretch in~
both the i.nferior and the posterior porNons of tohe join
capsu1le.
8. The basic concerns of a rellabilitation program for r
tator cuff tendonopathy are based on why and hO\'
the tendon has been damaged. If a comprehensive re­
habilitation program does not relieve the pain fu
shoulder, surgical repair of the tendon and ajteratiol"
of the glenohumeral jOint are performed. Surgica l re­
habilitation is similar to the nonsurgical plan, with the
time of progression altered, based on tissue heali ng
and tendon histology.
9. In cases of adhesive capsu\itis, the goals of rehabilit a­
tion are relieving the pain in the acute stages of th t'
disorder, graduaLly restoring proper arthrokinematics..
gradual restoration of range of motion, and strength­
ening the muscles of the shoulder complex.
10. Rehabilitation for thoracic outlet syndrome should be
directed toward encouraging the least provocative pos­
ture combined with exercises to strengthen postural
muscles (rhomboids, middle trapezius, upper trapez­
ius) and stretching exercises for the scalenes to in­
crease the space in the thoracic outlet in order to
Sports Physical
reduce musde impingement on the neurovascular -. Cox. J. S, 1 981.1be
bundle. leLic injuri es . .:Ir.
11. Management of brachial plexus injuries includes the 1:1. Culham. E.. and .
gradual restoration of cervical range of motion, ana the shoulder c,
stretching for the upper trapezius, levator scapul ae, iml Therapy 1811
and scalene muscles. Davies. G.. and
12. After identifying the cause of myofascial trigger testing and reh
points, rehabilitation may include a spray-and-stretch Orthopaedic and
method with passive stretching, gentle active range-of­ 18 . Depalma. 1\. F. 19 ­
pbia: Lippincoll.
motion exercises or active assistive exercises. encour­
19 . Dvir, Z.. and 1\. Ber
aging normal muscle activity and endurance, and
lion of the arm: A
gradual improvement of muscle endurance. c/Wl1iC5 11 :21 9-.:! c.
 CHAPTER 18 Rehabilitation of Shoulder Injuries 4 15

The ath letc may

:riod of time if he or References
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portions of the joint
of the acromion and its relation to rotator cuff Lears. Ortlw­ shoulder. Journal of Orthopaedic arId Sports Pilysical Therapy
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tion program for ro­ 8. Blackburn, T., W. McCloud. and B. White. 1990. EMG analy­ 26. Hawkins. R.. and R. Bell. 1990. Dynamic EMG analysis of the
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1 comprehensive FC­ 40-4'i. ing exercises. In Surgery of tile sllOulder, edited by M. Post. B.
re licvc the painful 9. Brewster. C.. and D. Moynes. 1993. Rehabilitation of the Morcy. and R. Hawkins. St. Louis: Mosby.
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rgie'll plan, with the 10. Burkhead. w., and' C. Rockwood. 1992. Treatment of insta­ 28. Howell. S .. an d T. Kraft. 1 991. The role of th e supras pin a ­
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of Bone alld JOint Swgcry 741\:890. of anterior shoulder il1stability. Clillical Ortlwpc(UcS
11. Butler. D. 2000. The sensitive nervous system. Adelaide . Aus­ 263:128-34.
• goals of rehabilita­
tralia: Noigroup. 29. Inman. \( T., ~. B. Saunders. and L. C. Abbott. 1944. Observa­
ac ute stages of the 12. Clancy, W. G.. R. I. Brand . amI J. 1\. Bergfeld. 1977. Upper tions on the function o~ the shoulder joint. Jounwl oj ROlle awl
:r arthrokinemalics. trunk brachial plexus injuries in contact sports. American Joint Surgery 26:1.
oliol1 . and slrength­ Jounzalof Sports lVledicinc 5:209. 30. Jobe. F. W.. ed. 1996. Opcrative tecilni'lues ill upper n{rell/it!!
complex. 13. Codman, E. A. 1934. Ruptures of the supraspinatus tendon sports injuries. St. Louis: Mosby.
syndrome should be and other lesions in or about the subacromial bursa. In The 3l. Jobe. F.. and R. Kvnite. 19H9. Shoulder pain in the overhand
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of the trapezius muscle to the sudden shoulder movement be­ teria and a rehabilitation program for rotator cuff injuries.
the scalenes to in­
fore and after a fatiguing exercise. Journal of Orthopaedic and American Jotlrnal of Sports Medicine 10(6): 336- 3 9.
outlet in order to
Sports Ph!lsical Therapy 32(5): 221-29. 33. Jobe. F. W., Schwab. K. E. Wilko and J. E. Andrews. 1996, Re­
tile neurov<lscular 15. Cox. J. S. 1981. Th.c fate of the acromioclavicular joint in ath­ habilitation of the shoulder. In Clinical orllwpedics rehabilita­
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nj uries includes the 16. Culham. E.. and P. Malcolm. 1993. Functional anatomy of 34. Kannus. P., L. Josza. E Renstrom. M. Jarvinen, M. Kvist. M.
mge of motion, and the shoulder complex. Jotlmal of Orthopaedic and Sports Phys­ Lehto. E Oja. and L. Vuori. 1992. The effects of training. im­
I . levator scapulae. ical Therap!l18(1): 342-)0. mobilization and remobilization on musculoskeletal tissue: 2.
17. Davies. G.. and S. Dickoff-Hoffman. 1993. Neuromuscular Remobilization and prevention of immobilization atrophy.
myofascial trigger testing and rehabilitation of the shoulder complex. Journal of Scandinavian Joumal of Sports Sciences 2:1fl4-7fl.
· a spra}1-and-stretch Ortiwpacdic awl Sports Ph!lsical Therapy 18(2): 449-58. 35. Keirns. M. 1993. Conservative management of shoulder im­
18. Depalma. A. F. 1973. Surgery of the slwulder. 2d ed. Philadel­ pingement. In Tile athlete's slwlIld('/; edited by J. Andrews and
~n t le active range-of­
phia: Lippincott. K. Wilko New York: Churchill Livingstone.
:e exercises, enrour­
19. Dvir. Z.. and N. Berme. 1978. The shoulder complex in eleva­ 36. Kelley, M. J. 1995. Anatomic and biOlnechanical rationale fllr
nd endurance, and tion of the arm: A mechanism approach. Journal of Biome­ rehabilitation of the athlete's shoulder. Journal of Sport Relw­
~d urance. bilitation 4:122-54.
chanics 11:219-25.
416 PARTTHREE The Tools of Rehabilitation

37. Kibbler. W. B. 1998. Role of tbe scapula in tbe overbead 55. Paine. R.. and M. Voight. 1993. Th e role of the scapula. JO llf' \Vith instability an...;
throwing motion . Contemporary Orthopedics 22:525-32. Ilal oj Orthopaedic alld Sports Physical Th erapy 18( 1): 386-91 Medici,.,,, 18(4 ): 3f"
38. Kibler. W. B. 1998. The role of the scapula in athletic shoul­ 56. Peat. M .. and E. CuJham. 1993. Functional anatomy of the Warren. R. E 19
der function. American Journal oj Sports lv(edicinc 26(2) : shoulder complex. [n The athlete's shoulder; edited by J. Ao­ Sports [\"eurology,
325-37. drews and K. Wilk. New York: Churchill Livingstone. Warren. Rock\;lIe
39. Leffert. R. D. 1990. Neurological problems. In The shoulder; 57. Petersson. C.. and I. Redlund-Johncll. 1984. The subacromiw - 6. Wilko K.. and J. 1
edited by C.A. Rockwood and F. A. Matsen. Philadelphia: space in normal shoulder radiograpbs. Acta Orthopedic Scali' acromial decolIlpR!
W. B. Sa unders. danavia 55:57. - 7. Wilko K.. and C. Arr
40. Lephart. S. M.. J. P. Warner. P. A. Borsa. and F. H. Fu. 1994. 58. Pettrone. F. A .• ed. 1995. Athletic injuries oj the shoulder: Nell per extremity ex
Proprioception of the shoulder joint in healthy. unstable. and York: McGraw-HHI. .'orth America 9. _
su.rgically repaired shoulders. Journal oj Shoulder and Elbow 59. Rathburn. J.. and I. McNab. 1970. The mi crovascuLar pattern - -. Wilk. K .• and C'. .-\r'
Surgery 3(6): 371-80. of the rotator cuff. Jou,."o1 oj Bone amI JOint Surgery 5 2B: 540. bi.litation of the
41. Lew. W.. J. Lewis. and E. Cra ig. 1993. Stabilization by capsule 60. Rockwood. C.. and F. Matsen. 1990. Tileshollider. Vols.l and Sports Physical ]10.
ligaments and labrum: Stability at the extremes of motion. In 2. Philadelphia: \IV. B. Saund'ers.
The shouldcr: A balance of mobility and stability. edited by F. 61. Rowe. C. R. 1956. Prognosis in dislocation of the shoulder.
Masten. F. Fu. and R. Hawkins. Rosemo nt. LL: American Acad­ Journal oJ Bone and Joint Surgery 38A:957. SOLUTIONS TO
elllY oj Orthopedic Surgery. 62. Salter. E. G.. B. S. Shelley. and R. Nasca. 1985. A morpholog­
42. Litch.field. R.. R. Hawkins. and C. Dillman. 1993. Rehabilita­ ical study of the acromioclavicular joint in humans [A\}·
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Piliisical Therapy 18(2): 433-41. 63. Skyhar. M.. R. Warren. and D. Altcheck. 1990. Instability of ice and el
43. Ludewig. P. M.. and T. M. Cook. 2002. Translations of the the shoulder. In Tile lIpper extremity in sports medicine. edited sling for a [I
humerus in persons with shou ld er impingement syndromes. by A. Nicholas and E. B. Hershmann. SL Louis: Mosby. begins to eaJ"::,
Journal oj Orthopaedic and Sports Pilysical Thrrapy 32(6): 64. Souza. T. A. 1994. Sports injll/'ies of tile shoulder: Conserva(il',' The athletic .­
248-59. managemellt. New York: Church.ill Livingstone. Lion witb a
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juries and rehabilitation. edited by J. Zachazewski. D. Magee. The Shoulder, edited by E. A. Codman. pp.344- S0. Boston: n .p. clavicJe alta\.
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ing posture
45. Matsen. F. A .. S. C. Thomas. and C. A. Rockwood. 1990. bility. In The athletc's shoulder. edited by J. Andrews and K. E.
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Glenohumeral instability. In Tire shoulder: ed ited by C. A. Wilk. New York: Churchill Livingstone.
incorporate
Rockwood and F. A . Matsen. Philadelphia: W. B. Saunders. 67. Taft. T. N .. F. C. Wilson. and J. W.Ogelsby. 1987. Dislocation of
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ited by F. A. Peltrone. Ncw York: McGraw-HUI. Surgery 69A:I045. humeral m
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48. Moseley. J.. F. Jobe. and M. Pink. 1992. EMG analysis of the 374- 81. 18-2 [t is importa
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American Journal oj Sports Medicin e 20: 128- 34. management. Journal oj Orthopaedic alld Sports Physical Ther­
Lions and go
49. Mulligan. E. 1988 . Conservative management of shoulder apy 11(5): 183-91.
coach shou l
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:;0. Neer. C. 1972. Anterior acromioplasty for the chronic im­ the glenohumeral muscles during a baseba ll rehabilitation 12 weeks. He
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Joumal oj Balle and Joint Suraery 54A:41. 71. Travell. J. G.. and D. G. Simons. 1983. Myofascial pain and strengthen 11
51. Nicholas. J. A.. and E. B. Hershmann. eds. 1990. The upper ex­ dysfunction. The trigger point ma/lual. Baltimore: Williams & and restore
tremity ill sports medicine. St. Louis: Mosby. Wilkins. The at.hletic Lra
52. O·Brien. S.. M. Neeves. and A. Arnoczky. 1990. The anatomy 72. Uthoff, H .. J. Loeher. and K. Sarkar. 1987. The pathogenesis of must now r,
and histology of Ihe inferior glenohumeral ligament complex rotator cuff tears. In The shoulder. ed ited by N. Takagishi. joint. The eoa.
of the shoulder. American Journal oj Sports Education 18:4 SI. Philadelphia: Professional Post Graduate Services. healthy streng!
53. Orner. G. E. )% 7. Osteoto my of the clavicle in surgical re­ 73. von Eisenhart-Rothe. R.. A. Jager. K. Englmejer. T. J. Vogl. and
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duction of anterior sternoclavicular dislocations. Journal oj H. Graichen. 2002. Relevance of arm position and muscle ac­
must maint ain
Trauma 7(4): 584-90. li\' ity in three-dimensional glenohumeral translation in pa­
54. Ozaki. J.. S. Fujimoto. and Y. Nakagawa. 1988. '[cars of the tients with traumatic and atraumatic shoulder instability.
thai is different
rotator cuff of the shoulder associated with pathological l!mel"iwilloumal of Sport.s Medicine 30: 514- 22. 18-3 The athletic lr.
changes in the acromion: A study of cadavers. Journal oJ Bone 74. Warner. J.. L. Michili. and 1. Arslanin. 1990. Patterns of Dex­ that pain shou
alld Joint Sumer!! 70A: 1224. ibi!ily. laxity. and strength in normal shoulder s and shou lders process. The &'i'

Ie of the scapula. Jour­
ropy 18(1): 386-91.
nal anatomy of the
wder. edited by J. An­
II Livingstone.
9 4. The subacromial
:ida Orthopedic Scan-
of the slzoulder. New
mic rovascular pattern
'm! Slirgery 52B:340.
t sholllder. Vols. I and
:aliOn of the shoulder.
J57 .
. 19 <' 5. A morpholog­
int in humans ri\b­
d. 1990. Instability of
ipOrts medicine, edired
l . Louis: Mosby.
sholllder: Conservative
109 ·lone.
tion with active-assisted ROM. He is then pro­
Iial plexus paralysis. In
gressed to isometric exercises for muscles with
~.3 {4-5(). Boslon: n.p.
clavicle attachments. When the appropriate carry­
lIlent of shoulder insta­
. J. Andrews and K. E.
~.
.'. 1987. Dislocation of
mal of Bone and JOillt
~_. latsuura. and T. Sasa.
(or strengthening the
lII10f SpOI·ts Medicine 30:
me and its conservattl'e
II1Id Sports Physical Ther­
19 91. EMG analysiS of
I baseball rehabilitation
Itdicille 19(3): 264-72.
p3 . Mvofascial pain and
l Baltimore: Williams &
7. The pathogenesis of
edited by N. Takagishi.
ate Services.
Englmcier, T. J. Vogl, and
pOSition and muscle ac­
eral translation in pa­
lie shoulder instability.
10: ~14-22.
n. J 990. Patterns of nex­
I houlders and shoulders
with instability and impingement. iln!erical! JOllmal of Sports
Medicine 18(4): 3116-75.
75. Warren. R. F. 1989. Neurological injuries in football. In
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Warren. RockviJle. ~,m: Aspen.
76. Wilko K.. and J. Andrews. 1993. Rehabilitation following sub­
acromial decompression. Orthopaedics] 6(3): 349-58.
77. Wilk, K.. and C. Arrigo. 1992. An integrated approach to up­
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Nortl! America 9(2): 33 7-60.
78. WLlk. K.. and C. Arrigu. 1993. Current concepts in tbe reha­
bilitation of the athletic shoulder. Journal oj Orthopaedic and
Sports Ph!Jsical Therap!! 18(]): 3113-78.
SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES
18-1 The athlete is treated for pain using modalities like
ice and electrical stimulation. He is told to wear a
sling for a few days, until he can tolerate pain and
begins to carry his arm in an appropriate manner.
The athletic trainer begins the athlete's rehabilita­
complex. Active strengthening exercises are fo­
cused on restoring force-couples acting around the
joint. The athlete shoulld not be progressed until the
ing posture for the involved upper extremity is re­
stored. the athlete's exercises are progressed to
incorporate scapular motion. This will help prevent
related shoulder discomfort due to poor gleno­
humeral mechanics. An athlete with this injury
can usuaJly return to play earlier if a pad is fitted for
the involved upper extremity and there is no deficit
in strength or R01vL
18-2 It is important to understand that 80 percent of
nrsHime dislocations have subsequent disloca­
tions and go on to need surgical correction. The
coach shoulld expect full recovery to take as long as
12 weeks. He will need to avoid combined position­
ing of external rotation and abduction. He must
strengthen his rotator cuff muscles aggreSSively
and restore neuromuscular control to the joint.
The athletic trainer should emphasize that the joint
must now rely on the dynamic stabilizers of the
joint. The coach will need to maintain a level of
healthy strength even after he has returned to his
normal activities, because the dynamic stabilizers
must maintain a level of proprioceptive awareness
that is different from the passive structures.
18-3 The athlletic trainer should explain to the athlete
that pain should not be part of the rehabilitation
process. The swimmer should stop swimming and
CHAPTER 18 Rehabilitation of Shoulder Injuries 417
79. Wilko K.. and C. Arrigo. 1993. Current concepts in rehabili­
tation of the shoulder. In The athlete's shoulder, edited by J. An­
drews and K. Wilko New York: Churchill Livingstone.
80. WilkoK.. M. Reinhold. J. R. Dugas. J. R. Andrews. 2002. Re­
habilitation following thermal-assisted capsular shrinkage of
the glenohumeral joint: Curren! concepts. JOlInzal oj Or­
thopaedic and Sports PhYSical Therap!f 32(6): 268-87.
81. Wilk, K., M. Voight. and M. Kearns. ] 993. Stretch shortening
drills for the upper extremity: Theory and application. JOlirnal
of Orthopaedic alld Sports Physical Therap!! 17(5): 22 5- - 9.
all other overhead activities. Therapeutic modali­
ties may be used to aid in athlete comfort. NSAIDs
are usually taken during the early stages or the re­
habilitation process. Exercises should begin by
restoring the arthrokinematics of the shoulder
athletic trainer is assured that exercises can be per=
formed paill-free. Strength progression begins with
isometrics, advanCing to isotonic exercises and
then to plyometric exercises. Force-couples around
the scapula should be aggressively strengthened
prior to addressing those involving the rotator cuff.
PNF exercises should follow a restored. force couple
driven, shoulder complex. Gradual movement of
exercises to a more functional position should be
achieved. Once the athlete can do exercises in a
functional range of motion without pain. a return
to swimming can be sought. The return should be
gradual and deliberate. Increases should be based
on pain-free activity. This should continue unUI the
swimmer is back to her normal regimen.
18-4 It is important for the athletic trainer to address the
underly,ing instability prior to addreSSing the pain
caused by impingement. Stretching of the rotator
cuff is also emphaSized early to normalize the ef­
fects of the tight structures. Rotator cuff exercises
should be done in a closed-kinetic-chain position to
ensure maximum congruity of the glenohumeral
joint. A progression of neuromuscular contro'l ex­
ercises should also begin. Once the athlete's pain
subsides. a progression of neuromuscular control
exercises should be emphasized. Exercise should
418 PART THREE The Tools of Rehabilitation
then be advanced to include more challenging ex­
ercises outside of the safe zone. Modalities can be
used to improve comfort and stimulate the healing
process. The pitcher should also be evaluated and
treated for any other areas of his body that may be
predisposing him to compensate for a lack of range
of motion during the acceleration portion of his
throwing molion .
18-5 The athletic trainer should first work to evaluate
and correct any biomechanical weaknesses that
might diminish the dynamic stability of the gleno­
humeral joinl. The athletic trainer must limit the
player's activities to eliminate overhead motions.
No painful activity should be undertaken during
the rehabilitation process. Once the strength
dellcits in the athlete's muscles have been negated ,
the ath letic trainer should gradually return the
athl ete to practice activities. Return should be
gradual, controlling the load on the rotator cuff
muscles and systematically increasing the fre­
quency of the activity. It may be necessary to avoid
any actions that place the shoulder in an impinge­
ment position, to give the inllammation a chance to
subside. It should be noted that during the rehabil­
itation process neuromuscular control should be
addressed to help avoid impingemenf du e to exces­
sive movement of the humeral head. Pain and stiff­
ness should be guides for the progression of
activity. Anti-inf1ammatories should be used in the
early stages of rehabilitation to better allow the
athlete to perform strcngthening exercises. The
athlete should not rcturn to full activity untLl there
is 00 longer a positive impingement sign.
18-6 It is important for the athletic trainer to identify
where the thoracic outlet is being impinged. It is
equally important to identify the causative factors CHAP
in the athlete's symptoms. This athlete has postural
tendencies for scapular abduction and increased
forces about the shoulder complex. Using a mouse
on a computer encourages a protracted scapular
posture with pectoralis minor hyperactivity. In­
Reh
creased forccs cause hypertrophy of the anterior
musculature and greater reaction forces. which are
Pete ZUliil
leading to impingement of the thoracic outlet un­ William E. l
der the coracoid process. To remove the stress on
the thoracic outlet, the athletic trainer must first
remove the causative factors. The athlete should be
educated on a more optimal posture for using a
mouse for long periods of time. The athlete should
have his racquet restrung. Removal of the athlete
~
from tennis activities is recommended until the
athlete can maintain a symptom-free posture. The Stutl
athletic trainer should then focus on lengthening To become more ram]
the pectoralis minor muscle and encouraging pos­ necessary to design. i
tural exercises for the scapular stabilizers. Exercises tic rehabil itation prO!
should focus on scapular adductors and upward leUc Training Fdllfnl1C
rotators. RehabUitation should progress to activi­ Projirimcies ' Tb erapt'
ties that gradually place the athlete's shoulder www.mhbe. com iDre1
complex in a more fun ctional position. A return to cises inlhe new Laoo
hilling should be gradual. with adequate recovery simu lales the atbletb.
time between sessions. The athlete should increase Wlvl-I',mUhe.com/esir
his workouts at regular intervals as long as he re­ visit our Health and I
mains pain-free. This will allow him to build en­ w\I'\\'.mhhe.comfbh[
durance for this appropriate posture. He may
return to full activity wben he is symptom-free After C
while hitting the number of forehands he would hit Chapter,
in a regular tennis match, If the athJete fails to Be Able t
progress, he should be sent back to the referring
physician to explore surgical options. • Discuss the f
biomechani
function of
• Identify and
tative streng
elbow. inclu
kinetic-ch .
regaining r
Ie CClusative factors CHAPTER 19
Ithlete has postural
no n and increased
,lex. Using a mouse
Jrolracted sCClpular
r hyperactivity. In­
Rehabi,litation of Elbow Inju'ries
l hy of the anterior
Pete Zulia
on forces. which are
tboracic outlet un­
William E. Prentice
~ move the stress on
lc trainer must first
he athlete should be
posture for using a
'. The athlete should
n ova I of the athlete
mmended unti.J the
Jm-free posture. The Study Resources • Identify the use of aquatic therapy in
lC US on lengthening To become more familiar with the kn owledge and skills elbow rehabilitation .
ad encouraging pos­ necessary to design, implement. and document therapeu­
stabilizers. Exercises tic rehabilitation programs as identified in the NATA Ath­ • Discuss exercise that may be used to
iuctors and upward letic Training Ldllcalional Competencies and Clinical reestablish neuromuscular contro1.
d progress to acLivi­ Projlcicllcies'Therapeutic Exercise content area. visit
e athlete's shoulder w\Vw.mbbc.com/ tlrenticcl1e. Also refer to the lab exer­ • Discuss criteria for progression of the
position. A return to cises in the new Laboratory Manual and to eSims, which rehabilitation program for different
:h a dequate recovery simulates the athletic training certification exam. at
www.mhh e.com/esims. For more o nline study resources.
elbow injuries.
blele should increase
,'als as long as he re­ visit our Health and Human Performance website at
ow him to build en­ www.mhhe.rom/hhp.
'e posture. He may
he is symptom-free After Completion of This
FUNCTIONAL ANATOMY
,reh ands he would hit Chapter, the Student Should
AND BIOMECHANICS
:r the athlete fails to Be Able to Do the Following:

back to the referring
pLions. • Discuss the functional anatomy and
biomechanics associated with normal
function of the elbow.
• Identify and discuss the various rehabili­
tative strengthening techniques for the
elbow. including both open- and closed­
kinetic-chain isometric. isotonic. plyo­
metric. and isokinetic exercises.
• Identify the various techniques for
regaining range of motion. including
stretching exercises and joint
mobilizations.
Anatomically. the elbow joint is three joints in one. The
humeroulnar joint, the humeroradial joint. and the proxi­
mal radioulnar joint are the arlicu,l ations that make up the
elbow complex (Figure 1 9-1). The elbow allows for Oexion,
extension. pronation. and supination movement patterns
about the joint complex. The bony limitations, ligamen­
tous support, and muscular stability will help to protect it
from vulnerability of overuse and resultant injury. ifn the
athletic environment, the elbow complex can be subjected
to forces that can result in various injuries ranging [rom
overhead throwing injuries to blunt trauma.
The elbow complex is composed of three bones: the dis­
tal humerus, proximal ulna, and proximal radius. The artic­
ulations between these three bones dictate elbow movement
patterns. )7 it is also important to mention that the appro­
priate strength and function of the upper quarter (cervical
spine to the hand) needs to be addressed when evaluating
the elbow specillcaUy. The elbow complex has an intricate

419
420 PARTTHREE The Tools of Rehabilitat ion

Supracondylar
region The capsul e is con '
articulations 23 ,24
Coronoid fossa
r not only support
lateral aon of the joint.
Medial
epicondyle
epicondyle '1e urologica l link be,
lateral condyle has an affect on u
Medial condyle
(capitellum) peet of the rehab'"
(trochlea)
Biceps tubercle
~­ Coronoid process
Radius
Ulna
I ~
'ti
Olecranon ~
Figure 19-1 130ny anato my of the elbow (an terior),

\I

"

Synovial
capsule - ­

Olecranon

Radial· humeral
1/)/ bursa
bursa
Humerus

Radial
col lateral
ligament
A Ulnar
collateral lum, whi ch is I
ligament humerus, With fieXl
dial fossa of th e dist
Annular .-­ r', radius and the hu m
ligament
Ulna

:Radius
The proximal radio
the rad ial notch of tb

B
the radi al head. an d tl•
The proximal and d:
.
Figure 19-2 A, Join t capsule at the elbow join t. B, Major supporting ligaments of for supination and pr
the elbow, lion, it is important
The proximal and disJ
 CHAPTER 19 Rehabilitation or Elbow Injuries 421

articulation mechanically between the three separate joints

of the upper quarter to allow for function to occur.
In the elbow, the joint capsule plays an important role.
The capsule is continuous (Figure 19-2A) between the three
articulations l J .14 and highly innervated. This is important
for not only support of the complex. but also for propriocep­
lion of the joint. The capsule of the elbow functions as a
neurological link between the shoulder and the hand. This
has an affect on upper-quarter activity and is an obvious as­
pect of the rehabilitation process if injury does occur.

Humeroulnar Joint
The humeroulnar joint is the articulation between the dis­
tal humerus medially and the proxima.l ulna. The humerus
has distinct features distally. The medial aspect has the me­
dial epicondyle and an hourglass-shaped trochlea 1.17 lo­
cated anterumedially un the distal humerus. The trochlea
extends more distally than the lateral aspect of the
humerus. The trochlea articulates with the trochlea.r
notch of the proximal ulna.
Because of the more distal projectiun of the humerus
medially. the elbow complex demonstrates a carrying an­
gle that is an abducted position of the elbow in the
anatomical position. The normal carrying angle (Figure
19-3) in females is 10 to 15 degrees and in males 5 de­
grees. J When the elbow is in f1exion. the ulna slides for­
Figure 19-3 The elbow carrying angle is an abducted
position of the elbow in the anaLomical po ilion. The no[­
ward until the coronoid process of the ulna stops in the
mal carrying angle in females is 10 to 15 degrees and in
floor of the coronoid fossa of the humerus. In extension. males 5 degrees.
the ulna will slide backward until the olecranon process of
the ulna makes contact with the olecranon fossa of the
humerus posterioriy. tion one without the other. Proximally. the radius articu­
lates with the ulna by the support of rhe annul ar ligam ent.
Humeroradial Joint which attaches to the ulnar not h anLeriorly an d po teri ­
orIy. The ligament circles the radial head for s upport. Tbe
The humeroradial joint is the articulation of the laterally interosseous membrane is the counect!\'C tissue that func­
distal humerus and the proximal radius. The lateral aspect tions to complete the inter val belw een the twu bones.
of the humerus has the lateral epicundyle and the capitel­ When there is a fall on the out tretched arm. the in­
lerai lum. which is located anteriolaterally on the distal terosseous membrane can transmit some forces off the ra­
-en! humerus. With flexion. the radius is in contact with the ra­ dius, the main weight-bearing bone to the ulna. This can
dial fossa of the distal humerus. whereas in extension the help prevent the radial head [rom having forceful contact
radius and the humerus are not in contact. with the capitellum. Distally. the concave 'r adius will artic­
ulate with the convex ulna . With supination and prona­
Proximal Radioulnar Joint tion. the radius will move on the ulna.

The proximal radioulnar joint is the articulation between Ligamentous Support

the radial notch of the proximal lateral aspect of the ulna.
the radial head. and the capitellum of the distal humerus.
The proximal and distal radiuulnar joints are important
for supination and pronation. When evaluating this mo­
tion, it is important to look at them as one. functionally.
The proximal and distal aspects of this joint cannot func-
The stability of the elbow first starts with the joint capsule
that is conlinuous between all three articulations. The
capsule is loose anteriorly and posteriorly to allow for
movement in flexion and exlension. H It is taut medially
and laterally due to the added support of the collateral
 422 PARTTHREE The Tools of Rehabilita lion

ligaments. The capsule is high ly innervaled for proprio­ originate via two heads proximally at the shoulder: the w in full extension
ception. as sLated earlier. long head from the supraglenoid tuberosity of the 'ions in flexion. e\'1.
The medial (ulnar) collateral ligament (MeL) is fan­ scapula and the short head from the coracoid process of movement patterns
shaped and has three aspects (Figure 19-2B). The anterior the scapula. The insertion is from a common tendon at 1-1:5 degrees of fl exi<
aspect of the MeL is the primary stabilizer in the MeL from the radial tube rosity and laeertus I1brosis to origins of the an d pronation. alt h
approximately 20 degrees Lo 120 degrees of motion. 39 The forearm flexors. The biceps brachii function is flexion of in divi dual for th e
posterior and the oblique aspect of the MeL add support the elbow and supination the forearm. 41 The brachialis ·oint.. 2i The capsu le.
and assist in stability to the MeL. originates from the lower two-thirds of the anterior live link of the uppe­
The lateral elbow complex consists of four structures. humerus to the cornoid process and tuberosity of the th e relationship
The radjal collateral ligament attachments are from the ulna. It functions to flex the elbow. The brachioradialis. needs the elbow for r
lateral epicondyle to the annular ligament. The lateral ul­ which originates from the lower two-thirds of the lateral neclion between mu
nar collateral ligament is the primary lateral stabilizer humerus and attaches to the latera ~ styloid process of the vii i work proximal!.
and passes over the annular ligament into the supinator distal radius. functions as an elbow flexor. semipronator. a whole.
tubercle. It reinforces the elbow laterali.y. and reinforces and semisupinator. The hand an d \\
the humeroradial join1. 2k . 19 The assessory lateral collat­ The elbow extensors are the triceps brachii and the ao­ capsule for stabLliIJ.
eral ligament passes from the tubeccle of the supinator coneus muscles.The triceps brachii has a long. medial and houlder can also at
into the annular ligament. The annular ligament. as pre­ lateral head origination. The long head originates at the in either area can
viously stated. is the main Sllpport of the radial head in infraglenoid tuberosity of tbe scapu1la. the lateral and me­ complex. For exam
the radial notch of the ulna. The interosseous membrane dial heads to the posterior aspect of the humerus. The in­ in supination due Lo.~
is a syndesmotic condition tbat connects the ulna and the sertion is via the common tendon posteriorly at the jury is an increa se ic
radius in the forearm. This struclure prevents the proxi­ olecranon . Through this insertion along with the an­ the shoulder and an
mal displacement of the radius on the ulna. coneus muscle that assists the triceps. extension of the el­ to allow function to
bow complex is accomplished . edge of biomec h an
dted jOints is essen ti
The Dynamic Stabilizers
rehabilitation.
of the Elbow Complex The Elbow in the Upper Quarter
The elbow flexors are the biceps brachii. brachia lis. and The elbow plays an important part ·i n functional activity
brachioradialis muscles (Figure 19-4). The biceps brachii in the upper quarter. An<ltomical position places the el-

Biceps brachii ~. Triceps brachii

A
A
B
Brachialis

Supinator
Brachioradialis

Pronator quadratus

Figure 19-6 A. Iso

ANTERIOR VIEW POSTERIOR VIEW ANTERIOR VIEW sist elbow extension \\.
Figure 19-4 Dynamic stabilizers of t.he elbow. for the early stages of
 CHAPTER 19 Rehabilitation of Elbow fnjuries 423

e shoulder: the bow in full extension and full supination. The elbow func­ REHABILITATION TECHNIQUES
ICrosity of the tions in flexion, extension. supin ation. and pronation
acoid process of movement patterns. The elbow allows for approximately FOR THE ELBOW COMPLEX
~on tendon at 145 degrees of flexion and 90 degrees of both supination
to origins of the and pronation, although normals for range of motion arc Isotonic Open-Kinetic-Chain
0 0 is rlexion of individual for the involved and for the noninvolved Strengthening Exercises
I The brachialis joint. 27 The capsule, as previously stated. is a propriocep­
~ f the anterior tive link of the upper quarter to the hand. Functionally,
Iberosity of the the relationship between the hand and the shou lder
brachioradialis, needs the elbow for normal movement to occur. The con­
Os of the lateral nection between multijoint muscles that affect the elbow
"d process of the will work proximally and distally in the upper quarter as
ir. semipronator. a whole.
The hand and wrist muscles add to the support of the
ichii and the an­ capsule for stability. Function of thc cervical spine and
og, medial and shoulder can also affect the elbow. Limitations in motion
riginates at the in either area ca n cause accommodations in the elbow
~ lateral and me­ complex. For example, for an at hlete who has a decrease
lumerus. The in­ in supination due to injury. an accommodation of the in­
eriori), at the jury is an increase in adduction and external rotation at
l_ with the an­ the shoulder and an increased valgus stress to the elbow
nsion of the el­ to allow [unction to continue. This is why proper knowl­
edge of biomechanics in the elbow complex and associ­
ated joints is essential for proper assessment of injury and
reha~ilitatioo .
•rter
Dc lional activity Figure 19-5 Gripp in g exercise. Used to strengthen the
bn places the el­ wrist flexors and the intrinsic muscles of the hanci.

A
B

Figure 19-6 A, Isometric elbow flexion; resist elbow rlexion with the opposite hand. 8, Isometric elbow extension; re­
~TERIOR VfE sist elbow extension with the opposite hand. The reeducatio n th at the isometric contractions proVide is a safe technique
for the early stages of rehabilitation. Con tractions can be performed in various angles prior to isutonic exercise.
A

Figure 19-7 A. Isometric wrist supination: resist supination wilh the opposite hand. B. Isometric wrist pronation: rv
sist pronation with the opposite hand. This exercise is performed with the same benefits for safe muscle reeducation in
the early rehabilitation stages. Resistance can be performed in various angles prior to isotonic exercise.

figure 19-11
A B c 'D uscle. A. COlleen
Figure 19-8 Isotonic elbow Ocxion. The biceps brachii. the brachialis. and the brachioradialis muscles are used wher - his is done by pu
moving the elbow from full extension into full flexion. A. Used in the standing position. B. In the seated position and the wering th e han
distal humerus resLing on the opposite forearm. C. With the use of tension band.

Figure 19-12
A B c muscle. A,
Figure 19 -9 Isoton ic elbow extension. The triceps brachii muscle moves the arm from full flexion to full extension. This is done by
A, Standing pOSition. B. In the supine position. C. With the use of tension band. lowering the hand in
 A B
B

Figure 19-10 Lsoto nic wris t supination / pronation. The forearm is in a stable position on the table. and the elbow is in
Tist pronation; re­ a 90-degree position. A. Supinate the forearm while holding onto a hammer. B, Pronate the forearm while holding a
de reeducation in hammer.
~.

A B

Figure 19-11 Concentric/eccentric flexion with the Llse of tension band for the benefits of maximum load on the
muscle. A. Concentric: This is done slowly. at first. the n the speed is increased to mimic functional activity. B. Eccentric:
les are used when This is done by pulling the muscle into a shortened position. then allowing a lengthen ing contraction to tClke place by
ed position and the lowering the hand in control. Increased speed is introduced when proficiency is obtained.

A B

Figure 19-12 Concentric/ eccentric extension with the use of tension band [or the benefits o[ maximum load on tbe
muscle. A, Concentric: This is done slowly at first. then the speed is increased to mimic functional activity. B. Eccentric:
I to rull extension .
This is done by pulling the muscle into a shortened position. th en allowing a lengthening contraction to take place by
lowering the hand in control. Increased speed is introduced when proficiency is obta ined.
426 PART THREE ThcTools or Rchabilit<ltion

Plyometic
Closed·Kinetic·Chain Exercises

Figure 19-13 Closed-kinetic-chain static hold . "l"11e figure 19-14 Gymnastic ball exercises. This exercise is
body weight is over the elboll' in varying degrees ror the lIsed for sport-specilk rehabilitation in sports that require
purpose of bearing weight and initialing kines thetic c1osed-kinetic-chain activity. There is sti mulation of the
awareness in the elbow joint. joint receptors.

A B

Figure 19-15 Pu~h -u ps. A, Standing. B, l'rol1c.

c
Figure 19-16 Ply,
tric load (stretch). a br
loSS. C, Two-h and sid
 CHM' TER 19 Rehabilitation of Elbo\\' Injuries 427

Plyometic Exercises

A B

.. c . This exercise is
n ports th at req uire
ti mu lation of the

c D E
Figure 19-16 Plyomelric exercise drills. Plyometric exercise wo rking on H Plyoback h as three phases: a quick eccen­
tric load (stretch), a brief amortization phase. and a concentric contraction. A. Elbow extensors. n, Two-hand overhead
lOSS. C, Two-hand side throws. D, Side-to-side throws. E, One-arm overhead throw.
428 PART THREE ThcToo[s of Rehabilitation

Isokinetic Exercises Stretching

figure 19-21
rs. The elbow is
he force is applied 1
rachioradiali s.

Figure 19·17 Jsokinetic elbow flexion (hand posi­ Figure 19·18 Isoki netic wrist flexion /ex tension.
tioned in supination).

Figurel9-23 S
arm with the elbOl"
;mlling the arm in!

Figure 19·20 Isokinetic elbow flexion / extension with

f igure 19-19 Isokinetic wrist supin atio n/ pronation . scapu lar retraction / protraction.
 CHAPTER 19 RchabilitaLion or Elbow Injuries 429

Stretching Exercises

Figure 19-2 iJ. Stretching of the elbow and wrist flex­

ors. The elbow is extended with the wrist in extension, Figure 19-22 Strelching or the biceps brachii. Extend
the force is applied to stretch the brachialis and the elbow and pronate the wrist. bring the arm inlo
brachioradialis. extension.

n /cxtension.

Figure 19-23 StreLching of the triceps brachii. Flex Figure 19-24 Stretching of the pronators of the elbow.
ann with the elbow in flexion, passive force is applied by Place the forearm on a wble.With the opposite hand, pull
pulling the arm into flexion. the wrist into supination.
430 PARTTHREE The Tools of RehabilitDlion

Figure 19-25 SLretchin g of th e supin ators of the el­ Figure 19-29

bow. Place the forearm on a Lable. To stretch the supina­ supine an d th e arm
tors. pull the wrist into pronati on . Figure 19-26 Stretc hin g of the wrist exte nsors. the forearm away fp
crease th e angle of
l lsed to in crease the
to enh a nce range Of

Figure') 9-27 Passive distractio n . The elbow is at 90
deg rees while tbe ath lete is sup ine. and Lhe arm is in the
plane of the body. hands are clasped while a pull on th e
proximal radi us and ulna is perfo rm ed. Used to increase
elasticity of the adhesed jOint capsule to enhance ra nge of
motioo in a ll pl a nes of m otion.
Figure 19-28 Passive flexion. While th e athlete is
supin e and the arm is in th e plane of th e body. a push of
the forearm toward th e shoulder is perfo rmed to increa
the angle of the elbow toward a straight position. Used 1 figure 19-3]
increase elas ticity o f the adhesed joint capsule to en­ to increase flexib ilil
hance range of motion in all planes of motion. fo r wrist flexors b~
 CHAPTER 19 Rehabilitation of Elbow [njuries 431

Figure 19-29 Passive extension. Whil e the athlete is

supine and the arm is in the plane of the body. a push of
extensors. the forearm away from the shoulder is performed to de­
crease the angle of tbe elbow toward a straight position.
Used to increase the elasticity of the adhesed joint capsule
to enhance range of motioo in all planes of motion.
B

Figure 19-30 Long-duration. low-inltmsily passive

range of motion. A. \lVith the use of tension band . B. Cuff
weight at the wrist. This will increase range of motion by
stretching the joint capsule while thr athlete is supinc
and the arm is in anatomic position at th e sh oulder and
the wrist.

He the athlete is
the body. a push of
performed to increase
igh t position. Uscd to Figure 19-31 Long-duration. low-intensity stretch log
t capsule to en­ to increase flexibility to the wrist extensors (ca n be used
of motion . for wrist flexors by supinating wrist).
432 PART THREB The Tools of Rehabilitation

Exercises to Reestabilish Bracing and Ta

Neuromuscular Control

Figure 19-32 Slide board exercises. The closed-kinetic­
chain patterns as shown incorporate joint awareness and
movement for proprioceptive benefits. Stress to the ath­
lete the importance of developing the weight over the up­
per quarter while movement patterns are worked.
Figure 19-33 Proprioceptive oscillation. This is for
kinesthetic/proprioceptive exercises for the elbow and the
entire upper quarter. An upper-quarter exercise tool, Figure 19-36 Bra
there are three metal balls in the ring that moves when tures. 'fhis brace b
th e upper extremity generates the movement. This can be LO the medial aspe(."
performed in various positions to mimic arm positioning I'eloped for valgu s a
in sporl. limits on nmge of m.

Figure 19-34 Kinesthetic trai ning for timing. This de­

vice is u sed for the purpose of improving proprioception
and timing with functional activity. The pulling of the
Figure 19-35 Surgical tubing exercises done in the
h a ndle causes the weight to move, and with the benefit
scapular plane to mimic the throwing motion using inter­
of inertia, proprioceptive and kinesthetic awareness
nal and external rotation .
can improve.
 CHAPTEl{ 19 Rehabilitation of Elbow Injuries 433

Bracing and Taping

llon. This is ror

the elbow and the
rr exercise tool. Figure 19-36 Brace to protect the medi<ll elbow struc­ Figure 19-37 Elbow brace for latera l epicondyliUs.
~at moves when tures. This brace is used when inj ury stress h<ls occurred This brace is used to decrease the tension or the extensor
ment. This can be to the medial <lspecl or the elbow. The hinge design is de­ muscles at the elbow. The brace b applied over the exten­
c arm positioning veloped ror valgus and also varus stress, and can have sor muscles just distal to the elbow joint.
limits on raoge of motion as well

rcises done in the

motion using inLer- Figure 19-38 Elbow taping ror hyperextension or the
elbow uses a checkrein to limit extension in the joint.
434 PART TERE}; The Tools of Rehabilitation

Functional Exercises trauma . They are m

by a 2:1 ratio.li Tht"
eing placed on a pr
falls and biking ac .
he radius is in com
This type of str
makes the medial 0
-\ valgus stress can
adolescent athlete
esult.
Rehabilitation
mally displaced fra
conservatively a nd •
Cases managed uSin
A B
. ORIF) surgical pr
riods of immobil iza
"veiling is extreme .
g rees. a posterior
motion is encou ra!!et
weeks. while a sli n~
tolerated.
Displaced or 0
d ults are u.suall~- In':
hours), to minimize,
f joint motion . trail::
!Il the anterior el bm'
Fractures in c' -
Fi gure 19-39 Functional exercise. Af Baseball/golf swing. Bf Volleyb<ill drills on a slide board.

REHABILITATIONI TECHNIQUES
FOR SPECIFIC INJURIES
Fractures of the Elbow
Pathomechanics. Fractures to the elbow proper
will be speci!1c to one or more bones in the elbow. with ef­
fects to the joint as a whole. The fractures seen in the
humeral shaft and distal humerus. the radial head. and!
the proximal ulna will affect the function of the entire el­
bow complex <is well as the individual bones themselves.
Dislocations might accompany an elbow fracture. depend­
ing on the specific mechanism of injury. With elbow frac­
tures. properly evaluating the neurovascular system is
critical. The ulnar. radial, median. and musculocutaneous
nerves pass the elbow in various positions anatomically.
The brachial artery has various branches that provide the
blood supply from the proximal elbow to the digits.
The radial. ulnar. and common interosseous arteries
(and the collateral and recurrent arteries). speCifically.
provide the circulation off the brachial artery to the strUl­
tures at and distal to the elbow.
Mechanism of Injury. The fracture of an c1bm' undisplaced fraelur
bone can have various injury mechanisms. The shaft spli nt for 2 weeks.
the humerus can fracture <is a result of a direct fotTe. a· .:<Inge-of-motion C)
well as from a rotational component with the hand in a. -luire open reducti
nxed position. There is also evidence that a direct blow car' bOny alignment and
fracture the bones of the elbow. via a stick . helmct. Regardless of
bal. l l A rotational or twisting mechanism can also occ ur extension at the el
when pushing ofr on a fixed hand (e.g.. a gymnast 00 a jonal impairment
vault)lO and can cause the onset of immediate pain a Rehabilitation
loss of function. Tbe increased load on the joint structure­ ng the injury or \ \i
from a direct blow can increase the possibility of supra ­ to minimize pain
condylar fractures. Olecranon proccss fractures will occur an d electrical stirn
with a fall directly on the tip of the elbow (e.g .. when a vol­ c-ises (see Figures 1
leyball player falls on an elbow). A forearm fracture will n f_ mediately after inj u
ten occur in the shafts of both the radius and ulna . . 0 5 degrees of mo
fracture of one of the forearm bones can result in a dislo­ 'lrst week isometric
cation of the other bone.8 . 35 Radial head fractures make u: Figure 19-6) and .l!
a third of all elbow fractures and a fourth of all elbm' ~'xercises (Figure 1

trauma. They are more common in females than in males
by a 2: 1 ratio. '1 The mechanism of ,i njury is an axia'i load
being placed on a pronated arm. This can occur in skating
falls and biking accidents when the posterolateral aspect of
the radius is in contact with the capitellum.
This type of stress, in addition to the carrying angle,
makes the medial collateral ligament susceptible to injury.
A valgus stress can also injure the epipbyseal plate of an
adolescent athlete with an avulsion fracture as a possible
result.
Rehabilitation Concerns. Undisplaced or mini­
mally displaced (ractures in adults and children are treated
conservatively and require little or no immobilization.
Cases managed using open reduction and internal fixation
B
(ORIF) surgical procedures require only slightly longer pe­ tablish neuromuscular control. including closed-kine tic­
riods of immobilization. The joint may be aspirated if the
swelling is extremely painful. IA/ith the elbow flexed 90 de­
grees, a posterior plaster splint and sling are applied . Early
motion is encouraged, and tbe splint is removed in 1 to 2
weeks, while a sling is continued for another 1 to 2 weeks
as tolerated.
Displaced or comminuted radial head fractures ,in
adults are usually treated by early surgery (within 24 to 48
hours), to minimize the likelihood of permanent restriction
of joint motion, traumatic arthritis. soft-tissue calcification
in the anterior elbow region, and myositis ossificans.
Fractures in children with less than] 5 to 30 degrees of
angulation are treated as undisplaced fractures. Displaced
fractures. or fractures angulated greater than 15 to 30 de­
grees, are treated by closed or open reduction.
Fractures of the olecranon can be either displaced or
ial artery to the stnK­ undisplaced. The extensor mechanism is intact in un dis­
placed fractures, and further displacement is unlikely. The
racture of an elbow undisplaced fracture is treated wi th a posterior plaster
lan isms. The shaft or splint for 2 weeks, followed by a sling and progressive
l of a clirect force, as range-of-motion exercises. Displaced fractures usually re­
l with the hand in a quire open reduction and internal fixation to restore the
at a direct blow can bony alignment and repair the triceps insertion .
a a stick. helmet, or Regardless of the method of treatment, some loss of
extension at the elbow is very likely however; little func­
e .g .. a gymnast on a tional impairment usually results.
immediate pain and Rehabilitation Progression. Immediately follow­
n the joint structure­ ing the injury or with ORIP surgical procedures, the goal is
possibility of supra- to minimize pain and swelling by using cold. compression,
fractures will occm and electrical stimu lation. Active and passive ROM exer­
bow (e.g. , when a vol­ cises (see Figures 19-21 through 19-31) should begin im­
rearm fracture will of­ mediately after injury.The goal should be to achieve l5 to
le radius and ulna. A ] 05 degrees of motion by the end of week 2. Within the
can result in a dislo­ first week isometric elbow flexion and extension exercises
ead fractures make up (Figure] 9-6) and gentle isometric pronation/supination
a fourth of all elbOl\ exercises (Figure 19-7) should begin . Isotonic shoulder
CHAPTER 19 Rehabilitation of ElbolV ~nj uries 435
and wrist exercises should also be used and should con­
tinue to progress throughout the rehabilitation program.
Joint mobilizations should begin during the second week
in an attempt to minimize loss of extension (see Figures
14-21 through 14-25 ).
Progressive lightweight (1-2 Ib) isotonic elbow flexion
exercises (Figure 19-8) and elbow extension exercises (Fig­
ure 19-9) can be incorporated during the third lVeek and
should continue for as long as 12 weeks. Active-assisted
passive pronation/supination exercises (Figure 19-10)
should begin at week 6, progressing as tolerated.
Beginning at week 7, eccentric elbow flexion and ex­
tension exercises (Figures 19-11 and 19-12 ) along with
plyometric exercises can be used. Exercises designed to es­
chain activities, should also be used to help regain
dynamic stability about the elbow joint (Figures 19-13
through 19-] 5,19-32 through 19-35). Functiona'l train­
ing activities will also begin about this time and should
progressively incorporate the stresses, strains. and forces
that occur during normal activities. Isokinetic training for
elbow flexion and extension can also begin at this time
(Figures 19-17 to 19-21). Each of these exercises should
continue in a progressive rnanner throughout the rehabil­
itative period.
Criteria for Return. Full return to activity is ex­
pected at about 12 weeks. The ath:lete may return to fuJi
activity when specific criteria Ihave been successfully com·
pleted. There should be clinical healing of the fract ure site.
Range of motion in flexion. extension , supination . and
pronation should be within normal limits. Strength should
be at least eq ual to the uninvolved elbow. and the athlete
should have no complaint of pain in the elbow while per­
forming a progression of activities in normal conditions.
The return to sport is progressed with the use of restric­
tions (e.g., pitch counts in baseball). which can be helpful
in objectively measuring activity and progression. The
throwing progression for the elbow shows a gradual in­
crease h1 activity in terms of time, repetitions, duration,
and intensity (see Table 19-1. at the end of this chapter) .
CLINICAL DECISION MAKING Exercise 19-1
A mountain biker fell off her bike whUe going downhill.
As she fell, she tried to protect herself with an out­
stretched pronated arm. Afterward. he felt pain along
the lateral side of the elbow with any mO\'emenl in the
arm. The biker had fraclured the radial head. How should
the athletic trainer manage this injury?
434 PART THREE Thc Too[s of Rehabilitatiun

Functional Exercises :rauma . They are rn

by a 2 :1 ratio. 3 >The r:
being placed on a pnY.
falls and biking acc id
the radius is in comaL
This type of s~
makes the medial col',
\ valgus stress can a
adolescent athlete \\i!
result.
Rehabilitation ~
:1laHy displaced fract1..&.
conservatively an d (1
Cases managed u s in~
A B IOR[F) surgical proca
riods of immobiliza
:;",eHing is extremelJ' •
grees, a posterior pi
motion is encourag,
weeks, while a sli ng
as tolerated.
Displaced or Co
adults are usually rrea
hours), to minimize th
of joint motion. tra~
in the anterior elbO\\
Fractures in chi!
Figure 19-39 Functional exercisc. A. Baseball/ golf swing. B. Volleyball drills on a slide board. angulation are trealft
fractures, or fractures
grees, are treated by c
Fractures of the c
REHABiliTATION TECH~IQUES provide the circulation off the brachial artery to the struc­ undisplaced. The ext.
FOR SPECIFIC INJURIES tures at and distal to the elbow. placed fractures, a nd
Mechanism of Injury. The fracture of an elbo\'. undisplaced fractUre"
Fractures of the Elbow bone can have various injury mechanisms. 'rhe shaft of splint for 2 weeks. '
the humerus can fracture as a result of a direct force. as range-of-molion ex
Pathomechanics. Fractures to the elbow proper well as from a rotational component with the hand in a quire open reductio
will be specific to one or more bones in the elbow. with cf­ fixed position. Therc is also evidence that a direct blow carr bony alignment a nd
fects to the joint as a whole. The fractures seen in the fracture the bones of the elbo\\', via a stick . helmet. or Regardless of th
humeral shaft and distal humerus, the radial head, and bat. l1 A rotational or twisting mechanism can also occur extension at the ell
the proximal' ulna will affectthc function of the entire el­ when pushing off on a fixed hand (e.g .. a gymnast on a tiona,l impairment
bow complex as weB as the individual bones themselves. vault)lo and can cause the onset o[ immediate pain an d Rehabilitation I
Dislocations might accompany an elbow fracture, depend­ loss o[ function. The increased load on the joint structures ing the injury or wi th
ing on the specific mechanism of injury. With elbow frac­ from a direct blow can increase the possibility of supra­ to minimize pain a nd
tures, properly evaluating the neurovascular system is condylar fractures. Olecranon process fractures will occur and electrical stimtili
criUcal. The ulnar. radial, median, and musculocutaneous with a fall directly on the tip of the elbow (e.g., when a vol­ cises (see Figures 19­
nerves pass the elbow in various positions anatomically. leyball player falls on an elbow). A forearm fracture will of­ mediately after inju _
The brachial artery has various branches that provide the ten occur in the shafts of both the radius and ulna. A 105 degrees of motic
blood supply from the proximal elbow to the digits. fracture of one of the forearm bones can result in a dislo­ first week isometri
The radial, ulnar, and common interosseous arteries cation of the other bone.8. 15 Radial head fractures make up (FiguJ'e 19-6) and g
(and the collateral and recurrent arteries), speciJ1cally, a third of all elbow fractures and a fourth of all elbow exercises (Figure 19­

trauma. They are more common in females tban in mates
by a 2: 1 ratio.); The mechanism of injury is an axial load
being placed on a pronated arm. This can occur in skating
falls and biking accidents when the posterolateral aspect of
the radius is in contact with the capitellum.
This type of stress. in addition to the carrying angle,
makes the medial collateral ligament susceptible to injury.
A valgus stress can also injure the epiphyseal plate of an
adolescent athlete with an avulsion fracture as a possible
result.
Rehabilitation Concerns. Undisplac.ed or mini­
mally displaced fractures in adults and children are treated
conservatively and require little or no immobilization.
Cases managed using open reduction and internal fixation
B
(ORIF) surgical procedures require only slightly longer pe­ tablish neuromuscular control. including closed-kinetic­
riods of immobilization. The jOint may be aspirated if the
swelling is extremely painful. With the elbow flexed 90 de­
grees. a posterior plaster splint and sling are applied. Early
motion is encouraged. and the splint is removed in 1 to 2
weeks. while a sling is continued for another 1 to 2 weeks
as tolerated.
Displaced or comminuted radial head fractures in
adults are usually treated by early surgery (within 24 to 48
hours), to minimize the likelihood of permanent restriction
of joint motion. traumatic arthritis, soft-tissue calcifkation
in the anterior elbow region. and myositis ossificans.
Fractures in children with less than 15 to 30 degrees of
angulation are treated as undisplaced fractures. Displaced
fractures. or fractures angulated greater than 15 to 30 de­
grees, are treated by closed or open reduction.
Fractures of the olecranon can be either displaced or
ial artery to the struc­ undisplaced. The extensor mechanism is intact in undis­
placed fractures. and further displacement is unlikely. The
fracture of an clbO\\ undisplaced fracture is treated with a posterior plaster
an isms. The shaft of splint for 2 weeks. followed by a sling and progressive
1 of a direct force, as range-of-motion exercises. Displaced fractures usually re­
1 with the hand in a quire open reduction and internal fixation to restore the
lhat a direct blow can bony alignment and repair the triceps insertion.
a a stick, helmet. or Regardless of the method of treatment. some loss of
a nism can also occur extension at the elbow is very likely however, little func­
(e.g .. a gymnast on a tional impairment usually results.
immediate pain and Rehabilitation Progression. Immediately follow­
n the joint structures ing the injury or with ORIF surgical procedures, the goal is
possibility of supra­ to minimize pain and swelling by using cold. compression .
5$ fractures will occur and electrical stimulation. Active and passive ROM exer­
bow (e.g., when a vol­ cises (see Figures 19-21 through 19-31) should begin im­
rearm fracture will of­ mediately after injury.The goal should be to achieve 15 to
It! r adius and ulna. ,\ 105 degrees of motion by the end of week 2. Within the
• can result in a dislo­ first. week isometric elbow flexion and extension exercises
e d fractures make up (Figure 19-6) and gentle isometric pronation/supination
a fourth of all elbO\\ exercises (Figure 19-7) should begin. Isotonic shoulder
CHAPTER 19 Rehabilitation of Elbow Injuries 435
and wrist exercises should also be used and should con­
tinue to progress throughout the rehabilitation program.
Joint mobilizations should begin during the second week
in an attempt to minimize loss of extension (see Figures
14-21 through 14-25).
Progressive lightweight (1-2 lb) ,isotonic elbow Oexion
exercises (Figure 19-8) and elbow extension exercises (Fig­
ure 19-9) can be incorporated during the third week and
should continue for as long as 12 weeks. Active-assisted
passive pronation /supination exercises (Figure 19-10)
should begin at week 6, progressing as tolerated.
Beginning at week 7. eccentric elbow flexion and ex­
tension exercises (Figures 19-U and il 9-U) along with
piyometric exercises can be used. Exercises designed to es­
chain activities. should also be used to help regain
dynamic stability about the elbow joint (figures 19-13
through 19-15. 19-32 through 19-35). Functional train­
ing activities will also begin about this time and shou'ld
progressively incorporate the stresses, strains, and forces
that occur during normal activities. Isokinetic training for
elbow flexion and extension can also begin at this time
(Figures 19-17 to 19-21). Each of these exercises should
continue in a progressive manner throughout the rehabil­
itative period.
Criteria for Return. Full return to activity is ex­
pected at about 12 weeks. The athlete may return to full
activity when specific crHeria have been successfully com­
pleted. There should be clinical healing of the fracture site.
Range of motion in l1ex'ion, extension, supination. and
pronation should be within normal limits. Strength should
be at least equal to the uninvolved elbow, and the athlete
should have no complaint of pain in the elbow while per­
forming a progression of activities in normal conditions.
The return to sport is progressed with the use of restric­
tions (e.g .. pitch counts in baseball), which can be helpful
in objectively measuring activity and progression. The
throwing progression for the elbow shows a gradual in­
crease in activity in terms of Lime. repetitions. duration.
and intensity (see Table 19-1, at the end of this chapter).
CLINICAL DECISION MAKING Exercise 19-1
A mountain biker fell off her bike wbile going downhll1.
As she fell. she tried Lo protect herself with an out­
stretched pronated ann. Afterward, she felt pain along
the lateral side of the elbow with any movement in the
arm. The biker had fractured the radial head. How should
the athletic trainer manage Ibis injury?
436 PART THREE The Tools of Rehabilitation
Osteochondritis Dissecansl
"Panner's Disease"
Pathomechanics. Osteochondritis dissecans and
"Panner's disease" are injuries that affect the lateral aspect
of the elbow. Osteochondritis dissecans is a condition that
affects the central and/or lateral aspect of the capitellum
or radial head in which an underlying osteochondral bone
fragment hecomes detached from the articular surface,
forming a loose body in the joint. [t can also be found in the
knee and ankle joints.
Osteochondritis dissecans is considered to be different
(rom osteochondrosis but might represent different stages
of the same disease. 14 .3> With osteochondritis there is no
inflammation. It is the most common cause of loose bodies
in adolescents, and although it is most often seen in pitch­
ers, it can also be seen in gynmasts or basketball players
between the ages of 12 and IS. 7 . 2 (, The primary cause is
thought to be trauma due to a repetitive compressive force
betwGen the radial head and the capitellum at the radioca­
pitular joint with valgus forces tbat foad the joint during
throwi ng. 6
Some confusion exists as to whether there is any differ­
ence between osteochondrilis dissecans and Panner's dis­
euse. Although Panner's disease might just be a part of the
spectrum of osteochondritis dissecans, it is probably better
to limit the diagnosis of Panner's disease to children age
] 0 or younger at the time of onset. lh Panner's disease is an
osteochondrosis of the capitellum in which there is a lo­
calized avascular necrosis leading to loss of the subchon­
dral bone of the capitellum that can cause softening and
fissuring of articular surfaces of the radiocapiteliar joint. If
loose bodies develop, Panner's disease will produce osteo­
chondritis dissecans. 4
Mechanism of Injury. Osteochondritis dissecans
occurs due to compressive forces at the lateral aspect of the
elbow. When the elbow is in the late cocking and accelera­
tion phases of throwing motion, there is a valgus condi­
tion that causes a compressive force to the articular
surface between the radial head and the capitellum. The
repetitive throwing motion causes vascular defects in the
area. Panner's disease is an idiopathic condition that en­
compasses the ent.ire capitellum. li .21 In the young athlete,
throwing under guidance and with good technique is es­
sentiallo preventing injuries.
Rehabilitation Concerns. Impaired motion and
pain to the laterallaspect of the elbow are among the most
common complaints. The caution is to avoid excessive and
repetitive compression of the joint surfaces. which can
lead to degenerative changes and the formatiOn of' loose
bodies withln the joint. Il ·11
Treatment of osteochondritis dissecans is variable. In .'ely incorporate the
some cases lesions in the skeletally immature elbow wiU e the athlete for gr
heal if properly managed. Treatment includes totally .Quld begin. For thea
avoiding any throwing or impact loading activities as seen gram can be iniru
in gymnaslics. Pain, tenderness. contracture, and radi­ romuscular cont
ographic changes provide objective parameters to deter­ ti llitjes. should also
mine the activity of the disease. If there is formation of ity about the eJbO\I
loose bodies or if healing has been incomplete (as is usuall~ -32 through 19- 3 5
the case) and symptoms persist. surgical intervention i Criteria for Retll
necessary. Arthroscopic joint debridement. and loose bod~ '1ITlpctitive activity \'
removal has been advocated.
Rehabilitation Progression. The functional pro­
gression after the injury has been diagnosed should be f~
and foremost pain-free. The injury is articular in aatun:
and a cautious rehabilitation program should be 1'01101\'1
Range-of-motion exercises should be Iull and pain-fr ·alisti call~
(Figures 19-21 through 19-29). Strengthening exerci ding act.'
(Figures 19-8 through 19-] 0) will progress at the pain­ ·.allr at a comPL
free level and with restriction from increased pressure be.­ lrainer should
tween the radius and the capitellum. The athlete migh ut this problem
have to decrease or modify the activity lcve:l to avoid th cent interven tion
compressive nature in the joint. A slow, progressive pro­ uce the likelib
gram that gradually increases the load on the injured
structure is essential.
FollOWing arthroscopic debridement and removal
loose bodies. the goal is to minimize pain and swelling by
using cold, electrical stimulation, and compression usin ga
bulky dressi'ng initiaUy followed by an clastic wrap. Acti\
and passive ROM exercises (Figures 19-21 through 19-3 j
shou'ld begin immediately after surgery, as tolerated. Th
goal should be to achieve full ROM within 7 to 14 days af­
ter surgery, although the athlete must continue to work 0
ROM throughout the rehabUitation period. Within the Ilr
2 days, isometric elbow flexion and extension exercises
(Figure 19-6). and isometric pronation/supination exer­
cises (Figure 19-7) should begin. Isometric ilioulder and
wrist exercises (Figure 19-5) should also be used and
should continue to progress throughout the rehabilitation
program.
Progressive lightweight (] -2 Ib) isotonic elbow llexion
exercises (Figure 19-8), elbow extension exercises (Figure
19-9), and pronation/supination exercises can be incorpo­
rated between days 3 and 7. Isotonic shoulder and wrist
exercises should begin during this period and continue to
progress throughout the rehabihtaUon program. tressed when val
At 3 weeks, eccentric elbow flexion and extension ex­ ulnar collateral lig.
ercises (Figures] 9-11 and 19-12) can be used. JOint mo­ anterior oblique lig
bilizations should begin in an attempt to normalize jOi nt out full ROM; the po
arthrokinematics. (see Figures 14-21 through 14-25). during flexion and I
Beginning at week 5. in addition to continuing verse obllque liga me
strengthening and ROM exercises. activities that progres­ the range but providd
 CHAPTER 19 Rehabilitation of Elbow Injuries 437

rans is variable. In sivcIy incorporate the stresses, strains, and forces that pre­ band of the ulnar collateral ligament has been demon­
mature elbow will pare the athlete for gradual return to functional activities strated to be the primary structure resisting valgus stress
It includes totally should begin. For throwing athletes, the interval throwing at the elbow and is t'i ght from 20 to 120 degrees of l1exion.
19 activities as seen program can be initiated. Exercises designed to establish The osseous articulation of the elbo'w contributes little to
xacture, and radi­ neuromuscular control. including closed-k.inetic-chain medial stability with the arm in this position. I 6
lrameters to deter­ activities, should also be used to help regain dynamic sta­ The ulnar collateral ligament provides the primary re­
ere is formation of bility about the elbow join t (Figures 19-13 through 19-15, sistance to valgus stresses that occur during the late cock­
n plete (as is usually 19-32 through 19-35). ing and early acceleration phases of throwing. 2i The
ieal intervention is Criteria for Return. The athlete may return to full moment during the throwing motion that places the most
lent and loose body competitive activity when (1) full range of motion in flex­ stress on the elbow is when the arm is [uliy cocked with
ion, extension. supination, and pronation has been re­ maximal shoulder external rotation. ll On examination
"he functional pro­ gained, (2) strength is at least equal to that in the the athlete typically complains o[ pain along the medial
IOsed should be first uninvolved elbow. (3) there is no complaint o[ pain in the aspect of the elbow. There is tenderness over the medial
articular in nature. elbow while performing throwing or loading activities, and colJ!aterall ligament, usually at the distal insertion and oc­
should be fo'llowed. (4) the interval throwing program has been completed. casiona'lly in a more diffuse distribution. In some cases the
. ru ll and pain-free Realisticaj,\y. the prognosis for full return to throwing athlete might describe associated paresthesias in the distri­
19thening exercises or to loading activities. as in gymnastics and wrestling, es­ bution of the ulnar nerve with a positive Tinel's sign.
'ogress at the pain­ pecially at a competitive level, should be cautious. The ath­ When valgus stress is applied to the elbow at 20 to 30 de­
:reased pressure be­ letic trainer should educate parents, coaches, and children grees of flexion. local pain, tenderness, and end-point lax­
. The athlete might about this problem so that early recognition and subse­ ity are assessed . On standard X ray, hypertrophy of the
t"y level Lo avoid the quent intervention and referral to medical personnel can humeral condyle and posteromediall aspect of the olecra­
JW. progressive pro­ reduce the likelihood of need for surgical intervention. Fol­ non , marginal osteophytes of the ulnohumeral or radio­
oad on the injured lowing an arthoscopic procedure, the athlete might be able capiteUar joints. ca'iciflcation witbin the medial collateral
to return to [ull throwing activities in 7 to 8 weeks. ligament, and/or loose bodies in the posterior compart­
en t and removal of ment might be presentY
lain and swelling by The adolescent elbow has an increased injury potential
CLINICAL DECISION MAKING Exercise 19- 2
o mpression using a due to l.igament laxity. which can produce stress on the epi­
la "lic wrap. Active physeal growth p'late and an avulsion fracture of the medial
A 9-year-o ld gymnast is having increased pain at the lat­
1-11 through 19-31) epicondyle (rom the pull o[ the medial collateral ligament.
eral aspect of the elbow. Her symptoms started after an
~'. as tolerated. The This can occur ,in athletes at or around the age o[ 13. IS
Impact with the vault. She is having dUficulty and pain
tb in 7 to 14 days af­ Mechanism of Injury. In athletes, the ulnar collat­
with motion In both llexioD and extension. and she has
continue to work on eralligament is most often injured as a result of a valgus
not been able to compete. How should the athletic trainer
~ri o d. Within the first force from the repetitive trauma of overhead throwing. It
manage th ' Injury?
extension exercises can also be injured during a forehand stroke in tennis. or
ionisupinalion exer­ in the trail arm during an improper golf swing. Jn the gen"
m etric shoulder and eral population acute injury to the ulnar collateral liga­
d a lso be used and Ulnar Collateral Ligament Injuries ment rarely results in recurrent instability of the elbow.

~
t the rehabilitation Stress o[ the medial complex can also result in ulnar nerve
Pathomechanics. The medial complex of the el­ inflammation or impairment:, or wrist flexor tendinitis.
to nic elbow flexion bow is susceptible to various injuries in the athletic popu­ During the late cocking phase through the early accel­
io n exercises (Figure lation. 5 The repetitive stresses that are placed on the eration phase of throwing, tremendously high. repetitive
rei es can be incorpo­ medial elbow increase the possibilities o[ injury. The ulnar stresses are applied to the medial elbow joint, frequently re­
~ shoulder and wrist collateral ligament, the medial aspect of the joint capsule, suIting in ligament failure. tendinitis. or osseous changes.
iod and continue Lo and the ulnar nerve can indiv'idually or collectively be Injuries can vary in degree [rom an overuse flexor/prona­
n program. stressed when valgus forces are applied to the elbow. The tor muscular strain to ligamentous sprains of the ulnar
n and extension ex­ ulnar collateral ligament is composed of three bands: the collateral ligament. These .injuries can result in elbow flex­
~ n be used. Joint mo­ anterior oblique ligament, which remains tight through­ ion contractures or potentially increase the instability o[
pl to normalize joint out full ROM; the posterior oblique ligament, which is tight the elbow in adolescents.
~ through 14-25). during flexion and loose during extension: and the trans­ Rehabilitation Concerns. Most ulnar eolilateral
li tion to continuing verse oblique ligament, which remains tight throughout l.igament injuries can be managed without surgery.14
cavities that progres­ the range bu t proVides little med ial stabilityY The an terior Conservative treatment of athletes with chronic ulnar
438 PARI'THREE The Tools of Rehabilitation
col1ateralligament injury should begin with rest and non­
steroidal anli-innammalory medication. With resolution
of symptoms, rehabilitation should be instituted with em­
phasis on strengthening. The athletic trainer along with
the coach should analyze the athlete's throwing mechan­
ics, which might include video assessment. to correct any
existing faulty mechanics. If periods of rest and rehabilita­
tion fail to resu lt in a resolution of sympto ms. surgical in­
tervention might be necessary.
Operative management consists of repair or recon­
struction. In the case of an acu te rupture, surgical repair
can be considered; however, the indications are extre mely
limited. The av ulsed ligament should be without ev idence
of calcification. and if there is any question as to the qual­
ity of the tissue. reconstruction should be performed.
Thc ulnar collateral ligament is the primary stabilizer
to valgus ~tress at th e elbow, so rcconstru ction is vital to
competitive throwing athletes who wish to return to their
previous levels of performance. An autograll, using ei­
ther the palmaris longus or extensor hallucis, is used to
reconstruct the ulnar collateral ligament. The grart then
simulates function of th e ulnar co llatera l ligament, par­
ticularly the anterior oblique portion, providing the pri­
mary restraint to valgus stre~s during th rowing. During
this surgical procedure, the ulnar nerve is transposed me­
dially and is held in place with fascial slings. Immediate
postoperative preca utions must be observed, especially in
relalion to the soft tissue of the fascial slings that stabilize
th e ulnar nerve.
Rehabilitation Progression. Following a requi­
site period of rest and rehabilitation techniques designed
to reduce infl amma tion . the rehabilitation progression for
ulnar coli ClterClI liga ment injuries should concentrate pri­
marily on strengthening of the flexor muscles, particu ­
larly the flexor carpi ulnaris and J1exor digitorum
superficialis, which can help prevent medial injury by
providing additional support to medial elbow struc­
tures. l 7 Strengthening exercises (Figures 19-5 through
19-12) should be done initially in the pain-free midrange
of motion with a gradual increase of forces at the end
ranges of motion. Exercises to increase both static and dy­
namic nexibility of the elbow without producing valgus
stress should be incorporated (Figures 19-13 through
19-15). Support taping can a lso assist in the protection
for re turn to activity (Figure 19-38) .
Following a reconstruction of the ulnar collateralliga­
ment. tbe initial goa l is to decrease pain and swelling (us­
ing a compression dressing for 2 to 3 days) and to protect
the h ealing reconstruction. The athlete is placed in a
90-degree posterior splint for 1 week. during which time
submaximal isometrics for the wrist musculature (Figurt"
19-5) and the elbow flexors and extensors (Figures 19­
CLINICAL DECI
19-7) are performed at mUlliple angles as long as all valglti
WhUe sllding he.
stress is eliminated. Isometric shoulder exercises, exce
for external rotation. along with isometric biceps exerci
should be used.
position. she I
In the second week th e athlete is placed into a RO\ \
ner 's arm . call
brace set at 30 to 100 degrees (Figure 19-36). Range
motion should be increased by 5 degrees of extension an d
medJal aspect 01
10 degrees of flexion each week, with full range of motion
paresthesia ala:
at 6 to 7 weeks. In addition to the exercises used during tilt
should lbe ath
first week, wrist isometrics an d elbow nexion and exten­
sion isometrics (Figure 19-6) should begin.
At 4 weeks. progressive lightweight (1- 2 Ib) isotonic
elbow nexion exercises (Figure 19-8 ). elbow extension ex­
ercises (Figure 19-9). and pronation/supination exercises
Nerve Entra
(Figure 19-10) can be incorporated. Isoton ic sboulder ex­
ercises (avoiding external rotation for 6 weeks) should be­ Pathomecha
gin during this period and continue to progres ulnar, median. an
throughout the rehabilitation program. Passive elbo" and entrapmel1l i
nexion and extension ROM exercises (Figures 19-4] . passes throug h lb
19-42) may begin during this period. i.ured with media
At 6 weeks. isotonic strengthening exercises for the scri bed. The Ilk
shoulder (now including external rotation ), elbow. an d supracondylar pr
wrist should continue to progress. come com pres
At 9 weeks. as strength continues to increase. more eral head of lh
functional activities can be incorporated. including eccen­
tric elbow l'I exion and extension exercises (Figures 19-] 1
and] 9-1 2) , PNF diagonal strengthening patterns (Figure
19-25 through 19-28). and plyometic exercises. (Figur
19-1 6). Exercises designed to establish neuromuscul ar
control. including c1osed-kinetic-chain activities. shouJd
also be used to belp regain dyn am ic stability abolli the el­ can occur from a
bow joint (Figures 19-13 through 19-15. 19-32 through trauma. (2) trac ti
19-35). dial complex, whi
Beginning at week 11. in addition to continuing placed on the nel'\'
strengthening and ROM exercises. activities that progres­ (3) compression dt.
sively incorporate the stresses. strains. and forces that pre­ pertrophied flexo r
pare the atJl'lete for gradual return to throwing activiti luxation or disl
should begin. For throwing athletes. the interval throwin g changes.ll In thr
program can be initiated at week 14 (see Table 19-1 ). most likely to de\
Criteria for Full Return. Generally the throwing that occur dUF,ing _
athlete can return to competitive levels at about 22 to 26 phases of th e thr o\\1
weeks postsurgery. The athlete may return to full competi­ neuritis often occurs
tive activity when (1) full range oJ motion in nexjon. ex­ dial epicondylitis. I I
tension, supination, and pronation has been regained. The term cubita
(2) strength is at least equal to that of the uninvolved el­ tify a speCific 3n8lOrl
bow, (3) there is no complaint of pa,in in the elbow while nerve. The ulnar
performing throwing or loading activities, and (4) th e in­ swelllng that occurs
ten7 al throwing program has been completed. tory changes thal r

nusculature (Figure
rlsors (Figures 19-6,
, as long as all valgus
ler exercises, except
etric biceps exercises
. placed into a ROM
re ]9-36) . Range of
'ees of extension and
fu ll range of molion
c i es used during tbe
~\' fl exion and exten­
begi.n.
ght (1-2 lb) isotonic
. e lbow extension ex­
su pination excrcis
ISOLOnic shoulder ex­
r 6 weeks) should bc­
nti nue to (Jrogre
~ram . I)assive elbml'
(Fig ures 19-41,
ung 'xercises for the
rotation). elbow, an d
Ie to increase. more
ated . including eccen­
rci es (Figures 19-11
!ling (Jatterns (Figure
~tic exercises. (Figure
r h neuromuscular
Lai n activities. shou ld
tab ility about the el­
~ - 1 5. 19-32 through
~jl i o n to continuing
ctivities that (Jrogres­
. and forces tha t pre­
to throwing activities
t he interval throwin g
l, eeTable 19-1).
n erally the throwin.
'"CIs at about 22 to 2 f'
ret urn to full comp ti­
mo tion in flexion, ex-
has been regained.
o the uninvolved el­
ain in the elbow whi le
\' ilies, and (4) the in­
tom pleted.
CLINICAL DECISION MAKING Exercise 19-3
Wbile sliding headfirst Into third base, a baseball player
caught his hand on the outer corner of the bag. As the
third baseman grabbed the bag to come up to a sta nding
position. she landed on the latera l aspect of the base ru n­
ner's arm. causIng increased force to the medial complex
of the arm. There i increa cd pain aod swelling to the
medial aspect of tbe elbow. an d the player complains of
paresthesia along the medial aspect of the forearm. How
should the athletic trainer manage this Injury?
Nerve Entrapments
Pathomechanics and Injury Mechanism. The
ulnar, median, and radial nerves are susceptible to injury
and entrapment in the elbow. The ulnar nerve, which
passes through the medial epicondylar groove, can be in­
jured with medial stress to the elbow as previously de­
scribed. The median nerve passing between the
supracondylar process, and the medial epicondyle can be­
come compressed . The radial Herve passes under the lat­
eral head of the triceps and, if compressed, can cause
weakness in the forearm extensors. Whenever nerve com­
pression conditions at the elbow arc considered, the ath­
letic trainer should a Iso consider the possibility of
compression lesions at other leve ls suc h as the cervical
spine, brachial plexus, and wrist.
Ulnar nerve entrapment. Ulna r nerve compression
can occur [rom a number ,of causes, including (1) direct
trauma, (2) traction du e to an increase of laxity in the me­
dial complex. which causes a com(Jressive force to be
placed on the nerve resulting in a tension neuropathy,
(3) compression due to a thickened retinaculum or a hy­
pertrophied flexor ca rpi ulnaris muscle. (4) recurrell t sub­
luxation or dislocation. and (5) osseous degenerative
changes. I I In throwing athletes, ulnar nerve irritation is
most likely to develo(J secondary to mechanical factors
that occur during the late cocking and early acceleration
phases of the throwing motion. In th ese ath.lctes, ulnar
neuritis often occurs along witb med ial instability and me­
dia l epicondylitis. I I
The term cubital tunnel syndrome is used to iden­
tify a speCific anatomic site for entrapment of the ulnar
nerve. The ulnar nerve can be compromised by any
swelling that occurs within the canal or with inflamma­
tory changes that result in thickening of the fascial sheath.
CHAPTER] 9 Rehabilitation of Elbow Injuries 439
The athlete generally complains of medial elbow pain
aSSOCiated with numbness and lingling in the wnar nerve
distribution. Paresthesias may be present that radiate from
the medial epicondyle distally along the ulnar aspect of the
forearm into the fourth and fifth fingers. These sensory
symptoms usu a lly precede the development of motor
deficits. There is tenderness at the cubital tunnel. w hich
may include the medial epicondyle. Tinel 's sign is generally
presen t at the cubital tunnel. Subluxation of the ulnar
nerve occurs in as many as ] 6 percent of athletes with
symptoms, (Jarticularly in those with a shallow medial epi­
condylar groove. Radiographs might show osteophytes on
the humeru s and olecranon, calcifications of the mediar
collateral ligament, and loose bodies. II
Median nerve entrapment. The median nerve can
be compressed under the ligamen t of Struthers , within the
pronator teres muscle, and under the superficial head of
the Oexor digitorum superficialis. The compression can oc­
cur as a res ult of hypertrophy of the proxima~ forearm
muscles, particularly the pronator teres muscle. that oc­
curs with repetitive grip-related ac tivity or pronation and
extension of the forea rm . as occurs in the racket sports
and other grip/hold aclivities. The athlete will usually de­
scribe aching pain and fatigue or weakness of the fore<lrm
muscles along with paresthesia in the distribution of the
median nerve. Symptoms seem to worsen with re(Jeliti{'e
pronation. as in practicing tennis serves . There is usually
tenderness of the proximal pronator teres with a positive
'nnel's sign. The athl ete might also complain of increased
pain while sleeping .
Radial nerve entrapment, Enlra(Jment of the ra­
dial nerve, specitkally the posterior illterosseous nerve. oc­
curs within the radial tunnel a nd has been referred to as
either radial tunnel syndrome in which there is pain
with no motor weakness. or posterior interosseous
nen'e compression where there is motor weakn ess in
the absence of pain. 11 The radial nerve innervates the bra­
chioradialis as well as the extensor muscles of the proximal
forearm. Radial nerve compression occurs in throwing
mechanisms a nd overhead activities such as swimming
and playing tennis. The athlete typically complains of lat­
eral elbow pain that is sometimes confused with lateral epi­
condylitis. There is tenderness distal to the lateral
epicondyle over (he supinator muscle. The pain is de­
scribed as an ache that spreads ,i nto the extensor muscles
and occasion ally radiates distally to the wrist. Nocturnal
pain might be present.
Rehabilitation Concerns. If rehabilitation begins
early after onset of symptoms, treatment should include
rest, avoiding activities that seem to exacerbate pain , use of
440 PART THREE The Tools of Rehabilitation
al1ti-inflammatory medications, protective padding, and
occasionally use of extension night splints. This should be
followed by a rehabilitation program that concel1trates on
range-of-motion exercises before returo to sport. A con­
cern that will arise and needs to be addressed with regard
to nerve entrapments is that of decreased muscle funct,i on,
which can lead to accommodative activity and possible
muscle imbalance. If the athlete remains symptomatic de­
spite a conservative program, surgery is generally recom­
mended. It should be noted that, although physical
findings other than local tenderness might be minimal and
electrodiagnoslic tests are rarely positive, good to excellent
results can be obtained by surgery. The surgical treatment
options include decompression alone and subcutaneous,
intramuscular, or submuscular transposition.
Rehabilitation Progression, Following a course of
conservative care involving rest and anti-inflammatory
medication, the rehabilitation program should concen­
trate on strengthening of the involved muscles to maintain
a balance between agonist and antagonist muscles (Fig­
ures 19-5 through 19-12). In addition, maintaining range
of motion through aggressive stretching exercises wiJ.l
help to free up entrapped nerves (Figures 19-21 through
] 9-31). Massage techniques that can be u tilized in the af­
fected area can prevent the development of adhesions that
would restrict injured nerves. Mobility of the nerve is crit­
ical in reducing nerve entrapment.
Followil1g surgical decompression or transposition of
an entrapped nenTe, the initial goal is to decrease pain and
swelling (using a compression dreSSing for 2 to 3 days). The
athlete is placed in a 90-degree posterior splint for 1 week.
during which lime gripping exercises (Pigure 19-5), isomet­
ric shoulder exercises, and wrist ROM exercises are used.
DurLng weeks 2 and 3, the posterior splint ROM is limited to
30 to 90 degrees initially, progressing to 15 to 120 degrees.
The splint may be removed for exercise. Isometric flexion
and extension exercises (Figures 19-6, ] 9-7) are begun, and
shoulder isometrics continue.
At 3 weeks, t he splint can be discontinued. Progressive
isotonic elbow flexion exercises (Figure 19-8), elbow ex­
tension exercises (Figure 19-9), and pronation / supination
exercises (Figure 19-10) cal1 be incorporated. Isotonic
shoulder exercises should begin during this period and
continue to progress throughout the rehabilitation pro­
gram. Passive elbow flexion and extension ROM exercises
(Figures 19-41, 19-42) continue during this period with
particular emphasis placed on regaining extension.
At 7 weeks, as strength continues to increase, more
functional activities can be incorporated:, including eccen­
tric elbow ilexion and extension exercises (Figures 19-11
and 19-12), PNP diagonal strengthening patterns (see Fig­
ures 15-6 through 15-13), and plyometric exercises (Fig­ n fossa with su
ure 19-16). Exercises designed to establish neuromuscu lar :r the coronoid pr
con trol, including closed-kinetic-chain activities, shoul ,ia tcd with ra dial
also be used to help regain dynamic stability about the el­ If Lhe disloc a Lir
bow joint (Figures] 9-13 through 19-13, 19-32 throu gh
19-35). for throwing athletes, the interval throwing pro­ ~o rs,exte nsors. a
gram can be initiated (Table 19-1 ). ir continuity, In
Criteria for Return, The throwing athlete can re­ ,d Ule ultimat e pr _
turn to competitive activity at about 12 weeks. The athlete ~h rapid swelling
must be able to demonstrate full function of the elbow af­ . with the oiCtr
ter nerve injury. Range of motion, strength, neuromUSClI­
lar control. and functional activities must be comparabll"
to preinjury levels. The athlete must also appropriatet
demonstrate activities related to his or her sport. and per­
form these Lasks without compensation or substitution
other structures. For example, a swimmer mus t demon­
strate the proper mechanics in the elbow while performi ll..
the stroke with the involved extremity comparably to Ih ted surgica ll).
uninvolved extremity. If it is not performed in a satisfat ­ Rehabilitation
tory manner, the rehabilitation wm be continued until elbow disloca ti
stroke can be performed appropriately. i ne the cour
results arc obla.
Elbow Dislocations followed by ren
y range of m Ol
Pathomechanics. Generally elbow dis location s a:­ 5 is particul arl}
clas.si11ed as either anterior or posterior dislocations. An mleral ligament
rior dislocations and radial head dislocations are not ccw-­ r dislocation ba-
mon, occurring in only I to 2 percent of cases. There ar
several different types of posterior dislocations. which
defined by the position of the olecranon relative to
humerus: (1) posterior, (2) posterolateral (most COIDm
(3) posteromedial (least common), or (4) latera!' DislOL
tions can be complete or perc/Jed. As compared with c
plete dislocations. perched dislocations have less Iiga lTlt"l"'
tearing, and thus they have a more rapid recovery and
habilitation period .2 .41 In a complete dislocation th ere
rupLure of the ulnar collateral ligament. a possibility
the anterior capsule will rupture, along with possible
tures of the lateral collateral ligament, brachialis m lb<.
or wrist flexor /extensor tendons. 38 Fractures occur in _
to 50 percent of patients with elbow dislocations, \ \ i
fracture of the radial head being most common.
With rupture of the anterior oblique band of th e u
collateral ligament. repair is sometimes necessary in
letes if the injury occurs in the dominant arm.
Injury Mechanism, Elbow dislocations mO ~ 1
quently occur as a result of elbow hyperextension rn.
fall on the outstretched or extended arm, althou gb 5S or motion. j
cation can occur in flexion. 19 The radius and ulna are a re morc likely t
likely to dislocate posterior or posterolateral to Rehabilitation
humerus. The olecranon process is forced into the 0

tric exercises (Fig­ non rossa with such impact that the trochlea is levered
5h neuromuscular over the coronoid process. Flexion dislocation is orten as­
activities. should sociated with radial head rractures.
bility about the el­ If the dislocation is simple without associated frac­
- . 19- 3 2 through tures, reduction can result in a stable elbow if the rorearm
~'a l throwing pro­ flexors. extensors, and a nnular ligament have matntained
th eir continuity. Tn these cases early motion is resumed
ing athlete can re­ and the ultimate prognosiS is good. The injury will present.
weeks. The athlete with rapid swelling. severe pain at the elbow, and a defor­
Dn of the elbow af­ mity with th e olecranon in posterior position, giving th e
19lh. neuromuscu­ appearance of a shortened forearm.
IU t be comparable Elbow dislocations that involve fractures of the bony
a ' 0 appropriately stabilizing forces about the elbow, such as a radial head or
her sport, a nd per­ capitular fracture / di slocation. creates a Significant insta­
lOr substitution of bility pallern thal cannot completely be corrected on ei­
Irncr must demon­ ther lhe medial or the lateral side of the elbow alone ror
\ while performing maximum functional return. These injuries must be
Lo mparably to thl' treated surgically.
cd in a satisfac­ Rehabilitation Concerns. Following reduction of
L ntin uee! until the an elbow dislocation. the degree of sLability present will de­
termine the course of rehabilitation . If the elbow is stable,
best results are obLained with a brief period of immobiliza­
lion fo'llowed by rehabilitation thaL is focll sed on restoring
early range or motion within the limits of elbow stability.
lOW dislocations are This is particularly true if the anterior band of the ulnar
• dislocations. Ante­ collateral ligament is stableY>Prolonged immobilization
:alions are not com­ arter dislocation has been closely associated with flexi on
o cases . There are conLractures and more increased pain. wiLh no decrease in
lCations, whi ch a re illstabllity. 1\n unsLable dislocation requires surgical repair
on relative to the of the uJ'nar collateral ligament a nd tbus a longer period of
-al (most common I. immobilization.
-1) la teral. Disloca­ Recurren t elbow dislocation is uncommon. occurring
m pared with com­ after only 1 to 2 percent or sim ple dislocations. Recurrent
have less ligament instability is more likely ir the initial dislocation involved a
~
id recovery a.nd r~­ fracture or if Lhe flrst incident took place during childhood.
dis location there l!! An overly aggressive rehabLlitation program is more
l. a possibility th at likely to result in c hronic instability. while being overly
g with possible ru p­ conservative can lead to a flexion contracture. Typically.
brachialis muscl nexion contracture is mu<: h more likely. It is not uncom­
mon to have a flexion contracture of JO degrees at 10
lVeeks. After 2 years a 1O-degree flexion contracture is of­
len still present. 2 Unrortunately this flexion contracture
does not improve with time. Por the athlete it is most desir­
able to regain full elbow extension. For [lonathletes. it is
nore important to ensure that th e joint structure and lig­
a ments are given sufficient lime to heal. to decrease the
re, tens ion from a risk or recurrent subluxation or dislocation.
arm . although di I Loss of motion, joint stiffness. and heterotopic OSSifica­
a nd ulna are mo:­ ti on are more likely complications following dislocation.
tcrolaLeral to th Rehabilitation Progression. The rehabilitation
reed into the olecra­ progression is determined by whether the elbow i~ stable or
CHAPTER [9 Rehabilit ation of Elba\- Injuries 441
unstable follOWing reduction. If the elbow is stable. it
should be immobilized in posteri.or splint at 9() degrees of
flexion for 3 to 4 days. During that period. gripping exer ­
cises (Figure] 9-5) and isometric shoulder exercises are
used. All exercises that place valgus strt\~~ on the elbow
should be avoided. Therapeutic modalities should also be
used to modulate pain and control swelling. On day 4 or 5,
gentle active ROM elbow exercises (Figures 19-8 through
19-10) and gentle isometric elbow flexion and extension
exercises (Figures 19-6. 19-7) can be done out of the splint.
Passive stretching is absolutely avoided because of the ten­
dency toward scarring of the traumatized soft tissue and
the possibility of recurre nt posterior dislocation. Shoulder
and wrist isotonic exercises may be done in the splint. Gen­
tle joint mobilizations can be used to regain normal joint
arlhokinematics (see Figures 14-21 through 14-25).
At 10 days the splint can be discontinued. Passive ROM
exercises (Figures 19-28 through 19-29) can begin. pro­
gressing to stretching exercises (Figures 19-21 through
19-25). Progressive isotonic elbow flexion exercises (Figu re
19-8). elbow extension exercises (Figure 19-9 ), and prona­
tion/ supination exercises (Figure] 9-10) should continue
and progress as tolerated. Isotonic s houlder exercises
should continue to progress throughout the rehabilitation
progrmn. Eccentric dbow flexion and extension exercises
(Figures 19-11 and 19-12) , PNF diagonal strengthening
patterns (see Figures 15-6 through 1 5-13). and plyometric
exercises (Figure 19-16) may be incorporated as tolerated.
Exercises designed to establish neuromuscular control, in­
cluding closed-kinetic-chain activities. should also be used
to help regain dynamic stability about the elbow joint (Fig­
ures 19-13 Lhrough 19-15, J 9-32 through 19-35). The
athlete should continue to wear the brace or use taping
(Figure 19-38) to prevent elbow hyperextension and val­
gus stress during return to activities.
For an unstable elbow. the goal during the first 3 La 4
weeks is to protect the healing soft tiss ue while decreilsing
pain and swelling. During this period the protective brace
should be set initially at 10 degrees less that the active
ROM extension limit. Starting at week 1. a ROM brace pre­
set at 30 to 90 degrees is implemented. Each week. motion
in this brace is increased by 5 deg rees of extension and 10
degrees of Ilexjon. The brace can be discontinued when
rull ROM is achieved. During this period. gripping exercises
(Figure 19-5) and wrist ROM exercises are used. /\11 exer­
cises that place valgus stress on the elbow should be
avoided. Shoulder isometric exercises avoiding internal or
external rota Lion may be used.
At 4 weeks. progressive lightweight (1-2 Ib) isotonic
elbow l1exion eXercises (Figure 19-8). elbow extension ex­
ercises (Figure] 9-9). and pronation/supination exercises
442 PART THREE 'fheTools of Rehabilitation
(Figure \9-.\ 0) may be incorporated. Isotonic shoulder ex­
ercises (avoiding internal and external rotation for
6 weeks) should begin during this period and continue to
progress throughout the rehabilitation program. Passive
elbow f1exion and extension ROM exercises (Figures
19-28.19-29 ) may begin during this period.
At 6 weeks. isotonic strengthen ing exercises for the
shou lder external and internal rotation should begin and
conti n ue to progress.
At 9 weeks. as slrenglh continues to increase. more
functional activities can be incorponlled. including eccen­
tric elbow f1exion and extension exercises (Figures 19-11
and 19-12) . PNF diagonal strengthening patterns (see
Figures 15-6 through 15-1 3). and plyometric exercises
(Figure 19-16). Exercises designed to establish neuromus­
cular control. including closed-kinetic-chain activities.
should also be used to help regain dynamic sLabil ity about
the elbow joint (Figures 19-13 through 19-15.19-32
through 19-35).
At 11 weeks. the athle te can begin some sport activi­
ties as tolerated while continuing to progress the strength­
ening program (see Figure 19-39). The protective brace
should be worn whenever the athlete is engaging in any
type of sport activity.
Criteria for Full Return. The criteria for a return
to full activity after an elbow dislocation are the same as for
any return to full activity. The elbow must demonstrate full
range of motion , and th e athlete must demonstrate
strength. endurance. and neuromusc ular control skills ap­
propriate to their Own sport without limiting performance.
A functional progression must be demonstrated. and suc­
cess in terms of the crileria of the rehabilitation protocol
must be reached.
CLINICAL DECISION MAKING Exercise 19-4
An offensive tackle in football fell while I1nishing a block.
His arm was fully ex tended. and he lel! severe pain and
bad acute swelling to the elbow. He also noted deformity.
with the elbow "stuck " in a flexed pOSition. The elbow
had dislocated. The team doctor performed a reduction
on the field. The pain is not oS severe postreduction. How
should th e athletic trainer manage this injury?
Medial and Lateral Epicondylitis
Pathomechanics and Injury Mec.hanism. The
medial and the lateral epicondyles of the distal humerus
arc tbe tendon atlachments of the wrisl f1exors an d exlen­
sors. 32 The medial epicondyle serves as the attachment for
the wrist llcxors. and the wrist eXLensors atlach to the lat­
eral epicondyle. MEDIAL
Medial epicondylitis. lHedial epicondylitis (golfer s
elboH', rocquelball elbow, or swimmer's clbow in adults and INJURY SITUATION
Little I.coguc elboH' in adolescents) genera]i]y occurs as a re­ peet of the elbo\\'. I
snit of repetitive microtrauma to the pronator teres and pajn has progres:,ed
the flexor carpi radialis muscles d nring pronation and f1 ex­ down th e medial a
ion of the wrist. The at hlete usua lly complains of pain on -ion of activity. the
the medial aspect of the elbow. which is exacerbated when SIGNS AND SYM
throwing a baseball. serving or hilling a fo reh and shot in ion cause pain at
racquetball, pulling during a swimming backstroke. or bj l­ hroughout except
ting a golf ball. in which case the trail arm is affected. bow. Palpation sho\'
There is tenderness at the medial epicondyle. and pain i nerve. There is pail'
exacerbated with resisted pronaUon. resisted volar flexi on
of the wrist. or paiisive exten iiion of the wrist with the el­ MANAGEMENT PLAN
bow extended. ASSOCiated ulnar neuropathy at the e1bo\\
hCls been reported in 25 to 60 percent of patients with me­
PHASE 0
dial epicondylitis. ] I GOALS: Pain m
Lateral epicondylitis. Lateral epicondylitis (tel1l1 is Es timated Length of
elbow) occurs \.vith repelitive microlrau ma that results in ei­ Th e goal is to estab
ther concentri c or eccentric overload of the wrist extensor a nd paSSive. acti \-e­
and supinators. most commonly the extensor carpi radi ali. me nded in this time
brevis. l2 There is pain along the lateral aspect of the elbo\\. ·tra int of no pain Ix
particularly at the origin of the eXlensor carpi radialis bre­
PHASE T
vis. Pain increases with passive f1exion of the wrist lV,ith th e
GOALS: Increase
elbow ex tended. as il does with resisted wrist dorsiflexi on .
a nd ulnar a nd r adi
Pain with resisted wrist exte nsion and full elbow extension
timated Length of
indicates involvement of the extensor carpi radialis longus.
\ !odalilies suc h a
Lateral epicondylilLs usually results from repeated forceful
grad ual progression
wrist hyperextension. as often occurs in hitting a back hand
\\' rist/hand. but aJs...
stroke in tennis. For beginning tennis players. the back­
the benefits of b u o~
hand stroke is somewhat unnatural. and to get enough
power to hillhe ball over the net there is a tendency to w PHASE T
forced wrist hyperextension. In more advanced players lat­ GOAI,s: Complete,
eral epicondylitis can develop in a number of ways. incl ud­
Estimated Length of
ing hitting a topspin backhan d stroke using a "flick" of th e
The a thlete can con
wrist instead of a long follow-through ; hitting a serve wit h
the water with a rae
the wrist in pronation and "snapping" the wrist to imparl
to all strengthening
spin : using a racquet that is strung with too much tension
CRITERIA FO R
(55 to 60 Ib is recommended): using a grip size that is too
I.
small; and hit ling Cl heavy. wet ball. l > Hmusl be empha­
sized that any acLivily that involves repeated forceful wrist ,.
)
extension can result in lateral epicondylitis.
Rehabilitation Concerns. iVledi<J1 ,md lateral epi­
c.
condylitis. but particularly lateral epicondylitis. can be
lingering. limiting. frustrating. painful pathological condi­ ,J.
tions for both th e athlete a nd the sports therapist. Pcrha p
4 . What modali Ue
the first step in treating these co nditions is alte ring faul t}
3. Are there eq uipll
performance mechanics to mjnimize the repetitive stres:
elbow?
created by these activities. The stressful components of
high-level activities can also be alleviated by altering th e
frequency. intensity. or duration of play.2<'
 REHABIL IT ATION PLAN

attach to the lat­

MEDIAL ELBOW PAIN
condylitis (golj(or's
1\V in adults and
INJURY SITUATION t\ 23-year-old tennis player is com plaining of increased pain to the medial as­
rll occ u rs as a rc­
pecl of the elbolV. He has been experiencing pain primarily in overhand and forehand strokes. The
pain has progressed over the past 4 weeks to now Lnclude periodic paresthesia (rom tile medial joint
rona tor teres and
ro nation and Oex­ down the medial aspect of the forearm to the fifth digit and one half of the fourth digit. VVith ces­
plains of pain on sion of activity, the pain subsides.
t'x acerbated when SIGNS AND SYMPTOMS The athlete's range of motion is normal. although the end ranges of mo­
orehand shOL in lion cause pain at the medial collateral ligament. Muscle tesUng shows strength to be normal
backstroke. or hit­ throughout except for wrist flexion and ulnar deviation, which is 4 / .5 with a pain at the medial el­
bow. Palpation shows pain at the medial collateralligamenl and a positive TiDel's sign at the ulnar
nd_rle. and pain is nerve. There is pain and slight laxilY to the medial collateralligamenl with valgus testing.
i ted volar flexion
~ \ITis t with the el­ MANAGEMENT PLAN Establish normal pain-free rangc of molion and return to activity without pain or disability to the elbow.
bathy at the elba\\'
patients with me­
PHASE ONE AClJTE INFLAMMATORY STACE
GOALS: Pain modulation and rehabilitate within healing constraints.

icondylilis (tCl mis Estimated Length of Time (ELT): Day 1 to Day 7

The goal is to estab li sh pain-free motion with a gradual and continual increase to full ROM with the use of modalities

and passive. active-assistil'c. and active motion exercises. Stoppage of the activities thal exacerbate symptoms is recom­

usar carpi rad ialls mended in this time frame. Strengthening exercises that benellt strength and endurance can be done within the con­

peel of the elbow. stra,i nt of no pa'in before. during, or after exercise.

ca rpi radialis bre­ PHASE TWO FIBROBLASTIC-REPAIR STACE

I tb e wrist with [he
GOALS: Increase the strength of the elbow flexors, extensors as well as the flexors, extensors, sLl pin ators, pronators.
wrist dorsiOexion.
and ulnar and radial deviators of the wrisl.
ull elbow extension
Es timated Length of Time (ELT): Day 8 to Week 3
flIpi radialis longus.
lvlodalities such as electrical stimulation for muscle reeducation and pain modulation as well as ice are conLinued. A
re pea ted forcefu l
gradual progression of rehabilitation exercises (PRE) is begun. These exercises incorporate not only the elbow and
I hit ting a backhand
wrist / ham!. but also the shoulder f()[ rotator cuff and scapular stabilization. Aquatic therapy can increase function with
players, the back­
lhe benefits of buoyancy, and is also recommended for the elbow and upper extremity.
and to get enough
- a tendency to use PHASE THREE MATlJRATIO~-RET\10I)ELf~(~ STA<~E
ti\'anced players lat­ GOALS: Complete elimination of symptoms for return lo sport.
r of ways. inelue!­
Estimated L.ength of Time (ELT): Week 3 to Full Return
. ing a "nick" of th e
The athlete can continue the PRE exercise regimen and increase acLivit}' in the aquatic setting. with stroke mechanics in
hilling a serve with the water with a racquet La mimic all forces that will be used when back on the co urt. The athlete should be accustomed
r the wrist to impart
to all strengthen ing and stretching exercises thal \VlU be continued after a pain-free return to play has been accomplished.
~ too much tensio n
CRITERIA FOR RETURN TO PLAY
I grip size that is too 1. No pain with exercises .
. It m u't be em pha­
2. i\,/orma\ strength and flexibility in Lhe elbow aud upper quarter.
peated forceful w risl
3. Successful completion of all functional progressions ilnd return-to-sport activity without pain or dysfuncLion .
. litis. DISCUSSION QUESTIONS
~ia l and lateral epi­
1. What factors can increase the tension to tbe medial dbow in tennis?
piwodylilis, can be 2. Whal exerc ises in the aquatic selling can 'be cfit this athlete?
I pathological condi­ 3. Describe the mechanics of the tennis swing that cou ld be developed to decrease pressure to the medial elbow.
therapiSt. Perhap

4. What modalities arc to be used for Lhis athlete during and after the rehabilitation process?
n is altering fa ult}
5. ;\re there equ ipm ent modifications that can be addressed to help distribute pressure and tension away from the medial
the repetitive slres
elbow ;
sful components of

iated by Clltering Lh~

444 I'MrJ' TI IREE The Tools of Rehabilitation

Two rehahilitation approaches may be taken in treat­ techniques is used. some submaximal exercise can begin

ing media} and lateral epicondylitis. The first approach in­ during this period as long as it docs not callse pain. If rest

volves using all of the normal measures to reduce and anti-intlammatory measures are used. 2 or 3 weeks of

inflammation and pain. Treatment may include several restricted activity with very limited or no submaximal ex­

weeks of rest or at least restricted activity dur ~ ng which ercise might be necessary to control pain and inflamma­

painful movements. like gripping activities thar aggravate tion. If the more aggressive approach. using transverse

the condition. are avoided; using therapeutic modalities fricLion massage, is chosen. submaximal exercises can be­

such as cryotherapy, electrical stimulating currents, ultra­ gin immediately within pClin-free limits.

sound phol1ophoresis with hyrocortisone, or iontophore­ Exercise intensity should be based on patient tolerance

sis using dexamethasone; and using nonsteroidal but should adbere to an exercise progression. Throughou t

anti-inflammatory drugs. If pain persists, some physicians the rehabilitation process pain should always be a guide for

might recommend a steroid injection if they feel that the progression. Each of the following exercises should con­

patient is incapable of progressing in the rehabilitation tinue in a progressive manner throughout the rehabilita­

program. I-:!owever, more than two or three steroid injec­ tive period: gentle active and passive ROM exercises for

tions per year is inappropriate and probably harmful, be­ both the elbow and wrist (rigurcs 19-21 through 19-3 1).

cause it can result in weakening of the surrounding gentle isometric elbow flexion and extension exercise

normal tissues. (Figure 19-6), gentle isometric pronation / supination exer­

A second approach would be to realize that the athlete cises (Figure J 9-7), progressive isoton ic elbow flexion ex­

has a chronic inflammation. For one reason or another the ercises (Figure 19-8), elbow extension exercises (Figure

inflammatory phase of the healing process has not ac­ J 9-9), ronation / supination exercises (Figure 19-10) be­

complished what it is supposed Lo and thus the inflamma­ ginning with lightweight (J -2 lh). Lateral counterforce

tory process is in effect "stuck." The goal in this approach bracing should be used as a supplement to muscu1lar

is to "jump-start" the inl1ammatory process, using tech­ strcng Uwning exercises (Figure 19- 37), with the athllete

niques that arc Hkcly to increase the inflammatory re­ gradually weaning from usc as appropriate. Eccentric el­

sponse, with the idea that increasing inflammation might bow flexion and extension exercises (Figures 19-1 1 an d
-ion

allow healing to progress as normal to the I1broblastic and 19-12), along with plyol11etric exercises (Figure 19-1 61

remodeling phases. To increase the inflammatory re­ and functiona l training activities should progressively in­

sponse, tnmsverse friction massage can be used. This tec b­ corporate the stresses, stmins, and forces that occur dur­

nique involves firm pressure massage over the point of ing normal sport activities. gradually increasing tbe

maximum tenderness at the epicondyle in a dimctLOI1 per­ frequency. intensity, and duration of play.

pendicular to the llIuscle fibers . The lise of effleurage pro­ Criteria for Full Return. Perhaps the biggest mis­

gressing to patrissage from origin to insertion of the take made with epicondylitis is trying to progress too

extensor muscles is recommended. This massage will be quickly in the exerCise program an d rushing full return to

painful for the athlete, so it is recommended that a stretch­ play. The athletic train er should counsel tbe athlete abo lll

ing of tbe wrist extensors followed by a 5-minute icc treat­ doing too much too soon. cautioning that rapid increase.

ment be used prior to the massage to minimize pain. in activity levels often exacerbate the condition. The in­

Transverse friction massage should be dODe for:; to 7 min­ volved muscles must regain appropriate strength, flexib il ­

utes, every other day. using a maximum of five treatments. ity. and endura nce witb reduced intlammation and pai n

lt is our experience that if the S)?iJ1ptoms do not begin to re­ FunctionClJ activity needs to progress slowly to prepare th ~

solve in a week t.o 10 cluys. it is unlikely that this approach athlete for the return without restrictions.

will eliminate t.he problem.

lL must also be emphasized that during this treatment
CLINICAL DECISION MAKING Exercise 19-5
period , aU measures previously described to reduce inflam­
mation should be avoided. Remember thai the idea is to in­
A male tennis player is having pain al lhe lateral aspect of
crease the inflammatory response. In those individuals
the right elbow. He states Ihat the pain has been progres­
who have persistent pain that does not resolve after I year
sh'e over the past 4 weeks. He notes that it started as sore­
of conservative trea tment. surgery should be considered.
ness with the single-haml backhand stroke and has
Ilehabilitation Progression. Rehabilitation time
progressed to pain and weakness when simply holding
frames will differ somewhat, depending on which of the
his coffee cup. How should the athlelic trainer manage
two approac hes is utilized in the early treatment of medial
this injury?
and lateral e picondylitis. Regardless of which of the two
 CHAPTER J 9 Rehabilitation of Elbow Injuries 445

exercise can begin

AQUATIC THERAPY TECHNIQUES
cause pain. If rest
~d . 2 or 3 weeks of TO ASSIST IN THE
l) s ubmaxlmal ex- REHABILITATION OF THE ELBOW
Bin a nd inflamma­
I using transverse Aquati c therapy is very he lpful in the rehab il itation or the
ill exe rcises cun be- elbow and the upper quarter as a whole. ,\ s described in
Chapter l6, upward buoyancy counteract s the force o J' the
n putient tolera nce
earth's gravity. Therel'ore. act ivity performed in the water
io n. T h roughout
enhances achievement in comp<lrison to la nd excrcise 21
way be a g u ide for
Treatment tec hniques that traditio n ally are performed
'rcises s hould COll­
when the athlete is in a su pine, prone. or standing position
o ut the rehabilita­
can be done in the aquatic setting with less stress to the el­
RO M exercises for
bow, maximizing activity and benefiting the rehabilitation
_1 through 19-31 ).
process (F igures 19-40 t.hrough 19-48).
xt ension exercises

n fsupin alion exer­

ic elbow flexion ex­

n exercises (Figure

Figure 19-10) be­

.atera I cou n terforce

me nt to mu scu lar
- I. with the athlcte figure 19-40 (Biccp) Start with elbow and arm in ex­
priatc. Eccen tric e1­ tcnsion. Lse thc adjustable resistance padd le to move the
Figures 19-11 and elbow into flexion.
;Le- (F igLlre 19- l6
iuld progrcssively in­
n:es that occur dur­
[ally increasing the
l a~.
aps the bigges t mis­
'11 _ to progrcss tOll
rushing full ret urn to
cI the athlete about
~ th at rapid increase
e co ndition . The in­
lale stre ngth. f1exibil­
a m mation and pain.
low ly to prepare the
io ns .

Exercise 19-5

.he lateral aspect. of

as been progres­
at it started as sorc­

oke and ha s

simply holding

Lrainer manage

figure 19-41 Keep th e wrist in supination and flex thc Figure 19-42 Elbow extens ion with use of buoyant
. . . . . . . . . . . . . . . . . . , It ••.••• • .. ·· • • • • ..­ elbow. dumbbell.
446 PART THI{EE The Tools of Rehabi li tation

Figure 19-44 Elbow ex tension with scapu lar protrac­

tion with tbe use of a kickboard.
Figure 19-43 Scaled dip.

• TABLE 19

4S-Foot Phase
Figure 19-46 Use of CI softb a ll or baseba ll bat against
the resislClncc of the water.
Step 1:

Step 2:

Figure 19-45 FUllctional exercise. Elbow

cupinatioll ipron ation with the use of adjustable resist­
D. Warm- u
ance pClddlcs. While seClted on a kickboard. dynCl mic stCl­
bili~ation is performed in the lumbar spine Clnd tJlE~ trunk. E. 45 feel I.
F Rest 1 (j
C. Warm ­
1-1.45 feel

Figure 19-47 Diagona l 1 PNF pattern.

 CHAPTER 19 Rehabilitation of Elbow Injuries 447

THROWING PROGRAM
FOR RETURN TO SPORT
The athlete progresses through a series of steps for return
to her or his sport. For the throwing athlete. the progres­
sion described in Table 19-1 is one of thc final criteria for
full return. 43 .44 During this throwing progression the ath­
lete is doing upper-quarter exercises that work on the cer­
vical spine. the shoulder rotator cuff. and muscles that
affect the glenohumeral joint, as well as exercises that
work on the elbow, hand, and wrist. The proprioceptive
and neuromuscular control effects stressed by this throw­
~a p u lar protrac-
ing program are critical in returning the athlete back to
full activity. The throwing program is progressive in dis­
tance. repetition. duration, and intensity. It is imperative
that the athlete successfully complete the criteria at one
level before progressing to the next.

CLINICAL DECISION MAKING Exercise 19-6

A 12-yea r-old pilcher has been complaining of increased

paill to tbe medial aspect of the elbow. He notes that his
team was In an important tournament and he had been
pitching more than he is used to in a week's time. The
pai n increases with any pronatory position associated
with the snapping of the wrL~t into flexion at ball release.
How should the athletic trainer manage this injury?
Figure 19-48 Diagonal 2 PNF pattern .

• TABLE 19·1 Interval Throwing Program

45·Foot Phase 60·Foot Phase 90·Foot Phase

;;eba ll bat against
Step 1: A. 'l\Iarm-up throwing Step 3: A. Warm-up throwing Step 5: A. Warm-up throwing
B. 45 feet (25 throws) B. 60 feet (25 throws) B. 90 ['eet (25 throws)
C. Rest 1 S minutes C. Rest 15 minutes C. Rest 1 5 minutes
D. Warm-up throwing D. Warm-up throwing D. Warm-up throwing
E. 45 feet (25 throws) E. 60 feet (25 throws) E. 90 feet (25 throws)
Step 2: A. Warm-up throwing Step 4: A. Warm-up throwing Step 6: A. Warm-up throwing
B. 45 feet (25 throws) B. 60 feet (25 throws) B. 90 feet (25 throws)
C. Rest 10 minutes C. Rest 10 minutes C. Rest 10 minutes
D. Warm-up throwing D. Warm-up throwing D. Warm-up throwing
E. 45 feet (25 throws) E. 60 feet (25 throws) E. 90 feet (2 S throws)
F. Rest 1() millutes F. Rest 10 minutes F. Rest 10 minutes
G. vVarm-up throwing G. Warm-up throwing G. Warm-up throwing
H. 45 feet (25 throws) H. 60 feet (25 throws) H. 90 feet (25 throws)
448 PART THREE The Tools of Rehabilitation

• TABLE 19-1 Interval Throwing Program-Con Cd. TABLE 1

120-Foot Phase ISO-Foot Phase lS0-Foot Phase

Step 7: A. Warm-up throwing Step 9: A. Warm-up throwing Step II: A. Warm-up throwing
B. 120 feet (25 throws) B. 150 feet (25 throws) B. 180 feet (25 throws)
C. Rest 15 minutes C. Rest 15 minutes C. Rest 15 minutes
D. Warm-up throwing D. Warm-up throwing D. Warm-up throwing
E. 120 feet (25 throws) E. 150 feet (25 throws) E. 180 feet (25 throws)
Step 8: A. Warm-up throwing Step 10: A. Warm-up throwing Step 12: A. Warm-up throwing
B. 120 feet (25 throws) B. 150 feet (25 throws) B. 180 feet (25 throws)
C. Rest] 0 minutes C. Rest 10 minutes C. Rest 10 minutes
D. Warm-up throwing D. Warm-up throwing D. vVarm-up throwing
E. 120 feet (25 throws) E. 150 feet (25 throws) E. 180 feet (25 throws)
F. Rest 10 minutes F. Rest 10 minutes F. Rest 10 minutes
G. Warm-up throwing G. Warm-up throwing G. \"'arm-up throwing
H. 120 feet (25 throws) H. 150 feet (25 throws) H. 180 feet (25 throws)
4S-Foot Phase 60·Foot Phase 90-Foot Phase

Step 13: A. Warm-up throwing

B. 180 feet (25 throws)
C. Rest 1 S lIIinutes
D. Warm-up throwing
E.180feet(25tbrows)
F. Rest 15 lIIinutes
G. Warm-up throwing
H. 180 feet (25 throws)
Step 14: Begin throwing off the mouno
or return to respective position

Summary

1. The elbow joint is composed of the humeroulnar joint,
humeroradial joint. and the proximal radioulnar joint.
Motions in the elbow complex include flexion. exten­
sion, pronation, and supination.
2. fractures in the elbow can occur from a direct blow or
from falling on an outstretched hand. They may be
treated by casting or in some cases by surgical reduc­
tion and fixation. Following surgical fixation the ath­
lete might require 12 weeks for return .
3. Osteochondritis dissecans and Parmer's disease are in­
juries that affect the lateral aspect of the elbow. Osteo­
chondritis dissecans is associated with a loose body in
the joint, whereas Panner's disease is an osteochon­
drosis of the capitellum. The prognosis for full return
to throwing or loading activities should be cautious.
4. In athletes, injuries to the ulnar collateral ligament
suit from a valgus force from the repetitive trau ma
overhead throwing, which occurs during the
cocking phase through the early acceleration ph ast'
throwing. Reconstruction is vital to compeli
throwing athletes. and rehabilitation can require
long as 22 to 26 weeks for full return.
S. In the case of entrapment of the ulnar, median.
radial nerves, mobility of the nerve is critical in red
ing nerve entrapment. Rehabilitation should cone
Irate primarily on stretching to free up the nen
conservative treatment fails, surgical release m igiu
indicated.
6. Elbow disTocations result from elbow hyperexte
from a fall on an extended arm, with the radius and
 CHAPTER 19 Rehabilitation of Elbow Injuries 449

• TABLE 19-1 Interval Throwing Program-Cont'd

Interval Throwing Program-Phase 2

1[Owing Stage I: Fastball only Stage 2: Fastball Only

jthrows) Step 1: Internal throwing Step 9:
45lhrows off mound 75%
utes 15 throws off mound 50% 15 throws in batting practice
uowing Step 2: Intervall throwing Step 10:
45 throws off mound 75%
; t hrows) 30 throws off mound 50% 30 throws in batting practice
tuowing Step 3: Interval throwing Step 11:
45 throws off mound 75%
) th rows) 45 throws off mound 50% 45 throws in batting practice
Uti'S Step 4: Interval throwing
lCowing 60 throws ofT mound 50% Stage 3

; throws) Step 5: Interval throwing

.US 30 throws off mound 50% Step 12:
30 throws off mound 75%
Towing Step 6: 30 throws off mound 75% warm-up
- throws) 45 throws off mound 50% 15 throws off mound 50%
Step 7: 45 throws off mound 75% breaking balls
15 throws off mound 50% 45-60 throws in batting practice (fastball only)
Step 8: 60 throws off mound 50% Step 13: 30 throws off mound 75%
.hr w ing 15 throws off mound 50% 30 breaking balls 75%
- throws)
30 throws in batting practice
[tS
Step 14: 30 throws off mound 75%
hrowing
60 to 90 throws in batting practice
~ throws)
25% breaking balls
:' us Step 15: Simulated game: progressing by 15 throws per
throwing
workout
. - t hrows)
ng off the mound
1\ote: lise interval throwing to 120-foot phase as a warm-up. All throwing off the mound should be done in the presence of the pitch­
pective position
ing coach to stress proper throwing mechanics. Use a speed gun to aid in effort control.

dislocating posteriorly. The degree of stability present itive microtrauma to flexor carpi radialis muscles dur­
will determine the course of rehabilitation. If the elbow ing pronation and flexion of the wrist. Lateral epi­
ollaleralligamenl re­ is stable, a brief period of immobilization is followed by condylitis (tennis elbow) occurs with concentric or
• repetitive trauma of rehabilitation. An unsLable dislocaLion requires surgical eccentric overload of the wrist extensors and supina­
urs during the late repair and thus a longer period of immobilization. tors, most commouly the extensor carpi radialis brevis.
acceleration phase of 7. Medial epicondylitis (golfer's elbow, racquetball elbow,
ital to competitive swimmer's elbow, Little League elbow) results from repet-
al ion can require as
turn.
e ulnar. median, and
.e is critical in reduc­ References
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 CHAPTER 19 Rehabilitation of Elbow Injuries 4S 1

SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES

1 -1 Axial loading injuries such as this will cause ar­ 19-4 The athletic trainer knows that the stability of the
ticular pain and potential epiphyseal plate pathol­ elbow after this injury wi.ll be the cornerstone of
ogy in the younger athlete. The athletic trainer the rehabilitation progression . If there i.<; stabili ty,
Function; H\lIIr. ·

must work on the upper quarter as a whole by the increase in motion and loadi ng with isometric,
Hill' and

urgery ~ ~
19-2
tuie. 1996. .\\
condition. the a't hletic trainer should exercise ex­
in Sports .\
treme cau tion in the rehabilitation of this athlete.
asLics. linics
rehabilita ti on of d­
Today 5 3):1 .
L Groppe l. and J. [
19-3
nis elbow: An in·
14.11):4 7- - ,.
forearm. In !lAO
i nL edited by L. Y
bondrosis of lh~
I , Spo rt,s MerUcill(
uries . In Athletirill­
Jti. D. Magee. and
working on strength and function of the neck. isotonic, and functional exerci.se can be progres­
shoulder, and wrist/hand. Techniques of func­ sive. If there is inherent instabi li ty due to boney sta­
tional progression and return-to-sport concepts bilizing force impairment. the rehabilit a ti ~ ll1 will be
must also be addressed. more tenuous.
Due to the complexities of this osteochondrotic 19-5 In this case, the athletic trainer must look at factors
such as strength and flexibility of muscb of th e
upper quarter, not only the affected extensor mus­
The fact that there is an articular surface pathology cle group. Stroke mechanics, [rom foot positioning
assoc iated with such a young ath'lete requires pain­ to the usc of a two- vs. a one-handed' backhand.
free activity initially that can be gradually pro­ must be evaluated. The amount of string tension
gressed within pain-free limits. on the racquet can also promote injury in the a£­
,"Vith the instability notec1to the medial complex as fected area.
a whole. the athletic trainer must consider how this 19-6 Skeletal immaturity and excessive activity are not
will affect other structures. The carrying angle in­ compatible. so the athletic trainer must establish a
creases media I stress an atomically. so increased lax­ pain-free rehabiHtative progression. It is essen tial to
ity of the ligament and medial complex will increase increase the musculoskeletal balance io tb e upper
pressure 0 0 the ulnar nerve. Duri og rehahilitation, extremity, develop a gradual increase in ac.ti vity
care must be taken not to increase paresthesia and progression, such as pitch counts, and use a proper
weakn ess in the forearm. throwing progression.

and W. E. Berdo n .
. g findings and re­
!nlica1 imaging and

Lion al anatomy of
. and Sports PhusicaJ

Brac hial artery dis­

of th e elbow. AllIeri·

WKtional anatomy of
edited by B. Zarins.
rna: \V B. Sa n nders .
. ocation rehabiliLa-

Ul. [n The extremities.

l£a & Fcbiger.
• 19 93. RehabilitaLion
Jou rnal of Orthopaedic
·1 7.

Ilion with the author.

IDd L. Bannister. 1989.

dlill Livingstoue.

 CHAPTER 20
Rehabilitation of Wrist, Hand,
and F'inger Injuries
Anne Marie Schneider

~
Study Resources • Discuss criteria for progression of the
To become more familiar with the knowledge and skill s rehabilitation program for differen t
necessary to design, implement. and doc ument therapeu­
hand and wrist injUries.
tic rehahilitation progra ms as identifi ed in the NATA Ath­
letic Trnlllll1!J EclllCiltionl1l Competellcies and Clillical • Describe and explain various splints for
Proflcicncies'Therapcutic Exercise conten t area, visit
the hand and wrist and how they re­
www.mhhe.eom/ prentice11 e.. Also refer to tlle lab exer­
cises in the new Laboratory Manu al and to eSi ms, which late to protection and return to play.
simulates the athleti c training certifIcaLion exam, at
www.mhh e. com/esims. For more online stu dy reso urces,
• Describe and explain the rationale
visit our Health and Hum an Performance website at for various treatment techniques in
wwv,.mhhe.com/ hhp. the management of wrist and hand
injuries.
After Completion of This

Chapter, the Student Should

Be Able to Do the Following:

• Discuss the functional anatomy and FUNCTIONAL ANATOMY

biomechanics associated with normal
function of the wrist and hand.
• Discuss various rehabilitative strength­
ening techniques for the wrist and hand.
• Identify techniques for improving
range of motion. including stretching
exercises.
• Relate biomechanical and tissue heal­
ing principles to the rehabilitation of
various wrist and hand injuries.
452
AND BIOMECHANICS
The hand is an intricate balance of muscles. tendons.
joints working in unison. Hands are almost always ex
and for that reason can be especially prone to injuries.
dally during sport contact. Changing the mechanic
greatly alter the fun ction and appeara.nce of the han d.
The Wrist
The wrist is the connecting link between the hand an
forearm. 5H The wrist joint is composed of eight c
bones and their articulations with the radius and
proximally, and the metacarpa ls distally.
There is an intricate relationsh ip between the
bones. 'fhey are connected by ligaments to each oth
to the ra dius and ulna . The palmar ligaments frorr
 CHAPTER 20
proximal carpal row to the radius are strongest, followed
by the dorsal ligaments (scaphoid-triquetrum. and distal
---.-- ......... ~.-
radius to lunate and triquetrum). with intrinsic ligaments
(scapholunate and lunotriquetral) being the weakest. R The
carpal bones are arranged in two rows. proximal and dis­
tal, with the scaphoid acting as the functional link be­
tween the two. i8 The distal carpal row determines the
position of the scaphoid and thus {he lunate. With radial
deviation the distal row is displaced radially while the
proximal row moves ulnarly. The distal portion of the
scaphoid must shift to avoid the radial styloid. The
sCClphoid palmar flexes. This is reversed in ulnar devia­
tion . il The total arc of motion for radial and ulnar devia­
tion averages approximately 50 degrees. 15 degrees
radially and 35 degrees ulnarly.il The uneven division is
due to the buttreSsing effect of the radiClI styloid. i 1
Flexion and extension occur through synchronous
movement of proximal and distal rows. The total excur­
sion is equally distributed between the midcarpal and ra­
diocarpal joints. H The arc 01' motion for flexion and
extension is 121 degreesY
There are no collateral ligaments in the wrist. Their
presence would impede fCldial and ulnar deviation. allow­
in g only flex.ion and extension. Cross sections through the
wrist reveal that tendons of the extensor carpi ulnaris
tECU) at the ulnar aspect of the wrist, and the extensor pol­
licus brevis (EPB) and abductor pollicus longus (APL) on
the radial side are in "collaterClI" position. 2 ; EMG studies
how that ECU. EPB, and APL are active in wrist flexion
an d extension. 2i These muscles show only small displace­
ent with flexion and extension so they are in an isomet­
ric position. 2 ; Their function can be described as an
djustable collateral system. The ECU shows activity in ul­
'Jar deviation and the APL and EPB in radial deviation. 1i
Stability of the ulnar side of the wrist is prov,ided by the
riangular fibrocartilage complex (TFeC). i8 This ligament
llises [rom the radius and inserts into the base or the ulnar
_: Ioid. the ulnar carpus, and the base of the fifth
tacarpal. iR This ligament complex is the major stabilizer
the distal radioulnar joint (DRUJ) Clnd is a load-bearing
lumn between the distal ulna and ulnar carpus. i 8
There are no muscular or tendinous insertions on any
:arpal bones except the flexor carpi ulnaris (FCU) into the
iform. i8 Muscles that move the wrist and fingers cross
c wrist and insert on the Clppropriate bones. There is a
rsal retinaculum (fascia) with six vertical septa that at­
' h to the distal radius and partition the first five dorsal
partmentsY These define flbroosseous tunnels that
ilion and maintain extensor tendons and their synovial
a ths relative to the axis of wrist motion. 41 The Sixth
om partment that houses the ECU is a separate tunnel
"lned from infratendinous retinaculum. This allows un-
Rehabilitation of Wrist. Hand. and Finger Injuries 453
restricted ulnar rotCltion during pronCltion and supina­
tionY The retinaculum prevents bowstringing of the ten­
dons during wrist extension.
VolClrly. the long lInger flexors. long thumb llexor, me­
dian nerve, and radial artery pass through the carpal tun­
nel. Bowstringing is prevented by the thick transverse
earpalligamenl.
CLINICAL DECISION MAKING Exercise 20-1
A tennis player has been diagnosed by a phy ician 'i\'ith
DeQuervain's tenosynovitis a nd wrist extensor tendinitis.
She is in season and would Uke to continue to play. She
has been referred to the athletic trainer for evaluation
and rehabilitation for return to sport. What can the ath·
letic trainer do to reduce tbe athlete's symptomsi'
The Hand
The metacarpal phalangeal (Mer) joints allow for multi­
p'l anar motion: however, the primary function is flexion
and extension. 58 The metacarpal heCld has a convex shape
that nts with a shallow concave proximal phalanx. The
stability of the MCr joint is proVided by its cClpSl\ole. collat­
eralligaments, accessory collateral ligaments. \'olar plate.
and musculotendinous units. i8 The collateral ligaments
are laterally positioned and arc dorsal to the Clxis of rota­
tion. In extension the collateral ligament is lax. in flexion it
is taut 24 This is important to remember if immobilizing
the MCP joint. If the joint is casted or splinted in extension.
the lax collateral ligament wiJl tighten. which will then
prevent nexion once mobilization has begun. The acces­
sory collaterall.i gament is volClr to the axis of rotation a.nd
is taul in exte nsion and Ilax in flexion.
The volar plClte helps prevent hyperextension of t he
Mep joint. It forms the dorsClI wall of the flexor tendon
sheath and the A I pulley. i ~
Several muscles cross the fvlCP joints. On the flexor sur­
face the Ilexor digitorum snperllcia'lis (FDS) and flexor dig­
itorum profundus (FOP) are held close to the bones by
pulleys. These pulleys prevent bowstringing during finger
flexion. The FDS flexes the proximClI interphalangeal (PIP)
joint. and the FOP .flexes the distal interphalangeal (DIP)
joint. The interosseous muscles are lateral to the MCP
joints and Clre responsible for abduction and adduction of
the Mep joints. The lumbrical muscles are volar to the axis
of rotCltion of the MCP joint, but then insert into the lateral
bands and are dorsal to the PIP Clnd DIP joints. Their func­
tion is Mep joint flexion and IP joint extension. (This is also
the reason there can be IP extension with a radial nerve
454 PART'J'HREE The Tools of Rebabilitalion

palsy.) Dorsally the extensor m ec hanism crosses the MCP
joint. The tcndon is held centrally by the sagitt al bands.
The Fingers
The IP joints are bicondylar hinge joints a llowing fl exion
and extension . Collateral and accessory collateral liga­
menls stabilize th e joints on th e lateral aspect. The coli at­
era lligament is taul in ex ten sion a nd lax in flexion . This is
impor tant wh e n splintin g the PI P joint. If il is not a con­
traindi ca lion to the injury (i.e.. PIP fracture dislocation ).
lhe joint should be spl inted in full extension to help prevent
nexi on contractures.
On the fle xor surface th e J.'])S bifurca tes proximal to th e
PIP joint. a llowing the I'DI' to become more superfkial as
ir co ntinu es to insert o n the dista l phalan x. allowing DIP
flexi oll .The J.'OS inserts on th c middl e phalanx for PIl' fl ex­
ion. rive annulm pulleys and three CrLl ciale pulleys be­
tlVee n the MCr and DIP joints prevcnt bOll'stringing of thc
tcndons and h elp provide nutrition to the tendons.
On the extensor surface the common extensor ten d
crosses the MCP joint then divid es into three slips. The cer.:­
tra! slip inserts o n tbe dorsal middle phalanx, allowin g f; ­
PIP extension. The two lateral slips. caUed the later
bands. get attachments from th e lumbrica ls, travel dor
and lateral to th e PIP joint, rejoin arter the PIP join t. a.
insert as the terminal extensor into the DIP joint. This is
delicately balanced system to ex tend the IP joints. Disru ~
tion of this system greatly alters the balance, and thus l
dynamic function. of the h an d.
CLINICAL DECISION MAKING Exercise 20-2
A football player presents at the end of the season saying
that 3 weeks ago he dislocated Ws finger during a game
but pulled on it and "popped" it into place. He pre~ents
with swelling and redness at the PIP joint. and passive ex­
tension to 30 degrees. He can !lex the finger to the palm .
but is unable to make a tight fist. What should the ath­
lctic trainer address first. and how?

REHABILITATION TECHNIQUES
Strengthening Techniques figure 20-1
or in supinat
g raded by ad
th en De:d ng.

A
B

c o
Figure 20-1 A, Wrist exlension should be don e in pronation to work again st gravity. This exercise en­
COUI'ages strength and motion of th e common wrist ex tensor te ndons (ECRL, ECRB. EC U). MCP flexion
should be maintained to eliminate ED C contribution a nd isolate wrist musc ulature. B, Strengthening of
wrist extensors can be initiated isometrically. C, This positio n can be graded by adding weights. D, Passive
wrist extension helps regain motion in th e wrist, which tlien needs to be maintained active ly.
 CHAPTER 20 Rehabilitation of Wrist. Hand. and Finger Injuries 455

x tensor tendon
ee slips. The cen­
~n x . allowing for
iilled the laLeral
tal'. travel dorsal
be PIP joint. and
liP joint. This is a
IP joints. Disrup­
cc . and thu s th e

Exercise 20-2
A B
ason saying
ring a game

.... .............................

c
Figure 20-2 A. Wrist flexion actively works on FeR and Fet:. It may be done in pronation as gravity assists
or in supin ation aga inst gravity. B. Strengthening of wrist f1exors can begin isomdrieally. C, Position may be
graded by adding weights. D. Passive wrist flexion should be done first by pulling out or dislracting the wrist.
then flexing.

.xercise en­
Ilexion
A
B

!Ihen ing 0(' Figure 20-3 A. Wrist radial deviation with neutral flexion and extension will exercise the F Rand ECRL. It may be
. '. D. Passive performed with palm nat on a table, or with a rm in neutral over the edge of a tab le. It may be graded to include weigh ts .
B. Isometric wrist radial eviation.
A B

Figure 20-4 A, Wrist uln<1r til:viation with neutral flexion and extension IVill exercise the Eell and FeU. It may be per­

form ed in n eu tra l ro tation with gravity assisted. or with pahn on the to bl e. It is clirncultto position for against gravity. H

can be graded to incl ude weights. B, Isometric wrist ulnar deviation.

A B c
Figure 20-5 A, i\ctive supination exercises the supinator and the biceps. It should be done with elbO\v at 90 degrees
of fl exion with the hum erus by the side. This eliminates shoulder rotation. B, This can be graded usi ng a hammer or
weights for strengthening. The flammer with lever action being hem' ier on one end will also assist with passive motion.
e, Passive strdching should be done in the same position. with force applied proximal to the wrist applying pressu re over
the radius rather than torquing the wrist.

.',
A.
..
'

A B c
Figure 20-6 A, Active pronation exercises thL: prona to r. It should be done Ivith e lbow fl exed to 90 degrees with t he A
hum erus by the side. This eUm inates shoulder rotation. B, This can be done wilh a h am mer or weigh ts for strengthen­
in g. e, Passi ve stTe tcllin g sh ould be don e in th e same position with th e pressure applied proximallo t he wdsl. Figure 20-9 A. "
 Figure 20-7 Thumb ROM is begun with opposi ti on to
each flngertip.

Fe . It may be per­
a gainst gravity. It

A
B
\bow at 90 degrees
Hgure 20-8 A. OpposiLion can be progressed to wmpos ite ncxion reaching ror the base of the little ilIlger. B. Com pos­
ite thumb extension,

Iril'grces with the A B

t ~ ['Of stre ngthel1­
th e wrist. Figure 20-9 A. Thumb abduction, B. Thumb adduction.
4 58 The Tools or Rchubilit<lliOIl

'.';'.:

PART THR EE

Closed Ki

r .

~ ::-.
.'"
•.

t, .
.'i"
"'. 'W

c:o
·l
.''j.
II
;...
Figure 20-11 Putty exercises are for grip strengthen­
ing and wrist stabilization. Putty tends to be more effec­
IF igure 20-10 Thumb retropulsion to test EPL function. tive than a ball because it gives resista nce throughout the
entire range of motion. Putty can be used for gross grasp.
pinch. or extension .

Closed Kinetic Chain Exercises

flex ion as necessar.

Figure 20-12 \lVall push-ups encourage wrist Jllotion Figure 20-13 Push- u ps Cell1 be progressed from tIl('
and general upper-body strengthening. They also encour­ wall Lo a Lable or countertop. This encourages increased
age weight bearing and closed-chain activities. weight but not the full weight of no or push-u ps.
 CHAPTER 20 Rehabilitation of ·Wrist. Hand. anel Finger fnjurics 459

Closed Kinetic Chain Exercises

grip strengthen­
Figure 20-15 Slretching wrist ex ten sor musculature is
to be more effec­
appropriate when tendinitis is present. The greatest
ie throughout the
for gross grasp. Figure 20-14 Push-ups on the floor require full. or
close to fu:JI. wrist motion and encourage full upper-body
stretch will occur with the elbow at full extension and the
arm at shoulder height. If this stretch is too great. in­
weight beming on the wrist. crease elbow tlexion to a comfortable stretch pOint. Do
oot bounce a t the end of a stretch.

Figure 20-16 Stretching wrist fl exor muscu lature is

appropriate with flexor tendinitis. Again the largest
stretch will occu r with full elbow extension. :Vlodify elbow
tlexion as n ecessary. Stretching should not be painful.
from the
Figure 20-17 Butler describes median nerve gliding
exercises to be don in tbc cl inic. It is also important to
leach athletes to stretch on their own. This is a median
nerve glide that alhletes can perform on their own
against a wall. Start with arm at shoulder height. elbow
extended. and wrist extension with palm againstlhe wall.
Rotale shoulder externally. Turn away from the waH so <IS
to be perpendicular. The last step is to add latera l neck
Oexion. Stop at any point along this progression where
numbness or burning is felt along the arm.
460 P!\l{l THR EE Th e Tools of Rehabilitation

Figure 20-21 \'

he intrinsi c ll1 usd
ontrol an d m uscle
with distal rad ius fl
or llling 11' ex tensi
,on concentrates l
beneficial for lP i

A B c D
Figure 20-18 Tendon gliding exercises allow I(lr maximum gliding of the FDS and FDP independ ent of eac h onh er.
Sta r t with rull composite finger ex tension A. move to hook listing which g ives the maximum glide of th e I'DI' B. return
to extension. move to long fisting with Mel' and PIP fl ex ion and DlP extension ror Inaximum FDS glide C. return to ex­
Exercise for
tension. then to composite flexion with full flsting D. Neuromuscul

Figure 2 0-19 Blocked PIP exercises encou rage FDS
pull-throu gh. Stabilizing the proxi mal phalanx then al­
lows th e fl exion rorce to aeL at the PIP joi nt. It is most or­
ten used with tendon injuries, or finger fracture s.
Figure. 20-2 3
ble surface. to en
Figure 20-20 Blocked DIP exercises encourage FOP
pull-through. SLabilizing Lhe middle ph a lanx a llows the
flexion force to concentrate at Lh e Ofr joint. These are
most orten don o with fl exor tendon injuries. exLensor ten­
don injuries, or fin ger fra ctures.
 CHAPTER 20 Rehabilitation of Wrist. Hand. and Fingl' r In juries 461

Figure 20-21 (vICI' flexion with IP extension exercises
the intrinsic muscles of the hand. It may help with edema
control and muscle pumping. This is most often done
with distal radius fractures or \-Iep joint injuries. Per­
[a rming IP extensio n with the MCI' joi nts blocked in flex­
ion concentrates the extension force at the IP Joints. This
is beneficial for IP joint injuries or tendon injuries.
Figure 20-22 isolated superflcialis exercises are done
for tendon gliding of the FDS. on invol ed fingers
should be held in full ex tension, allow in g only th in­
volved finger to flex. This is most helpfu l during flexor
tendon lacerations.

Exercise for Reestabilishing

Neuromuscular Control

Figure 20-23 Push-ups on the ball a ll ow for e10 unsta­ Figure 20-24 Exercising prone over a large gym ball
ble surface. to encourage strengthen ing and upper cx­ allows for weight bearing throughout the upper extrem­
ncourage FOP
tremity control. Overhead plyometric activities encourage ity. weight shifting. and balance acti"ities .
lam: allows the
endurance and strength of entire uppcr extremity.
jo int These <lre

juries, extensor ten-

462 PART THREE TheTaals of Rehabilitation

Taping and Bracing Techniques [lcan also lead to

increased ulnar I
The norm a l ana.
in a comminuted fIT
the most disabli ng_
problems. decrell5
(strength). Arti cuh
Radial shortenin g r:­
The external fll
~. ~ the second metacar;
held with the tracti"",
ator was not in piaL!:
weight and analo!I!_
the muscles would
A B c of the radius. The
Figure 20-25 1\, l\ wrist splint may be made dorsally. B, Volady. or C. Circumferentially, depending on support needs and displacement
and type of injury. These splints mDY be used far tendinitis, wrist fraclures. wrlst sprains. and carpa·1tunnel syndrome.
tor). Once red uced . i
to be sure reductior
Rehabilitation
ilar. regardless of
Hange of motion a
are essential. so th
rehabilitation ca o
ann rather than a
Injury Mech a
juries, distal radi u
stretched hand. 11

lion and immobi li

fracture must be cI
lion is being mai m
is imperative. Th i~
f'igure 20-26 Wrist taping may be done when Figure 20-27 Circumferential wrist splint with sepa­ muscle pumping lO
extra support is needed but hard p~aslic splinting is rate elbow "sugartong" component to prevent supination
inappropriate. and pronation.
Other conce rn s
or reflex sympal he
Ilrst noted ,in th e th
referral should be
REHABILITATION TECHNIQUES simple or comminuted? open or closed? Is the radius short­ possible. One ot her
FOR SPECIFIC INJURIES ened? Is the ulna also fractured? Answers to these ques­ late in a seemingly i
tions help guide treatment and expected outcomes. dillS fracture. is an
Simple. extra-articular, nondisplaced fractures tend to lure. 2~ It is thou ght
Distal Radius Fractures
heal without incident with immobilization. with full or around the fracture
Pathomechanics. Fractures of the distal radius nearly full motion expected following treatment As the would be unable to.
can be described in many different ways. by several classi­ fractures become more involved (intra-articular or com­ this is to put th e in;
fication systems. For trea tment it is important to be able minuted), chances of full return of motion are decreased. the thumb off the
to describe the fracture and X ray. Is the fracture intra­ The normal anatomic radius is tilted volarly. If in a frac­ this movement is r<
articular or extra-articular? displaced or nondisplaced? ture the volar tilt becomes dorsal, motion will be affected. need to be surgica lJ_

: on support needs
LW nci syndrome.
r
~t splint with sepa­
prevent supinatiol:
; Is the radius short­
vcrs to these qu
ed outcomes.
ced fractures tend
Li2ation. with full or
ng treatment. As t
tra-articular or co m­
n tion are decreased.
ted volarly. If in a fra c­
lotion will be affected.
CHAPTER 20
It can also lead to midcarpal instability. decreased strength.
increased ulnar loading. and a dysfunctiona'l DRUJ. 19
The normal anatomic radius is longer than the ulna. If
in a comminuted fracture tbe radius is shortened. this is
the most disabling. 19 .2o Radial shortening can lead to DR
:problems. decreased mobility. and decreased power
(strength). Articu lar disp'lacemen t correction is critical.
Radial shortening must be corrected via external fixation.
The external fixator will attach to the mid radius and to
the second metacarpal shaft. Length may be restored and
held with the traction bars of the external fix a tor. If the flx­
ator was not in place and the fracture was not reduced. th e
weight and anatomy of the carpal bones and the lorce of
the muscles would cause Joss of reduction and shortening
of the radius. The type of fracture. size of the fragments.
and displacement determine initial treatment (cast vs. fixu­
tor). Once reduced. the fractures must be closely monitored
to be sure reduction is being maintained.
Rehabilitation lollowing a distal radius fracture is sim­
ilar. regardless of method of fixation (cast. ORIF. or ex fix).
Range of motion and edema control of non involved joints
arc essential. so that when immobili;;:ation is discontinued
rehabilitation can be concentrated on the wrist and fore­
arm rather than also on the fingers. elbow. and shoulder.
Injury Mechanism. As is true of most wrist in­
juries. distal radius fractures occur [rom a fall on an out­
stretched hand. It might be a high-impact event. but docs
not have to be.
Rehabilitation Concerns. Early and proper reduc­
tion and immobilization are of utmost importance. The
fracture must be closely watched initially to be sure reduc­
tion is being maintained. Early ROM to noninvolved joints
is imperathre. This helps prevent muscle atrophy. aids in
muscle pumping to decrease edema. and most importantly
maintains motion so treatment can focus on the wrist once
the fracture is healed and fixation is removed.
Other concerns include compHcations of carpal tunnel
or reflex sympathetic dystrophy (RSD)2R If present and
Ill'st noted in the therapy clinic or athletic training room.
referral should be made back to the physician as soon as
possible. One other complication, which usually occurs
late in a seemingly inconsequential nondisplaced distal ra­
dius fracture. is an extensor pollicus longus (EPL) rup­
ture. 2~ rt is thought that this occurs from the EPL rubbing
around the fracture site near Lister's tubercle. The athlete
would be unable to extend the thumb IF joint. The test for
this is to put the injured hand flat on the table and try to lift
the thumb off the table toward the ceiling. The term lor
this movement is retropulsion (Figure 20-10). This would
need to be surgicaHy repaired.
Rehabilitation of \'Vrist. Hand. and Finger Injuries 463
Rehabilitation Progression. Rehabilitation may
be initiated while the wrist is immobilized. This should in­
clude shoulder RO iVI in all planes. elbow flexion and exten­
sion. and finger flexion and extension. Fin ger exercises
should include isolated MCP flexion . composite flexion
(full fist). and intrinsic minus flsting (Mel" extension with
IP nexion) (Figure 20-18). Coban ran lsotoner glove may
be used for edema control if necessary.
If a fixator or pins are present. pin site care may be per­
formed. depending on physician preference. Most physi­
cians this author works with prefer hydrogen peroxide
with a cotton applicator to remove the crusted areas from
around the pins. l\ different applicator should be used on
each pin. to prevcnt possible spread of infection . Some
physicians allow patients Lo shower with the flxator in
place (not soaking while bathing); other physicia ns prefer
to cover the pin sites with a plastic bag to keep them dry.
Once immobilization is discontinued (at approximately
6 weeks lor casting. 8 weeks with an external fixator. 2
weeks for ORIF with plate and screws). ROM to the wrist is
begun. Active motion is begun immediately. Wristl1ex ion.
extension. and radial and ulnar deviation arc evaluated.
then instructed. Wrist ext ension should be taught w ith fln­
ger (especiaHy l'vlCP) flexion (Figure 20-1) . This isolates the
wrist extensors and prevents "cheating" with the e ' ten sor
cligitorum communis (EDC). The importance of wrist ex­
tensor isolation is for hand function. H the EDC is used to
extend the wrist. then flexing the fingers to gras p some­
thing will cause the wrist to also flex. because th ere is not
enough wrist strength to keep the wrist extended. Tenode­
sis will extend the fingers. and the object ~ ill be dropped.
isolating wrist extension should be the emphasis of treat­
meltt Oil the first visit.
Passive ROM (PROM) may depend on physician prefer­
ence. Many let PROM begin immediately. others prefer
waiting 1 to 2 weeks (Figures 20-1 and 20-2 ) for passive
stretching exercises. F rearm rotation (supination and
pronation) must not be ignored. Active ROM (AROM) and
PROM are both important. \V.hen stretching rotation pas­
Sively. pressure should be applied althe distal radiu s. prox­
imal to the wrist. not at the hand. This will belp apply
pressure where the limitations are and not put unneces­
sary torque across the carpus (Figures 20-S. 20-h).
Active motion can be progressed to strengthening.
Light weights. TheraHand. or tubing may be graded for all
wrist andlorearm motions. This can be in conjunction with
or in a progression to closed-chain weight-bearing activi­
ties. Start with wall push-ups. then progress to countertop
or table then to noor (Figures 20-12 through 20-14). Push­
ups on a ball may be the next progression (Figure 20-23) ,
464 PART THREE The Tools or Rehabilitation

along with lying prone over a large ball and "walking" out trauma. The diagnosis should be one of exclusion. Injudes Injur}' Meehan
and back on extended wrists (Figure 20-24). that must be ruled out include scaphoid fracture. traumatic occur after a coli isim
tJsing putty for grip strengthening can be started and instability patterns, lunate fractures. dorsal chip fractures. hand , a pileup on tht
upgraded to harder putty beginning about 1 to 2 weeks al~ other carpal fractures and injuries. and ligament tears. 19 twisted. or hitlin g a
ter immobilization. This also helps to strengthen the wrist Injury Mechanism. The injury is usualJy a minor Rehabilitation
musculature (Figure 20-] 1). trauma. either a fall landing on an outstretched hand . a correct diagnosis , T
Plyometric exercises lar the wrist and general upper­ twisting motion. or some impact such as striking the ulnar-side wri st pair
extremity strength are next. Activities are graded from a ground with a club. jury. or just pa in frO!
playground-type ball to a large gym ball to weighted balls. Rehabilitation Concerns. The primary co ncern is actively and passi Wi
Activities can be done in supine, against a wall, or. if avail­ ruling out more serious injury. .once other diagnoses are sion. utnar devia tion
able. using a rebounc!er. Specific return-to-sport exercises ruled out. treatment is focused on edema control. pain replicate pain shaull.
and activities must also be done. control. maintaining (or increasing) active a nd passive side of the wrist. 8\\ .
Criteria for Return. Return to play depends on the ROM to the wrist and other. noninvolved joints. l[ neces­ for scaphoid pain . dl' ,
sport and the severity of the fracture. If the fracture is sary. splint immobilization (Figure 20-25) may also be ulnar to tha t (just pf'l'
nondisplaced, the athlete usually may return to sport tried for pain relief. If activities increase pain. those activi­ nate pain . Then palp
when it stops hurting (2 to 3 weeks. or sooner). \vith pro­ ties should be examined to determine whether modillca­ the ulml head. a nd
tection. There should be early signs of healing, no pain at tions can be made to decrease pain and increase activity mobilization s of th(
rest. and no pain with a direct bl'o w to the protection. If a level for return to sports. Tbis is followed b}
nondisplaced fracture is treated by ORIF with plate and Rehabilitation Progression. Following decrease supination, th en in ~
screw f1xation. the athlete might be able to return to play in pain and edema. and return of ROM , strengthening du clion of pi:!in and I
at about 3 weeks \,v ithout protection if the sport is non­ should be performed to all wrist motions and. if necessary. compared to the nor
contact or with protection if a contact sport. At approxi­ to grip strength and entire arm. Refer to the section on dis­ arthrosco py can COD
matel'y 6 weeks the athlete may play without protection, tal radius fracture for specific exercises (Figures 20-1 not associated wi th ~
The sport must be tak en into consideration, An athlete in through 20-14. 20-23.20-24). Joint mobilizations for the
a high-contact sport might need protection longer than an wrist can certainly help improve joint arthrokinematics
athlete in a noncontact sport. and R.oM (Figures 14-26 to 14-30). paired. There is gooo
M 8
If the fracture was displaced, the athlete is usually ou t Criteria for Return. Athletes may return to sport to hea l. A cen tral
of competition for about 6 weeks. then returns with pro­ when they are comfortable. Taping the wrist (Figure 20-26) ically debrided with
tection for an additiona l 2 to 6 weeks (Figures 20-2" and can help provide support and decrease pain. The athlete Rehabilitation I
20-26), should not return to play until all other serious conditions had surgery lar re
As with all injuries. return to sport depends on the are ruled out. tive dressing for 10 d
sport. position played. and physician. The athlete's tures will be rem o
strength must also be adequate for the position played. to protective splin 1. The
Triangular Fibrocartilage Complex
p revent reinjury. splint that immob'"
(TFCC)
Pathomechanics The TFCC is the primary stabi­
CLINICAL DECISION MAKING Exercise 20-3
lizer of the radio-u' nar joint. It consists of dorsal and volar
radio-ulnar ligaments. ulnar collateral ligament, menis­ supination and pr
A lacrosse player has had a blow to the dominant distal ra­ immobilized lar 4 \\
cus homologue. articular disc. and extensor carpi ulnaris
dial foreano with a stick. Radlograpbs are negative for ion and extension (Fi
tendon sheath . 38 The TFCC functions as a cushion for th e
fra cture, but the player has localized edema (swelling,. ec­ 4 weeks. preven ti ng
ulnar carpus and a major stabilizer of the distal radio­
chymosis (bruisIng', localized pain, and "squeaking" with an d ulnar deviatio Il.
ulnar joint. The TFCC arises from the radius and inserts
thumb motion. The physician has cleared him to play splint is removed. Ire
into the base of the ulna stylOid. It flows distally (t he ulnar
once the pain Is gone and strength has returnt'd. What 20-25). The athlete
collateral ligament). becomes thickened (the meniscus ho­
can the athletic trainer do to help decrease lnJlammation pronation exercises (
moloque), and inserts distally into the triquetrum. ha­
and pain, and increase range of motion for return to play?
mate. and base of the fifth metacarpal. 36 fl ex ion and extensiorl
Blood supply to the TFCC is limited to the peripheral 15 continued and passi
to 20 percent. The central articular di sc is relatively avas­ strength ening begin:
cular.';8 Generally the TFCC tears that occur traumatically progression to wei gh
Wrist Sprain
are in the periphery and can be surgically repaired because (Figures 20-] 2 to 2
Pathomechanics. The term wrist sprain is often seen of the blood supply. Most degeneratjve tears are central If the athlete haS
when patients complain of pain and have a history of minor and are best treated by debridement. cast. once the ca st i'
 CHAPTER 20 Rehabilitation of Wrist. Hand , and Finger Injuries 465

~. ·clusion. Injuries
Injury Mechanism Injuries to wrist ligaments can AROM for 1 to 2 weeks. with progression to PROM, then
"CIcture, traumatic occur after a collision on the field. a fall on an outstretched strengthening. ivIost surgeons th e author works with pre­
al chip fractures. hand, a pileup on the field where the wrist is landed on and fer to have ARm,I close to normal before beginning
gament tears. 19 twisted. or hitting a bad shot in tennis or golf.'~ strengthening.
usually a minor Rehabilitation Concerns The primary concern is Criteria for Return Return to sport with t'his in­
_tretched band. a correct diagnosis. The athlete will usually present with jury. like many others. is dependent upon sport. position
b as striking the ulnar-side wrist pain. There may have been an acute in­ played. and ability to play in a splint or cast. ;\s a g neral
jury. or just pain from overuse. ROM should be evaluated rule. the athlete may begin conditioning activities (such
lrimary concern is
actively and passively. Pain is usu ally present with exten­ as running) at 2 weeks. when the sutures arc removcd
ther diagnoses are
sion. ulnar dev ialion, and forearm rotation .,R Palpation to and the arm is p'taced in a long arm splint. At 8 weeks th ey
ema control. pain
replicate pain should be performed. Start with the radial may begin weight lifting with the wrist taped for support.
aetive and passive
side of the wrist. away from the pain. Palpate the snuffbox An athlete who plays a sport requiring slick work may be­
eel joints. If neces­
for scaphoid pain. dorsally for scapholunate ligament pain. gin stick skills at10 weeks if t his does not make the wrist
-25) may also be
ulnar to that Uust proximal to the third metacarpal) for lu­ more painful. Return to full activity usually occurs about
: pain, those aclivi­
nate pain. Then palpate over the ulna head. just distal to 3 months after surgical repair, when the ligament is
whether modi fica­
the ulna head. and on the ulnar border of the wrist. JOint healed . th e wrist is pain-free. and full RO,vI and strength
,d increase activity
mobilizations of the carpus on radius can be performed. h ave returned.
This is followed by ulna on radius in neutral. then in
'ollowing decrease supinalion. then in pronation. You are looking for repro­ Scaphoid Fracture
O~t strengthening duction of pain and excessive movement on any direclion
and. if necessary. compared to the noninjured side. An arthrogram or wrist Pathomechanics, Fractures of the scaphoid ac­
o the section on dis­ arthroscopy can confirm the diagnosis. If an acute injury count for 60 percent of a ll carpal injuries. J The prognosis
:ise (Figures 20-1 not associated with significant separation from the radius is related to the site of the I'racture. obJiq ulty. displacement.
nobilizations for the or ulna, it can be treated by cast immobilization . A periph­ and promptness of diagnOSis and treatment. J'J The blood
t ar throkinematics
eral tcar of the radial or ulnar allachments should be re­ supply of the scaphoid comes distal to proximal. Fract ure
paired. There is good blood supply and it has the potential through the waist of the proximal one-third of the
[0 hea'\.Hs A central linear or nap tear can be arthroscop­ scaphoid can result in delayed union or avascu lar necrosis
"llay return to sport
wrist (Figure 20-26 ) ically debrided with good resu lts. ,2 secondary to poor blood supply. It ca n take 20 wee ks for a
pain. The athlete Rehabilitation Progressions An athlete who has proximal one-third fracture to heal. compared to .5 or 6
e£ serious conditions
had surgery for repair of the 'lJ-'CC will be in a postopera­ weeks at the scaphoid tllbcrosity. 19 Displaccmcnt of the
tive dressing for 10 days to 2 weeks. At that time the su­ I'racture occurs at the time of injury and must be treated
lures will be removed. and the athkte will be placed into a early using ORIP.
protective splint. The author makes a circumferential wrist Ninety percent of scaphoid fractures heal without
Complex splint that immobiliL:es the wrist and goes two-thirds of the complications if treated early and propef'iy.l9. jO H the frac­
way up the forearm, leaving the fingers and thumb fre e. A ture does go on to non-union. whether symptomatic or
• the primary st abi­ second splint is then applied around the elbow and over­ not. it should be treated . Not treating wil/lead to car pal in­
of dorsal and volar lapping the wrist splint (Figure 20-27) . This is to prevent stability and periscaphoid arthritis. li. 49
ligament. meni ­ supination an d pronation. Some surgeons keep the ann Diagnosis is made by X ray. Patients will have wrist
ensor carpi ulnari!i immobilized for 4 weeks: others will allow active wrist flex­ pain . especially in the anatomic snuffbox (Figure 20-28) .
a cushion for the ion and extension (Figure 20-1, 20-2) only during the first Injury Mechanism, ScaphOid fractures result [rom
r or the distal railla­ -t weeks. preventing supination or pronation and radial a fajIJ on an outstretched hand. The radial stylOid may im­
e radius and inser ts and ulnar deviation. At 4 weeks the elbow portion of the pact against the scaphoid waist. causing a fractllre. ~ The
\ distally (the ul nar splint is removed, keeping the wrist splint applied (Figure scaphoid fails in extension when the palmar surface expe­
ed (the meniscus h 20-25). The athlete may then begin active supination and riences an excessive bending movement. , 0 Because the
the triquetrum. ha­ pronation exercises (Figure 20-:;. 20-6) and continue with scaphoid blocks wrist extension. it is at risk for injury.1 9
3~ t1exion and extension. At 8 weeks, splinting is usu ally dis­ Rehabilitation Concerns, Of primary concern is
to the peripheral l ­ continued and passive RU'd exercises are started. Gentle proper diagnosis. If the athlete has a history of falls on an
di c is relatively ava . trengthening begins between week 8 and week 10. with outstretched hand and has pain in the anatomic snuffbox,
I occur traumatical•. progression to weight bearing and plyometrics as tolerated but the initia'l X ray is negative. they should be treated con­
I Figures 20- 12 Lo 20-14 . 20-23. 20-24). se rvalively in a thumb spica east for 2 weeks. then be X
ally repaired becau
rive tears are cenlf If the athlete has been treated conservatively with a rayed again. 11.3 1 If the X ray is negative after 2 weeks. the
ast. once the cast is removed (at 6 to 8 weeks). begin cast may be removed and ROM begun.
466 PART THREE The Tools of Rehabilitalion

REHAB ILI TATION PLAN

ULNAR WRIST PAIN The postoperative dre
in a circumfere nti al ,'
INJURY SITUATION A 20-year-old college lacrosse pl ayer complains of pa in in his nondomin a nt (lert) ulnar wrist. He has tion and prevell t fore"
had this pain for several weeks. since he fell on his wrist whil e holding his lacrosse stick during practice. but h e does n ot deViation should be PI
really know how he injured it. '!'he pain has increased so much that he cannot control his stick ing. such as runni n g
to catch a ball Or shoot.
PHASE T
SIGNS AND SYMPTOMS The athlete complains of pain in the w rist with gripping. forearm ro­
tation. and trying to hold and shoot with his lacrosse stick. He has pain with end ROM for wrist
GOALS: fncreasi ng
Estimated Length of 1
extension. resisted wrist extension. and resisted supination. Palpation reveals pain in the ul­
The elbow componen
nar side of the wrist. Joint mobilization of the radius on the ulna in neutral. supination. and
gentle PROwL ~ nit ial(.·
pronation . and of the ca rpu s on the radius shows minimal, if any. differen ce in jOint mobility
compared to the noninjured side. but is painful. PHASE T
MANAGEMENT PLAN The goal is to decrease pain initially. regain ROM and strength . and de­ GOALS: Increasi ng:
termine whether a more serious injury has occurred. Estimated Length of J
NON·SURGICAL PLAN Initiate a strengtheniI
return to sport can DC'
PHASE ONE !\CllTE TNFLA:VI i\,L\TORY ST;\C;E tha t lime as well. ReLU
GOALS: Decrease pain a nd begin ROM exercises
above.
Estimated Length of Time (ELT): Day 1 to Day] 4
DISCUSSION QlIE~
Use ice for pain relief if swelling is present. Ice on th e hand can be painful. Anti-inl1ammatory medications can help de­
1. What other inj urit
crease edema and pain. Splinting the wrist when th e athl ete is not involved in sport activity can proVide pain relief as well.
2. What therapeu lic
Begin AROM exercises in a pain-free range. If wrist taping provides sufficient support and pain relief. participaUon in 3. If pain does n ot (
sports may be allowed. If not. the athl ete may need to sit out practice for several days. to play?
4. Explain why su p'
PHASE TWO FIBROBU\STIC-REI'J\IR STJ\(; E
GOALS: Increase ROM and strength; pain relief
Estimated Length of Time (ELT): Weeks 2 to 4
Ice. anti-infl am mat ories. and splinting may be continued. Continue with ROM exercises . adding supination and prona­
tion. Strengthen ing may be started for the wrist and forearm if pain has decreased. Return to sport with tapin g if neces­
sary. Fitness level's must be maintained if wrist pain continues and sport participation not possible.

PHASE THREE JvlJ\Tl I R ;\TIO~-RElVIOJ)ELI ~(; ST;\(;E

GOALS: Complete eliminatio n of pain ancl return to fu ll activity
Estimated Length of Time (ELT): Week 4 to Full Return
Con tinue wilh ROM <il1d strengthening. Return to activity as tolerated. VVean from splint. VVean from taping during activity.
CRITERIA FOR RETURNING TO COMPETITIVE LACROSSE
1. Pain is elimin<ited with ROM of wrist and forearm.
2. Full ROM in wrist and forearm.
3 . FulJ return or strength in wrist. forcarm. andl grip.

If p<iin does not stop with ice. a nti-inflammatories. and rcst, the wrist might need furth er eva luation and prolonged im­

lUobilization. Prolonged uln a r-side wrist pain without relief might indica te a TRCC tear. The diagnosis can be co nfirmed

with an arthrogra m . An acut e tra uma ca n be surgically repaired. It is possible to delay repair until the end of the season

if the athlete is able to play without risk of further injury. Follow the plan above until surgery.

Figure 20·28 'l'he

SURGICAL PLAN under which the sca p
painful to palpation \\1
PHASE ONE ACliTE Jr\FL\I\;IM/\'!'ORY STAGE nate 'ligament injury.
GOALS: Protection of surgical repair

Estimated Length of Time (ELf): Day 10 Postsurgery to Week 4 (continued)

 CHAPTER 20 Rehabilitation of ·Wrist. Hand. and Finger Injuries 467

R E H A B I LIT A T ION P LAN (CONT'D)

The postoperative dressing is removed 1 () days to 2 weeks after surgery. The sutures are removed. and the arm is placed
in a circumferential wrist splint, with a sugartong component around the elbow to place the forearm in slight supina­
n ar wrist. He has tion and prevent forearm rotation. AROM is begun for wrist flexion and extension only. No rotation or radial and. ulnar
e, but he does not deviation should be performed. (Check with the physician; some do not want any ROM activity for 4 weeks.) Condition­
ing. sllch as running. can begin at approximately 2 weeks. once the athlete is comfortable in the protective splint.

PHASE TWO FIBROBLJ\STIC-Rlm\IR S'L\CF

GOALS: Increasing ROIvl of the wrist and forearm. while protecting the surgical repair
Estimated Length of Time (E1'f): Weeks 4 to 8
The elbow component of the splint is discontinued. Continue with the wrist splint. Continue with wrist ROM. beginning
gentle PROM. Initiate forearm rOlation actively. Afler approximately 2 weeks of AROM to rolation. begin PROM.

PHASE THREE ~IATl I RAT[ON-REMOJ)ELIN(; STJ\(iE

GOALS: Increasing ROM and strength, and return to sport activity
Estimated Length of Time (ELT): Weeks 8 to 12
Initiate a strengthening program. Begin with isometrics. progress to weights, and then weight bearing. Weight lifting for
return to sport can occur at 1 () weeks. with the wrist taped for support if ,it is pain-free. Stick work can be ,i nitiated at
that time as well. Return to competitive lacrosse occurs at approximately 12 weeks. Criteria for safe return are listed
above.
DISCUSSION QUESTIONS
(ms can help de- l. What other injuries could occur with a fall on a wrist?
o pain relief as well.
2. What therapeutic modalities could help decrease pain.i
ief. participation in 3 . If pain does not decrease with immobilization. modalities. and anti-inflammatories. should the athlete continue
to play?
4. Explain why supination and pronation are not allowed initially.

lalion and prona­

Ilh ta ping if neccs­

Another concern is scaphoid non-unions. which can

lead to carpal instability or periscaphoid arthritis. ROl'vI of
non injured and noncasted joints must be maintained dur­
ing prolonged periods of immobilization.
ping during activit\. Rehabilitation Progressions. Treatment of the
nondisplaced scaphoid is casting. Following casting, an
additional 2 to 4 weeks of splinting (figure 20-29) may be
used, with the splint removed for the exercise program.
AROM exercises of wrist f1exion, wrist extension (with fin­
and prolonged im­ ger f1exion to isolate wrist extensors). and radial and ulnar
can be conflfmed deviation are initiated following immobilization (Figures
e nd of the season 20-1 through 20-4). Thumb flexion und extension. abduc­
Figure 20-28 The * indicates the anatomic snuflbox. tion and adduction, and opposition to each finger are also
under which the scaphoid is positioned. This area will be initiated (Figures 20-7 through 20-9). After upproxi­
painful to palpation with scaphoid fracture or scapholu­ malely 2 weeks (sooner if cleared by the physician). PROM
nate ligament injury. to the same motion is begun. Gentle strengthening with

(continued ,
468 PART THREE The Tools of Rehabilitation

ing reduction of the

tusion of the nerye
Injur.y Mech a
the wrist is the in;
stretched hand proc
when the luna te L
dorsal aspect of the
lunate or scaphoid
nate dislocation can
Rehabilitation
early surgical repaa:
cations include paw
Figure 20-29 /\ thumb spica splint is circumferential Figure 20-30 The * indicates the position of the lunate slipping. R Carpa l lUI
and includes the thumb and wrist. ft might or might not and the location of pain with lunate or scapholunate lig­ dressed at the lime
include the thumb IP joint. It is most commonly used for ament injuries. must be maintai nt
a scaphoid or thumb metacarpal fracture. Rehabilitatio n
similar to the reh­
other wrist injuri
weights or putty may be started around the same time. pLicable). AROM i
Strengthcning is progressed over the next several weeks to ~tretching and g.
include weight-bearing activities. plyometrics. and general comes more aggr,
arm conditioning to rdurn to sport-specific activity (Fig­ bearing and plyom
ures 20-12 through 20-14. 20-23 , 2-24). addressed for RO.\\
Surgical repair rehabilitation iollows the same pro­ ,ion. radial de\'ial
gression as for nonsurgical rehabilitation. The time frame pronation (Fig ure-. ,
of immobilization might be less because of the repair of 20-14. 20-23. 2 0- ~ !
the scaphoid with rigid nxaLion. Criteria for R
Criteria for Return. Return to play depends on the the need for OR!
sport, location and type of fracture. and type of immobi­
lization. If the fracture is non displaced and treated in a
cast, return to play in a padded cast might be at 2 or 3
weeks or sooner-when the arm stops hurting. there are
early signs 01' healing. and there is no pain with a blow to
the cast. The athlete should continue to play wHh protec­
tion unLiI the bone has healed and adequate strength has
returned to help prevent reinjury. or new injury to a sepa­
rate site. If the nondisplaced [racture has undergone ORIF Figure 20-31 Hand placement to relocate a lunate.
or if the athlete is participating in a noncontact sport, lhe
athlete may return. if cleared by the physiCian. in about 2
or .3 weeks without additional protection. An athlete in a sal perilunate type. Many people believe that a lunaLe
contact sport should participate with protection. rr the location is the end of a perilunate dislocation. 1 y The lun 'lexor and oppon en
fracture is displaced and surgically repaired, time until re­ dislocates palmariy with the loss of ligamentous stabilil) .:arpalligament. ",
turn to play may be longer. The athlete must lVear a padded may be reduced. i[ seen early. by placing t.he wrist in ~ s a hamate hook r,.
protecUve cast upon return to play. In all cases, close com­ tension and pulling pressure on the lunate volarly (rig ul"'_ the fragment wi th
munication is essential for return to competition. 20-30 and 20-31). The wrist is then brought into fle xi n early impossible to.
and illlmobilized. It is very common for reduction to be I as a result these one
Lunate Dislocations over time with this injury. so percutaneous pinning pated on the volar su
ORLF is rccommended.l ~ pothenar eminen ce
Pathomechanics. Stability of the carpus is depend­ Median nerve compression is frequently caused by til­ The hamate isin
ent upon the maintenance of bony architecture interlaced injury. The palmariy displaced lunate puts pressure on In artery on the ulna r sil
with ligaments. 19 Most carpal dislocations are of the dor- nerve. Symptoms might continue for several weeks foIl O\\ · small finger in th e c

) iLion of Lhe lunate
r scapho\unate lig­
relocate a lunate.
ie\'e that a IUllate dis­
location. 1Y The lunale
'gamentolls stability. I
adng the wrist in ex­
lun ate volarly (Figur
brought into flexi n
for reduction to be 10
.:u taneous pinning or
ieq uently caused by th ~
te puts pressure on Lh.
r everal weeks follo \\ ­
CHAPTER 20
,i ng reduction of the lunate secondary to swelling and con­
tusion of the nerve.
Injury Mechanism. A violent hyperextension of
the wrist is the injury mechanism. s.l ,) A fall on the out­
stretched hand produces a translational compressive force
when the lunate is caught between the capitate and the
dorsal aspect of the distal radius articular surface. 19 If the
lunate or scaphoid docs not fracture. a periscaphoid or lu­
nate dislocation can occur.
Rehabilitation Concerns. The primary concern is
early surgical repair. Without surgical correction. compli­
cations include pain. weakness . wrist clicking. and bones
slipplng. 8 Carpal tunnel syndrome. if present. must be ad­
dressed at the time of surgery. ROM of noninvolved joints
must be maintained during immobilizaLion.
Rehabilitation Progressions. Progression is very
similar to the rehabUitation of distal radius fractures and
other wrist injuries. FollOWing cast and pin removal (tf ap­
plicable). AROM is beguo. This is progressed to passive
stretching and gentle strengthening. Strengthening be­
comes more aggressive with free weights and weight­
bearing and plyometric acLivities. Ivlotions Lhat need to be
addressee! for ROM and strengthening are nexion. exten­
sion. radial deviation. ulnar deviation, supination, and
pronation (Figures 20-1 through 20-6, 20-12 through
20-14.20-23,20-24).
Criteria for Return. The severity of this injury. and
the need for ORIF secondary to frequent loss of reduction
if not repaired. wiH keep this athlete from competition for
at least 8 weeks. Upon return at 8 weeks. the wrist may be
taped for support and protection (Figure 20-26). The ath­
lete should not be favoring or protecting the hand during
periods of noncom petition . Athletes should have good
ROM and strength prior to return to help prevent reinjury.
Hamate Fractures
Pathomechanics. Fractures of the hook of the ha­
mate are more common than hamate body fractures. i The
hook is the attachment for the pisohamate ligament. short
flexor and opponens to the small finger. and the transverse
carpal ligament. i8 Because of these a ttachments. if there
is a hamate hook fracture there are deforming forces on
the fragment with intermittent tension. This makes it
nearly impossible to align and immobilize th e fracture. and
as a result these often do not heal. is The hook can be pal­
pated on the volar surface of the hand allhe base of the hy­
pothenar eminence deep and radial to the pisifor m.
The hamate is in close proximity to the ulnar nerve and
artery on the ulnar side. and nexor tendons to the ring and
small finger in the carpal canal on the radial side (Figure
Rehabilitation of Wrist. Hand. and Pinger Injuries 469
Figure 20-32 The * indicates the point that will elicit
pain with palpation (especially deep) for a hamate hook
fr ac ture. Some pain might also be referred to the ulnar
wrist.
20-32). There is a possibility of an ulnar neuropathy. ten­
dinitis. or tendon ruplure with this injury.12,H4i
Injury Mechanism. The sllspected injmy mecha­
nism is a shearing force transmitted from the handle of a
club to the hamate. It often occurs when striking an unex­
pected object (as when a golfer strikes a rock or tree root) .
It most frequenLly occurs in golfers but can occur in any
slick sport. such as baseball or field hockey. There is also a
possibility of a stress fracture from tension from ligament
and muscle attachments. but lhis ,is rare.'
Rehabilitation Concerns. The first concern is di­
agnosis. Athletes might have felt a snap or pop. They will
have localized tend erness over the hamate hook. ulnar­
side wrist pain. and weakness of grip that increases over
time. A carpal tunnel view X ray will confirm the diagno­
sis. The athletic trainer or therapist must also be con­
cerned and watch for signs of ulnar neuritis or
neuropathy, and nexol' tendon ruptnre.
Rehabilitation Progressions. Treatment has been
described as casting an acute hamate hook Cracture 2 . 33 or
bone grafting a non-union. il However. as described previ­
ously. these fractures do not usually heal secondary to
forces applied to the fracture fragment. Treatment for
symptomatic hamate fractures is fragment excision.'u;
Treatment foIlowing excision is edema control. scar
massage (3 to :; minutes, :; limes/day). and grip strength­
ening if necessary.
Criteria for Return. Acute injuries must be treated
symptomatically. Tape or padding. if allowed. may be
placed in the palm. Chronic fractures arc also treated
symptomatically. with pain being the limiting factor. It is
not detrimental for the athlete to continue to play with a
fracture and have the fragment rerno~led at the end of the
470 PART THREE The Tools of Rehabilitation

and external or inL

lipoma. diabetes. 01
occur following a
edema or a frac m
nerve.
Rehabilitatior
is tried first and con
neutral (Figure l C
and relative rest Cre
Occasionally phy
splinting. This aulh'
during the day. as tJ
Figure 20-34 Phalen 's test for ca rpal tunnel injury is pain from distri bUL
extreme wrist flexion, which narrows the space in the may be done by LI::
carpal canal. The test is positive if there is numbness and is also diagnos tic. lJ
tingling in the median nerve distribution within 60 sec­ tion, the diagnosis ~
Figure 20-33 Otoform is used as a scar control pad. It onds. Do not nex elbows or rest elbows on tile table. as gliding exercises d~
comes in \'arying size containers. The needed amount of this can elicit ulnar nerve symptoms.
myofascial release c
"putty" is taken from the jill". mixed with a catalyst. and tivity analysis and
applied directly to the scar <Jrea. Once it hardens. in 1 to 2 that increase symp
minutes. it can be rinsed and applied with Coban or a
technique will deere
similar covering. It is usually worn 23 hours per day for
scar control. It docs need to be removed. as it does not If conservalin'
breat.he and skin can become macerated . or a rash can lease may be perfo
develop. n may also be worn during sport activity for ad­ lease consists of 11'0\
ditional protection to a sensitive area. and ROM exercises
improve ROi\,1 and
start with full- fin~
maximize FOP pul
season. as long as they are able to play with their symp­ long fist to maxim i
toms. ff tb e alhlete is unable to play. the injury should be fist. Full extension _
surgically addressed. sition (Figure 20- \
Once th e fragment has been excised. the athlete may formed (Figures 10 J
return to sport as soon klS they are comfortable. A small Figure 20-35 Firm pressure over the carpal tunnel can
Rehabilitation
elicit numbness or tingling in the median nerve distribu­
splint, padding, or scar control pad such as Topigel or Oto­ carpal tunnel rel e
tion. This alone is not indicative or carpal tunnel injury.
form (figure 20-33) might be helpful initially for scar con­ cises should begin
but provides more information.
trol and to decre ase hypersensitivity around the incision Wrist strengtheoin
area. FuJI return is expected. ing is generally beg
sultation with the
Carpal Tunnel Syndrome in the hanel Symptoms might increase with static posi­ should also be perfo
tioning (e.g., when driving or reading a newspaper) Y Di­ Criteria for Re
Pathomechanics. Carpal tunnel syndrome is com­ agnosis is made by history, Phalen's test (Figure 20-34). with carpal tunnel.
pression of the m edian nerve at the level of the wrist. The Tinel's sign. nerve conduction studies. direc t pressure over to see whether it co
carpal tunnel is made of the carpa1 bones dorsally and the carpal tunnel (Figure 20- 3 S). and EMGs. Injection can Activity level is basd
transllerse carpal ligament volarly. Located in the carpal help confirm diagnosis and may relieve symptoms. ment fails and a relea
tunnel are the FDS and FOP tendons to all digits, FPL, me­ Injury Mechanism. The incidence or carpalt unnel return to sport once
dian nerve, and median arlery. 2J If tendons become in­ is extremely low in most athletes. Ii but the injury is found is rarely necessary iQ
named. the space within the carpal tunn el is decreased in cyclists , throwers, and tennis plilyers. 39 Pressure fr0111
and the nerve becomes compressed. Excessive wrist nexion resting on handlebars can cause symptoms. Sustained
Ganglion Cyst!
or extension will also increase pressure in the carpal tun­ grip and tbe repetitive actions of throwers and racquei
nel. Symptoms of classic earpa,l tunnel are numbness and sport.s can also increase symptoms. Illnesses or injuries Pathology. A!
tingling in the thumb through the radial half of ring fin­ tha t have been associated with carpal tunnel include soft.tissue tumor in
ger. pain or waking at night. and clumsiness or weakness tenosynovitis from overuse or from rheumatoid arthritis. from the synovial lin
 CHAPTER 20
and external or internal pressure from conditions such as
lipoma, diabetes, or pregnancy, 54 Acute carpal tunnel can
occur foJlowing a fracture or otber trauma, by either
edema or a fracture fragment pressing on the median
nerve,
Rehabilitation Concerns. Conservative treatment
is tried first and consists of night splinting with the wrist in
neutral (Figure 20-25), anti-inflammatory medication,
and relative rest from the aggravating source (if known),
Occasionally physicians will recommend full-lime wrist
splinting, Th,is a u thor prefers that wrist splin ts not be worn
during the day, as this leads to muscle weakness and arm
I tunnel injury is pain from distribution of forces to new areas, Injections
1e pace in lhe may be done by the physician for symptom relief-this
'i numbness and is also diagnostic, If the symptoms disappear with injec­
,n wiLhin fiO sec­ tion, the diagnosis is correct. Symptoms can recur, Nerve­
on the table, as gliding exercises described by Butler 7 (Figure 20-17) and
myofascial release might also help relieve symptoms, Ac­
tivity analysis and biomechanical analysis of activities
that increase symptoms should be done to see if changes in
technique will decrease symptoms,
If conservative treatment fails, a carpal tunnel re­
lease may be performed, Rehabilitation following a re­
lease consists of wound care (if necessary), scar massage,
and ROM exercises, Tendon-gliding exercises are done to
improve ROM and isolation of tendons, These exercises
start with full-finger extension, then a hooked fist to
maximize FOP pull-through in relation to FDS, then a
long fist to maximize FDS pull-through, then a composite
fist. Full extension should be performed between each po­
sition (Figure 20-18), Wrist ROM should also be per­
formed (Figures 20-1 and 20-2),
e earpall unncl can Rehabilitation Progressions. Progression for
an nerve distribu­ carpal tunnel release includes grip strengthening. Exer­
-pal lUlll1el injury, cises should begin slowly, to not increase the symptoms.
Wrist strengthening may also be performed. Strengthen­
ing is general'ly begun 2 to 4 weeks postsurgery, after con­
sultation with the physician. Upper-body conditioning
e wilh stntic po i­ should also be performed if necessary for return to sport.
a newspaper) 2 1 Di­ Criteria for Return. Athletes may continue to play
e L (Figure 20-3 4 with carpal tunnel. Activity should be examined. though,
direct pressure o\'e~ to see whether it could be altered to decrease symptoms,
I E. ! s, Injection car. Activity level is based on symptoms. If conservative treat­
e ymptoms, ment fails and a release is performed, athletes can typicaJly
nee of carpal tun n return to sport once sutures are removed. Surgical release
t the injury is foun is rarely necessary in athletes.
ers,39 Pressure fro
~p toms, Suslain Ganglion Cysts
owers and racq ut
mn esses or inj urit Pathology. A ganglion cyst is the most common
lfpa l tunnel inclu soft-tissue tumor in the hand. 6 It is a synovial cyst arising
rhe umatoid arth rit" from the synovial lining of a tendon sheath or joint. The
Rehabilitation of Wrist, Hand, and Finger Injuries 471
Figure 20-36 This is a dorsal wrist ganglion, These
vary in size and shape and will transilluminate,
etiology is unclear. They are most common on the dorsal
radial wrist, but can also be volar (Figure 20-3h). They
originate deep in the joint and can be symptomatic before
they appear at the surface. The usual origin is [rom tlIe
area of the scapholunate ligament. 6 Ganglion cysts are
translucent, which can help confirm the diagnosis.
Treatment is aspiration of the cyst. Results of recur­
rence are variable, In adults, multiple aspirations Hre sug­
gested, with success rates of 51 to 85 percent. 2 i [f multiple
aspirations are not successful and cysts recur, they may be
surgically excised.
Injury Mechanism. In the athletic population . it
appears that ganglions most often form with repealed
forceful hyperextension of the wrist. as would occur in
weight lifters, shot putters, wrestlers, and gymnasts. Pain
is the indication for treatment.
Rehabilitation Concerns. These patients do not
need to be seen for rehabilitation once diagnosed and aspi­
rated, The aspiration usually decreases pain and allows for
full ROM. Following ganglion cyst excision, patients may
need to be seen for ROM, passive stretching, strengthening,
and scar control. ROM emphasis should be on wrist flexion
and extension and finger flexion and extension (Figures
20-1,20-2, 20-l8), Scar massage and desensitization !Uay
be done with lotion. rubbtng on the scar. tapping on the
scar, and performing vibration to the scar. Less noxious
stimuli should be done first, with increasing difficulty be­
ing added to program . Scar control pads such as Oto['orm
(Figure 20-33) or Topigel sheeting may also be used, held
in place with Coban,
Rehabilitation Progressions. Following excision
and return of ROM, strengthening may be done as neces­
sary for grip, wrist flexion and extension, and general
upper-extremity return-to-play exercises,
472 PART THREE The Tools of Rehabilitation

A B c
Figure 20-37 A, i\ boxer's fracture splint protects the ring and small finger proximal phalanxes and metacarpals. in­
cluding the l'v[CP joint. The splint may be modified for a different neck fracture (immobilizing the involved MCP joint). B, Figure 20-38 F
Metacarpal shaft fracture (possibly only the metacarpal will need to be in the splint, leaving the wrist and MCP joints in DeQuervain·s.
rree). C, Metacarpal base fracture (this might need to include the wrist, usually leave the MCP joints free) (C). ulnar deviation is l
pare Lo the non im
fortable nOl'maJJy.

Criteria for Return, Activity is limited by pain. (figure 20-37). The latter is often preferred as it allows for
Athletes may participate with a ganglion if it is not symp­ skin hygiene. wrist ROM, and IP joint ROM. The splint im­ i EPL),is usually ON
tomatic. If symptomatic, it may be aspirated with immedi­ mobilizes only the ring and small finger Mep jOints. The thumb does not n
ate return to activity. rr it recurs, it may be aspirated again splint is also easily remolded if necessary as edema de­ dition can be aggrm
with no loss of playing time. If necessary, the ganglion creases. Splinting is continued for approximately 4 weeks. deviation. flexjo n ar.
may be excised at the end or the season. Ii' excised. sport Rehabilitation Progression. During the lime of and adductioll of l
activity may begin once sutures arc removed. at approxi­ immobilization. ROM to non involved joints is maintained thumb flexion in to
mately 10 days. Full return is expected. by active and passive exerdses. At approximately 4 weeks
the splint is discontinued and ROM to MCP joints is begur..
Boxer's Fracture Buddy taping may be done to encourage RO:'l'l. Between 4 uncomfortable 1m
and 6 weeks gentle re.sistance may be performed . with vig­ will be positive for
Pathomechanics, A boxer's fracture is a fracture of orous activities at about 6 weeks. Injury Meehl
the fifth metacarpal neck . This is the most commonly frac­ Criteria for Return. An athlete may return when
tured metaearpal. 2l Tt will frequently shorten and angu­ there is a s.ign that the fracture is healing. it feels stable.
late on impact. 'fherc is a large amount of movement of and there is no pain with the fracture or movement. This 1.s
the fifth metacarpal. For this reason. perfect anatomic re­ generally at 3 to 4 weeks with protection. Generally by f lJ:equent causes inc.
duction is not necessary. It should be noted. however, that weeks the athlete may play with only buddy taping protec­ Clcute strain as in Iii
excess angulation can lead to either an imbalance between tion. This, as always, depends on the sport. the athlete, and compartment. 26
the intrinsic and extrinsic muscles of the hand, leading to the physician. Rehabilitation
clawing, or to a mass in the palm. H
Injury Mechanism, This injury occurs most fre­ OeQuervain's Tenosynovitis a fracture or liga men
quenLiy from conlact against an object with a closed fist. known injury h as
The impact is usually through the fifth metacarpal head.
and Tendinitis
inflammatory m edi
Rehabilitation Concerns, Of concern is skin in­ Pathomechanics, Tendinitis. most simply put. is ities. Modalities for
tegrity. The injuries frequently occur as a result of a fighl, inflammation of a tendon. It can occur on the dorsal wrist.
and pieces of tooth might be in an open wound. Tf the in­ volar wrist. or thumb. Symptoms are pain along the mus­
jury is closed, concern is for proper immobilization, edema cle, pain with resisted motions. and/or swelling. II is fre­ ics arc aggravatin g
control. and ROM of noninvolved joints-especially the IP quently caused by overuse. Injections can help relieve weak shoulder I11W
joints of the small nnger. Occasionally ORIF is required. symptoms and confirm diagnosis. be contributing to
Edema control is critical. AROM may be initiated 72 hours DeQuervain's tenosynovitis is an inflammation in the mechanics .
o
after the RTF. 34 first dorsal compartment; the abductor pollicus longus Splinting for \\Ti.
Treatment is immobilization in a plaster gutter splint, (APL) and extensor pollicus brevis (EPB) are affected.! The (Figure 20-25). Spli
or in a thermoplastic splint fabricated by a hand lherapist third dorsal compartment, the extensor pollicus longus thumb MCP and C,\1(
 CHAPTER 20 Rehabilitalion of Wrist. Himd, dnd Finger Injuries 473

I m etacarpals, in­
.ed \lICP joint). B, Figure 20-38 Finklestein 's test will be positive for pain
md ~i[CP joints in DeQuervain 's, Passive flexion of the thumb with wrist
Figure 20-39 A DeQuervain 's splint is a radial gutter
~I (C). ulnar deviation is the provocative position, Always com­
thumb splint.lL s upports the wrist and thumb Co/Ie and
pare to the non involved side, ,IS this test can be uncom­
Mer joints. It is used to rest the thumb a nd IVris t with
fortable normally. ,oeQuervain's .

..red as it allows for

, \ 1. The splint in ­ IEPL), is usually not affected, and as such th e IP joint of the
er \ICP joints. Tht' thumb does not need to be included in any splint. The cou­
,..;ary as edema de­ dition can be aggravated by excessive wrist radial and ulnar
xi m ately 4 week: . deviation , flexion and extension of the thumb, or abduction
Juring the time f and adduction of the thumb 2h Finklestcin's tcst, I ! passive
ints is mainl<1in ed thumb [lexion into the palm with passive wrist ulnar devi­
roximately 4 wee ' ation, will be positive [or pain (figure 20-38), 1\lways com­
, CP joints is begun. pare to the noninjured side, as -Ihis test can be
=- ROM. Between 4 u ncornfortable normally. Resisted wrist flexion or extl't1sion
rformed, with vig­ will be posiLive for pain with wrist tendinitis.
Injury Mechanism. Tendinitis is usually caused by
~ m ay return wh ell overuse, It can a-lso be caused by weakness, poor body me­
ilin g, it fe els stable, chanics, or abnorm a l postures, DeQucrvain 's can be
'(' m ovement. This is ca used by repeated wrist radial and ulnar deviation. Less
lion. Generally by 6 frequent causes include a direct blow to the radial styloid,
>u dy taping protec­ acute strain as in lifting., or a ganglion in the first dorsal
IOrt. the athlete, and compartment. 26
Rehabilitation Concerns. If a direct blow to the
wrist or forearm or fall on outstretched hand ha s occurred,
is a fracture or ligament injury should be ruled out first. If no
known injury has occurred, initial trcatment is anti­
inflammatory medication and rest. from aggravating activ­
ost simply put, is ities. Modalities for edema reduction and pain control,
ro n the dorsal wrist. such as ultrasound, iontophoresis, or ice, can be effective,
pa in along the mus­ Analysis of activity should be done to see if poor mechan­
pr swelling, IL is fre­ ics arc aggravating symptoms, Look proximally to see if
rs can help relieve weak shoulder musculat ure or scapular stabilizers could
be contributing to compensatory techniques and poor
~ nammation in t.he mechanics,
,tor pollicus longus Splinting for wrist tendinitis includes the wrist on ly
'BI are aUected, 1 The (Figure 20-25), Splinting for DeQuervain's includes the
or pollicus 10llgns thumb MCP and CMC joints, and wrist, usually in a radia l
gutter fashion (Figure 20-39). Splinting is usually full­
time except for hygiene for the first 2 to '3 weeks, then if
symptoms are subsiding, wearing time is slowty decreased
while activity is increased. If pain is persistent. splintiug
continues ,
Rehabilitation Progressions. Stretching 0(" t he
affected areas in a pain-free range (Figures 20-1),20-16)
three times per day should begin Immediately with rest
(s plinting) and anti-inflammatory medication. Once pain
has decrea sed, strengthening of grip and wrist muscula­
ture may begin. Strengthening should begin isom etri­
cally, progressing to full ROM against gravity, and then
light weight in the pain-[ree ra nge (F igures 20-1 through
20-4), Progression to weight bearing and plyometrics
may occur if there is no increase in symptoms (FigufCs
20-12to 20-14,20-23, 2 0-24). If strengLhening is begun
too early, symptoms will be re-exacerbated, If tendinitis is
a result of mu scle imbalance. the weak muscle groups
must be stre ngthened. If symptoms do not subside, and
injections are helpful but do not cure the symptoms, a re­
lease of the first dorsal com partment, iJ l)eQuerain's
tenosynovitis, migh t need to be performed ,
Criteria [or Return. Pain and stre ngth are limiting
factors for return. Athletes should have pai n -frce ROM to
the affected part. Strength should be significantlo prevent
reinjury, T he athlete may participate prior to absence of
pain if th ey are taped for support. use a splint for rest while
they arc not participaLing in sports, and pai n docs n ot im­
pnir performance.
If a release is performed, it may be don e a t the end of
the season if symp tom s permit play. If not. th e athleLe can
return when comfortable, as early as Hl days postsurgery.
474 PART THREE The Tools of Rehabilitation

Rehabilitation
trealment is im p<>
sion. if n ot trea t
un stable witb In:
Treatment for
biUzalion in a thu
wit h addilion a l
10-42). A ROJ\l Ii)

follOWing the first

Treatment for
joint) should be
as successful a s ea
is recommended. ­
Figure lO-40 The ulnar collateral ligament provides splint is worn for
support on the ulnar MCr joint. i\ fall on an abducted splinting excepl
thumb can cause injury or rupture. extension .
Figure 20-41 A gamekeeper's UCL injury. Enlarge­ Concerns dun. =
ment of the MCP joint is normal. elude prolectil'e
Strength should be sufficient to prevent reinjury. aggra­
maintaining mOl
vating forces should have been addressed. and support ini­
lional concern. i.
tially might be needed.
radial stress on lh
Rehabilitati on
Ulnar Collateral Ligament Sprain splinting is (jjscop
(Gamekeeper's Thumb) exercises are upge;
sioll to active a
Pathomechanics. The ulnar collateral ligament be taken n ot to ap
(UCL) injury to the MCr joint 01 the thumb is tbe most ing the first 2 to t-
common ligament inj ury40A l.i6 The injury can be classi­
fied as grade I or grade II. in which the majority of the lig­
ament remains intact. Grade III is a complete disruption of
the UCL. and surgical repair is recommended. Rupture oc­
curs most often at the distal attachment of tbe liga­
ment 2212 (figure 20-40. 20-41). made by the phy~
The athlete will complain of pain or tenderness on the icine staff. Len gt h
ulnar side of the MCl> joint. X rays should be taken to rule by the sport and
out fracture. Following X rays. ivlCP joint stability should Figure 20-42 A gamekeeper's splint may also be called needs to use b is or
be evaluated at full extension and at 30 degrees of flexion . a hand-based thumb spica spliJJt. It always includes the
a cast or splint m.
These two posilions will test the accessory collateralliga­ thumb MCr joint and may include tbe CMC or IP joint.
tum to play. Once
ment and the proper collateral ligament. respectively. An­ depending on the injury or sport.
protective splin t If.
gulation greater than 35 degrees or 15 degrees greater jury from ex tcnsiol',
than the noninjured side indicates instability and surgery a hand therapiSl
is recommended. 22 the lTCr.. 9 It was not an acule injury. as it most commonly
during sports sb ou
If the ligament is completely torn. one must also worry is in sports.
pain and swellio g
about a Stener lesion. This is where the torn LJ CL protrudes Injury Mechanism. UCL injuries occur when a tor­ ·free RO M.32
beneath the adductor apponeurosis. This places the ap­ sionalload is applied to th e tbumb.s it frequently occ urs in
If surgical repru
pOlleurosis between the ligament and its insertion. If tbis pole or stick sports (e.g.. skiing) where the thumb is ab­
for a minimom of 2
occurs. reattachment will not occur spontaneously with ducted to hold the pole or stick and the athlete falls and
that tbe position an
casting or splinting and surgery is needed ." tries to catch herself on an outstretched hand. landing on
until return. If tb e
A more appropriate term for this injury in an athlete an abducted thumb. 3 2.4o.56 Defensive backs in football
thomb. follow pro t
would be skier's thllmb. In itially. CampbC'lI described game­ might also sustain this injury while abducting the tbumb
alive conditions ab
keeper's injury as being due to chronic repeated stress on before making a tackle. 12
thumb movement is I
 CHAPTER 2() Rehabilitation of Wrist, Hand. and 475

Rehabilitation Concerns. Early diagnosis and

treatment is important. An unstable thumb or Stener le­
sion, if not treated, will become chronically and painfully
unstable with weak pinch and arthritis as sequelae.-12
Treatment for incomplete (grade I or II) tears is immo­
bilization in a thumb spica cast (Figure 20-29) for 3 weeks.
with addition a l protective splinting for 2 weeks (Fi gure
20-42). AROM to flexion a nd extension mcly be performed
fo llowing the fLr st 3 weeks.
Treatment for complete tears (grade Ill, un stabl e Mep
joint) should be surgical repair. Late reconslruction is not
as successful as early surgery, so early operative treatment
is recommended. 11 Postoperatively, a thumb spica cast or
splint is worn for 3 weeks. with a n additional 2 weeks of
splinting except for exercise sessions of active flexion and
Figure 20-43 Thumb spica taping may be L1sed when
extensio n.
additional support is needed to the wri st and thumb. Ten­
Concerns during the initial 5 or 6 weeks poslinjury in­ dinitiH, gamekeeper's inj uries, or healed fracture s are
'llury. Enlarge-
clude protective LmJl1obilization, controlling edema, and some indications.
maintaining m otio n in all ooninvolved joints. An addi­
tional concern. is once movement is begun , is to not place
of the quarterback). the athlete will be out at lea st 4 to 6
radial stress on th e thumb to stretch the eeL.
weeks. 40 Strength should be sufficient and pain decreased
Rehabilitation Progression. After protective to prevent reinjury.
splinting is discontinu ed (a t approximately:; to 6 weeks),
exercises are upgraded [rom AROM of flexion and ex ten­
sion to active a ssistive and passive exercises. Ca re should CLINICAL DECISION MAKING Exercise 20-4
be take n not to app ly abduction stress to the MCr joint dur­
ing the first 2 to 6 weeks following immobiliza tion . Putty A basketball player's thumb was hyperextended when she
exercises for stre ngth m ay be performed at approximately caught it pass during practice. It began swelling immedi­
8 weeks postinjury. When meas uring thumb RO~1. always atdl' in the thenar area and Mel' joint. She had pain Hnd
compare to the noninjured side. There is a lar ge am ou nt of tenderness at the Mep join!. The athletic trainer rcferred
variation in MCP and II' RO:V[ from person to peIson. her to the physician, who sent her back with the diagno­
Criteria for Return, Return-to-play decisions arc sis or grade 2 lICL sprain. What can the athletic trainer
made by the physician in conjunction with the sports med­ do to decrease pain. provide stability, amI return the ath­
icine staff. Length of time to return to play is determined lete to play i
by the sport and p()sition played, and whether the athlete
needs to usc hjs or her thumb. For nonoperative treatment
a cast or splint mi gh t proVide adequate protection for re­
Finger Joint Dislocations
turn to play. Once the athlete is medically cleared to play. a
protec tive splint (fi gure 20-42) or taping to prevent rein­ Pathomech a nics. Dislocation of th e VIep joint is
jury from extension and abducti on should be fabricated by very infrequent. Th e force is dissipated by joint mobility. s;
a hand therapist or athletic trainer. Protective splinting These injuries can be a simple dorsal subluxation, in whi ch
it most. commonly during sports should co ntinue for at least 8 weeks until the proxima!] phalanx rotates on th e metacarpal head a nd
pain and swelling subside an d patient has complete pain­ locks the joint in 60 degrees of hyperextension: or an irre­
occu r when a tor­ 'free R01VL l l ducible dorsal dislocation where th e volar plate is inter­
frequenlly occurs in If su rgical repclir is performed, th e athlete wHl be out posed dorsally to th e metaca rpal head and prevents
ere t he thumb is ab-
for a min imum of 2 weeks while the incision heals. !\fter reduction . For a simple dIslocation , after reductlon some
the alhlete falls and
th a t the position and sport det er mine the le ngth of lime physicians splint the Mel' joints in .:;0 degrees of flexion for
ed hand, landing or:
until return. If th e athlete does not have to use his or h er 7 to 10 days. ;; Others buddy tape and allow full motion
\ e backs in football
thumb, follo w protective splin ting guidelines for nonoper­ immediately. If the fracture is irreducible, it mu st be ope nly
abducting the thumb
ative conditions above. For either treatment where active red uced with the \7o lar plate retracted. The MCl' joints are
thumb movemeot is n ecessa ry (e.g.. in the throwing hand then splinted at 50 degrees or greater of l1exion.
476 PART THREE The Tools of Rehabilitation

Injury Mechanism. The mechanism for all finger Criteria for I

dislocations is a hyperextension force or a compressive joint dislocations i
load force. S dislocation and \\
Rehabilitation Concerns. The initial concern is 10 MCP joints have;
rule out a fracture and relocate the injured joint. If the duced, and rem ai
joint is not reducible. appropriate surgical intervention is buddy taped. Coba
needed. Once reduced. Coban (Figure 20-44) should be ap­ tectjve splinted for
plied Lo decrease edema. Protective splinting or buddy tap­ sport immediately
ing is also applied. [n PIP dorsal dislocations without If it is a complex d
fracture. immediate ROM is important to decrease stifl~ athlete will be ou t
ness. Complications of finger dislocations include pain. For PIP jOint
swelling. stif't'ness. or loss of reduction. once the jOint is re
Rehabilitation Progressions. Simple dorsal sub­ Coban wrapped ill
Figure 20-44 Coban is similar to Ace wrap in lbat it is luxation of the MCP joints are reduced and splinted in 50 splint is optional fo
elastic. It Slic.ks to itself. so there is no need for clips. 11 degrees of nexion for 7 to 10 days. FoHowing splinting, athlete may retun
comes in varying widths from 1 to 3 inches. One inch is AROM is begun . Because the joints are immobilized in flex­ not reducible. or lb
perfect for fingers. StClrt wrapping from distal to proximaL iOll. the collateral ligaments remain taut and full MCr flex­ from sport will \'ar
pulling slightly' but still leaving some wrinkles. Check cir­ ion shouJd be maintailled. Extension is not lost at the MCr of injury.
culation following application. CobCln is perfect Lo help
joints with lhis injury. Progression is from full ROM to gen­ For DIP join l cL
prevent swelling in Jlnger injuries. especially PIP disloca­
tle strengthening to more aggressive strengthening. athlete may return
tions. immediately following injury.
If the ,\1CP jOint dislocation is irreducible. it will re­ the disloca tion is 0(
quire open reduction. Pins may be placed holding MCP ally return once s
Dislocation of the PIP joint volarly is vcry rare and is joints in flexion. If not. the hand needs to be splinted with about 10 days. \\;l
usually a grade TIl irreducible fracture. It requires opcn re­ Mep joints in flexion. Once motion is allowed. active flex­ the DIP jOillt is vCr)
duction. Because it is very complex and rare in athletes. it ion and extension are initiated. SUffness can be a problem.
will nol be covered in depth in this chapter. as can tendon adherence in the scar. Hehabilitation might
Flexor Digit~
Dorsal dislocations are mucb more common in sports. be dimcult and require consultation \~Tilh a hand therapist
The athlete might not even bring the injury to the Cltten­ for splinting to regain motion. HONI is progressed to ADLs.
Avulsion (Jen
tion of the atJlletic traioer, but might instead just pull the strengthening. and functional relurn to sport activities.
finger bClck into place independently. II a finger prJ' is dor­ prp dislocations witllOut fractures, once reduced. need flexor digitorum pr,
sally dislocated, immediate reduction (usually by physi­ to be wrapped in Coban for edema conLrol (Figure 10-44) on the dista 'l phal
cian) is preferred. If a phYSician is not present. and an and started on early motion. Exercises include composite finger. It may be a\
expericllced athletic traincr is not present. an X ray flexion and extension . and blocked PIP and DIP flexion ex­ with bone, depend'
should be taken prior to reducLion to be sure there is no ercises (Figures 20-18tllrough 20-20). Buddy taping is of~ don will usually n
fracture. If there is no fracture. and th e PIP joint is re­ ten helpful to enc.ourage HOM and provide protection. This "caught" on the p
duced and stable. the fing er should be wrapped in Coba n is frequently enough to maintain moLion and strength. [I' only a very sma II n
(Figure 20-44) for edema control and buddy taped to stiffness does occur, a rcferr-al to a hand therapist may be ret ract back in to
the adjacent finger. ROM is begun immediatQly (Figures necessary for dynamic splinting, serial casting. or an ag­ Each time the athle
20-18 through 20-21). These injuries do not need to be gressive strength and motion program. cle is contracting
splinted, and should not be overtreated. If the DIP is dislocated. closed. and easily reduced. it brings the inser tiOI
DIP jOint dislocations arc more rare than PIP di sloca­ should be splinted in neutral to sligbt flexion for 1 to 2 The way to isol
tions. 10 Dorsal dislocations occur more frequently than weeks. AROM begins at 2 to 3 weeks. with protective tegrity is to hold th
volar. .If the injury is closed. it is usually reducible. X rays splinting continued between exercise sessions for 4 to (, ger in full cxtensioq
should be takcn to rule out fracture. If the joint is reduced weeks. Si At that time putty for strengtbcning (Figure the DIP jOint. [f it n
and there is no fracture, splint the DIP only in neutral for 1 20-] 1) and blocked DIP exercises (Figure 20-20) may tured (Figure 20-2
Lo 2 lVeeks (Figure 20-48). If the DIP dislocation is open begin. If the tendon is I
(and it frequently is) or is irreducjble. it necds to be surgi­ Open or irreducible fractures require surgical wound is do nothing. If the
cally addressed. i i With all finger dislocations in a gloved care with debridement to prevent infection. These in­ be unable to flex lh
.athlete, the glove must be removed to determine whether juries are then treated like mallet fingers and progressed strength. and mig ht
the injury is open or closed. accordingly, 55 traction. but funeti
 CHAPTER 20 Rehabilitation of Wrisl, Hand, and Finger Injuries 477

sm for all ringer Criteria for Return. Return to play for all finger
Ir a compressive joint dislocations is dependent upon the complexity of the
dislocation and whether a fracture has occurred. H the
:tial concern is to MCP joints have a simple dislocation and are easily re­
Jred joint. If the duced, and remain reduced, the affected finger may be
al intervention is buddy taped, Caban wrapped for edema control, and pro­
4c-l ) should be ap­ tective splinted for pain control if necessary. with return to
i ng or buddy tap­ sport immediately or within the first few days after injury.
)Cations without It' it is a complex dislocation and surgery is necessary, the
to decrease stiff­ athlete will be out a minimum of 2 to 3 weeks.
in S include pain, For PIP joint dorsal dislocations without fracture,
once the joint is reduced and stable, the finger shouJd be
Im ple dorsal sub­ Coban wrapped and buddy taped. A dorsal Alumafoam
IOd splinted in 50 splint is optional for pain control during sport activity. The
athlete may return to activity immediately. If the joint is Figure 20-45 A jersey finger (F-OP avulsion) injury is
11 wing splinting,
not reducible, or there is a fracture, the length of time lost named for the injury mechanism-forced hyperextension
lUllobi Iized in f'Iex­ with finger flexion, as in trying to grab a shirt during a
and full MCP flex­ from sport will vary depending on the sport and severity
tackle. The position or the DIP joint after injury will 'be
lot lost at the Mel' of injury.
extension or hyperextension.
m rull ROM to gen­ For DIP joint dislocations that are easily reduced, the
rn gthening. athlete may return immediately with Caban and splint. If
ducible. it will re­ the dislocation is open or irreducible, the athlete can usu­ second option is to have the tendon surgically repaired. If it
Iced holding MCP ally return once sutures are removed after surgery, at is repaired. the athlete should be inlcJrlned that this is a
LO be splinted with about 10 days, with protective splinting. The criteria for labor-intensive operation and rehabiJitation, there is a risk
llowed. active flex­ tbe DIP joint is very similar to criteria for mallet ,finger. of scarring with poor tendon glide, and there is a risk of ten­
•ca n be a problem. don rupture. The atblete will not have full activity level for
-habilitation might Flexor Digitorum Profundus approximately 12 weeks after surgery. The repair shou(J. be
Ih a hand therapist Avulsion (Jersey Finger) done within] 0 days of injury for the best results.
mgrcssed to ADLs. Injury Mechanism. Forceful hyperextension of the
1 port activities. Pathomechanics. Jersey ilnger is a rupture of the fingers while tightly gripping into flexion is the injury
on 'e reduced, need flexor digitorum profundus (FOP) tendon from its insertion mechanism. It most frequently happens in football when a
lTol (Figure 20-441 on the distal phalanx. It most frequently occurs in the ring shirt is grabbed to try to make a tackle and the finger gets
incl ude composite finger. It may be avulsed with or without bone. If avulsed caught; " (Figure 20-45).
and DIP flexion ex­ with bone, depending on the size of the fragment, the ten­ Rehabilitation Concerns. This can be a very diffi­
. Buddy wping is 0.'­ don will usually not retract back into the pallm, as it gets cult li njury to treat if surgically repaired. The surgery
ide protection. Tbis "caught" on the pulley system of the finger. If no bone, or should be done by an experienced hand surgeon 1 J with re­
n a nd strength. r only a very sma'" fleck of bone, is avu'lsed. the tendon will habilitation by an experienced hand therapiSt. Close com­
d lherapist m ay be retract back into the palm . This is the most common. 56 munication between band surgeon, hand therapist. and
'asling. or an ag,­ Each time the athlete tries to flex his or her ,finger, the mus­ athletic training staff is a must. All protocols arc guide­
cle is contracting but the insertion is not attached. This ]lines and as such may need to be altered if complications
easily reduced. brings the insertion closer to its origin. such as infection, poor tendon glide, or excellent tendon
nexion for 1 to .: The way to isolate the FOP to evaluate function and in­ glide occur. With this injury, unlike most others , the better
. w ith protecli\ tegrity is to hold the Mep and I'll' joints of the affected fin­ a person is doing (i.e .. full active tendon glide) the more
. ions for 4 LO ger in full extension, then have the athlete attempt to flex they are held back and protected. Good tendon glide is in­
the DIP joint. If it Ilexes, it is intact. If it does not, it is rup­ dicative of less scar, which means there is less scar holding
tured (Figure 20-20). the repaired tendon together, thus less tensile strength and
If the tendon is ruptured, there are two options. The first increased chance of rupture. If a tendon is ruptured. it
Ire sur gical wou is do nothing. If the tendon is not repaired, the athlete will must be repaired again and the prognosis is poorer.
fee llon. The e be unable to flex the DIP joint, might have decreased grip Proper patient education is a must. Instruction in what
rrs and progre '­ strength, and might have tenderness at the site of tendon re­ to expect, reasons for specific exercises, and consequences
traction, but functionally should not have difficulty. 56 The must be conveyed.
478 PART THREE The Tools of Rehabilitation
Figure 20-46 1\ flexor tendon splint-usually applied
within 5 days postsurgery- is dorsally based and in­
cludes the wrist in neutral to slight flexion. Mep joint
flexion. and II' jOint extension. Depending on the location
01 injury. the amount of flexion may be increased or de­
creased. and rubberband truction may be applied from
flngcrnuils to forearm strap.
Rehabilitation Progressions. The following are
guidelines. They are not all-inclusive. nor are they an indi­
ca tion that just anyone can treat this injury. For more spe­
cific information on the protocol. readers are encouraged
to read <lnd revi ew the Roslyn Evans article on zone I flexor
tendon rehabilitation.]"
Between 2 and') days postoperative. the bulky dressing
should be removed and a dorsal splint fabricated to hold
th e wrist in neutrul. Mep joints in 30 degrees of flexion.
a nd IP joints in full extension with the hood extending to
the fi ngertips for protection (Figure 20-46 ). The affected
DIP joint is splinted at 45 degrees of llexion with a second
dorsal splint that extends from t.he PIP jOint to the finger­
tip. held on with tape at the middle phalanx only. Exercises
for th c first 3 weeks are (1) passi ve DIP flexion; (2) full com­
posite passive flexion. then extend MCP joints passively to
a modified hook position; (3) hyperflexion of MCP joints
with active extensionof PTF joints to 0 degrees; (4) strap or
hold nooinvolved fingers to the top of the splint. Position
PIP joint in flexion passively then actively hold the joint in
flexion (Figure 20-22 ). All exercises should be done with
the splint on. at a frequency of ten repetitions every wak­
ing hour. The pCltients should not use the injured hand for
anything. extend the wrist or fingers with the splint ofr. or
actively flex the fingers-all of these could callse tendon
rupture. In addition . during the first weeks Coban (Figure
20-44) can be used for edema control and scar control.
Scar massage may be performed in the splint. The dressing
may be changed at horne. but the DIP splint should remain
in place at all times for 3 weeks .
Between 3 and 4 weeks post repair the digital splint is
discontinued. passive fist and hold is begun for composite
flexion. and dorsal protective splinting is continued. Be­
tween 4 and 6 weeks active hook fist and active composite
flsting is begun. wrist ROM is begun . and gentle isolated
profundus exercises are initiated (Figures 20-18 through
20-20) . The splint may be discontinued if poor tendon
glide is presen t.
At 6 to 8 weeks the splint is discontinued. ADLs may be
done with the injured hand. and tendon-gliding exercises
and blocked DIP exercises are continued. Light resistive ex­
ercises (putty) (Figure 20-11) may be initiated. Graded re­ Figure 20-47 A
sistive exercises are begun if there is poor tendon glide. Be ion. There migh t or
very careful during this time--it is a prime time for tendon
ruptures. Patients are excited to be out of their splints and
might overdo. Graded resistive exercises and dynamic
splinting. if necessary. are initiated at 8 to 10 weeks.
Between 10 and 12 weeks strengthening is begun. By
12 weeks patients should be back with full tendon glide
and good tendon strength to return to all normal activities.
Activities and sports Ln which a sudden surprise force
might pull on flexed fingers . such as rock climbing. wind­
surfing. water skiing. or dog walking. should not be done
until 14 to 16 weeks postoperative.
Criteria for Return. Return to activity is depend­ joint. The presenlin
ent on sport and position played. and the deciSion must be DIP joint (Figure 21
made with physician. hand therapist. and athletic training Treatmenti
staff involved. It \>vill be 10 to 12 weeks before the athlete hyperextension (Fi
can play without protection and with little risk of tendon nexion of the DIP i
reinjury. There are instances where a non-ball-handling once during th at tin
athlete may return sooner if cleared by the physician. In Injury Mech
these cases the athlete's affected hand must be tightly Ilexion of the OIl) i
taped into a fist and then casted with wrist in flexion. frequently h appen.
padded according to sport rules. Nothing hard should be a ball.
placed in the athlete's hand-if they squeeze against re­ Rehabili t.atio ~
sistance. they might rupture. The athlete and coaching mallet fi nger is min
staff must be made aware of the possibility of rupture with prefabricated. sue
early return to sport. sbouJd hold the or~
sion. Skin inte g r i l~
CLINICAL DECISION MAKING Exercise 20-5 modified or red esig
involved fingers and
A football player makes a tackle and feels a pop in his ring ion with the DIP sp
fi nger. When he comes to the sideline. he Is unable to flex and should be ene
his DIP joint actively. The team orthopedist diagnoses an
Rehabilitation
PDP avuJsion injury. or Jersey fmger. What can the ath­ healed . at approx inl
letic trainer do immediately on the field. and what infor­ discontinued. If an
mation can be provlded to the athlete regarding be continued 10ngeJi
treatment options? 2 weeks after full -li
DIP joint followi ng
 CHAPTER 20 Rehabilitation of Wrist, Hand. and Fi nger lnjuries 479

int. The dressing

~l hould remain

le digital splint is
un for composite
IS continued. Be­
active composite
A

Id gentle isolated
20-18 through
d if poor tendon

ued, ADLs may be

I-gliding exercises
Light resistive ex­
Figure 20-47 A mallet finger deformity w ith DIP flex­
itia ted. Graded re­
io n. T here might or might not be redness dorsally.
r tendon glide. Be
pc ti me for tendon
r their splints and Mallet Finger
s and dynamic
to 10 weeks. Pathomechanics. A mallet finger is the av ulsion of
B

Ding is begun. By the termina l extensor tendon,41 which is responsible for

11 full tendon glide
Dormal activities.
de n surprise force
k climbing, wind­
fo uld not be don e
activity is depenci­
Ile dec ision must b
rd athletic trainin"
before the athlel
i tie risk of te ndon
Do n-ball-handlin g
" . the physician. In
~d must be ligh tl~
lli wrist in nexioo
~ g hard should be
sq ueeze against re­
Wete and coachin"
lUi y of rupture wit
Exercise 20-5
a pop In hi ring
is unable to [lex
l diagnoses an
al can the ath­
.... ....... ......... ............
extension of the DIP joi nt. It can occur with or without
[racture of bone. If there is a la rge fracture fragment,
where the fracture fragment is displaced greater than 2
mm, or the DIP joint has volar subluxation on X ray. the in­
jury will require ORIF.
There is llO other mecha nism for ex tending th e DIP
joint. The presenti n g complaint is inability to extend the
DIP joillt (figure 20-47) .
Treatment is spli n ting the orp jOint in neutral to slight
hyperex ten sion (Fig ure 20-48 ) for 6 to 8 weeks with no
nexio n of the DrP jOin t. 14.46 If the DIP joint is flexed even
once duri n g that time. the 6 weeks starts again.
Injury M echanism, Injury mechanism is forced
11cxion of the DIP joint while it is h eld in full extension. 55 It
frequently happens when the end of the linger is struck by
a ball.
Rehabilitation Concerns. Rehabilitation of the
mall el finger is minimal. J\ splint may be custom made or
prefnbricated, such CIS a stack splint or Alumafoam. It
should hold th e DIP joint in neutral to sligh t hyperexten­
sion. Skin integrity n eeds to be monitored, and the splint
modified or redes ig ned if breakdown occu rs. ROM of n on­
involved fingers and joints sh ould be ma intained. PIP flex­
ion with the DIP spli n ted will not put lension on the injury
and should be en couraged .
Rehabilitation Progressions. Once the tendon is
healed, at approximately 6 to 8 weeks, splinting mny be
discontinued. If an extensor lag is present. splinting may
be con tinu ed longer. Night splinting is often continued for
2 weeks after fuJI -li me splinting is discontinued. AROM to
!)Ir join t following splin t removal. No attempts to passively
Figure 20-48 A mall et linger splint must hold the DIP
in neutral to slight hyperext ension . lL may be dor a ll.
based , volariy based, or circumferential. A, A dorsa l
splint mad e from Alumafoam. B, A stack-type splint.
These kinds are usually preferred. as th ey rare ly impede
PIP motion.
Oex the linger to rega in ROM should be attempted fo r 4
weeks. Blocked DIP nexion exercises arc m ost important.
Full ROM is usually gained through blocked exercises (Fig­
ure 20-20) an d regular fun ctional hand usc.
Criteria for Return. Return to spo rts is permitted
immediately with the DIP joint splinted in full exte mi on. J f
the sport does not permit playing with the finger splint on.
the athlete will be out of co mpetition for 8 weeks.
CLINICAL DECISION MAKING Exercise 20-6
A baseball player was fielding a ground ball when the ball
ppcd up and jammed his fmgertip. He continued to
play. Althe conclusion of the game. the ring finger has
the DIP lolnt resting in 70 degrees of flexion. The finge r is
red over the dorsal DIP loint and swollen. Wbat should
the athletic trainer do?
480 PAKTTHREE The Tools of Rehabilitation

Summary

1. rIexor tendo n in,

cant injuries..\!'
therapist m ust
must be ma de a
2. The goal in the
juries (gamelv
Athletes will Ix _
Figure 20-4.9 A boutonniere deformity might start as Figure 20-50 A boutonniere splint needs to immobi­ lelic trainer sh
a PIP contracture. In time it will cause hyperextension of lize the PIP joint in full extension. leaving the MCP and 3. E(lriy treatm cn
the DIP joint. DIP joint free. The author makes these in two pieces, over­ tial. as is propt:r
lapping slightly, held on with tape. fully exten ded
4. The mallet fin~
interrupted for
Boutonniere Deformity eVel] once. an_
weeks begins a:,
Pathomechanics. The posture of a finger with a Injury Mechanism. Injury occurs when the ex­
-. Dislocation s of
boutonnierc deformity is FIP jOint f1exion and DIP joint hy­ tended finger is forcibly f1exed, as when being hit by a ball
ll:n complicatt
pcrextcnsion (Figure 20-49). It is caused b5' interrupUon of or striking the Ilnger on another player during a faU. '"
ture are co m m
the central slip and triangular ligament. Normally the cen­ Rehabilitation Concerns. Of primary concern i5
edema con trol.
tral slip will initiate extension of f1exed I'll' joints. The lat­ early and proper diagnosis and treatment. X rays should be
lion is accepla
eral bands cannot initiate PIP joint extension but can taken to rule oul fracture or PIP joint dislocation. It is also
ncld unless tJle
maintain extension if paSSively positioned. because they very important to splint the PIP in full extension. If edema
are fre qu entl}
arc dorsal to thc axis of motion. When the central slip is is present when initially splinted. as edema decreases the
treated like a m
disrupted. the extensor muscle displaces proximally and splint gets loose and full extension is no longer achieved.
6. Roxer's fra cm
shifts the lateral bands volarly. The F!)S is unopposed with­ Passive flexion should not be performed to the PIP joint fol­
fuB return of
out an intact central slip and will fl ex the PIP joint. As the lowing removal of the splint. Blocked PIP RO.M exercise
lization shoula
length of time postinjury increases, the latcral bands dis­ are appropriate to isolate flexion (Figure 20-19). If diag­
move.
place volarly and might become fixed to the joint capsule nosis is made late and there is a fixed PIP f1exion contrac­
or collatcralligamenl. This makes passive correction very ture, serial casting may be necessary to restore extension.
difficult. The DIP joint hyperextends because all the force Following return of full extension, the f'inger is then
to extcnd the PIP is transmitted to the DIP joint. 50 splinted for 8 weeks. One other factor to keep in mind i
Oocc a fixed deformity is prcsent. it is much more diffi­ that initially a central slip injury does not presenl. as a bou­ References
cult to treaL However, many athletes do not seek immedi­ tonniere, but ratber a PIP flexor contracture. DIP hyperex­
1.
ate medical allention, feeling that the finger was tension comes later. III Co ncepts ill
"jammed" and will be nne in several days or weeks. Rehabilitation Progressions. The progression is S. M. Tribuzi. P
Treatment for the acute injury is uninterrupted increasing ROM follOWing splint removal. Strengthenin g 2.
splinting of the PIP joint in full extension for 6 weeks (Fig­ of grip may also be performed. if needed, atlO to 12 week
ure 20-50). The DIP joint is left free with motion encour­ following acute injury (approximately 4 weeks following l.
aged. This will synergistically relax the extrinsic and splinting).
intrinsic extensor tendon muscles and also exercises the Criteria for Return. The athlete may return to ac­ 4 . Bowers. W. H. 1
oblique retinacular Iigamenl. 4 ! tivity when lhe finger is comfortable. The affected finger
Following 6 weeks of immobilization. gentle careful must be splinted at all times in full extension . If the sport
;). Bryan . R. S.. and
flexion of the PIT' joint is begun. Continue splinting for 2 to does not allow for the finger to be splinted. the athlete will
lured carpal bon
4 weeks when not exercising. \oVhen full PlP joint exten­ be out approximately 8 weeks. 149:] 08 - 9.
sion can be maintained throughout the day, then night The au/hal' wishes [0 thank DI: Wallace Andrew of Raleigh fl . Bush. D. C. 19 95.
splinting only is appropriate. Length of treatment and Orthopaedic Clinic }in' his support, knowledge. and IVillingllcss latioll of tile lIand:
splinting may be several months. /0 answer m!f coulltless questions. Hunter. E. J. Mackj
 CHAPTER 20 Rehabilitation of Wrist, Hand, and Finger Injuries 481

Summary

1. Flexor tendon injuries are very labor-intensive, signifi­ 7. Tendinitis and DeQuervain's tenosynovitis should be
cant injuries. An experienced hand surgeon and hand immobilized for 2 to 3 weeks with gentle pain-free
therapist must be involved in the care. and the athlete range of motion performed daily to maintain mobility.
must be made aware of what to expect. Activity should be increased as pain decreases.
2. The goaHn the treatment of ulnHr collateral ligament in­ 8. Carpal tunnel syndrome is very rare in athletes.
juries (gamekeeper's thumb) is stability of the MCP joint. 9. Ganglion cysts need to be treated only if s)7mptomalic.
ALhletcs will be stiff following immobilization-the ath­ j\l!ultiple aspirations may be performed during the sea­
~ds to immobi­ lelic trainer should not passively push motion hlilialiy. son with excision postseaso n if necessary. There are
g (heMCP and 3. Early tr eatment of the boutonniere deformity is essen­ usually few rehabilitation needs.
J two pieces, over- tial, as is proper splint position. The PIP joint should be 10. Wrist sprains are a diagnosis of exclusion. All other
fully extended with the DIP jOint free. pathology must be ruled out prior to return to sport.
4. The mallet finger must be spUnted in full extension un­ 11. Lunate dislocations arc serious injuries that require
interrupted for 6 to 8 weeks. If the DIP joint is nexed. ORJF and pOssible lengthy rehabilitation.
even once, any healing is disrupted and the 6 to 8 12. Hamate hook fractures are not seen on regular X ray
weeks begins again . views. A carpal tunnel view will confmn the diagnosis,
If when the ex­
5. Disloca tions of the Mep joints are very rare and are of­ and the fracture should be treated symptomatically.
bein g hit by a ball
tcn com plicated. Dorsal PIP dislocations without frac­ 13. Scaphoid fractures might not be seen on initial X ray.
during a fall. 010
ture arc common and need early range of motion and If suspected. but the X ray is negative. the athlete
..imary concern is
edema control. SplLnting for comfort during competi­ should be treated as if a fracture is present. with X
It.. rays should bc
tion is acceptable, but does not need to continue 01'1'­ rays repeated in 2 weeks to conl1rm diagnosis. Early
JocatioD. It is also
field unless the dislocation is unstable. DIP dislocations proper immobilization is importan t to the long-term
xlc nsion . if edema
are frequently open and require surgery. They are outcome.
ema decreases the
treated likc a mall et finger. 14. Distraction of the wrist while performing passive
o I nger achieved.
6. Boxer's fractures tend to heal without incident with range of motion alter fracture can help increase mo­
to t he PIP joint fol­
full return of molion in 4 to 6 weeks. Spl'i nt immobi­ tion and decrease pain during stretching.
PIP ROM exercises lization should leave the PW joint and wrist free to
re 20-19). If diag­ move.
IP nexion contrac­
re tore extensi.on.
the [Jnger is then
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ot present as a bou­ References
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to ligament rupture. Jou mal 0/ Halld Surgery 3 :507. 20-1 Splinting for
38 . Palmer. A. K., a nd F. W. Werner. ] 981. The trianguLar I1bro­ sians can h _
cartilage co mpk~x of the wrist-ilnatomy aud fun ction. Journal
inOammat0'1
oj Halld Surgay Ii: 1 ~ 3- 62.
taphoresis. Til
39. Piankil. G.. and E. 13. Hershman. 1990. Neurovascular in­
decrease pai
juries . In Uppa e.ttrelllily ill sports lIledicille. edited by j. A.
N icholas and E. B.lJe rshman. 8t. Louis: Mosby.
modifi ed to
40. Rettig, A. C. 1991. Cu rrent concepts in mUllagl'mc n l or root­ ph ase. Once
or
ball injuries of the han d and wrist. Journal Hal11! 1'1!"m!!y '1 body 111echa
(April- Jun e). practice and I
41. Rosenthal. E. A. 199 '1. The extensor tcndons: An atomy an d 20-2 Extension sh
managemenl. 1n Rehalii/itatioll of tll C fJaIJ(I: SurgCl'y and ther­ r e g ain. as (I
aP!I, 4th cd .. edited by j. M. Hunt cr. E. j. r-lackin. and 1\ . IJ castin g H ) wi!
Callah a n . st. Louis: Mosby.
ne utral warn
42. 8m-milan, S., j. L. Me lamed . and G. ~I. Goshgari<lTl. 1977.
Study of wrist motion in flexion and extension . ClilliCili Or­
thopaedics 126:153 .
43. Smith. R. J. 19 77. Postt raum a tic instability of the metacur­
pophalungeal joint of the thumb. Journal oj BOil" and JOilll
Surgery 59 ;1.4-2 1.
44. Stark. H . H. et aJ. .1977. Fracture of the hook of the hamat e 20-3
in athletes. Jourll ai oj BOlle ami jOi llt.Surgrr.ll 'i9A:S75-8 2.
45. Stark. H. H. et a l. 19 89 . Fracture of the h ook of th e h amalc.
Jour/liU oj Bone allli Joil1l Sur.'}tr!J 71 i\: 1202- 7.
46. Stark. H . H .. J. H . Bayer. and J. ~ . Wilson. 1962. ?vlaUet Hn ger.
JOllmal of Bone awl Joi l1( Sllr!JC1'!1 4.4: 1061.
47. Stener. B. 1962. Displacement of the ruptured ulnar co ll m­
eral liga ment or the metacarpophalangeal joint of tl
thumb. Journal of BOlle and JOint Sllryer.1l44B:86':J-79.
48. Thiru-Pal.hi. R. G.. et al. 1':J8h. Arterial ana tomy or tbe tn­
angular fibrocartilage of the wrist and its surgical sign lfi ­ area llJ a} be
Cilnce. JOllrl1ul oJ Halld Sur.qery 11 A: 268- 6 3.

of the carpal navic­
the literature. Jow'­
h311d. In Til e illjured
delphia: Lippincott.
lnar collatera l Iiga­
allIi Sports Atledidllc
l in juries in the atb­
-:27 5-86.
na gement of nonar­
i/itatioll of the hand:
J. M. Hunter. E. j.
osby.
ie and entrapments
dellllj or
Orthopaedic
Fliurics if! at/detes. ed­
antes of the di stal ra­
1related researc/l. ed­
tl.
cheid. 1 <J7 S. Mon ­
the wrist secondary
au 3:507.
The triangula r Hbro­
and function. JOIII"Illll
'eurova_scular In­
II.
iJle. edited by j. A.
\losby.
m nagement of foot­
lof Halld Th erapu 4
dons: ,\n alo my and
-ru/: 511 rgery alld ther­
J. ~f ack in. and A. D.
I. oshgarian . 19 77.
. ctc nsion. Clillical Or­
bility of the meta car­
-naI of BO ll c a/1d Joillt
hook of the hamate
~ry 'i9A:575-il2.
hook of the hamate.
201-7 .
. 19 62. 'l'I aUet finger.
161.
rupt ured ulnar collat­
Ilangeal joint of the
'II HB :869-79.
al anatomy of the tri­
d its surgical signili­
- fi3 .
CHAPTER 20
49. Vender. M. 1. 19 8 7. Degenerative chan ges in symptomatic
scaphoid non-union. Journal of Hawl Surgery 12A: 514.
'i(). V,iegas. S. P. et [1\. 1991. Simulated scaphoid prox imal pole
(racture. JOllrlwl of Halld Surany 1 6A:48 5-500.
51. \1012. R. G.. M. Lieb. and J. Benjamin. 1980. Biomechanics of
the wrist. Clinical OrtllOpoedic:s and Related Research
149:11 2-17.
52. Warhold L. G.. and A. L. Os ter man. 1992. Sc.aphoid fractu re
and non-union: Trea tment by open reduction . bone graft and
a Herbert sc rew. Clinical OrtllOJluecucs 7:7-18.
53. ·Watson. II. K.. and W. D. Rogers . 1 ':189 . 'onunion of the
hoo k of the hamate: An argument for bone grafting the
nonunion. Journal of Halld Surgery 14A:486-90 .
54. Weinstein. S. !Vl.. and S. A. Herring. 1992. erve problems
a nd compartment syndromes in the hand. wrist. and fore­
arm. Clillics ill Sports .Vledicine 11 (1).
55. Wilson. R. 1.. and j. Hazen. 1995. Management of joint in­
juries and intraarlicular fractures of the hand. In Re/lIlbilita­
SOLUTIONS TO CLiNICA,L DECISION MAKING EXERCISES
20-1 Splinting for immob ilization between practice ses­
sions can help decrease pain. as can oral anti­
inflammatory medications and ultrasound or ion­
tophoresis . 'i/"a ping for support during play may help
decrease pain. The practice schedule may need to be
modified to decrease playing time during acute
phase. Once the pain is decreasi ng. strength and
body mechanics should be addressed. Ice [allowing
practice and play may also decrease symp tom s.
20-2 Extension s h ould be addressed first. It is hardest to
regain. as functionally it is not used much. Serial
casLing JO will provide a sus tained ex te n sion stretch,
n eutral warmth for pa in relief. and immobilization
to decrease edem a . Because it may not be removed
by the athlete. com pliance is better and res ults are
quicker. Once exte nsion is full. sw itc h to a static
splint. weaning out of it for flexion while maintain­
ing ex tens ion.
20-3 Oral anti-inflammatories and ice will be helpful ini­
tialiy to decrea se pa in and inflamma tion. Ultra­
sound or iontophoresis to the radial forearm may
h e lp with pa in relief. Rmv! and wrist stre tching
should be done within pain limits as soon as possi­
ble [ollowing injury. A splint immobilizing the
thumb a nd wrist (Figure 20-29) m ay be helpful for
pain relief as well. rf th e athlete ca n m ove his w r is t
withou t pain. but a blow to the area is painful. th e
area may be padd ed for return to play.
Rehabilitation of Wrist. Hand. and Finger Injuries 483
or
li OI! the hand: Surgery and thcrapy. 4th cd .. edHed by J. M.
lIunter. E. j. Ma ckin. an d A. D. Ca llahan. St. Louis: Mosby.
56. Wright. H. H.. and A. C. Rettig. 199'i. Management of com­
mon sports injuries. [n Re/wiJilitatioll of the hal/d: Surgery and
therapy. 4th cd .. edited by j. M. Hunter. E. j. Mackin. and A. D.
Callahan . Sl. Louis: Mosby.
57. Zeme\. N. P. Anatomy and surgical approaches: [land. VI'!'i,t
and lorearm. [n Operati ve tedllliques ;11 upper ex tremity sports
injuries. edited by F. W. jobe. M..',;1. Pink. R. E. Glousman. R. S.
Kvitne. and N. P. Zemel. St. Louis: '<Iosby.
58. Zemel. :\. P. Fract ures and ligament injuries of the wrist. In
Operative tecirniqlles in IIppcr extremity spor ts injuries. edited by
1'. W. jobe. M. M. Pink. R. E. GloLlsman. R. S. Kvitne. and N. P.
Zemel. St. Lo ui s: Mosby.
59. Zubowicz. V N.. and C. H. Ish ii. 1987. Management of gan­
glion cysts by simple aspiration. Journal oj" Halld Surgery
12:618.
20-4 Splinting for s upport should be initiated ImmedI­
a tely to help provide stabili ty and decrease chances
of instability later. The splint should be worn full­
Lime for approximately 4 weeks.lf the ath lete is able
to play in the splint, she may play. Be sure support is
provided over th e LP joint to pre vent dislocation of
that joint. Once the period of splinting is flnished.
taping the lvl CP joint during play a nd pracLice may
provide s upport and pain relief. R01v! e..xcrcises may
be initiated if necessary ; passive is not done unlil 6
to 8 weeks postinjur y.
20-5 Coban can be applied immedi ately to control
swelling. Tee may be used. but ice can be unco m­
for table in the hand. The athle tic trainer needs to
spend time with the athlete. and with the parents i[
appropri a te. discussing options. The fu ture needs of
the athlete should come before "I want to play" ,is­
s ues. If the tendon will be repaired. the best results
will occur if it is repa ired within 2 weeks of injury.
and prefe rably with 5 to 7 days. rf the tendon is re­
paired, the rehabilitation following surgery will last
approximately 12 weeks. T he athl ete willi be in a
splint full-time for 4 to 6 weeks follOWin g urgery.
The athlele will probably be in pain. and will usu­
ally be out of competition for 4 or more weeks. de­
pending on the spo rt and position played. This is
inte nsive rehab ilitation. and the athlete n eeds to
be prepared for that. There is risk of re-rupture or
484 PART THRIlli The Tools of Rehabilitntion
infecLion. The a thlete who chooses not to have the
tendon repaired will never again be able to actively
flex the DIP joint. The athletic twiner can demon­
strate this by bending all of bis or her fingers except
the DIP of the affected fingc:r. FunctionaLly this is
usually not a problem. but the athlete's fut urc plans
need to be addressed. rr the athlete plans on medical
school and surgery, or on playing an instrument.
they should not choose to lose DIP tlexion. The dan­
ger in not repairing the tendon is that if the joint
hyperexlends. if the alhlete pinches against it. the
OIl' will hyperextend. they will lose the stability of
the joint. Functionally this mayor may not be a
problem. It is importa nt to have close communica­
tion with all involved parties for this injury.
20-6 Referral for an X ray should be made to be sure a CHA I
more seriolls injury has not occurred. The 1110
lil(ely diagnosis is mallet finger. Treatm ent is fut
DIP extension by splinLing. lL is impor tan t to ex­
plain to Lhe athlete that he must keep his finger fu l _
extended at all limes. Flexing it once results i
Re
counting the 6 to 8 'weeks again. The athleli
trainer can make a splint and teach the athlete ho\\ an
to remove the splint and reapply it safely. Once th e .
weeks of immobilizalion have passed. th e athletic Bernie l A
trainer can instruct th e athlete in AROM exerci s~
and the importance 01 not pushing the Dlp joint
passively.
and biom
and thigh.
• Discuss ath
hip, and till.
chanical ch
and after in
• Describe f1
,ade to be sure a
CHAPTE R 21
rred. The most
t'reatmcnt is full
jmportant to cx­
!ep his lInger fully
once res ults in
Rehabilitation of Groin, 'Hip,
ilin . The athtetic
~ the athlete how
and Thigh 'I njuries
safely. Once the 8
15 ·ed. the athletic Bernie DePalma
l RO IVI exercises
ling the DIP joint

Study Resources • Recognize abnormal gait patterns as

To become more fumiliar with the knowledge and skill s they relate to specific groin. hip. and
necessary to design. implement. and document thcrapeu­
thigh injuries and utilize this knowl­
tic rehabil ita tion progrums as identified in the ATA Ath ­
letic Trailling HdllcatiOIl!l1 Competencies al/ll Clinical dge during the evaluation process and
l'rojlcicncics ""herapclltic Exercise co ntcn t areu. visit rehabilitation program.
w\\'\\'.mhhc.com / prenticc ) 1 e. Also rercr to the lob exer­
cises in the new Labora tory Manual and to eSims. which • Explain the various rehabilitative tech­
simula tes the aUllctic tr<lining certification exam. at niques used for specific groin. hip. and
\\'wIV,mhhe.com /csim -. ror morc online study resources.
thigh injuries. including open- and
visit our Hea lth and Human Performance websitc at
www.mhhe.com/hbJ2.
closed-kinetic-chain strengthening ex­
ercises. stretching exercises. and plyo­
metric. isokinetic. and PNF exercises.
After Completion of This

Chapter, the Student Should

• Discuss the role of functional evalua­

Be Able to Do the Following:
tion in determining when to return an
• Understand the functional anatomy
and biomechanics of the groin. hip.
and thigh.
• Discuss athletic injuries to the groin.
hip. and thigh and describe the biome­
chanical changes occurring during
and after injury.
• Describe functional injury evaluation.
utilizing biomechanlcal changes to the
groin. hip. and thigh.
athlete to competition. based on reha­
bilitation progression.
T
his chapter describes functional rehabilitation pro­
grams th at follow grOin. hip. and thigh injuries. The ath­
le tic trainer and athlete. together. should develop the
rehab ilitation program with an emphasis on injury mecha­
nism, the athletic trainer's functional and biomechanical
evaluation. and clinical fmd ings. Each exercise program
should be presented to the athlete in terms of short-term
goals. One objective for the athletic trainer is to make the re­
habilitation experience challenging for the athlete while pro­
moting adherence to the rehabilitation program .

485
486 PART THREE The Tools of Rehabilitation
FUNCTIONAL ANATOMY
AND BIOMECHANICS
The pelvis and hip are made up of the pelvic girdle and the
articulation of the femoral head to the bony socket of the
pelvic girdle. the acetabulum. forming a ball-in-socket
joint. 16 The acetabulum's labral rim is I1brocartllage that
deepens the "socket" and helps stabilize the hip joint. Thi s
joint connecLs the lower extremity to the pelvic girdle. 7The
angle of inclination and angle of declination are used to
describe the position 01 the femoral head and neck with re­
spect to the shaft of the femur. 7 The frontal projection of
the angle formed by the femoral shaft and neck is the angle
of inclination. The angle of declination is sometimes re­
ferred to as the angle of anteversion. 7 This is the angle
formed between the femoral neck down through the femur
to the femoral condyles. Changes in both these angles
could cause changes in rotation of the femonll head
within the acetabulum th at predispose the athlete to stress
fractures and overuse hip injuries. as well as hip subluJG1­
tion a nd injury to the labral rim.
The pelvis itself moves in threc directions: anteropos­
terior lilling. lateral tilting. and rotation. The iliopsoas
muscLe and other hip flexors. as well as extensors of the
lumbar spine. perform anterior tilting in the sagittal plane
and facilitates. lumbar lordosis. The rectus abdomillus.
obliques. glutcus n~a x imu s. and hams trings posteriorly
tilt the pelvis and cause a decrease in lumbm Iordosis. i
During lateral tilting in th e frontal plane the hip joint acts
as tllC center of rotation. i FIip abducti on or adduction is a
result of pelvic later<ll tilting. The hip abductors control
lateral ti lting by contracting isometrically or eccentri­
cally? Pelvic rotation occurs in the transverse plane,
again USing the hip joint as the axis of rotation. The
gluteal muscles. external rotators. adductors. pectineus.
and iliopsoas all act together to perform this movement in
the transverse plane. 7 These movements of the pelvis are
important when analyzing gait. injury evaluation, and
teaching correct gait.
The hip joint is a true baH-in-socket joint and has in­ RE'HABILlT~
trinsic stability not fou nd in other joints. 7 This intrinsi
stability docs not prevent the hip join t from retaining greal
FOR THE GI
mobility. 7 During normal gait. the hip jOint moves in all
three planes: sagittal. fro ntal. and transverse. To partici­ Stretching Ex
pate in athletic activities. a greater range of motion i~
needed. Witb the increased range of motion. the hip is ca­
pable of performing a wide range of combined movements.
Forces at the hip joint have been increased to five times the
body weight during running. These forces can also con­
tribute to injuries to muscles, bones. and the fibrocartilag'
labral rim.
The most frequently injured structures of the groin.
hip. pelvis . <md thigh are the muscles and tendons that per­
form the movements. The majority of these muscles origi­
nate on the pelvis or the proximal femur. The ilia c eresl
serves as the attachment site for the abdominal muscle,
the ilium serves as the attachment for the gluteals and
then the gluteals insert to the proximal femw-. The pubb
and pubic bone serve as the attachments for the adductor~
as docs the deep posterior abdominal n1uscle wall. and the' Figure 21-1 Hip;
iliopsoas inserts distally to the lesser trochanter of lbe'
proximal femur.' Due to all the attachments in a sm
area. injury to these struclures can be very disabling and
difficult to distin guish. 7.27.l~
The quadriceps inserts by a common tendon to the prox­
imal patella. The rectus femoris is the only quadriceps ml15­
de that crosses the hip joint. which not only extends tht'
knee but also flexes the hip. Th is is very important in differ­
entiating hip flexor strains (e.g.. iliopsoas vs. rcctus femori
and the ensuing treafment and rehabilitation programs.
The hamstrings all cross the knee j(lint posteriorly. ane.
all except t.he shorl head of the biceps cross the hip joi nt.
These biarticular Illuscles produce forces dependent Up O£1
the posiLion of both the knee joint and the hip joint. The
positions of the hip and knee during movement and injur)
mechanism playa vcry important role and provide infor­
mation to utilize when rehabilitating and preventing ha m­
string injuries.
 CHAPTER 21 Reh abilitation of' Groin . Hip, an d Thigh In juries 487

II a nd has in­ REHABILITATION TECHNIQUES

his intrinsic
FOR THE GROIN, HIP, AND THIGH
etain in g greac
moves in all
-e. To parlici­

Stretching Exercises
of m olion is

. the hip i~ ca­

_ movements.

o five times the

ca n also CO(1­
~ fibrocarlilage

of th e groi n .
ndons tha t per­
~ m uscles o rigi­
The iliac ere 1
rni nal muscle .
e olu tea ls an d
Imur. The pubis
r th e addu c tor~ .
Ie wall. a nd the Figure 21-1 Hip pOinter stretching with ice.
/Cha nter of th e
cots in a small
~ d isabling and Figure 21-3 Hip Oexo r stretc h with kn ee Oexcd to iso­
late the rectu s fe moris.
don to the prox­
quadriceps mus­
n ly extends the
Jrlant in differ­
• rectus femoris I
Ion programs.
poste riorly. and
s the hip joint.
dependent UpOIl
c hip joinL. The
mle nt and injury
~d provide infor­
Ipr venling ham-

Figure 21-2 Hip Oexor stretch.

Figure 21 -4 Passive static stretch over end of table with

hip ext ended (usi n g ice or hea t [or 15 to 20 minutes).
488 PART THREE The Tools of Rehabilitation

Figure 21-6
curve.
B

Figure 21-5 A, Hamst ring st retch . B, gl uteus stretch.

 CHAPTER 21 Rehabilitation of Groin . Hip. and Thigh Inju ries 489

Figure 21-7 Hip adductor stretch.

figure 21-6 Ha mstring stretch maintaining lordotic

curve. •

Figure 21-8 Standing hip adductor stretch.

490 PART THREE The Tools of Rehabilitation

Figure 21-9 Hip abductor streLch.

Figure 21-10 Standing hip abductor stretch. Figure 21-11 Hip intern s! rotator stretch .
 CHAPTER 21 RehabiJitation of Groin. Hip. and Thigh Injuries 491

Figure 21-12 Hip external rotalor stretch. Figure 21-13 Piriformis eva luation stretch test.

Figure 21-14 Piriformis stretches.

!retch.
492 PART THREE The 'lbols of Rehabilitation

Strengthening Exercises

Figure 21-15 Pain-free hip flexion iliopsoas progres­ Figure 21-16 Straight leg raises (quadriceps a nd iliop­
sive resistive strengthening exercIses: 4 sets of 10 to 15 soas). 4 sets of 10 repetitions. da ily.
repcULions daily.

Figure 2] -] 8 Pain-free hip adduction (adductor mag­

Figure 21-] 7 Pain-free hip ex tension (gluteus max­ nus. brevis . longus. pectineus. and gracilis) progressive
imus and hamstring) progressive resistive strengthening resistive strengthen ing exercIses: 4 sets of l' 0 to 15 repet i­
exercises: 4 sets of 10 to ] '5 repetitions dai ly. tions daily.

Figure 21-22
resistive strength
bar curve). Isolonics p
10 repetitions. 2 to 3
 Figurl." 21-19 Pain-free hip abduction (gluteus medius . mClximu s. and tensor facia latae)
progressive resis tive strengLhening exe rcises: 4 sets of IO to I ) repetitions daily.

Idriceps and iliop-

Figure 21-20 Pain-free hip internal rotati on (gluteus Hgure 21-2 1 Pain-free hip external rotation (piri­
minimus. tensor faci,] latac. semitendinosLis. and semi­ formis and gluteus m<lximus ) progressive resistive
membranosus) progressive resistive strengthening exer­ strengLh ening exercises: 4 sets of I () Lo 1) repetitions
cises: 4 sets of 10 to I ) repetitions daily. daily.

Figure 21-22 Pain-free seated hamstring progressive Figure 21 -23 Pa in-free prone hamstring single-leg
resistive strengthening exercises (maintain lordotic lum­ progressive resis tive strengthening exercises: 4 sets of ] 2
bar curve). Isoto nics performed on the _ K table. 4 sets of repetitions, 2 to 3 days/ week.
10 repetitions. 2 to 3 days/week.
494 PARTTHREE The Tools or Rehabilitation

Figure 21-24 Manu al resistancc hamstring strcngth­

ening to fatigue. f\thlc te lies pron e with knee over the
edge o f trea tm ent t.able. With the at hlet e in full knee ex­
te nsion. resistance is appli ed to the back of th e heels as
the at hlete co ntra cts concentrica lly to full kn ee flexion for
a co unt of ') seconds. ;\ftcr a 2-second pause at full flex­
ion. resistLl nce is applied into exte nsion for a count of ') as Figure 21-25 Pain-free seated quadriceps progressive
the athlete co ntrac ts the hamstrings eccent ri ca lly. This is resistive stren gthening exe rcises. [sotonics using th e i\K
repeated. contractin g as fast as possible for 2 to 3 sets of table. 4 sels of 10 repetitions. 2 to 3 days/ week.
] 0 to 12 repetitions or unti l failure. I to 2 days/ week.

Figure 21-27 Pain-free supine quadriceps progressi . ­

resistive strengthening exercises. single leg (lying supirh
to isola te rec tu s femoris. 2 to 3 sets of IOta 12 repeti­
ti on s. ] to 2 days/ week.
f igure 21-28 Pa
lition5. 1 to 2 days
D, Adduction . E, El
nosis. and gluteus m~
maxi mus) .
Figure 21-26 Pain-free seated qua driceps progressive
resistive strengthening exercises. single leg. 3 to 4 sels of
10 to 12 repetitions, 1 to 2 days/week.
 A B

c D

heeps progressive
(' leg (lying supine).
o to 12 repeti-
Figure 21-28 Pain-free multi-hip progressive resistive strengthening exercises in all four liirections. 2 sets of J :; repe­
titions. 1 to 2 days/ week. A, Flexion with knee Ilexcd (rec tus fellloris) and B, knee extended (iliopsoas). C, Abduction.
D, Adduction. E, Extension with knee extended start position to knee bent terminal position (semjmembranosus. tendl­
llosis. and gluteus lIlClximus) Clnd knee bent start position to knee extended terminal position (biceps femoris and gluteus
maximus ).
496 PART THREE The Toob of Rehabilitation

Figure 2 I -28 t:Otltinlled

A B

Figure 21-32
fonvard of the at
1 to 2 inches of'
per hamstrings. an
Figure 21-29 Pain-free low cable column starting posi tion of hip abduction. extension. and external rotation to ter­
sccnds. keeping a I
minal position of adduction. flexion. and internal rotation. 3 sets of 15 repetitions. 1 to 2 days/ week .
hip joints break par
form 3 sets of 12 r
 Closed-Kinetic-Chain Strengthening Exercises
Figure 21-30 Hamstrin g strengthening closed chain.
SlighLly flexed knee stiff-legged dead lifts (A), ({otate at
the hip joiot into flexion and keep back arched in lordotic
curve until there is lightness in the hamstring muscles
(8). Then uli!i7,e the hamstring muscles to extend the hip
joilllto the upright position (A). Perform 3 sets o r 15
reps. 2 days / week.
Figure 21-32 Smith press squats with feet placement
rorward of the athlete's center of grav ity and close (wilhin
I to 2 inches of each other) or hack squat (quadriceps . up­
per hamstrings. and gluteus maximus). The alhlete de­
'oal rotatioo to ter­
sce nds, keeping a lordotic curve in the luw back, until the
hip joints break parallel (lower than the knee Joints) . Per­
form 3 sets of 12 repetitions, 2 days/week.
Figure 21-31 Leg press with feet high on the foot plate
and shoulder-width apart to work the upper hamstring
while keeping knees over the feet (not over the toes or in
front of the toes). Seat selling sholdd be close so th at at
the bottom of the motion the hips are lower than the
kn ees (quadriceps. upper hamstrings. and gluteus max­
imus). Perform 3 sets of 12 repetitions. 2 days/wee k.
Figure 21-33 Smith press squats wit h feet behind the
athlete's center of gravity and hip io extension (as on a
hip sled) (quadriceps, lower lateral hamstring. and glu­
teus maximus). The athlete descends while keeping a lor­
dotic curve in the low back . Perform 3 se ts of 12
repeti tions, 2 days/ week.
 A

Figure 21-34 Lunges (quad riceps. hamstrings. gluteus

maxim us. groin muscles. a nd iliopsoas ) stepping onto 4­
to 6-inch step heigh t. Once the foot hi ts the step. th e ath­
lete should bend the back knee straight down toward the
floor to work the upper hamstring of the rrontleg and the
hip I1cxors of the back leg. Perform 2 sets 01'1 2 to 1 :; rep­
Figure 21-35 Sta ndard squats below parallel (quadri­
etitions. 2 days /week. ceps. upper hamstrings. groin mu scles. and gl uteus max­
imLls). 3 sets or 12 repetitions. 2 days/ week.
Figure 21-38 S
days/ week. Resist
resisting hip C'xten,
through the entire r;

Isokinetic Exe

Figure 21-36 Hamslring leans-kneeling eccentric

hamstring lowering exercises. With the at hlete kneeling
on a treatment table and feet ha nging over the end. the
athletic trainer stabi lizes the lower legs as tbe athlete low­
ers th e body to lhe prone position. eccentrically contract­
ing the hamstri ngs. The ath lete should mainta in a
lumbar lordotic curve and stay completely erect. avoiding
any hip flexion . The athlete should perform 2 sets of 8 to
1() repetitions or until failure . 1 to 2 days/week.

-
'
-

Figure 21-37 Lateral step-ups (quadriceps. ham­

strings. gluteus maximus. gluteus medius. and tensor fa­ Figure 21-39 :>ea
cia latae) using repetitions and sets. or time. 2 to 3 ceps strengthening.
days/ week. repetitions eac h selll
 A B

arallel (quadri­
nd gluteus max­
~k .
Figure 21-38 Standing running pattern. man ual resistance starLing position, 2 sets of 20 repetitions, 1 to 2
days/ week. Rcsistance is applied to thc back of the heel. resisting hip flexion and knee l1exion to terminal posilion. then
resisting h ip extension and knee extension back down to starling position. A, Thc at hlete contracts as fast as possible
through the entire range of running molion . B, Standing running palLcrn, terminal position .

Isokinetic Exercises

-
. rieeps , ham­ Figure 21-40 Prone-lying si ngle-leg isokinctic ham­
lill S. and tcnsor fa­ figure 21-39 Seated isokinetic hamstring and quadri­ string and quadriceps strength ening. 3 speed settings, 2
lime. 2 to 3 ceps strengthen ing. J speed settings, 2 sets of 1:; to 20 sets of 1:; to 20 repetitions each setti ng, for each leg. 1 to
repetitions each selling, each leg. 1 to 2 days/ week. 2 days/ wcek.
500 1'/\IrJ'THREE The To()l~ of Rehabilitation

Plyometric Exercises

and pain can sel'ere:

cases. a fracture of •
juries must be rill.
signs and symptolIl5
determined to h are ~
Injury Meehan!
by a direct blow to t

Figure 21-41 Slide board or Filler. keeping knees bent

and maintaining a squat position for tile entire workout Figure 21-42 Jump-down exercises (sets and repeti­
(increases hamstring activity). Utilize sets and repeti.tiollS. tions, or time). 1 to 2 days/week.
Dr time. 1 to 2 days/wecl<.
taken to rule out Hi
especially in yO Ull=
t rea ted ca r1y, wit hiP
lete may experience
lion of the tnUlk
involved.
As in most com
athlete with a gradt: .
gait cycle and nonn
f slight pain on pa
athlete might also p
trunk. especially \\
the opposite side or
An ath lete \\'itb

Hgure 21-43 Lateral bounding (sets and repetitions. Figure 21-44 Latera l sliding (sets and repetitions. or
or time). 1 to 2 days/ week. lime). ito 2 days/ week.

ore posture migh t

REHAB'ILITATION TECHNIQUES
FOR SPECIFIC INJURIES
Preferred trcatmenL and rehabilitation of these injuries
arc broken down into phases. During the early phase of rc­
habiHtation. icc. compression. and modalities are utilized
with pain-free active rangc of motion as early as possible.
Try to avoid any movement that causes pain. especially
passive range of motion started too early. After the acute
phase. thc athletic trainer shou ld utilize modalities in com­
bination with active n1nge or motion and the beginning of
active resistive pairl-(ree strengthening exercises. both
open- and c1osed-kinetic-chain, as well as concentric and
eccentric contractions. Pain-free stretching is a lso starte.... :\clive hip and tr
in this phase. During the later phases the athletic train
should progress the athlete into plyometric activilil."<.
sport-specil1c function<ll training with i:lgility. an
ground / power-based activities. Keep in mind that li1e til
sequences for programs ancl phases are approximatior
Hnd should be adjusted depending upon lhe degree of ir ·
jury, the sport. and the alhlete.
with very slow. deli
stride length and s\\
Hip Pointer
lUre might prese nt a,
Pathomechanics. A hip pointer can best be Trunk range of mo
scribed as a subcutaneous contusion. In most cases. u~ .-\ctive hip and trun
 CHAPTER 21
contusion can cause separation or tearing of the origins or
insertions of the muscles that attach to the prominent
bony sites. 1o Us ually the athlete has no immediate con­
cern, but within hours of the injury. bleeding, swelling,
and pain can severely limit the athlete's movement. In rare
cases, a fracture of the crest may occur. I More serious in­
juries must be ruled out. One athlete who reported the
signs and symptoms of a hip pointer on the field later was
determined to have a ruptured spleen.
Injury Mechanism. A hip pointer is usually caused
by a direct blow to the iliac crest or the anterosuperior iliac
spine. A strain of the abdominal muscles at their attach­
men t to the an terior and inferior iliac crest can be differ­
entiated from a contusion by obtaining a good history of
the mechanism of injury at the time it occurs. A forceful
contraction of the abdominal muscles while the trunk is
,I cts and repeli­ being passively forced to the opposite side can cause a
strain of the muscles at their insertion to the iliac bone. 37
Rehabilitation Concerns. An X ray film should be
taken to rule out iliac crest fractures or avulsion fractures,
especially in younger athletes. 3o If the hip pointer is not
treated early, within approximately 2 to 4 hours, the ath­
lete may experience severe pain and limited range of mo­
tion of the trunk because of the muscle attachments
involved.
As in most contusions, the hip pointer is graded . An
athlete with a grade] hip pointer might have both normal
gait cycle and normal posture. The athlete might complain
of slight pain on palpation with little or no swelling. This
athlete might also present with ,full range of motion of the
trunk. especially when checking for lateral side bending to
the opposite side of the injury.
An athlete with a grade 2 hip pointer might have mod­
erate to severe pain on palpation, noticeable swelling. and
an abnormal gait cycle. The gait cycle might be changed
because of a short swing-through phase on the affected
side; the athlete might take a short step and be reluctant to
keep the foot off the ground. The athlete's pelviS and there­
fore posture might be slightly lilted to the side of the injury.
tchi ng is also stant'\.. :\ctive hip and trunk nexion might cause pain, especially if
the anterosuperior iliac spine is involved because of the in­
: the athletic trai nt"'"
sertion of the sartorius muscle. Range of motion might be
iyometric activili
limited. especially lateral side bending to the opposite side
with agility. al
of the injury and trunk rotation in both directions .
.D mind that the ti m..
An athlete with a grade 3 hip pointer might have se­
\'ere pain on palpation, noticeable swelling, and possible
discoloration. The athlete's gait cycle could be abnormal,
with very slow, deliberate ambulation and extremely short
tride length and sWing-through phase, The athlete's pos­
ture might present a severe lateral tilt to the affected side.
Trunk range of motion could be limited in all directions.
. In nlost cases. l. Ac tive hip and trunk nexion might reproduce pain .
Rehabilitation of Groin. Hip, and Thigh Injuries SO 1
With atl hip pointers. continue with ice. compression,
and rest. Subcutaneous steroid injection has been known to
decrease innammation and enable early range of motion ex­
eroises. Oral anti-innammatory medication is also beneficial
in the early stages to reduce pain and innammation and fa­
cilitate early range of motion. Transcutaneous electrical
nerve stimulation (TENS) may be helpful on the day of in­
jury to decrease pain and allow early range of motion exer­
cises. To regain normal function and speed recovery. use ice
massage with pain-free trunk range of motion exercises at
the same time. Concentrate on lateral side bending to the
side opposite to the injury (Figure 21-1). Other modalities
such as ultrasound and electric stimulation are beneficial
for increasing range of motion and functional movement.
Pain-free active motion and active resistance range of mo­
tion exercises are vital to the functional recovery process.
Active motion helps promote healing and decreases the time
the athlete is prohibited from practice and competition. Ex­
ercises as shown in Figures 21-15 through 21-21. 21-28,
and 21-29 should be utilized to progress the athlete. Trunk­
strengthening exercises may also be added.
Rehabilitation Progression. A grade 1 hip
pointer usually does not prevent the athlete from compet­
ing. An athlete with a grade 2 hip pointer coul'd miss 5 to
14 days, and an athlete with a grade 3 hip pointer could
miss 14 to 21 days of competition. An athlete with a grade
2 or 3 hip pointer can progress to active resistive strength­
ening exercises. if pain-free. after the initial 2 days of ice,
compression, and active range of motion.
Criteria for Full Return. The athlete ,is capable of re­
turning to compet,ition when full trunk range of motion is ob­
tained and the athlete can perform aU sport-specific activities,
such as cutting and changing directions (see Figures 17-4
through 17-14), Compression shoutd be maintained
throughout the ,period, and on returning to competition
the athlete should wear a custom-made protective relief
doughnut pad with a hard protective shell over the top.
CLINICAL DECISION MAKING Exercise 21-1
A college football athlete sustained a direct hit to hilIlat­
eral abdominaJ and rib area. After trying to play through
the pain. he reported severe pain and tenderness on, and
slightly anterior to. the Wac cresr. The teamphysiclan's
evaluation shows a grade 2 hip pointer. The next day the
athlete reports to the athletic trainer with severe pain.
swelling. and posture Wted to the side of the Injury. The
athlete walks very slowly and with a limp. "''bat can the
athletic trainer recommend Lo help with pain and range
of motIon and eventually to get the athlete to a full return
to football?
502 PART THREE The Tools of Rehabilitation
Injury to the Anterosuperior Iliac
Spine and Anteroinferior Iliac Spine
Pathomechanics. PaiD at the site of the anterosu­
peri or iliac spine might indjcate contusion or apophysitis,
an inflammatory response to overuse.] Severe pain associ­
ated with disability requires an X ray to rule out an avul­
sion fracture. ]
As with the anterosuperior iliac spine. the anteroinfe­
r ior iliac spine can also present with apophysitis or a con­
tusion. An avulsion fracture should also be ruled out with
severe pain . These injuries are seen more oflen in younger
athletes. 19
Injury Mechanism. The anterosuperior iliac spine
serves as an attachment for the sartorius. and the an­
teroinferior iliac spine serves as an attachment for the rec­
tus femoris. In both cases a violent, forceful passive stretch
of the hip into extension or a violent. forceful active con­
traction into flexion can cause injury to these sites. 44
Apophysitis or a contusion to these two sites may accom­
panya hip pointer to the iliac crest.
Rehabilitation Concerns and Progression. After
ruling out an avulsion fracture, rehabilitation for these in­
juries should follow the same guidelines as for a hip pointer.
Posterosuperior Iliac Spine Contusion
Pathomechanics. Contusions to the posterosupe­
rior iliac spine must be differentiated from vertebral (rac­
tures and mOre serious internal organ injuries.] Depending
upon the athlete's pain and range of motion, an X ray
should be taken to rule out vertebral fractures, vertebral
transverse process fractures. and fractures of the postero­
superior iliac spine. Other injuries to this area are not com­
mon because of the lack of muscle attachments. 25
Avulsion fracLures are rare in this area, although a fracture
of the posterosuperior iliac spine should be ruled out. The
injury can be painful but usually does not cause disability.
Injury Mechanism and Rehabilitation Concerns.
A contusion to the posterosuperior iliac spine is usually
caused by a blow or fall. An athlete with a contusion might
complain of pain on palpation and have swelling that is
usually not extensive. The athlete's gait cycle may look
normal except in severe cases. when the athlete may take
short. choppy steps to avoid the pain associated with land­
ing at heel strike. In severe cases , the athlete's posture may
show a slight forward flexion tilt of the trunk. This athlete
might show full active range of motion of the trunk, with
mild discomfort. In moderate to severe cases. up to 3 days
of rest may be needed before return to competition .
Rehabilitation Prog,r ession and Criteria for FUJ
Return. The same treatment can be followed that
used for hip pointers. Pain-free active and passive range
motion exercises of t.he trunk and hip can be utilized in s
and repetitions. with stretches held for 20 to 30 secon
for each repetition. Guidelines for return to competiti
are the same as for a hip pointer. and protective paddi n,
recommended.
Piriformis Syndrome (Sciatica)
Pathomechanics. The sciatic nerve is a continuz­
tion of the sacral plexus as it passes through the great
sciatic notch and descends deeply through the back of
thigh. 1H Hip and buttock pain is often diagnosed as scia
nerve irritation. The sciatic nerve can be irritated by a I
back problem. but it is also subject to trauma where
nerve passes underneath or through the piriformis m
cle, in which case sciatic nerve irritation b also called P!~­
formis syndrome.1.22 In approximately] 5 percent of
population , the sciatic nerve passes through the piriform..
muscle. separating it in two. This condition is seen in mc"',
women than men, and the cause of piriformis syndrol!:
might be Cl tight piriformis muscle. "4
Injury to the hamstring muscles can also cause scia
nerve irritation. as can irritation from ischial bursitis. "~
a traumatic accident that causes posterior dislocation
the femoral head, the sciatic nerve might be crushed
severed and require surgery. 24
Injury Mechanism. The most common cause
sciatic nerve irritation in athletics. especially conta .
sports, is a direct blow to the buttock. Because of the lar
muscle mass. this injury is not usually disabling when t CLINICAL DEctS
sciatic nerve is not involved. When the sciatic nerve is i,,­
volved, however, the athlete may experience pain in t :\ female col
buttock, extending down the back of the thigh. possib._ trai ner with
into the lateraJ calf and foot. Sciatic pain is usually a bur back of the thi
ing sensation. 3 7
Rehabilitation Concerns. With sciatica. the al h·
letic trainer must rule out disk disease before starting an
exercise rehabilitation program. Stretching exercises th with sciatica ca
are indicated for sciatica, such as trunk and hip flexi or, and the sciatic
might be contraindicaled ror disk disease. To differentia ommend to help
low back problems (disk disease) from piriformis syndro thigh. and calf.:
as the cause of sciatica. determine whether the athlete ha
low back pain with radiation into the extremity. An MRI ·
very useful [or differentiating sciatica due to piriformis ver­
sus due to disk disease. Back pain is most likely midline, ex­
acerbated by trunk flexion and relieved by rest. ·­
Coughing and straining may also increase back pain an
 CHAPTER 21 Rehabilitation of Groin, Hip, and Thigh Injuries 503

Criteria for Full possibly the radiation. Muscle weakness and sensory is irritated and the athlete complains of radiation into the
e followed that is numbness may also be found in an athlete with disk dis­ extremity. the first 3 to 5 days should consist of rest and
, d passive range of ease. 14 Athletes with piriformis syndrome may have the modalities to decrease the pain associated with sciatica.
In be utilized in sets same symptoms without the low back pain and without After the acute pain has been controlled. the athlete
. 10 to 30 seconds the low back pain being reproduced with coughing and may perform pain-free stretching exercises for the low
1m to competition straining. If, after treatment and rehabilitation, the athlete back and hamstring muscles. as long as disk disease has
'otective padding is still maintains neurological deficits, further evaluation to been ruled out. Stretching exercises (Figures 2] -5. 21-6.
rule out disk disease is necessary. 21-11. 21-14) can be used to treat piriformis syndrome.
In the case of piriformis syndrome, the athlete might Piriformis strengthening may be accomplished through
tical report a deep pain in the buttock without low back pain resistive external rotation of the hip (Figure 21-21).
and possibly radiating pain in the back of the thigh, lateral Reviewing a normal gait cycle can also aid in gaining
erve is a continua­ calf. and foot, also indicating sciatica. 24 The athletic range of motion if the athlete has been ambulating with a
tJ rough the greater trainer's evaluation should include the low back, as well as flexed knee. The hamstrings. as well as the sciatic nerve,
Llgh the back of the the hip and thigh. The athlete's gait cycle could include may have shortened in this case.
:lla gnosed as sciatic lack of heel strike. landing in the foot-flat phase. a short­ Criteria for Full Return. The athlete should be ca­
)1' irritated by a low ening of the stride. and possible ambulation with a flexed pable of performing pain-free activity, such as running
trauma where the knee to relieve the stretch on the sciatic nerve. The ath­ and cutting. without neurological symptoms, before re­
the piriformis mus­ lete's posture. in severe cases, shows a llexed knee with the turning to competition (see Figures 17-4 through 17-14).
In is also called piri­ leg externally rotated. Palpation in the sciatic notch could Participating with constant radiation into the extremity
15 percent of the also produce pain. poses a risk for developing chronic problems. The best
-ough the piriformis With the athlete lying prone and the hip in a neutral method of treatment is prevention by instituting a good
Irion is seen in more position with the knee in flexion. active resistive external flexibility program for all athletes.
,iriformis syndrome rotation and passive internal rotation of the hip might re­
produce the pain 24 (Figure 21-13). Performed supine. Trochanteric Bursitis
an also cause sciatic straight leg raises performed passively or actively might
isc hial bursitis.24 In also cause symptoms. With the athlete supine and the Pathomechanics. The most commonly diagnosed
terior dislocation of knee in extension and relaxed, a decrease in passive inter­ hip bursitis is greater trochanteric bursitis. Thc greater
Ilight be crushed or nal rotation of the hip joint as compared to the uninjured trochanteric bursa lies between the gluteus maximus and
side may indicate piriformis tightness . the surface of the greater trochanter. 2M3
. common cause of Bursitis and other disorders of the bursa are often mis­
es pecially contact taiken for other injuries because of the location of nlilner­
Because of the large ous other structures around the bursa. The bursa is a
disabling when th e CLINICAL DECISION MAKING Exercise 21-2 structure that normally lies within the area of a joint and
e ciatic nerve is in­ produces a fluid that lubricates the two surfaces between
perience pain in th A female coUege soccer player reports to the ath letic which it lies. IS It aliso may attach. very loosely. to the joint
r the thigh, possib l~ trainer with pain in the bullocks and burning down tbe capsule. tendons, ligaments, and skin . Therefore. it is indi­
:un is usually a bu rn ­ back of the thigh to the lateral calf. After the trainer ob­ rectly involved with other close structures. IS The function
tain a hi tory. the athlete reports having fallen on her of the bursa is to dissipate friction caused by two or more
'~h sciatica, the ath­ buttocks 2 days earlier in a game. Tbe athlete does not re­ structures moving against one another.
before starting any port ha\llng any back pain. After the athlete is diagnosed Bursitis associated with bleeding into the bursa is the
ch ing exercises th ai with sciatica caused by the direct blow Lo the buttocks most disabling form. With hemorrhagic bursitis, swelling
and the sclaUc nerve. what can the athletic trainer rec­ and pain may limit motion. 32 The athletic trainer must

~
nk and hip flexio n.
ase. To differentiat ommend to help with the burning pain in the buttocks. also consider the possibility of an infected bursa. If it is sus­
piriformis syndrome thigb. and calf? pected. the athlete should be referred for a medical evalua­
e er the athlete h as tion immediately.
e:memity. An MRI is Injury Mechanism. Bursitis in general is usually
due to piriformis ver­ caused by direct trauma or overuse stress. One possible
lO l likely midline. ex:­ Rehabilitation Progression. Severe sciatica cause for trochanteric bursitis may be irritation caused by
re lieved by rest. l caused by piriformis syndrome can keep the athlete out of the iliotibial band at the insertion of the gluteus max­
ease back pain and competition for 2 to 3 weeks or longer. If the sciatic nerve imus. 24 Repetitive irritation such as running with one leg
504 PART THREE The Tools of Rehabilitation I'"
.,(.
'- .~
slightly adducted (as on the side of a road). can cause chanics{r:hial bursitis is often seen in people who sit fo r knee extended rna}
trochanteric bursitis on the adducted side. long periods. 24 In athletes. ischial bursitis is more com­ guinal area may a:
Trochanteric bursitis caused by overuse is mostly seen monly caused by direct trauma. such as falling or a diree: some cases, the ne
in women runners who have an increased Q angle with or hit when the hip is in a Oexed position that exposes the ts­ na med and cause r.l
without a leg-length discrepancy.! Tight adductors can chial area. knee. 2-1 Osteoanhr'
cause a runner's feet to cross over the midline. resulting in Rehabilitation Concerns. The a thlete might re­ iliopectineal bursi '
excessive tilting of the pelvis in the frontal plane. and con­ port trauma to the area. With the hip in a Oexed position Rehabilitation
sequently place an exceptional amount of force on the palpation over the ischial tuberosity might reproduc tory medicatio n In<
trochanteric bursa .2o the pain. The athlete might experience pain on ambula­ heal or ice ma ssa
Lateral heel wear in running shoes can also cause ex­ tion when the hip is Oexed during the ga it cycle. Also. Oammation and p
cessive hip adduction. which may indirectly result in stair climbing and uphill walking and running may ["­ stretched (Figur
trochanteric bursitis. In contact sports. a direct blow may produce pain. trengthening exen
result in a hemorrhagic bursitis. which coule! be extremely Rehabilitation Progression. Treatment for ischial knee straight (Figill'
painful to the athlete.! S bursitis consists of positioning the athlete with the hip in a
Rehabilitation Concerns. Traumatic trochanteric flexed position to expose the ischial area. After the initial
bursitis is more easily diagnosed than overuse trocha.nteric phase of treatment with ice and anti-inOammatory med­ CLINICAL DECIS
bursitis. Palpation produces pa in over the lateral hip area ication, the athlete may begin a pain-free stretching pro­
aJJd greater trochanter. In both cases the athlete's gait cy­ gram (Figures 21-5 through 21-12. 21-14.. A remale track a
cle may be slightly abducted on the affected side to relieve Criteria for Full Return. Depending on injury short sprints ha~
pressure on the bursa. An athlete's attempt to remove severity, this athlete need not miss competition time with a grade 2
weight from the affected extremity may cause a shortened' Avoiding direct trauma to the area usually allows healin g cleoThe athlete I
weight-bearing phase. The athlete might report an increase within 3 to 5 days. For contact sports, a protective pad
in pain on activity, and active resistive hip abduction might should be worn (see tTeatment for all) hip bursitis injuries .
also reproduce the pain. Sport-specific functional testing and exercises should be
A complete history must be taken to determine the performed as described above before the athlete returns I
cause of trochanteric bursitis. The athlete's gait cycle, competition.
posture. Gexibility. and running shoes should be exam­
ined. Oral anti-inGammatory medication usually helps Groin and Hii
-../~, -

decrease pain and inOamrnation initially. After the initial
treatment of ice. compression. and modali ties the athlete
can utilize various stretchi ng exercises (Figures 21-2.
21-5 through 21-14.
Rehabilitation Progression. An orthotic evalua­
tion should be performed to check for any ma la'iignment
that may have caused dysfunction , excessive adduction.
or leg,length discrepancy. Progressive resistive strength·
ening exercises in hip abduction may be performed when
the athlete is free of pain. Also see treatment for all hip
b ursitis injuries .
Criteria for Ful1 Return. This athlete could miss 3
to 5 days of competition, depending on the severity of the
bursitis. For contact sports, a protective pad should be
worn upon return to competition after the athlete can per­
form the sport-specific functional tests (see Figures 17-4
through 17-14).
Ischial Bursitis SI { ~\ ~
Pathomechanics and Injury Mechanism. The
ischial bursa lies between the ischial tuberosity and the
gluteus maximus (also see Bursitis of the Hip, Pathome-
Groin Injuries Pathomechani
pain is a st.rain to
Evaluation and diagnosis of groin injuries requires an u
occur to any mu
derstanding of the biomechanjcs, a natomy. and mecha ·
to the sarloris. ren
nism of injury. A correct diagnosis req uires a thoro ug,'"
soas, the muscl e
understanding of all possible causes of pain, due to tll_
possibility of more than one injury existing at the sam,
time. 29 Examples of djfferential diagnosis are intra­
abdominal pathology. genitourinary abnormalities. r..·
ferred lumbosacral pain . and hip joint. disorders.29
Iliopectineal Bursitis
Pathomechanics and Injury Mechanism. r· -\ groin strain can
iopectineal bursitis is often mistaken for a strain of t.he n ally rotating the
iopsoas muscle and can be difficult to differentiate. Rar, muscles into fie xi
seen in athletes. iliopectineal bursitis could potentially
caused by a tight iliopsoas muscle. 24 Osteoarthritis of th..
pip can also cause iliopectineal bursitis.24
t Rehabilitation Concerns. Resistive hip Oexion­ With a grade 1
sitting with the knee bent or lying supine wi th the knee of mild discomfort
extended-may reproduce the pain associated with i1­
iopoeliMal bo"ili', AI'~' hip ","0"00 with : ' with negative swe lJ ~
 CHAPTER 21 Rehabilit<lLion of Crain. Hip. and Thigh Injuries 505

e \ ho sit for
knee extended may produce pain. Palpab e pain in the in­ With a grade 2 groin strain , palpation may reproduce
more COrI!­
guinal area may also help in evaluating the athlete. In pain and show a minimal to moderate defect. Swelling
g or a direct
some cases, the nearby femoral nerve may become in­ might also be detected. This athlete may show an abnor­
r:-POses the is­ named and cause radiation into the front of the thigh and mal gait cycle. Ambulation may be slow, and the stride
knee. 24 Osteoarthritis must be ruled out in evaluating length may be shortened on the affected side. l'he athlete
te might rc­
iliopectineal bursitis. may tend to hike the hip and tilt the pelvis in the frontal
oed position.
Rehabilitation Progression. Oral anti-inf1amma­ plane rather than drive the knee through during the
t reproduce
tory medication may be helpful initially. A farm of deep swing-through phase. Range of motion may be severely
o n ambula­
heat or ice massage may be used to aid in decreasing in­ limited, and resistance could cause an increase in pain.
t cycle. Also.
f1ammation and pain. The iliopsoas tendon must be When the ihopsoas is involved, the athlete may experience
ning may re­ stretched (Figures 21-2 through 21-4). and hip ilexion severe pain after the initial injury. This is thought to be
strengthening exercises are performed pain-free with the caused by spasm of the iliopsoas muscle, which tilts the
ent for ischial knee straight (Figures 21-16, 21-28B). pelvis in the frontal plane. The athlete will walk with a
Lh the hip in a flexed hip and knee and will be unable to extend the hip
er the initial during the push-off phase of the gait cycle because the
matary med­ CLINICAL DECISION MAKING Exercise 21-3 muscle spasm does not allow hip extension and active hip

F
,
etching pro­

ing on injury
A female track athlete who competes in the long jump and
short sprints bas been diagnosed by llie team physician
t1exion during swing-through. This athlete will also exter­
nally rotate the hip in order to uti.tize the hip adductors for
<the SWing-through phase.
with a grade 2 hlp flexor strain to the deep iliopsoas fiU ­
lpetition time. An athlete with a grade 3 groin strain may need
allows healing cleo The athlete Is In severe pain and ambulating very
crutches to ambulate. A moderate to severe defect may be
protective pad slowly with a flexed hip and knee. What can the athletic
detected in the involved muscle or tendon. Point tender­
trainer recommend to decrease pain and improve her gait?
lfsitis injuries). ness may be severe, with noticeable swelling. Range of mo­
: ises should be tion is severely limited, especially if the iliopsoas is
hlete returns to involved . The athlete might splint the legs together and be
apprehensive about allowing movement in abduction. Re­
Groin and Hip Flexor Strain sistance might not be tolerated.
~_ Differentiating a hip adductor strain froIll a hip f1exor
Pathomechanics. The number one cause of groin strain is the first step in treating this injury. Resistive ad­
pain is a strain to the adductor muscles. A groin strain can duclion while lying supine with the knee in extension may
requires an un­
occur to any muscle in the inner hip area. Whether it is significantly increase pain if the hip adductors are in­
DY. and mecha­
to the sartoris, rectus femoris, the adcluctors. or the iJiop­ volved. Flexing the hip and knee and resisting hip aclduc­
ires a thorough
soas, the muscle and degree of injury must be determined tion may also increase pain. If the injury is a pure hip
~ain. due to the
and the injury treated accordingly.h adductor strain, the supine position with the knee ex­
in g at the same
Discomfort may start as mi,ld but develop into moder­ tended may reproduce more discomfort than nexing the
I is are intra­
ate to severe pain with disability if not treated correctly. A hip and knee. If resistive adduction with the hip and knce
,normalities. re­
chronic strain can cause bleeding into the groi.n muscles, f1exed produces more discomfort, the hip f1exor may also be
orders. 29
resulting in myositis ossi.ficans (sec the section on myositis involved.
ossificans). If a groin strain is treated acutely, myositis os- With the athlete lying supine, more pain on resistive
silkans can be avoided. hip Hexion with the knee in extension (straight leg raise)
Injury Mechanism and Rehabilitation Concerns. tests for iliopsoas involvement. More pain on resistive hip
lechanism. 11­ A groin strain can develop from overextending and exter- f1exion with the knee f1exed tests l'or rectus femoris in­
a strain of the ii­ nally rotating the hip or from forcefully contracting the volvemenl. After determining the muscle or muscle
rcrentiate. Rarely muscles into flexio. n and internal rotation as involved in~groups invol.ved and the degree of the injury, treatment
llId potentially be running, jumping. twisting, and kicking. Differential diag- and rehabilitation is the next step.
eoarthritis of the nosis and treatment may be difficult because of the num- · Rehabilitation Progression and Criteria for Full
-l ber of muscles in the area. Return, With a grade 1 strain, modalities and pain-free hip
~i vehip tlexion­ With a grade I groin strain, the athlete may complain stretching exercises can begin immediately (Figures 21-2
ne with the knee of mild discomfort with no loss of function and full range through 21-4. 21-7, 2l-8, 2l-11, 21-12). Pain-free pro­
. ociated with iI­ of motion and strength. Point tenderness may be minimal. gressive strengthening exercises may also be performed
(tension with the with negative swelling. The gait cycle may be normal. (Figures 21-15, 21-16, 21-18, 21-20, 21-21. 21-28 ),
506 PART THREE The Tools of Rehabilitation
progressing to Oexion with knee straight and bent and ad­
duction (Figures 21-29 ,21-34,21 -37,21-38 ), and PNF ex­
ercises (see Figures 15-14through 15-21) . Depending upon
the severity of the injury, this athlete need not miss competi­
tion time and can be progre&sed to the slide board (Figure
2]-39). plyometrics (Figures 21-42 through 21-44). and
sport-specific functional drills (see Figures 17-4 through
1 7-1 4) as soon as pain allows.
An athlete with a grade 2 strain should be started im­
mediately, with gentle, pain-free, active range-of-motion
exercises of the l'1ip. When the Uiopsoas is involved, it h as
been found that lying supine on a treatment tab le with the
leg and hip hanging over the end of the tabl e, 'with the hip
in a passively extended position. while applying ice for] 5
to 20 minutes. can help eliminate muscle spasm and pain
(Figure 21-4). Electrical muscle stimulation modalities
can be very useful in tbe ea rly stages to decrease inflam­
mation, pain , and spasm and to promote ra nge of mo­
tl on 34 ]isometrics should also be performed as soon as
they can be managed without pain. If crutches are used ,
a normal gait cycle is taught. The athlete can begin pain­
free stretching as soon as possible (Figures 21-2, througb
21-4.21-7.21-8,21-11, 21-12). As soon as pain allows.
the athlete can begin pain-free strengthening exercises
(Figures 21-15 , 21-16, 21-1 8, 21-20, 21-21. 21-27, 21­
28 ), flexion and a dduction strengthening exercises (Fig­
ures 21-29, 21-34. 21-37, 21- 38), and PNF (see Figures
15-14 through 1 5-21). After approximatdy 1 week the
athlete can begin pain-free slide board exercises (Figure
21-41) and plyometrics (Figures 21-42 througb 21-44),
as well as sport-specific functional drills (see Figures 17-4
thro ugh 1 7-]4). This athlete may miss 3 to 14 days of
competition. depending on the severity of injury. Hip ad­
ductor strains usually take longer to treat and rehabilitate
than hip flexor strains of the same grade. especially if the
muscle spasm involved witb a hip Oexo r is eliminated as
soon as possible. Treatme nt and reh8bilit8tion should be
modified accordingly.
An atblete wilh a grade 3 strain should be iced. com­
pressed. immobilized. and non-weight-bearing. Electrical
muscle stimulallon modalities are useful in the acute stage
to decrease inOammation and pain and to promote range
of moti on. Rest for 1 to 3 days is recomm ended. with com­
pression at all times. If the iliopsoas is involved. passive
stretching with ice (Figure 21-4) can be started after the
third day.
If surgery is ruled oul. the a thlete may perform pain­
free iso metric exercises between days 3 and 5. Slow. pain­
free. active range of motion exercises may also be
performed between days 3 and 5. A normal gait cycle
should be emphasized using crutches. Crutches should not
be eli minated until the athlete can ambulate with a nor­ continuously pn
mal. pain-free gait cycle. Between days 7 and 10. the ath­ time with deep
lete may perform pain-free stretching exercises (Figures lower abdomin al ru
21-2 through 21-4 . 21-7. 21-8. 21-11. 21-]2) an d can eles during pehi
begin progressive resistive strengthening exercises with­ compartment-like
out pain. progressing in weight and motion (Figures with repeated ada.
21-15.21-16.21-18, 21-20 .21 -21. 21-27 . 21-28). flex­ sisto the athlete usu
ion and adduction (Figures 21-29. 21- 34.21-37.21-38 ). re p8irY·19 The alb.
and PNF (see Figures 15-14 througb 15-21 ). The athlete hip adduction and
needs to ac hieve a good strength level. usually within 10 cribe a trunk hYIl
days after starting progre&sive resistive strengthening ex­ curred some time at
ercises. to perform pain-free slide board exercises (Figure ite of insertion 01"
21-41) and plyometrics (Figures 21-42 through 21-44 i pain. As described t
as well as sport-specific functional activities (see Figure, bis. tendinitis. blll~
17-4through 17-14). contribute to (he
Treatment and rehabilitation timetables may be modi­ curs where the ad
fied. The modifications should be based on the degree of in­ posterior aspect
jury within the grade presented. This athlete could repair" is describro
potentially miss 3 weeks to 3 months of competition. dominal musclest
ous other comlX
literature. 17 Tills ~
Sport Hernia/Groin Disruption
pelvis and has
Pathomechanics. The syndrome of groin pain of­ X rays. bone
ten includes the posterior abdominal wall. This syndrome ential diagnosi s.
has manifested itself over the past 5 years and has cre8ted nosing sports her
much confUSion when diagnosing. trea ting. and rehabili­ Rehabilita li o
tati ng. Many athletes who complain of groin paiD do n01
show improvement over a 4-to 6-month period or even af­
ter a year. All kinds of treatment and rehabilitation. in­
eluding extended rest. have not produced positive results.
This nondescriptive groin paIn has come under tt: t
umbrella "sports hernias. " The phrases groin disrupti o
and athletic pubalgia have also been used interchange­
ablyY·19 The anatomy and physiology involved are not
fully understood because there hasn 't been a detailed de­
scription with empirical evidence in the literatureY Whal lherapy invoh'io c
is known is that a sports hernia is described as a wakening ward. and side \\~
of the posterior inguinal wall with possibly an und e­ At approxima'
tectable inguinal herni a due to tbe location behind the strengthening ex,
posterior wal1. 29 Taylor et al. reported success repairin g a a ll performed wi lh
small tear at tb e attachment of the rectus 8bdominis to th gresse d to jogging
pubic boneY th e sides (carioca.
Injury Mechanism and Treatment. Due to the cardiovascular \\',
many biomecbanical movements that occur in sports. the per body ergomete
pelvis is torqued in all its planes. The forces produced by At approxlmat
the muscles that both stabilize and move the pelvis result in ing all mllScl('s and
injury to the abdominal muscles. hip Oexor. and adductor gun previously. A
groupsY An athlete with a sports hernia will usually pres­ be added if pain-fr,
ent the same signs and symptoms as those who have osteiLis may begin ligh t sk
pubis and adductor strains. The symptoms simply la land athletes. pr
longer, even with conservative treatment. The athlete will 10 weeks.
 CHAPTER 21 Rehabilitation of Groin, Hip, and Thigh [njuries 507

ate with a nor­ continuously present a gradual increase in symptoms over At 12 weeks, the athlete can begin weight-lifting exer­
and 10, the ath­ time with deep groin/pelvis pain. Pain may radiate into the cises such as squats, power lifts, lunges, and plyometrics.
tcrcises (Figures lower abdominal area. A weakness of the abdominal mus­ The athlete can progress the running program and add
11-12) and can cles during pelvic and trunk stabiJization may creale a sport-specific drills.
~ exercises with­
compartment-like syndrome injury caused when combined From 3 months forward, the athlete may be cleared for
motion (Figures with repealed adduction of the hip. When symptoms per­ sport participation if all activities arc pain-free.
2 t. 21-28), flex­ sist, the athlete usually responds extremely well to surgical
:.21-37.21-38). repair. 27 .29 The athlete will usually have pain with resistiVe Osteitis Pubis
-21 ). The athlete hip adduction and resisled sit-up2 7 Some patients may de­
u ally within 1() scribe a trunk hyperextension injury that may have oc­ Pathomechanics. Pain in the area of the pubic
rengthening ex­ curred some time ago. The abdominal muscles and adductor symphysis may be difncult to diagnose. Unless the athlete
exercises (Figure site of insertion onto the pubic bone are the main sites of reports being hit or experiencing some kind of direct
rhrough 21-44). pain. As described earlier, other injuries, such as osteitis pu­ trauma, pubic pain might be caused by osteitis pubis, frac­
ities (see Figure~ bis. tendinitis, bursitis. and adductor muscles strains, can tures of the inferior ramus (stress fractures and avulsion
contribute to the symploms. Significant inf1arnmation oc­ fractures), or a groin strain. I
~les may be modi­ curs where the adductors attach to the pubis and along the Because an overuse situation and rapid repetitive
rthe degree of in­ posterior aspect of the adductor insertion. The "pelviC floor ­
repair" is described as the surgical reattachment of the ab­
changes of direction predispose an athlete to this injury,
osteitis pubis is seen mostly in distance running. football,
is athlete cou'ld
competition. dominal muscles to the pubic boneY'l'here are also numer­ wrestling, and soccer. Constant movement of the symph­
ous other components of this repair described in the ysis in sporls such as football and soccer produces inllarn­
literatureY This procedure helps stabilize the anterior mation and pain .
ion pelvis and has been shown to be very successfuJ.27 Injury Mechanism. Repetitive stress on the pubic
bof groin pain 01'­ X rays, bone scans, and MRIs can be helpful in differ­ symphysis, caused by the insertion of muscles into the
al l. This syndrome ential diagnosis, but they usually are not helpful in diag­ area, creates a chronic inflammation. l Direct trauma to
IrS and has created
nosing sports hernias .29 the symphysis can also cause periostitis. Symptoms de­
lling, and rehabili­ Rehabilitation following Pelvic Floor Repair. velop gradually, and might be mistaken for muscle strains.
. groin pain do not After pelvic 1100r repair, the first 4 weeks and first phase of Exercises that aid muscle strains might Calise more irrita­
h period or even af­ rehabilitation invofves nothing more than rest with no ac­ tion to the symphysis: thus early active exercises are con­
reh abilitation. in­ tivity or exercising. At approximately week 5, the athlete traindicated. 21l
ed positive results. can begin posterior pelvic tilts (Figure 25-23: hold 5 sec­ Rehabilitation Concerns. Referral to a physician
~ 'ome under the onds for 3 sets of 10 repetitions), along with gentle pain­ to rule out hernia problems, infection, and prostatitis may
groin disruptioll free stretching of the iliopsoas, hamstrings, grOin, bip be helpful in evaluating osteitis pubis 2u Changes in X-ray
used interchange­ extensors, quadriceps, and trunk. (See the stretches in Fig­ ftlms can take 4 to 6 weeks to show. The athlete should be
~y involved arc not
ures 21-2 to 21-8, and trunk side bends shown in Figure treated symptomatically.
'-been a detaLled de- 25-36). The athlete may also at this time begin aquatic An athlete with osteitis pubis may have pain in t'he
e lileratureP Whal therapy involving simple walking forward. walking back­ groin area and might complain of an increCise ,in pain with
ribed as a wakenin" ward. and side walking. running. sit-ups. and squatting. l The athlete might also
p ssibly an unde­ At approximately week 8, the athlete can add the complain of lower abdominal pain with radiation into the
strengthen~ng exercises shown in figures 21-15 to 21-21. inner thigh. Differentiating osteitis pubis from a musoie
loc ation behind th
I success repairing a
a'll performed without weight. Aquatic therapy can be pro­ strain is difficult.
tus abdominis to th gressed to jogging and running forward, backward, and to Palpation over the pubic symphysis may reproduce
the sides (carioca). At this time the athlete can also begin pain. In severe cases the athlete may show a waddling gait
ment. Due to the cardiovascular work on the Stairmaster. bike, and/ or up­ because of the shear forces at the symphysis. l Rest is the
. occ ur in sports. thl' per body ergometer. main course of treatment. with modalities and anti­
~ forces produced b_ At approximately 10 weeks the athlete can begin stretch­ ,i nflammatory medication to ease pain. As soon as pain
I\'e the pelvis result in
ing all muscles and add weight to the straight leg raises be­ permits, the athlete should begin pain-free adductor
fl exor, and adductor gun previously. Abdominal crunches (see Figure 25-24) can stretching exercises as shown in Figures 21-7 and 21-8.
'nia wiJlusualJy pr be added if pain-Cree. [n the sport of ice hockey, the athlete Also, pain-free abdominal strengthening, low back
lose who have osteitis may begin light skating (pain-free) at this time. For dry­ strengthening, and open-chain hip abductor, adductor,
, ploms simply las land athletes, progressive jogging can also be added at flexor, and extensor strengthening can be started (Figures
nen t. The athlete wi.. 10 weeks. 21-1 5 through 21-19). Because excessive movement that
508 PART THREE The Tools of Rehabilitation

causes shear forces at the symphysis is the main cause of utilized. Return to activity should be gradual and deliber­ 5 da~' s . tb e a
pain, stabilization exercises that concentrate on tighten­ aLe. and must be pain-free. ·.mctional c\r'
ing the muscles around the pubic symphysis are recom­ d prog ress to (:
mended. 'The athlete is asked to concentrate on tightening Snapping or Clicking Hip Syndrome all are pain-fr'
the buttock, groin , abdomen, and low back (the entire
pelvic area) wh ile performing a closed-chain exercise Pathomechanics and Injury Mechanism. Clint­
such as the leg press (Figure 21-31) and lunges (Figure cally, snapping hip syndrome is secondary to what could h~
Acetabulum I
21-34). This stabilization technique helps to control ex­ a number of causes.? Excessive repetitive movement ha Pathomec
cessive movement at the pubic symphysis while the ath­ been linked to snapping hip syndrome in dancers. gym­ '"e\riew of acetab
lete performs movemenls at other joints. These nasL~ . hurdlers, and sprinters where a muscle imbalance or)' that is \'£'1'"
closed-chain exercises may be started. for stabilization develops.l The most common causes of t.he "snapping. ·
purposes, and might actually be pain-free before the start when muscle is involved, is the iliotibial band over the Diagnosis of
of open-chain exercises. greater trochanter resulting in trochanteric buxsitis (see like diagnosing
Rehabilitation Progression and Criteria [or Full Trochanteric Bursitis) and the iliopsoas tendon over the il­ menl. incl uding
Return. The lower body must be protected from shear iopectineal eminence. I Other extra-articular causes of th mapping hip sp
forces to the symphysis area. Most athletes will miss 3 to 5 "snapping" are the iliofemoral ligaments over tbe femoral "trains in ge nera
days of competition. [n severe cases, from 3 weeks up to 3 head. and the long head of the biceps femoris over the is­ provement. Roc,
months and possibly 6 months of rest and treatment may chial tuberoSity.? Extra-articular causes commonly occur m inor hip 1\\15
be necessary. In severe cases. the athlete should not parLic­ when the hip is externally rotated and flexed. Other cause:. during chan gin~
ipate until able to perform pain-free plyometric exercises or anatomical structures that can predispose "snapping hlp caused by a
(Figures 21-42 through 21-44). Sport-specil'ic functional hip" arc a narrow pelvic width, abnormal increases in ab­ labrum. The athl
drills may be started as soon as the athlete can perform duction range of molion. and lack of range of motion into wi th or wi thou'
them pain-free (see Figures 17-4 through 1 7-14) . external rotation or tight internal rotators. l Intra-articular th at a more seri
causes are less likely but may co nsist of loose bodies. syn­ th is injury.3o
Fractures of the Inferior Ramus ovial ( hondromatosis, ost.eocartilaginous exostosis. ac­ In 1999. Has
etabulum labral rim t.ear of ,fibrocartilage. and possibly oose acetabulum
Pathomechanics. Stress and avulsion fractures subluxation of t.he hip joint itself. I .3D ing" and "cHcki.n::c
should be ruled out before treating the pubic area for in­ Rehabilitation Concerns, Progression, and Cri­ with it flexed at
jury. The extent of an avulsion fracture must be diagnosed teria for Full Return. Due to the extra-articular
by X ray. fn some cases. a palpable mass may be detected causes, the hip joint capsule. ligaments, and muscles be­
under the skin. Stress fra ctures may be diagnosed with the come loosened and allow the hip to become unstable. The
same symptoms as in osteitis pubis. \'Vith a stress fracture athlete will complain of a "snapping," and this snapping train. with th
an X ray might appear normal untH the third or fourth might be accompanied by severe pain and disabiHty upon report groin and
week. Obtaining a good history can aid in diagnosing a each "snap." thlete is usu all~' .
stress fracture. The key to treating and rehabilitating the snapping hi p checked for possi
Injury Mechanism. Avulsion fracture of tbe inferior syndrome is to decrease pain and inflammation witb ice. time passes, th e a'
ramus is usually caused by a Violent, forceful contraction of anti-inflammatory medication . and olher modalities such of hip range of
the hip adductor muscles or forceful passive movement into as ultrasound. This could signil1cantly decrease the pain cbange in pain or
hip abdu ction, as in a split. Stress fractures can occur from initially so that the athlete can begin a stretching an lete may repon a
overuse (see trealment for Femoral Stress Fractures). strengthening program. The most important aspect of tb e with pain associa
Rehabilitation Concerns, Progression, and Cri­ evaluation process is to ,find the source of the imbalanc may show a tear -
teria for Full Return. Rest is the key in treating frac­ (which muscles arc light and which are weak). early interventio[]
tures of the inferior ramus. Hip stretching and In the case of t.he iliopsoas muscle snapping over the il­ \lRf arthrogram.
strengthening exercises may be performed. as in pubic in­ iopectineal eminence. the following stretches should be uti­ and pain. The qu
j,uries, within a pain-free range of motion. An avulsion lized (Figures 21-2 through 21-4). Strengthening should pnss before such
fracture might keep an athlete out of competition for up to take into account the entire hip, especially the hip extensors Treatment.
3 months. An athlete with a stress fracture may miss 3 to and internal and external rotators (Figures 21-17. 21-20. have varied, Wilh
6 weeks of competition. Rest from the activities that cause 21-21). snch as crutcht>5J
muscle contraction forces at. the inferior ramus slJould be After pain has subsided anel the athlete can actively inllammatories rna
avoided. and closed-chain stabilization exercises as de­ flex the hip pain-free, the athlete can begin strengthening lime signs and sy
scribed in pubic symphysis injury rchabUitation should be exercises for the hip flexor (Figures 21-15, 2] -16. and fnjecLing the c.
21-28) Ilexion with the knee straight. After the first 3 to suIt in improvemd
 CHAPTER 21 Rehabilitation of Groin. Hip. and Thigh Injuries 509

tlual and deliber­ 5 days. the athlete can begin jogging and sport-specinc will revert to preinjection status. The same has been re­
functional drills (see Figures 17-4. 17-7 through 17-14) ported with intra-articu1lar injections. 4 The benellt of
and progress to exercises shown in Figures 17-5 and 17-6. intra-articular injection is that it can help with differen­
if all are pain-free. tial diagnosis and ruling out snapping of the iliopsoas
'ndrome
tendofi over the iliopectineal eminence. 31l
·hanism. Clini- Acetabulum Labral Tear It appears that the treatment of choice is to operatively
LO what could be remove or dissect the labral tear arthroscopically. Hase and
'e movement has Pathomechanics. Moul et al. present an excellent Ueo(l 5,10) reported return to full pain-free activities (some
n dancers. gym­ review of acetabulum labral tear and present a case his­ in 6 weeks) lin most patients (83 percent). as compared to
~lUscie imbal~nc~ tory that is very familiar to the athletic trainer work,ing conservative treatment (13 percent).
"snappmg. with chronic hip. groin. and lower abdominal pain. JO

~
lhe Rehabilitation after acetabulum Ilabral tear arthro­
band over the Diagnosis of acetabulum la'bral tear is difficult. much scopic resection follows tbis progression : Following an
Leric bursitis (see like diagnosing "sports hernia." After months of treat­ arthroscopic excision at the torn piece of labrum. begin­
e ndon over the i1­ ment. including rest. for hip f1exor/adductor strains . ning a day or two after surgery the athlete is allowed to per­
~ar causes of the snapping hip syndrome. hip bursitis. and hip sprains and form pain-free active range of motion (without weight) as,
Fover the femo~al strains in general. the athlete usually does not show im­ shown in Figures 21-15 through 21-21. At approximately
m roris over the IS- provement. Recently it has been shown that a relatively day 5. the athlete may begin adding weigh t to the exercises
o commonly occur minor hip twist caused by direct blow. forceful cutting described in Figures 21-15 through 21-21 and also add
excd. Other causes during changing directions. or a quick movement at the the exercises shown in Figures 21-28A-E. 21-29A.B. At
dis p se "snapping hip caused by a slip can cause a tear of the acetabular approximately week 3 the athlete can add pain-free
lal increases in ab­ labrum. The athlete may report hyperextending the hip stretching as shown in Figures 21-2.21-5 through 21-14.
n ge of motion into with or without abduction. Previously. it was thought Also at week 3 or 4. if pain-free. the athlete can add Fig­
If .1 Intra-articular that a more serious hip dislocation had to occur to cause ures 21-30 to 21-35. and 21-37. At approximately weeks
r loose bodies. syn­ this injury. J{) 4 to 6 the athlete can begin sport-specific functional train­
ous exostosis. ac­ In 1999. Hase and Ueo described signs that help diag­ ing and return when all activities are pain-lIee.
ilage. and poSSibly nose acetabulum labral tears. I ; These indude hip "catch­
ing" and "clicking." pain with internal rotation of the hip CLINICAL DECISION MAKING Exercise 21-4
ression, and Cri­ with it f1exed at 90 degrees. axial compression of the hip
b e extra-articular joint with the hip f1exed at 90 degrees and slightly ad­ A male college soccer athlete has been receivlng treat­
l5 . and muscles be­ ducted. and pain at the greater trochanter. 15, 30 ment for a gr010 strain for 6 weeks and has participated
come unstable. The The athlete's gait might suggest a severe hip f1exor in his sport with pain. During the 6 weeks of trealment
. and this snapping strain. with the hip flexed and guarded. The athlete might with modalllies including ice. heat. electric stimulation.
and disability upon report groin and lower abdominal pain. At this point the ultrasound. phonophoresis. oral antl-innammatory med­
athlete is usually treated for hip flexor/adductor strain and icalions. as well as modifying hi run conditioning and
n ~ the snapping hip checked for possible hernia. which is always negative. As practice L schedule with the coach, the athlete reported
am mation with ice. time passes. the athlete will report and show signs of loss no change in symptoms. What can the athletic trainer
h er modalities suer. of hip range of motion and strength. with either no recommend at thi point to help this athlete?
\. decrease the pain change in pain or an increase in pain. At this point the ath­
~ a stretching and lete may report an audible "clicking" and/or "catching"
r tant aspect of the with pain associated. If not performed previously. MRI
ce of the imbalance may show a tear in the labrum. It ·is recommended that Hip IDislocation
re weak) . eady intervention utilizing diagnostic tools such as MRJ.
. napping over the il­ MRI arthrogram. and cr arthrogram scans may save time Pathomechanics. Dislocation of the hip joint is ex­
etches should be uti­ and pain. The question remains. how much time should tremely rare ,in athletics and takes a considerable amount of
o-engthening should pass before such diagnostic tools are ordered? force because of the deep-seated ball-in-socket joint. 11.18
aU I the hip exCensor5 Treatment. Treatrnents of acetabulum labral tears Fractures and avascular necrosis. which is a degenerative
gures 21-] 7.21-20. have varied, with mixed results. Conservative treatment condition of the head of the femur caused by a disruption of
such as crutches. modalities. and nonsteroidal anti­ blood supply during dislocation. should always be consid­
athlete can actively inf1ammatories may have a positive affect acutely. but over ered.l.l J ,21 Dislocation should be treated as a medical emer­
begin strengthening time signs and symptoms usually return. gency. The athlete should be checked [or distal pulses and
21-15. 21-16. and Injecting the capsular area outside the joint might re­ sensation. The sciatic nerve should be examined to see if it
it. After the nrst 3 to sult in improvement initially, but over time the athlete has been crushed or severed. I Do this by checking sensation
510 PART THREE The Tools of Rehabilitation
and foot and toe movements. If the sciatic nerve is damaged.
knee. ankle. and toe weakness may be pronounced.
Injury Mechanism. A hip dislocation is generally a
posterior dislocation that takes place with the knee and hip
in a flexed position . The athlete may be totally disabled, in
severe pain, and usually unwilling to allow movement of
the extrremity.l'he trochanter may appear larger than nor­
mal with the extremity in internal rotation, flexed, and ad­
ducted. 17 X-ray studies should be performed before
anesthetized reduction. 3!
RehabiUtation Concerns, Progression, and Cri­
teria for Full Return. Two or 3 weeks (and in some
cases, a longer period) of immobilization is initially
needed. Rehabilitation of the thigh, knee. and ankle may
be included at this time. Pain-free hip isometric exercises
should be performed. Electrical muscle stimulation modal­
ities may be used initially to promote muscle reeducation
and retard muscle atrophy. 37 At approximately 3 to 6
weeks, pain-free active range of motion exercises can be
performed (Figures 21-15 through 21-21 ) with no resist­
ance/weight. Crutch walking is progressed and performed
uDtiI the athlete can ambulate with a normal gait cycle
and without pain. At approximately 6 weeks, the athlete
may perform gentle progressive resistive strengthening ex­
ercises with a weight cuff or weight boot. All six move­
ments of the hip should be included in the progressive
resistive strengthening exercises (hip flexion. abduction,
extension, adduction, internal rotation. and external rota­
tion, (Figures 21-15 through 21-21, 21-28) and PNF ex­
ercises (see Figures 15-14 through 15-21 ). Pain-free
slretching exercises should not be performed until 8 to 12
weeks (Figures 21-2, 21-3. 21-5 through 21-14). At ap­
proximately 12 weeks, the athlete may begin closed-chain
exercises (Figures 21-30 through 21-37), as well as open­
chain exercises (Figure 21-29). At 16 to 20 weeks, the ath­
lete may progress to pain-free slide board (Figure 21-41),
plyometric exercises (Figures 21-42 through 21-44), and
sport-specific fl.lnctional activities (see Figures 17-4 , 17-7
through 17-14) and then progress to the functional exer­
cises (see Figures 17-5, 17-6). If pain returns, the athlete
must eliminate plyornetrics and functional activities until
they can be performed pain-free. This athlete may return
to competition in 6 to ] 2 months if there have been no de­
lays and the athlete is pain-free with all activity.
Hamstring Strain and Avulsion
Fracture of the Ischial Tuberosity
Pathomechanics. The ischial tuberosity is a com­
mon site of injury to the hamstring muscle group (the bi­
ceps femoris, semitendinosus, and semimembranosus). All
three hamstring muscles originate from the ischia_ range of motio n l~
tuberosity. The most common ischial injury, as it relates to Lring slretching t:
the hamstring group, is an avulsion fracture of the performed. Rega:
tuberosity.l.33 rehabilitation prop
Injury Mechanism. This injury usually resul ts n ever gain full h"
from a violent, forceful flexion of the hip. with the knee in jury.
extension.! A less severe irritation of the hamstring orig' ''''eeks 6 throu
at the ischial tuberosity may also develop. ree hamstring pr ...
Rehabilitation Concerns, Rehabilitation Pro­ :ises (Figures 11 ­
gression, and Criteria for Full Return (Strain). An closed-chain exte/!
athlete with a less severe injury OF irritation of the ham­ 11-32,21· 35 , 21 -1
string origin at the ischial tuberosity may complain or dis­ and PNF exercises '
comfort on sitting for extended periods and discomfort on to 3 weel,s th e a
palpation. This athlete may a'lso complain of ,pain whH hown in Figures ~
walking up stairs or uphill. The athlete may ambulate wit Rehabilita tion
a normal gait cycle. 1\1 so, the athlete may be able to jog Return (Avulsion
normally. but pain may be present with attempts at sprint­ necessary. 1ml11oh
ing. Resistive knee flexion and resistive hip extension with usually enough to
the knee in an extended position may reproduce the pain. tiv ity that invo" ,
Passive hip flexion with the knee in extension may als kn ee flexion ror Lhr
cause discomfort. sary. Crutche
After the initial treatmen t phase of ice and other During weeks 6 10 ~.
modalities. the athlete may begin gentle. pain-free ham­ swimming. bikw~
string stretching exercises (Figures 21- 5, 21-6). To iso­ avoid forceful knre
late the hamslring muscle while stretching, the ath le te sian. Afler week 12
should maintain a lordotic curve in the lumbar bar k. 10 the slide bo~
area while flexing at the trunk to stretch the hamstring 21 -42 throu gh 2: "';
(Figure 21-6) . Pain-free hamstring muscle progressive I see Figures] 7-:\ " ­
resistive strengthening exercises may also be performed to the exercises sh
as soon as possible, (Figures 21-17, 21-22. through
21-24. 21-38), closed-chain extension exercise (Figure<;
21-30 through 21-37), and PNF exercises (see Figure<;
15-14 through 15-21). This athlete might not miss com­
petition time and can be progressed runctionally as tol­
erated. string muscles and
Rehabilitation Concerns (Avulsion Fracture). \'ery complex bee:
The more severe ischia'! tuberosity avulsion fracture pres­ This produces fon;
ents a different clinical pictUre. Palpatiotl may produce strings dependent
moderate to severe pain. and the athlete may be in moder­ Some dissection r
ate to severe pain with a very abnormal gait cycle. The at h­ lent overlap of Ie
lete's gait cycle may lack a heel-strike phase and have " muscle. with the,
very short swing-through phase.2 The athlete may at­ research showin g
tempt to keep the injured extremity behind or below the main injury s.i te.
body to avoid hip flexion during the gait cycle. Resistive SlIsceptible to iuju _
knee flexion and hip extension with the knee in an e.x­ The athlete mi
tended or flexed position may reproduce the pain. Passi\'<" iest way to ideoti_
hip flexion with tbe knee extended and with the kn ee though bleeding I
flexed may cause moderate to severe pain at the ischi pie believe tha t ti .
tuberosity. X rays might or might not show the injury.3 7
After week 3 and the initial acute phase of treatmem
with modalities, the athlete may begin pain-free acti\'e plain of sore hamstr;
 CHAPTER 21 Rehabilitation of Groin. Hip. and Thigh Injuries 511

m the ischial range of motion lying prone and supine. Pain-free ham­ tion and possibly minimal swelling. An athlete with a
.'. as it relates to string stretching ellercises (Figures 21-5, 21-6) may also grade 2 hamstring strain may report having heard or felt a
acture of the be performed. Regaining full range of motion during the "pop" during the activity. At the first or second day. moder­
rehabilitation program is very important. Many athletes ate ecchymosis may be observed. Palpation may produce
usually results never gain full hip Ilexion range of motion after this moderate to severe pain. and even though a defect and no­
with the knee in injury. ticeable swelling in the muscle belly may be evident. the
~ amstring origin Weeks 6 through 12 are a progressive phase for pain­ grade 2 hamstring strain most likely occurs at the musculo­
free hamstring progressive resistive strengthening exer­ tendinous junction either mid to high sernimembranosus/
iJilitation Pro­ cises (Figures 21-17, 2]-22 through 21-24, 21-28) , tendinosis or lower lateral biceps femoris. An athlete with a
n (Strain). An closed-chain extension exercises (Figures 21-30, 21-31, grade 3 strain may report having heard or felt a "pop" dur­
n on of the ham­ 21-32,21- 35.21- 37), isokinetics (Figures 21-39, 21-40), ing the activity. The athletic trainer may detect swelling and
r complain of dis- and PNr exercises (Figures 15-14 through 15-21). After 2 severe pain on palpation. A noticeable defect may be pres­
d discomfort on to 3 weeks the athlete may progress to the exercises as ent, again at the musculotendinous junction as described
lin of pain while shown in Figures 21 -34, 21~36, 21-38. above. After the flfst through third days, moderate to severe
~y ambulate with Rehabilitation Progression and Criteria for FujI ecchymosis may be observed.
lay be able to jog Return (Avulsion Fracture). Surgery is usually not Injury Mechanism. A quick, explosive contraction
tlempts at sprint· necessary. Immobilization and limiting physical activity are that involves a "rapid activity" could lead to a strain of the
'p extension with usually enough to allow healing. Ice and limited physical ac­ hamstring muscles. Many theories try to explain the cause
foduce the pain. tivity that involves hip .flexion and forceful hip extension and of hamstring strains. Imbalance with the quadriceps is
ension may also knee Ilexion for the flfst 3 weeks are usually all that is nec­ one theory. according to which the hamstring muscles
essary. Crutches should be used until normal gait is taught. should have 60 to 70 percent of the quadriceps muscles'
r ice and other During weeks 6 to 12, the athlete will begin activities such strength. Other possibilities are hamstring muscle fatigue,
e. pain-free ham­ as swimming. biking, and jogging. but the athIete should running posture and gait. leg-length discrepancy, de­
-=}. 21-6). To iso­ avoid forceful knee and hip l1e}.ion and forceful hip exten­ creased hamstring range of motion, and an imbalance be­
:h ing. the athlete sion. After week 12 the athlete, without pain. may progress tween the medial and lateral hamstring muscle.]
lhe lumbar back to the slide board (Figure 21-39), plyometrics (Figures Another factor that plays a role in injury. as well as re­
:h the hamstrings 21-42 through 2]-44), and sport-specific functional drills habilitation, is that the semitendinosus, semimembra­
luscle progressive (see Figures] 7-4, 17-7 through 17-14) and then progress nosus, and long head of the biceps femoris are innervated
il 0 be performed. to the exercises shown in Figures 17-5 and 17-6. from the tibial branch of the sciatic nerve, while the short
. 21-22. through head of the biceps femoris is innervated by the peroneal
1 exercise (Figures
Hamstring Strains branch of the sciatic nerve. 7 This innervation difference
rei es (see Figures makes the short head a completely separate muscle-"a
ight not miss com­ Pathomechanics. Hamstr.ing strains are common , factor implicated in the etiology of hamstring muscle
unctionally as tol­ and the causes are numerous.46 The ability of the ham­ strains" as described by DeLee and Drez. 7
string muscles and quadriceps muscles to work together is Two phases of the running gait described by Delee
a1sion Fracture). very complex because the hamstrings cross two jointsY and Drez show that the support phase and the recovery
ion fracture pres­ This produces forces and therefore stresses on the ham­ phase may predispose the athlete to hamstring strains.
loo n may produce strings dependent upon the positions of the hip and knee. 7 During the support phase, foot strike. mid-support. and
:e may be in moder· Some dissection research has shown that there is consis­ take-off occurs. 7 During recovery phase, follow-through.
Igait cycle. The ath· tent overlap of tendon vertically, over the course of the forward swing, and foot descent occurs. 7The two portions
• phase and have a muscle. with -the exception of the semitendinosus. ? With of these two phases that are implicated in hamstring
ile athlete may at­ research showing the musculotendinous junction as the strains are the late forward swing segment of the recovery
e hlnd or below the main injury site. anywhere along the muscle/tendon is phase and the take-off phase of the support phase. EMG
gait cycle. Resisthe sllsceptible to injury.7 data show that the semimembranosus is very active dur­
the knee in an ex­ The athlete might report a "pop." Palpation is the eas­ ing the late forward swing segment and that the biceps
ee the pain. Passive iest way to identify the site and extent of injury. Even femoris is inactive. ? At take-off of the support phase, the
and with the knee though bleeding (ecchymosis) may be present, some peo­ biceps femoris shows maximal activity.? This shows that
pa in at the ischial ple believe that this isn't associated with the degree or the mid to high semimembranosus and semitendinosus
mow the injury.37 severity of injury.? strains may occur during the deceleration portion of the
phase 01 treatment An athlete with a grade 1 hamslring strain will com­ running cycle while the lower lateral biceps femoris
gin pain-free acti\' plain of sore hamstring muscles. with some pain on palpa­ strains are occurring at the take-off or push-off portion of
512 PART THREE The Tools or Rehabilitation
the running cycle. The rehabilitation implications are
connected to the position of the hip and knee while reha­
bilitating in order to isolate and identify the specific mus­
cle and nerve innervation involved. S Utilizing the correct
biomechanical positions du.ring rehabilitation, based on
the EMG findings presented , will enhance rehabilitation
and improve preventive programs.
Rehabilitation Concerns. An athlete with a grade
1 hamstring strain may have a normal gait cycle. Hip flex­
ion range of motion is probably normal. with a tight feel­
ing reported at the extreme range of hip flexion. Resistive
knee flexion and hip extension with the knee extended are
probably free of pain or possibly produce a tight feeling
with good strength present.
An athlete with a grade 2 hamstring strain usually
ambulates with an abnormal gait cycle. The athlete may
lack heel strike and land during the foot-flat phase of the
gait cycle. Tbe swing-through phase may be limited
because of the athlete's unwillingness to flex the hip
and knee. The athlete may tend to ambulate with a flexed
knee. Resistive knee flexion and hip extension with the
knee extended may cause moderate to severe pain. The
athlete may also have a noticeable weakness on resistive
knee flexion and hip extension with the knee extended
and flexed. Resistive hip extension with the knee flexed
also tests the strength of the gluteus maximus muscle.
Passive hip flexion with the knee extended may also pro­
duce moderate to severe pain. The athlete's range of mo­
tion may be moderately to severely limited in hip flexion
with the knee extended and moderately limited in hip
flexion with the knee flexed.
An athlete with a grade 3 hamstring strain may be un­
able to ambulate without the aid of crutches. The athlete
may have poor strength and be unable to resist knee flex­
ion and hip extension with the knee extended. The athlete
may have fair strength upon resistive hip extension with
the knee flexed because of the gluteus maximus muscle.
Resisting these motions usually causes pain. Passive hip
flexion, with the knee extended, might not be tolerated be­
cause of pain. Passive hip flexion, knee flexed, may be
moderately to severely limited.
Because most hamstring injuries occur due to a "rapid
activity" that involves an explosive concentric contraction
during toe-off or a strong eccentric contraction during de­
celeration swing-through, it is this author's belief that the
hamstring should be rehabilitated in a "rapid activity"
fashion with high intensity and a high volume of exer­
cises. After the initial treatment of ice. rest, compression,
and active range of motion. the following exercises, in the
order given and with a load that doesn't produce pain,
should be instituted. Alternating a single-joint open-chain
exercise with a mulLijoint closed-chain exercise. with 3C
seconds rest between sets and actual exercises, has shown
to facilitate rapid healing and earlier return to activity, as
well as present preventive advantages (all exercises a
performed pain-free and in the order given). ing strain. lh
Depending on the degree of injury, the athlete shou l '.orks best after j
warm up by utilizing a stationary bike, Stairmaster. and/or d a II exercises
aquatic therapy followed by stretching. It has been ShO\\T "ra m also worl­
that the Stairmaster produces more hamstring activilli' ~o n: a modillc
than the bike and may be used in lateT stages to provide­ Rehabilitati
more hamstring isolation. 7 Stretching includes the exer­ the order gin~
cises shown in Figures 21-SA,B, 21-6 through 21-11 h ould be progr
21-14. h'es pain . ran!=
Depending on the degree of injury, at approximatet IUS workout
days 3 to S stretching can then be followed. if pain-free. ~ eels. Days bel
the strengthening exercise shown in Figure 21-17 ane hou ld be uUliz
then by the exercise shown in Figure 21-28E (multihip ~tair master. and
hip extension with knee straight to knee flexed at end .]\-iLy (Figure 2!.....,
hip extension for mid/ high semirnembranosus/ tendinoslL above.
strains, and knee bentlf]exed at the beginning to kn a.­ pain-free
straight at the end of hip extension for lowerllateral bice possible. and
femoris strains). The closed-chain exercise shown in Fig­ :lOrmal gail c~
ure 21- 30 is also added as long as the athlete keeps Ih
stretch in the hamstring pain-free.
After a few days of performing those exercises, the fl-­
lowing strengthening exercises may be added, in order.
long as they are performed pain-free: open-chain in Figun
21-22 followed by closed-chain in Figure 21-31 and the
open-chain in Figure 21-24 (if pain-free), followed I .
closed-chain in Figures 21-32 and 21-37 (feet in front fi
a mid-high strain) or Figure 21-33 (feet in back for
lower/lateral strain). The exercise in figLlre 2 J -3S can Ix
added at this time, combined with the exercise in Figurt'
21-30 as described previously.
Again, after a few more days the following strengthening
exercises should be added, in order, as long as they are per­ witb paio-free
formed without pain: open-chain in Figure 2] -2 3 (after sin­ pain-free. th e a
gle-leg concentric, follow with heavy negative started bet wee n d
repetitions/sets-two legs up. one leg down eccentrically. for Criteria for f
2 sets of 8 repetitions. followed by closed-chain in Figures
21-30 and 21-34, and ending with Figure 21-36. Also aL
this time, PNF exercises shown in Figures 15-14 through program descJi bed
lS-21 can be added. !ber injury. An at
After a week or so performing the preceding exercise~ . could miss ~ to 21
the following exercises can be added: Figure 21- 38A, B (for grade 3 hamstring
both mid/high and lower/ lateral strains) and Figure 21-3 9 petition or more. In
for mid/high strain or Figure 21-40 for low/ lateral strain. turn to compeliti
The time between adding new open- and closed-chai n t.hrough 21-44 ) a
combinations depends upon the degree of injury and figures 17-4 throll.
whether the exercises are all performed pain-free. For ex­ Once you begin 5 .
ample, with a moderate grade 2 hamstring strain, pro­ up the athlete's co
 CHAPTER 21 Rehabilitation of Groin. Hip. and Thigh Injuries 513

l. ercise. with 30 gression to all strengthening exercises described takes

place in the first 3 to 10 days. With a more severe grade 2
complished by uti.lizing hamstring functional ac1i\'ities
such as backpedals. side shuffles. carioca. plyometrics. and
h:ises. has shown
lrr n to activity. as hamstring strain. progressing Lo all the strengthening ex­ straight-ahead pain-free strides up to 100 yards in length.
I all exercises are ercises described may take 2 weeks. For a grade 3 ham­
~n . string strain. the strengthening progression described
CLINICAL DECISION MAKING Exercise 21-5

~
e athlete should works best after 3 to 4 weeks of healing has been allowed
irmaster. and/or and all exercises can be accomplished pain-rree. This pro­
gram also works well prophylactically during the off­ A football running back has suffered a grade 2 hams tring
t has been shown
strain. His pain is in the middle upper aspect 01 the ham­
~mstring activity season; a modified version can be effective during the season.
string muscle. The tea m physician has r{'ferred Ihe ath­
I stages lo provide Rehabilitation Progression. Each exercise done
lete back to the athletic trainer for rehabilitalion and
!Dcludes the exer­ in the order given and sets. reps. and suggested rest periods
return to play. What can the alhletic trainer recommend
through 21-11. should be progressed based on daily evaluation that in­
volves pain. range or moLlon. muscle strength from previ­ in order for this athlete 10 return to play al full speed?

at approximately ous workout session. ami how the athlete subjectively

oro. ir pain-rree. b feels. Days between strengthening workout sessions
=igure 2l-17 and should be utilized for aerobic conditioning such as biking. Hamstring Tendon Strains
~1 -28E (multihip: Stairmaster. and aquatic therapy. as well as slide board ac­
ee flexed a t end or tivity (Figure 21-41) followed by stretching as described Pathomechanics. Another injury that occurs to the
Illosus/tendinosus above. hamstring muscles is a strain of the hamstning tendons near
Jeginning to knee 1\ pain-free normal gait cycle should be taught as soon their alla chments to the tibia and ,fibula. This injury has
)\\'erllateral biceps a~ possible. and crutches should be used to accomplish a also been diagnosed as tendinitis. Injury to the gastrocne­
cise shown in Fig­ normal gait cycle. Icc. compression. and gentle. pain-free mius muscle tendons ,in the same area must be ruled out.
, tblele keeps the hamstring stretching exercises. making sure the athlete Injury Mechanism. The athlete might report pain
maintains a lumbar lordotic curve to isolate the hamstring but might not experience disability. An athlete with a ham­
e exercises. the rol­ muscles. are performed on day 1. Electrical muscle stimu­ string tendon strain or tendinitis may present a history of
added. in order. as lation modalities may be used to promote range of motion overuse and chronic pain for a few days with no specific
ten-cha in in Figure and to decrease pain and spasm. 22 Active knee and hip mechanism of injury.
.re 21- 3 1 and then range of motion while ,lying prone may also be performed Reha'b ilitation Concerns, Rehabilitation Pro­
-free ). followed by on days 1 through 3. if the athlete can do so without pain. gression, and Criteria for Full Return. Palpation
37 (reet in rront ror Hamslring isometric exercises arc taught as soon as possi­ helps to isolate which tendon or tendons are involved. and
reet in back ror ,1 ble. again within pain-free Hmits. Starting pain-free active resistive knee flexion. with the tibia in internal and exter­
gure 21- 3 5 can be range of molion. as soon as possible. is very important and nal rotation. aids in the evaluation. If resistive ankle plan­
. exercise in Figure usually decreases the length of time an athlete misses tar flexion with the knee in extension cloes not reproduce
competition. At approximately clay 3. the athlete may be­ symptoms. gastrocnemius involvement may be ruled out.
\,i ng strengthening gin heat in the form or hot packs and whirlpool. combined An athlete who presents with this condition responds
Jog as they are per­ with pain-free stretching exercises described earlier. If nicely to ] to 2 clays of resl with oral anti-inflammatory med­
.Ire 21-23 (arter sin- pain-free. the above strengthening program may be ication. Ice massage and ultrasound help decrease inllanuna­
heavy negative started between days 3 ancl 7. tion and pain. Gentle hamstring slretching exercises (Figures
\\ 1 eccen trically. ror Criteria for FuU Return. An athtete with a grade 1 21-5.21-6) with the hip in internal and external rotation
oed-chain in Figures hamstring strain might not miss competition but should help to isolate the tendon or tendons involved. and PNF
:- e 21-36. Also at be watched closely for further injury. The rehabilitation stretching (see Figures 15-14 through 1,)-2 j ) should be per­
).fes 15-14 through program described should begin immediately to avoid fur­ formed on day 1. Hamstring progressive resistive strengthen­
ther injury. An athlete with a grade 2 hamstring strain ing exercises that isolate the hamstring muscles can be
preceding exercises. could miss 5 to 21 days of competilion. An athlete with a performed on day 1 (figures 21-17.21-22.21-1".21-24.
gure21-38A.B(for grade 3 hamstring strain could miss 3 to 12 weeks of com­ 21-28F.l. along with closed-chain han1strillg leans (Figures
I a nd Figure 21-39 petition or more. In aU situations the athlete should not re­ 21-30.21-36). U' they can be performed without pain .
r lowllateral strain. turn to competition until plyometrics (Figures 21-42
n - and closed-chain through 21-44) and sporl-specil'ic functional drills (sec
Femoral Stress Fractures
~ree or injury and Figures 17-4 through 17-14) are accomplished pain-free.
C'd pain-free. for ex­ Once you begin sport-specinc drills. it is advised to warm Pathomechanics and Injury Mechanism. A
nstring strain. pro­ up the athlete's core body temperature. This can be ac­ stress fracture. often described as a partial or incomplete
514 PARTTHHEE The Tools of Rehabilitation
fracture of the femur, may be seen because of repetitive
microtrauma or cumulative stress overload to a localized
area of the bone, 10.;17 Young athletes are more likely to de­
velop this injury. The athlele may complain of pinpoint
pain that increases during activity. The initial X-ray 111m is
usually nega tive. Obtaining a good history is very impor­
tant and should include activities, cha nge in activities and
surfaces. and runni.ng gait analysis. 47
Th.e basic biomechanics and biodynamics of normal
bone are very important 10 understanding the mechanism
of stress fractures. A process of bone resorption. followed
by nelV bone formation , in normal bone. is constantly oc­
curring through turning over and remodeling by the dy­
namic organ itself.47This remodeling occurs in response to
stress, weight-bearing, and muscular contractions that
cause stresses. Responses by the bone to these loads allow
the bone to become as strong as it has to be to withstand
the stresses placed upon it during the required activity. ll ,4 7
Because bone is a dynamic tissue. there is a cell system in
place that. carries out the process of constant bone break­
down and bone repair for the task at hand. 47 There are 1:\"10
types of bone cells responsible for this dynamic procedure--­
osteoclasts. which resorb bone, and ostcoblasts, which pro­
cliuce new bone to fill the areas that have been resorbed ."
Vlihcn stress is applied. the oste.oblasts produce new bone at
a rate comparable to the osteoclasts. When the stress is ap­
plied over time, as in overuse, the osteoclasts work at a faster
rate than the oSleob'lasts and a stress fracture occurs. Some
studies have shown that this stress reaction occurs approxi­
mately dming the third week of a workout session. 12 This
becomes very important when developing a rehabilita tion
program in reference to utilizing the advantages of bone
physiology within the rehabilitation program La facilitate
new bone formation.
Rehabilitation Concerns, Progression, and Cri­
teria for Full Return. As with all stress fractures, find­
ing the cause is the first step in treatment and
rehabilitation 4 o The athlete may perlorm pain-free thigh
strengthening and stretching exercises and progress as
shown in the sections on h a mstring and quadriceps reha­
bilitation programs.
The most important treatment for stress fractures is resL.
especially from the sport or activity that caused the fracture.
rna period of 6 to 12 weeks, most femoral stress fractures
heal clinically U' the specific cause is discot1ti..nucd. 4 7 The re­
sorptive process will slow down, and the reparative process
will catch up. with simple rest from the activity that caused
the problem. Rest should be "active." This allows the ath lete
to exercJse pain-free and helps prevent muscle atrophy and
deconditioning. Except in special "problem" fractures, im­
mobilization in a cast or brace is usually unnecessary. When
there is excessive pain or motion of the part, casts or braces
may be used. In unreliable patients, a cast or some form of
immobilizatioQ may be recommended. Non-weight-bearing
or partial-wcight-bearing with crutches is highly recom­
mended as the process of ambulating wWh a normal gail.
while utiliziGg crutches, can facilitate bone [ormation at the
FEMOR A
fracture site. 26
INJURY SITUATION
UntH ordinary. "normal" activities are pain-free wilh
week of cross-cour'
no tenderness or edema over the fracture site and no ab­
mid thigh stnce the
normal gait patterns during ambulation. the athlete is ward the end of her
held back from sport activities. Pain-free rehabilitation
ing the day a nd ha
shoul d start immediately and continue throughout the re­
told her she prob
covery period with a slow progressive return to activity.
Immediately discontinue all activity with recurrence o[ SIGNS AND SYMPT1l
any symptoms 47 thigh approxi malt:,
The first phase of the rehabilitation program begins campus and cro5,'; -­
when the stress fracture is diagnosed. 'I'his phase consists fore reporting ror
of modalities to decrease pain and swelling and to increase ning 7 days per \\
or maintain ac.tive range of motion to the hip, knee, an d began intensive \\
ank le joints." 7 The second phase of rehabilitation begins as train 7 days per \\­
acute pain subsides. This phase consists of functional re­ remember feeli ng
habilitation and conditionin g in a progression of spOrl­ (during the last 6 .. ,
specific training. Keeping in mind bone physiology a The athlete is "
described, the athlete who has begun sport-specific train­ having over 50 0 IP
ing is advised not to run, jump. or force activity during th e During pal pali
third week after 2 weeks o[ vigorous "normal" exercise or
rehabilitation and conditioning. This cycle is repeated- 2
weeks of vigorous "normal" activity, followed by 1 week of
either eliminating running and jumping or at least cutti.ng
it back to half the "norma l" activity level. This cyclin g of
activities, every third week, facilitates osteoblast functi on
(bone formation) and , therefore. new bone growth at the
fracture site as the osteoblasts are able to keep pace wit'
and actually work faster than the osteoclasLs. MANAGEMENT P:
Rehabilitation and treatment sho uld be an ongoin g
process as described above, with general physical condi­
tioning as part of th e "active rest" period. Aquatic excrc'
and conditioning. such as swimming. treading water. ru n­
ning in a swimming pool, biking, Stairmaster, and the slid PHASE 0
board, (Figure 21 -41). should be started as soon as the.
GOALS: I'rotectiL,
are pain-free. These activities could come under the um­
F.stimated Length of
brella of "normal" exe rcise or rehabilitation and con d. ­
Unlilthe result ~ or
tioning. Upper-body ergometers may also be utilized . A:
athlete's sport a nd
athlete with a femoral stress fracture should also be evalu­
vhile wearing s
ated for lower-extremity deformities and foot malalign­
program . Durin g 1
ments.47 Orthotics can be very useJul in treating a fem Ole:
Based on bone
stress fracture if a malalignment is foun d.
Avulsion Fracture of the
Femoral Trochanter
at the fracture site.
Pathomechanics and Injury Mechanism. A
The followin g ~
letes might suffer an isolated avulsion fracture of 1
-ardiovascular prog
 CHAPTER 21 Rehabilitation of Groin. Hip. and Thigh fnjurie:; 5 15

}; some form or
,\\'cight-bearing REHABILITATION PLAN

; highly recom­
I a normal gait.
FEMORAL STRESS FRACTURE
fo rmation at the
INJURY SJ1UATION An 1 R-year-old female cross-country student-athlete visits the athletic training room during the fourth
, pain-free with week of cross-country practices her freshman yeill' in college. She has been experiencing right thigh pain approximately
ite and no ab­ mid thigh since the end of the summer. and the pain has increased during Lhe past 4 weeks . At first it was present only to­
I, the athlete is ward the end of her running workouts and immediately after running. Lately, her pain has been a constant dull ache dur­
e rehabilitation ing the day and has increased during workouts to the point where she can no longer finish an entire workout. Her coach
'o ughoutthe re­ told her she probably has a quadriceps strain and she should go see the athletic trainer.
tu rn to acLi\1ily.
., recurrence of SIGNS AND SYMPTOMS The athlete is compl'aining of a constant dull ache to the anterior
thigh approx.i mately mid quadriceps that increases with activities such as walking around
program begins campus and cross-country workouts. During the last 6 weeks of her summer vacation (be­
i. phase consists fore reporting for her freshman year of college) she increased her mileage and started run­
g a nd to increase ning 7 days per week in preparation for college competition. Upon reporLing to campu~, she
Ie hip. knee, and began intensive workouts with the team, again increasing her mileage and continuing to
\it alion begins as train 7 days per week. There was no specific mechanism of injury. She didn't get hit. fall, or
of functional re­ remember feeling thigh pain during a specil'ic run/workout. The pain developed over time
ression of sporl­ (during the last 6 wccks of the summer).
Ie physiology a~ The athlete is wearing older running shoes, which appear worn down. and shc reports
lrt-specific lrain­ having over 500 miles on them. She is currently wearing these shoes to train in.
~li l'ity during the During palpCl trion. the Clthlete describes a low-grade pain approximately mid thigh in an area 1 to 2 inches in length. Thcre
rm al" exer 1se or is 110 noticeable slVelling or muscle defect. She shows full active and passive quadriceps and hip range of motion when seated.
-Ie is repeated-2 lying supine, and lying prone. There is mUd discomfort on resistive knee extension both seated and lying supine with the knee
lwed by ] week of bent over the end of th e tablc. The right hip shows a significant decrease in strength compared to the left hip in the movements
or a least cutting of abduction. flexion , and extension. She shows mild tightness in her hamstrings equally bilateral. She also shows a slightly in­
~1. This cycling of creased Q angle and does show excessive pronation upon weight bearing in her right foot but not in her Ik:ft. She presents nor­
.teoblasL function mal alignment with the subtalar joil1t in neutral non-weight-bearing. Also, to observiltion, her right quadriceps is slightly
ne growth at the smal.ler and less defined than her left quadriceps. Her leg lengths are approximatcly the snme.
t keep pace with
MANAGEMENT PLAN The initial goal is to eliminate the cause of pain and refer the student-athlete to the team physician.
I , ts.
The main question is whcther this athlete has a femornl stress fracture or simply a Ilow-grade quadriceps strain that needs
d be an ongoing
rehnbilitation and active rest. Thc team physician reports a negative X ray but orders a bone scan. which is scheduled for
' physical comli­
1 week from the datc or the X ray. The athletc is also referred back to the athletic trainer for treatment and rehabilitation
Aquatic cxerci~~c
[ for a possible stress fracture.
ading water, run­
IlSter. emd the slide PHASE ONE ,\CT IVE REST
~ as soon as they GOALS: Protection
ne under the um­ Estimated Length of 'rime (ELT); Days 1 to 14
ta tion and condi­ Until the results of the bone scan arc reported. the athlete is treated as though she docs have a stress fracture. Due to lhe
'0 be ulilized. An
athlcte's sport and history (the cumulative stress overload of running 7 days per week during the previoLls 10 wcel<s
u ld also be evalu­ while wearing shoes with more than 500 miles on them). the athlete is placed on a stress fracture cyclic rehabilitation
nd foot malalign­ program. During this phase. the bone scan results return positive for a right mid shaft remoral stress fracture.
treating a femoral Based on bone physiology. a schedule is made that presents to the athlete no running, jumping, or forced weigbt-bearing
Id. activities every third week after 2 weeks of stressing lhc bone in a pain-free "normal" manner. This cycle is repeated- 2 weeks
of "normal" pain-rree activity followed by 1 week of either eliminating weight-bearing activities or at least cuttin g it back to
half the "normal" activity levc.l and possible returning to crutches with pmLial weight bearing. This cycling of activitics every
third week promotes the resorptive process to slow down and the reparative process to catch up. enhancing new bone growth
at the fracture site.
eehanism. Ath­ The follOWing schedule is developed and the athlete is instructed in a non-weight-bearing to partial-weight-bearing
n fracture of th(' cardiovascular program .
516 PART THREE The Tools of Rehabilitation

R E H A B I LIT A T ION P LAN (CONT'D)

1. Biking 30 to 40 minutes daily (5 days/ week). PHASE

2. Aquatic therapy non-weight-bearing swimming, treading waler. etc., 2 to 3 days per week. GOALS: Retu rn l
3. Aquatic therapy with partial-weight-bearing chest-height water-walking 10 to 20 minutes, or to pali n-free limits . Estimated Length (
2 days per week. The third cycle of,
4. Pain-free open-chain quadriceps, hamstring. and hip-strengthening exercises 2 or 3 days per week. for returning to a r
Ice and el'e ctrical stimulation are utilized! to decrease discomfort. Crutches should be utilized for pain-free partiaJ 1. This phase begJ
weight bearing. An orthotic that doesn't require posting. but provides a rigid arch support. should be constructed to cor­ 2. Closed-ch ain
rect the excessive pronation during weight bearing. 3. Stairmaster is.
PHASE TWO REPARATIVE PI L\SE 4. Aquatic th era;::
plyomeLrics In
GOALS: Rest and Repair

J. Dry-land ru
Estimated Length of Time (ELT): Weeks 2 to 3

If. by the end

This phase of the rehabilitation program continues with modalities to decrease pain and maintain active range of mo­

her Learn and retu;­

tion at the hip and Imee. During the third week the athlete discontinues weight-bearlng/ partial-weight-bearing activilie­

the ,i ndoor tra ck ar

to provide rest from the stress and to allow the reparative process to work at a faster rate than the resorptive stress

bearing reparath
process.

1. This phase begins with returning the athlete to crutches non-weight-bearing for 7 days.
rr pain returll!!
weight-bearing ) ­
2. Aquatic therapy with non-weight-bearing deep-water treading and swimming only (discontinue chest water-walking
pain-free.
for 7 days).
OTHER POIN T:
3. Biking and open-chain strengthening are continued.
This athlete shOll
PHASE THREE SECOI\[) .2-WEEK CYCLE OF WEJCI-rr-BE J\RJ N(~
to stress fractur~.
STRESS
bone density test:.r
GOALS: Gradually Progress Exercise DISCUSSION Ql
Estimated Length of Time (ELT): Weeks 4 to 5 1. Would medica'
This phase begins the second 2-week cycle of stressing the bone to promote bone formation after a 7-day period (phas 2.
2) of the non-weight-bearing reparative process/cycle. 3.
1. If fully pain-free, eliminate crutches (as long as the athlete has a normal gait pain-free). 4.
2. Continue biking.
J.
3. Begin Stairmaster (weight-bearing) pain-free. 20 to 30 minutes 2 to 3 days per week.
4. Aquatic therapy with waist-deep water-walking and possibly jogging if palin-free. Also can add carioca and backward coach?
w,llking, 15 to 20 minutes total time over 2 or 3 days per week.
5. Can Linue open-chain strengthening and add closed-chain leg press and squats. Weight appropriate to complete '3 or -t
sets of 10 reps without pain. 2 days per week.

PHASE FOUR I{EPAI{I\TIVE PIIJ\SE

GOALS: Rest and Repair femoral trocha nt&
Estimated Length of Time (ELT): Week 6 volved. the cause
This phase is a 7-day rest period to again allow the resorptive process to slow down and the reparative process to speed of the hip abdu
UP. which continues to enhance new bone formation. lesser trochanter
1. This phase begins with returning the athlete to crutches for partial weight bearing (50 to 7:; percent). The athlete m<1_' traction of th e ilio
not wish to return to crutches. The athletic trainer can win compliance by explaining the bone physiology and tryin~ Palpation rna}"
to get the athlete to look long-term. defe.:t of the grea
2. Weight bearing in the pool is eliminated. Deep-water treading and swimming are continued. passive range of
3. The Stairmaster is eliminated. the bike is continued. X rays must be tak,
4. Closed-chain strengthening is eliminated and open-chain is continued. may be the treatm
For cardiovascular conditioning. the time spent in aquatic therapy and on the bike can be increased accordingly. fracture. With a c
 CHAPTER 21 Rehabilitation of Groin. Hip, and Thigh Injuries 517

R E H A B I LIT A T ION P LAN (CONT'D)

PHASE FIVE I{ETl ll{:\ TO NOIUI,\L ,\(''1'1\,1'1''1'
GOALS: Return to normal activity
pain-Cree limits. Estimated Length of Time (EL'f): Weeks 7 to 8
The third cycle of weight bearing is also called the return to "normal" activity phase. This is when the athlete is tested
for returning to a running program specific to cross-country (sport-specific).
['ree parlial 1. This phase begins with the elimination of crutches again.
ucted to cor­ 2. Closed-chain strengthening is started again.
3. Slairmaster is started again.
4. Aquatic therapy with weight bearing is started again. This is progressed to running in waist-deep water and possibly
plyometrics in waist-deep water.
5. Dry-'land running is started and progressed if pain-free, 3 or 4 days per week.
If, by the end of this 2-week phase. the ath'lete has progressed pain-free with all activities. she can begin training with
e ran ge of mo­
her team and return to competWon when appropriate. At this time in the calendar/schedule. this athlete may be starting
bearing aclivities
the indoor track and field program and should be watched closely. If necessary, another week of a non- to partial-weight­
.tive stress
bearing reparative cycle could be added (week 9).
If pain returns during phase 5. another 3-week cycle, phase 6 (2 weeks of weight bearing, followed by 1 week of non­
weight-bearing) should be added to the rehabilitation program, and the athlete should continue in this manner until
_l water-walking
pain-free.
OTHER POINTS OF INTEREST
This athlete should be asked about her nutritional habits (assessment) and menstrual cycle. as these can also contribute
to stress fractures. If the athlete continues to have problems with bone pain and repetitive stress fractures in the future, a
bone density test should be conducted and the athlete should be referred to a nutritionist and a gynecologist.
DISCUSSION QUESTIONS
1. Would medications and/or supplements help with this problem?
I~ period (phase 2. Would a running-gait biomechanical analysis help with diagnosis and prevention?
3. Should an External Bone Healing Stimulator be considered?
4. How many weeks of sport participation would you expect a cross-country athlete to miss during this type of rehabili­
tation program?
5. How would you communicate the diagnosis/problem, rehabilitation program/process. and timetable to the athlete and
:>ea and backward coach?

to complete 3 or -i­

femoral trochanters. When the greater trochanter is in­
volved, the cause is usually a violent, forceful contraction
of the hip abductor muscles. An avulsion fracture of the
~rocess to s pecd
lesser trochanter occurs because of a violent. forceful con­
traction of the iliopsoas muscle. 3 5
ll. Thc athlete may
, iology and trying Palpation may produce pain and possibly a noticeable
defect of the greater trochantcr. Resistive movements and
passive range of motion of the hip may reproduce pain.
X rays must be taken to conftrm the injury. Immobilization
may be the treatment of choice for a incomplete avulsion
fracture . With a complete avulsion fracture, internal fIXa­
d accordingly.
tion is usually required.
Rehabilitation Concerns, Progression, and Crite­
ria for Full Return. During the initial immobilization pe­
riod, as prescribed by the physician. the athlete with a
femoral avulsion fracture should perform isometric hip exer­
cises on the ftrst day of rehabilitation , with isometric quadri­
ceps and hamstring exercises and ankle-strengthening
exercises. Crutches should be used for the ftrst 6 weeks until
a pain-free normal gait cycle can be accomplished. After
6 weeks, the athlete may perform pain-free active range of
motion exercises, as well as pain-free stretching exercises
(Figures 21-2 through 21-8, 21-14). When pain allows,
the athlete may add stretching (Figures 21-9 through
518 PART THREE The Tools of Rehabilitation
21-12. 21-14). The aLhlete may also begin pain-free
straight-leg-raise exercises (Figures 21-16 through 21-18).
and progress La hip abduction and roLation (Figures 2]-19
through 21-2]). During approximately week 8. the athlete
may perform hip progressive resistive exercises in all four di­
rections (Figure 21-28). Swimming can be added as soon as
pain allows, and biking is performed when sufficient range of
motion is aLLained. The athlete is then progressed to closed­
chain weight-bearing lifting activities (Figures 21-30,
21-31. 21-32 . 21-34, 21-35, 21-37, 21-38). Jogging, plyo­
metrics (Figures 21-42 through 21-44), slide board (Figure
21-39), and sport-specific functional drills (sec Figures 1 7-4
through 17-14) can be started as soon as Lhe athleLe is pain­
free and has the necessary strength base.
Traumatic Femoral Fractures
Pathomechanics and Injury Mechanism. A
femoral neck fracture is ofLen associated with osteoporosis
and is rarely seen in athletics. 1S . ll However, a lwisting mo­
tion combined with a fall can produce this fraclure. Be­
calise the femoral neck fracture can disrupL the blood
supply to the head of the femur, avascular necrosis is often
seen later. This injury must receive proper treatment.
Rehabilitation Concerns, Progression, and Cri­
teria for Full Return. After surger)! or during immobi­
lization, isometric hip exercises are started immediately.
Athleles, especially younger athletes, are progressed
slowly. A normal gail cycle should be taught to the athlete
as soon as possible. In some cases where osteoporosis has
been known to be involved, exercise has been shown to in­
crease bone density and reverse the rate of osteoporosis.
Progress the athlete with funcUonal range of motion and
functional strength, aquatic t.herapy, and biking, if pain­
free. Within 6lo 8 weeks. gentle active hip range of motion
exercises wiLh no weight Can be performed (figures 21-1 5
through 21-21). Stretching exercises are performed at ap­
proximately week 8 ([ligures 2] -2 through 21-10) and
progress to stretches for hip rotation and the piriformis
([ligures 21-11, 21-1' 2. 2] -14). Progressive resistive m us­
c1e-strengthening exercises should be sLart.ed after 2 to 4
weeks of active range of motion and stretching exercises.
At approximately week 12, weight can be added Lo the ex­
ercises shown in figures 21-15 through 21-21, and the
exercises shown in Figures 21-23,21-26, 21-2H can be
added, along with closed-chain exercises (Figures 2]1-30 to
21-32,21-34, 21-35.21-37,21-38A.B).
Aller the athlete's strength level has reached the
"norms," the athlete may begin pain-free slide board (fig­
ure 21-4]). plyomeLrics (Figures 21-42 through 21-44),
and sport-specific functional drills (see Figures 17-4, 17-7
through 17-14), and then progress to the exercises shown the swing-throu=
in Figures 17-5 and] 7-6. pelviS in the fron ta
den twinge and pai
during activity. 1 S\'
Quadriceps Muscle Strain
may produce pain
Pathomechanics. A strain to the large quadriceps dent in a grade 2
muscles in the front of the thigh can be very disabling, es­ when sitting a nd
pecially when the rectus femoriS muscle is involved due to Lying supine a nd
its involvement at two jOints. J9 The four quadriceps mus­ painful when the n
cles share the same innervation and lendon of inserlioJJ .­ lete lying prone. ac
The rectus femoris is the only quadriceps muscle th at
crosses the hip joint. therefore it is considered a biarticul ar
muscle. The quadriceps muscles are very similar to th e knee flexioo ran"
hamstrings in th nt they produce a great deal of force an d a grade 2 or 3 s~
contract in a "rapid" fashion. 7 Most strains occur aL tb l" An athlete wi.th
musculotendinous junctions. A strain shows acute pai n. able to ambuJ ate
possibly after a workout has been completed, swelling to a severe pain, \\ith
specific area. and loss of knee flexion. If the reclus femoris muscle. Palpa ti
is involved, knee flexion range of motion l5'ing prone (hip weiling will be p!1
in extended position) will be severely limited and painfu may not be able lO =
Rectus femoris involvement is more disabling than a straiI:. s istance. An isome.:
to any of the other quadriceps muscles. produce a buJge
Injury Me chanism. With nO hisLory of direct con­ iaily the reclu s fi."l::
tact to t he qnadriceps area, the injury can be tre.at.ed as is live knee flexi on ra
muscle strain. i\ quadriceps srrain. with the biceps i'emoru and might n ot be to:
involved. usually occurs because of a sudden, \>iolen Rehabilitatior
forceful contraction of the hip and knee into flexion, wi athlete with a graj
the hip initially extended. All overstretch of the qu adn­
ceps, with the hip in extension and the knee Ilexed, CaJ:
also cause a qUCldriceps strain. Tighl quadriceps. im bal­
ance between quadriceps muscles. and leg-length discrep­
ancy can predispose someone to a quadriceps strain J
An athlete wilh a grade 1 quadriceps strain may com­
plain of tightness in the front of the thigh. The athlete mac
be ambulating with a normal gaiL cycle and present wil h
history of the thigh feeling fatigued and Light. Swellin:"
might not be present, and the athlete usually has very ml
discomfort on palpation. With the ath'letc sitting over t h
edge of a table. resistivc knee extension might nol produ
discomfort. If the athlele is lying supine with the kn
nexed over Lhe edge of a table, resistive knee extension ma
produce mild discomfort. if Lhe rectus femoris is invol ved
With the athleLe lying prone. active knee flexion may pr~
duce a full pain-free range of motion, with some ligbtn-­
al extreme flexion.
An alhlete with a g.rade 2 quadriceps strain may ba\ modalities may be
an abnormal gait cycle. The knee may be splintcd in exten­ nanunation, a n d
sion.The alhlete may present an externally rotated hip L approximately day
use the adducLors to pullthc leg through and avoid hip ex­ may perform quadr
tension , during the swing-lhrough phase from push-oi quadriceps active Ii
especially when the rectus femoris is involved. In severe and lying prone. Th
cases, it may also be accompanied by hiking the hip durin:o then progressed to
 CHAPTER 21
~x ' rcises shown the swing-through phase, which causes a tilting of the
pelvis in the frontal plane. The athlete may have felt a sud­
den twinge and pain down the length of the rectus femoris
during activity.! Swelling may be noticeable, and palpation
may produce pain. A defect in the muscle may also be evi­
arge quadriceps dent ,in a grade 2 strain. Resistive knee extension, both
~y disabling, es­ w"hen sitting and when lying supine, may reproduce pain.
- involved due to Lying supine and resisting knee extension may be more
~u adriceps mus= painful when the rectus femoris is involved. With the ath­
on of insertion. ' lete lying prone, active knee flexion range of motion may
_p muscle tha t present a notkeable decrease, in some cases a decrease up
fred a biarticular to 45 degrees. With a quadriceps strain, any decrease in
~ similar to the knee flexlon range of motion should classify the ,i njury as
~eal of force and a grade 2 or 3 strain.
lin occur at lh An athlete with a grade 3 quadriceps strain may be un­
ows acute pai R. able to ambulate without the aid of crutches and will be in
ed . swelling to a severe pain, with a noticeable defect in the quadriceps
ne rcctus femoris muscle. Palpation will usually not be tolerated, and
lyLng prone (hip swelling will be present almost immediately. The athlete
ited and painfu l. may not be able to extend the knee actively and against re­
ing than a strain sistance. An isometric contraction will be painfu'l and may
produce a bulge or defect in the quadriceps muscle, espe­
ry of direct con­ cially the rectus femoriS. With the athlete lying prone, ac­
be trea ted as a tive knee flexion range of motion may be severely limited
.he biceps femoris and might not be tolerated .
udden, violent. Rehabilitation Concerns and Progression, An
into flexion, with athlete with a grade 1 quadriceps strain should start ice,
~h of the quadri­ compression, pain-free active range of motion, and iso­
knee flexed, can metric quadriceps exercises immediately. Pain-free quadri­
uadriceps, imbal­ ceps progressive resistive strengthening exercises may be
~ -length discrep­ performed within the first 2 days, in the order given (Fig­
ieeps strain. I ures 21-16, 21-25 through 21-27), hip nexion with knee
strain may com­ both extended and flexed (Figures 21-28A,B, 21-31 to
1. The athlete may 21-35, 21-37), and isokinetics (Figures 21-39, 21-40).
md present with a The NK table (Figure 21-25) is utilized because of its abil­
~d tight. Swelling ity to change the force on the quadrkeps muscles by
lally has very mild changing the lever arm, and therefore the torque and
'Ie sitling over the forces placed upon the injured muscle(s). It ,is very impor­
night not produce tant that this athlete be able to stretch pain-free and begin
ne with the knee pain-free stretching as described in Figures 21-2 and 21-3.
Ilee extension may Compression should be used at all times until the athlete is
~m o ris is involved. free of pain and no longer complaining of tightness.
e nexion may pro­ An athlete with a grade 2 quadriceps strain should be­
ith some tigh tness gin ice, 24-hour compreSSion, and crutches immediately
and for the first 3 to 5 days. Electrical muscle stimulation
JS train may haw modalities may be used acutely to decrease swelling, in­
~ splinted in exten­ flammation, and pain and promote range of motion. 22 At
lally rotated hip to approximately day 3, or sooner if pain-free, the athlete
b a nd avoid hip ex­ may perform quadriceps isometric exercises and pain free
ase from push-olT. quadriceps active range of motion exercises, both sitting
n volved. In severe and lying prone. These active range of motion exercises are
dn g the hip during then progressed to the supine pOSition with the knee bent
Rehabilitation of Groin, Hip, and Thigh Injuries 519
over the end of a table to allow more efficiency and range
of motion to the rectus femoris muscle (Figure 21-27), but
with no resistance or weight. [ce used in conjunction with
active range of motion, as described above, is very helpful
in regaining motion, and strengthening the quadriceps
muscles without pain. Passive stretching exercises to the
quadriceps muscles are not recommended in the rehabili­
tation program until later phases, because a passive
stretch might have been the cause of the strain. Twenty·
four-hour compression is continued throughout the reha­
bilitation period. A pain-free normal gait cycle is reviewed
and emphasized, with and without crutch es.
At approximately days 3 to 7, the athlete may begin
heat before exercise even though ice is still preferred if the
athlete has not obtained full pain-free range of motion.
During this phase of rehabilitation, pain-free st,r aight-ileg
raises without weight, ,progressing to straight-leg raises
with weight, are performed (Figure 21-16).
Continue pain-free quadriceps progressive resistive
strengthening exercises on days 7 through 14. The athlete
should be progressed. in the order given and pain-free,
through the exercises shown in Figures 21-16 and 2l-25 to
21-27, hip flexion with knee both extended and flexed (Fig­
ures 21-28A,B. 21-31 to 21-35,21-37), and isokinetics
(Figures 21-39 and 21-40). Swimming and biking can also
be performed as long as the ath1lete avoids forceful kicking.
The bike seat should be adjusted to accommodate a pain­
free range of motion. Pain-free passive quadriceps stretch­
ing exercises are not performed until days 7 to 14 (Figures
21-2,21-3). All exercises should be pain-free.
An athlete with a grade 3 quadriceps strain should be
on crutches for 7 to 14 days or longer to allow for rest and
normal gait before walking without crutches. Twenty­
four-hour compression. ice. and electrical muscle stimula­
tion modalities should be used immediately. Quadriceps
stretching exercises are not performed until later phases.
Twenty-four-hour compression is maintained until the
ath'lete has full pain-free range of motion. When pain-free,
the athlete may begin quadriceps isometric exercises. Gen­
tle pain-free quadriceps active range of motion exercises,
while the athlete is lying prone and/or sitting, should be
performed if special attention is paid to avoiding over­
stretching the quadriceps muscles. Ice, in conjunction
with active range of motion while sitting over the end of a
table, is very useful in regaining range of motion. Heat (hot
packs, whirlpool, ultrasound) may be used if the athlete is
approaching full range of motion. Pain-free straight-leg
raises without weight may be performed. Weight may be
added after days 10 to ] 4 (Figure 21-16).
Depending upon active range of motion, swimming
and bik,ing may be added to the rehabilitation program. The
bicycle seat height should be adjusted to accommodate the
520 PART THREE The Tools of Rehabilitation

athlete's available range of motion. Also, depending upon rect blow to the lateral quadriceps area because of the dif­ bulge of muscle Li
active range of motion, pain-free quadriceps active pro­ ferences in muscle mass present in the two areas. BloDe the athlete is lyin g I
gressive resistive strengthening exercises may be performed vessels that break cause bleeding in the area where muscle lion may be sel'ere­
after the third week, in the order given (Figures 21-16, tissue has been damaged.) If not treated correctly or if sion while the ath
21-25 to 21-27), hip llexion with knee both extended and treated too aggressively. a quadriceps contusion can lead knee bent over the
Hexed (Figures 21-2SA,B, 21-31 to 21-3),21-37) , and iso­ to the formation of myositis ossificans (see Myositis Ossill­ and severe weaknC"
kinetics (figures 21-39, 21-40). cans). Rehabilitation
Depending on the severity of the injury, the athlete Atthe time of injury, the athlete may develop pain,los~ athlete with a gl
should have full active range of motion by the fourth week. of function to the quadriceps mechanism, and loss of knee ice and 24-hour
Only when full active range of motion is accomplished should f1'exion range of motion. How relaxed the quadriceps were hour compression
quadriceps stretching exercises be added (Figures 21-2 at the lime of injury, and how forceful the blow was, deter­ symptoms are abse::
and 21-3 ). mine the grade of injury. ing exercises (Fig
Criteria for Full Return. An athlete with a grade 1 Injury Mechanism, An athlete with a grade 1 con­ Ilrst day. Quadrio
quadriceps strain might not miss competition but should tusion may present a normal gait cycle, negative swelling. ercises may also be
be watched closely and started on a rehabilitation and and only mild discomfort on palpation . The athlete's actin on the second da!.
strengthening program immediately. knee f1exion range of motion while lying prone should bt 21-16,21-25 thn,
An athlete with a grade 2 quadriceps strain might miss witihin normal limits. Resi.stive knee extension while sit­ both extended an
7 to 21 days of competition, depending upon the amount ting and lying supine with the knee bent over the end of a 21- 37), and isok"
of activc range of motion present. The lack of range of mo­ table might not cause discomfort. lete's acUve ran ge
tion and the number of competition days missed are usu­ An athlete with a grade 2 contusion may have a nor­ 11' motion dec rea
ally directly correlated. At approximately days) to 7 and mal gait cycle, but before notifying the athletic trainer of grade Il contusion
within pain-free limits, this athlete may begin the slide the injury might attempt to continue to participate whlie An athlete l lil
board (Figure 21-41). plyometrics (Figures 21-42 through the injury progressively becomes disabling. If the gait cycle very consen1 ali\
21-44), and sport-specific functional drills (see Figures is abnormal. the athlete will splint the knee in extensio mal gait can
17-4 through 17-14). and avoid knee f1exion while bearing weight because the compression. and
An athlete with a grade 3 quadriceps strain might miss knee feels like it will give out. This athlete might also exter­ may be started i
3 to 12 weeks of competition . In severe cases. surgery may nally rotate the extremity to use the hip adductors to pu ll mation, and pa in
be a consideration. At approximately day 14 or later, and the leg through during the SWing-through phase. Thi pression shou ld
within pain-free limits, this athlt'te may begin the slide move might be accompanied by hUdng the hip at push-off. bleeding into the
board (Figure 21-39), plyomctrics (Figures 21-42 through which causes tilting of the pelvis in the frontal plane. ercises may be
21-44). and sport-specific functional drills (see Figures 17­ Swelling may be moderate to severe, with a noticeable de­ within the first 3
4 through 17-14). fect and pain on palpation. While the athlete is lying prone. Unued with pain­
active range of motion in the knee may be Iinuted, with athlete is sitting a
possibly 30 to 45 degrees of motion lacking. Resistive kn ee lying supine with t
CLINICAL DECISION MAKING Exercise 21-6 extension while sitting and lying supiue with the knee bem be added. Passi\'!'
over the end of a table may be painful. and a noticeable phases of rebabili
A female volleyball athlete has been diagnosed with a weakness in the quadriceps mechanism may be evident.
grade.2 quadriceps strain after lunging for a ba ll. The A grade 2 quadriceps contusion to the lateral thigh
athletic trainer has determined thal the reel U5 femoris is area is usually less painful because of the lack of muscle
involved a nd tha t the athlete bas lost 45 degrees of knee mass involved at tbe injury site. The athlete might experi­
fiexion while lying prone. What can rhe athletic trainer ence pain on palpation but not have disability. While th
recommend to help this athlete return to play? athlete is lying prone, knee f1exion, range of motion will motion increase'
be within normal limits, with possibly a small decrease in knee f1exion, S\\'j
range present. Resistive knee extension while the athlete be performed if th
is sitting and 'lying supine with the knee bent over the end athlete's available
Quadriceps Contusion
of a table may cause mild discomfort with good strength days 7 and] O. hea·
Pathomechanics. Because the quadriceps muscle present. or Whirlpool may
is in the front of the thigh, a direct blow to the area that An athlete with a grade 3 contusion might herniat and the athlete is a
causes the muscle to compress against the femur can be the muscle through the fascia to cause a marked defect. se­ while lying prone.
very disabling.l.lh A direct blow to the anterior portion of vere bleeding, and disability. The athlete may not be able t tive strengthening e
the muscle is usually more serious and disabling than a di­ ambulate without crutches. Pain, severe swe'lling, and a given (Figures 21 -1
 CHAPTER 21
bulge of muscle tissue may be present on palpation. When
the athlete is lying prone, knee flexion active range of mo­
tion may be severely limited. Active resistive knee exten­
sion while the athlete is sitting and lying supine with the
knee bent over the end of a table might not be tolerated,
and severe weakness may be present.
Rehabilitation Concerns and Progression. An
e\'e[op pain. 10 athlete with a grade] quadriceps contusion should begin
and loss of kn ee ice and 24-hour compression immediately. Twenty-four
quadriceps \I'e hour compression should be continued until all signs and
I blow was. deter- symptoms are absent. Gentle. pain-free quadriceps stretch­
ing exercises (Figures 21·2.21-3) may be performed on the
a grade 1 con­ first day. Quadriceps progressive resistive strengthening ex­
egative swellin". ercises may also be performed as soon as possible, usually
e athlete's acth' on the second day, in the order given and pain-free (Figures
I prone should b
21-16,2]-25 through 21-28A. B), hip flexion with knee
~
ion while il­ both extended and Ilexed (Figures 21-3] through 21-35,
over the end of a 21-37). and isokinctics (Figures 21-39, 21-40). This ath­
lete's active range of motion should be carefuLly monitored.
may have a nor­ If motion decreases. the injury should be updated to a
t h letic trainer of grade II contusion and treated as such.
par ticipate whUe An athlete with a grade 2 contusion should be treated
g. If the gait cycle very conservatively. Crutches should be used until a nor­
~ee in extension mal gait can be accomplished free of pain . Ice, 24-hour
eight because th compression. and electrical muscle stinmlation modalities
~ might also exter­ may be started immediately to decrease swelling. inflam­
adductors to pull mation. and pain and to promote range of motion. 34 Com­
[)uoh phase. This pression should be applied at all times to counteract
he hip at push-off. bleeding into the area. Pain-free quadriceps isometric ex­
:he frontal plane. ercises may be performed as soon as possible, usuaHy
.b a noticeable de­ within the first 3 days. Between days 3 and 5, ice is con­
lete is lying prone. tinued with pain-free active range of motion, while the
} be Bmited, with athlete is sitting and lying prone. Active range of motion
mg. Resistive knee lying supine with the knee bent over the end of a table can
I :ilh the knee bent be added. Passive stretching is not used until the later
. and a noticeable phases of rehabilitation. Massage and heat modalities are
may be evident. also contraindicated ,in the early phases because of the
, the lateral thigh possibility of promoting bleeding and eventually myositis
me lack of muscle ossificans. At approximately day 5, the athlete may per­
dele might ex peri­ form straight-leg raises without weights and then progress
ability. While the to weights, pain-free (Figure 21-16). As active range of
19 of motion will motion increases and approaches 95 to 100 degrees of
I mall decrease in knee flexion. swimming. aquatic therapy. and biking may
1 while the athlete be performed if the bicycle seat height is adjusted to the
~ bent over the end athlete's avai'lable pain-free range of motion. Between
lith good strength days 7 and 10. heat in the form of hot packs, ultrasound,
or whirlpool may be used, as long as swelling is negative
[) 1might herniate and the athlete is approaching ('ull active range of motion
I marked del'ect. se­ while lying prone. Pain-free quadriceps progressive resis­
' may not be able to tive strengthening exercises may be performed in the order
~re swelling, and a given (Figures 21-16.21-25 through 21-27). hip flexion
Rehabilitation of Groin . Hip. and Thigh Injuries 521
with knee both extended and flexed. (Figures 21-28A,B.
2]-31 through 21-35, 2]-37). and isokinetics (Figures
21-39. 21-40). Ice or heat modalities. with active range of
motion. should be continued before all exercises as a
warm-up. Pain-free quadriceps stretching exercises should
not be rushed and can be started between 10 and 14 days
(Figures 21 · 2,21-3).
An athlete with a grade 3 quadriceps contusion should
use crutches. rest, ice, 24-hour compression. and electri­
cal muscle stimulation modalities immediately to decrease
pain. bleeding, and swelling and counteract atrophy.14 Af­
ter surgery has been ruled out. the athlete may begin pain­
free isometric quadriceps exercises between days 5 and 7.
Ice and 24-hour compression should be continued from
day 1 through day 7. Pain-free active range of motion ex­
ercises, while the athlete is sitting and lying prone. are
added about day 7. Active range of motion lying supine
with the knee bent over the end of a table can also be
added. At approximately day 10. the athlete may perform
straight leg raises without weights and then progress to
weights by day 14 (Figure 21-16). Electrical muscle stim­
ulation modalities may be very helpful in this phase to
counteract muscle atrophy and reeducate muscle contrac­
tion. Again, as active range of motion increases and ap­
proaches 95 to 100 degrees of knee Ilexion, swimming.
aquatic therapy, and biking may be performed if the bicy­
cle seat height is adjusted to the athlete's pain-free avail­
able range of motion. After day 14, the athlete may use
heat in the form of hot packs or whirlpool, as long as the
swelling has decreased and the athlete has gained active
range of motion. At approximately the third week of reha­
bilitation, pain-free quadriceps progressive resistive
strengthening exercises may be performed in the order
presented (Figures 21-16. 21-25 through 21-27) . hip
flexion with knee both extended and flexed (Figures
21-28A. B, 21-31 through 21-35.21-37). and isokinetics
(Figures 21-39, 21-40). Pain-free quadriceps stretching
may also be performed (Figures 21-2,21-3) if the athlete
is careful not to overstretch the quadriceps muscles.The
rehabilitation timetables presented for grades 2 and 3
quadriceps contusions may be modified, depending upon
the severity of the injury within its grade.
Criteria for Full Return. An athlete with a grade I
quadriceps contusion might not miss competition, but
compression and protective padding should be worn until
the athlete is symptom-free.
An athlete with a grade 2 quadriceps contusion might
miss 3 to 21 days or participation, depending upon the
severity of the injury. Jogging, slide board (Figure 21-41),
plyometrics (Figures 21-42 through 21-44), and sport­
speCific functional drills (see Figures 17-4 through 17-14)
522 PARTTHREE The Tools of Rehabilitation
may be used after the fourteenth day. Compression and
protective padding should be worn during all competHion
until the athlete is symptom-free.
An athlete with a grade 2 quadriceps contusion to the
lateral lhigh area might not miss competition but should
wear compression and protective padding during partici­
pation.
An athlete with a grade 3 quadriceps contusion might
miss 3 weeks to 3 months of competition time. In general, at
approximately week 3 or later. the athlete may begin jogging,
slide board (Figure 21-41) , plyometrics (Figures 21-42,
21-44), and sport-specific functional drills (Figures 17-4
through 17-14). Again. compression and protective padding
should be worn during all competition until the athlete is
symptom-free.
G[ade 3 lateral quadriceps contusions are very rare
due to the lack of muscle belly tissue. If a grade 3 lateral
quadriceps con tusioo is diagnosed, a femoral contusion
and possible fracture should be ruled out.
M yositis Ossificans
Pathomechanics and Injury Mechanism. With
a severe direct blow O[ repetitive direct blows to the quadri­
ceps muscles that cause muscle tissue damage, bleeding,
and injury to the periosteum of the femur, ectopic bone
productinn may occur. 1.11 In '3 to 6 weeks, calcium [orma­
tion may be seen on X-ray nims. If the trauma was to the
Summary
1. Injuries to the groin. hip, and thigh can be extremely
disabling and often require a substantial amount of
time for rehabilitation .
2. Hip pOinters are contusions oj' the soft ti ssue in the
area of the iliac crest and must be treated aggressively
during the first 2 to 4 hours after injury.
3. Piriformis syndrome sciatica should be specilkally dif­
ferentiated from other problems that produce low back
pain or radiating pain in the butlocks and leg. Reha­
bilitation programs a re extremely variable fo[ different
conditions and can even be harmful if used inappro­
priately.
4. Trochanteric bursitis is relatively common in athletes .
as is ischial bursitis. T[eatment involves effo[ts di­
rected at protection and [eduction of inflammation in
the affected area.
quadriceps muscles only and not th e femur. a smaller bon) hl"
mass may be seen on X-ray nims. I
rr qUCldriceps contusion and strain are properly treated
and rehabilitated, myositis ossiftcans can be prevented.
Myositis ossificans can be caused by trying to "pia}
through" a grade 2 O[ 3 quadriceps contusion or stra il'1
and by early use of massage, active range of motion iot
pain, passive stretching exercises into pain. ultrasoun
and olhe[ heat modalities. !
Rehabilitation Concerns and Progression. Af­
te[ 1 year. surgical removal of the bony mass may be hel p"
fut If the bon~1 mass is removed too earIy, the trau ma
References
caused by the s urgery can actually enhance the cond.itioo,
After diagnosis by X-ray film. treatment Clnd rehabili­
tation should follow the guidelines for a grade 2 or 3
quadriceps contusion or quadriceps strain (see trealmen
and [ehabilitation for grade 2 and 3 quadriceps contusion:.
~
and strains). The bony mass usually stabilizes after th
sixth month. 20 If the mass 'docs not ca~se disability, th~
athlete should be closely monitored and hlHow the treat·
ment and rehabilitation programs outlined in grade 2 an
3 quadriceps contusions and strains. It has also been ra ­
ommended that myositis be treated using acetic acid wi
ion tophoresis. 4 i
The ilut/wr wOlild like tv thilnk Jim Cilse, lVI. A., A. T. C.
Associilte Head IltiJ/rtic Trailler ilt COl'lwl/ University, jor h:..
colltrilJZ.ltioll tv varivus pvrtions vj flUs chapter.
5. Snapping or clicking hip syndrome most often oem:
when the iliotibial band sna ps over the g rea
trochanter, causing trochanteric bursitis. Acetabul
labra'l tears should be ruled out.
6. Osteitis pubis and'fractures of the inferior ramu s
produce pain at the pubiC symphysis and arc
t[eated with rest.
7. Hip dislocations arc [arc in athletes and requires 6'
1 2 months of rehabilitation O[ more before the ath l
can return to full activity.
8. Strains of the groin musculature, the hamstrin g. a
the quadriceps muscles can require long periods of
habilitation for the athJete. Early return often exa
bates the problem.
9 . Prolonged groin pain can include the posterior
dominal wall. This nondescriptive groin pain , cal
 CH/\PTER 21
Ur. a 'maller b n~ "sports hernia." lasts over 4 LO 6 months and responds
well to surgery.
;e roperly trea ted 10. The femur is subject to stress fractures. avulsion frac­
ran be prevented. tures of the lesser trochanter. and traumatic fractures
lrylng to " pla~ of the femoral neck.
n Lusion or strain 11. Protection is the key to treatment and rehabilitation of
igc of motion in t quadriceps contusions and accompanyi ng myositis os­
pain . ultrasou nd sil1cans.
ogression. Al­
ma s may be help­ References
early. the trauma
lnce the conditio 1. Arnhcim, D. D., and W. E. Prentice. 1 997. Principles of alllleUe
rnrnt and rehabili- training. MiJdison. WI: BrOllln & Be nchmark.
2. Berry. j. M. 1992. Pract ure of the tuberosity of the ischium
due to muscular net ion . journal of American MedIca l Asso­
ciation 59:1450.
3. Brunet, M .. and R. Hontas. 1994. The thigh. In Orthopaedic
sports medicine. vol. 2. edited by j. C. DeLee and D. Drez.
Philadelphia: W. B. Saunders.
4. By rd. j. W. T.-1996. Labrallesion s: An elusive so urce of hip
pain: case reports and literature review. flrthroscopy
12:603-12.
5. Coole. W. G.. and j. H. Gicck. 1987. An analysis of hamstring
strains and their rehabilitation. Journal oj Ortlwpaedic and
LIl., A. T C Sports Physical TI,erapy 9(2): 77-85.
6. Daniels.!... and C. Worthingham. 1996. MII$de testing: Tech­
niqlles of IIUlIIlIal eXllIlIilwtiOIl. Philadelphia: W. B. Saunders.
7. DeLee. j. C.. and D. Drez. 1994. (Milopaeliic sports medicine.
Vol. 2. Philadelphia: W. B. Saunders.
8. DeLorme, T. I., and A. L. Watkins. 1952. Progressive resistive
exercise technique and lIIedical application. ell' York: Appleton­
Century-Crofts.
9. DePalma. B. E. and R. R. Zelko. 1986. Knee rehabilitat·io n fol­
lowing anlerior cruciale ligament injury or surgery. Athletic
Tntillin,q 21: 3.
10. Devas. M. B. 19 75 . StressJracWres. New York: Longman.
mo ,t often occu
11. Frost. H. 1964. Laws oj bOlle strucwres. Springfield, lL:
over the gr at Chades C. Thomas.
rsitis . Acetab ul 12. Gilbert, R. S.. and II. A. john son. 1966. St:res fractures in
military recruits: A review of 12 years' experiences . .vIiliCar!f
inferior ramuS Medicine 131: 716- 21.
bysis and are be5 13. Gordon. E. J. 1981. Diagnosis and treatment of common hip
disorders. Me(Ucal Trauma Technology 28(4): 443.
and requires 6 14. Harvey, j. 1985. ed. Rehabilitation oj the injured atllietc: Clinics
e before the at in sports medicine. Philadelphia: WB. Saunders.
15. Hase, 1.. and T Ueo. 1999. Acetabular labral tears: Arthro­
Kopie diagnosis and treatment. LlrtllrosCop!l15: ]3 8-4 1.
16. Hollinshead . W. H. 1976. t'lInctionalallatomy of the limbs and
lJack. Philadelphia : W. B. Sau nders.
17. IIoppenfield , S. 19 76 . Ph!lsical examination oj tllr spille and ex­
tremities. New York: f\ppleton-Century-Crofts.
L8. Hunter-Griffen, L. 198 7. ed. Overuse injuries: Clinics in sports
c groin pain. ca medicine. Philadelphia: W. B. Saunders.
Rehabilitation of Groin, Hip, and Thigh Injuries 523
] 2. Student athletic trainers should be able to demon­
strate and instruct knowledge and skills spccit1c to the
NATA's Athletic Training Competen cies and Clinical
Prol1ciencies.
19. jaivin. j .. and j. Fox. 1995. Thigh injuries. In The lower ex­
tremity and spine ill sports medicine. edited by j. Nicholas and E.
Hcrshman. St. Louis: Mosby.
20. Kuland , D. N. 1982. Th e illjured athlele. Philadelphia: Lippin­
cott.
21. LClV inneck , G. 1980. The significa nce and compariso n
analysis of the epidemiology of hip fractures. Clinical Ortho­
pedics 152:35.
22. Lewis. 1\. 1977. 'ormal human locomotion. Hamden, CT:
Quinnipiac College.
23. Lipscomb. A. B. 1976. Treatment of myositis ossificans trau­
malic in athletes. Joumal oj Sports ,\1eciicille 4:61.
24. Malone. 1'" et al. 1996. OrtilOprdic and sports physiml therapy.
St Louis: .10sby.
25. Magee. D. j. 1997. Orthopedic pizysimlassessmmt. Philadel­
phia: W ll. Saunders.
26. Mendez. A .. and R. Eyster. 1992. Displaced nonunion stress
fracture of the femoral neck treated with internal [hat ion
and bone graft. fllllerican Joumal oj Sports Medicine 20(2):
220- 23.
27. Mcyers. W C .. D. P Fole}'. W E. Garrett. j. H. Lohnes. and B. R.
Mandlebaum. 2000. Management of severe lower abdomi­
nal or ingu inal pai n in high-performan ce athletes. Amerimn
JounzaloJ Sports Medicille 2S( 1): 2- 8.
28. Moore. K. L. 1985. ClilliCilI orient.ed allatomy. Ba ltimore:
WUliams & Wilkins.
29. Morelli, V., and V Smith. 2001. Groin injuries in athletics.
Ilmerimn Family Physician, Joumal of tize AlIlerican Academy oj
Pamily Physicians (October).
30. Mou l. J. L" and A. Leslie. 2001. Acetabulum labrum tear in a
male collegiate soccer player: A case report. "'ATA SewsJrom
the JOIII'lIilI oj L1thletit' Tmininy (.october).
31. Naclkarni. j. 1991. Simultaneous anterior and posterior di s­
location of the hip. Joumal oj Posl!lraduate Education 37(2):
117-18.
32. Norkin. L., and P. LeVange. 1983. Joint structure and Junction.
Philadelphia: r. A. Davis.
33. Orava. S.. and l i. Kujala. 1995. Rupture of the ischial origin
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702-5.
34. Prentice. W E. 1998. Therapeutic modalities in sports medicine.
Dubuque. IA: WCB/McGraw-Hill.
524 PART THREE The Tools of Rehabilitation
35. Pruner. R.. and' C. Johnston. 1991. Avulsion fracture of the
ischial tuberosity. Pediatric Ortlzopedics 13(3): 357-58.
36. Ryan. 1'. J. Wheeler. aod W. Hopkinson. :I 991. Quadriceps
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37. Sanders. B.. and W. Nemeth. 1996. Hipand Thigh injuries. In
Athletic injuries and relwbiliwtion. edited by J. Zachazewski. D.
Magee. and S. Quillen. Philadelphia: W. B. Saunders.
38. Schlickewei. w.. and B. Elsasser. 1993. Hip dislocation with­
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39. Sim. F. . M. Rock. and S. Scott. 1995. Pelvis and hip injur·ies in
athlete: Anatomy and fun ction. In The lower extremity and
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41. Stevens. J. 1962. The incidence of osteoporosis in patients
with femoral neck fractures. Journal oJ Bone IlIIdJoilH Surgery
44:520.
SOLUTIONS TO CLINICAL DECISION M~KING
21-1 It is important to rule out a fracture and other in­
ternal organ injuries. The athletic trainer should
refer the athlete back to the team physicia n for a fi­
nal diagnosis. possible oral anti-inflammatories.
and/or injection . Pain management should begin
with modalities such as ice and electric stimula­
tion . as well as active ROM exercises (side bending) .
Ice and compression should be continued until full
active ROM is accomplished and functional rehabil­
itation has begun. Upon return to the spor t of foot­
ball. the athlete should wear protective padding.
21-2 It is important to perform a thorough low back. hip.
and thigh evaluation to rule out disk injury. hip in­
jury (e.g.. subluxation). and hamstring injury. Once
those injuries are ruled out. the athletic trainer
should provide pain man agement mod a lities for the
first 3 to 5 days with rest. The a thletic trainer should
then progress the athlete with pain-free stretching
exercises and functional rehabilitation.
21-3 The athlcte may be suffering [rom a severe spasm to
the iliopsoas muscle. Having the a thlete lie supine
on a treatmen t table with the leg and hip hanging
over the end of the table with the hip in a passive
extended stretch position may help eliminate or
ease the spasm and acute pain. Pain management
modalities (ice. electric stimulation. etc.) can be
used with the passive stretching. Once pain has
been managed, the a thlete should be directed in
42. Taylor. D. C.. W. C. Meyes. J. A. Nloylan. et al. 1991. Abdomi­ A realisti
nal muscular abnormalilies as a cause of grOin pain in ath­ should bed
letes: Inguina l heroias and pubalgia. American Joumal oJ and retur
Sports Medicine 19: 239--42. be parti eipa
43 . Tinker. R. ed. 1979. RmllamurU's orthopaedics in primary rare. season pr,
Baltimore: Williams & Wilkins. preven tion.
44. Targ.J.. J. Vegso. and I~Torg. 198 7. RellilbilitaUonoJ athletic ill­
21-6 The athlete
juries: A guide to therapel/ric exercise. St. Louis: IVlasby.
45. Wieder. D. 1992. Treatment of traumatic myositis ossii1cans compressiD:'
with acetic acid and iontophoresis. Ph!lsical Therap!I (around da.
72: 133-3 7.
46. Worrell. T.. and D. Perrin. 1992. Hamstring muscle injury:
The influence of strength. flexibility. WaIJl1Up and fatigue.
]oumal oJ Orthopaedic alld Sports PhYSical Therap!/16:12-18.
47. Zelko. R. R.. and B. F. DePalma . 198 6. Stress fractures in Ath­
letes: DiagnOSis and trealment. Fartenl ,\lledicus: Posfgraduate
,1dvullces ill Sports Medicine I-XI.
EXERCISES
stretching and strengthening cxercises. as well as a
progression into running and jumping. The athlete
needs to k now it can take 3 to 7 days or more before
she will be able to begin running and jumping.
21-4 This athlete should be referred to the team physician
for follow-up to rule out abdominal pathologies. gen­
itourinary abnormalities. hip disorders. and pel vi
stress fractures. The team phYSician should then fol­
Ilow with diagnostic testing (X ray. bone scan. MRl.
etc.). If all are negative. the athletic trainer should
treat the injury as a chronk groin strain (and possi­
bly osteitis pubis) and recommend a stretching an d
strengthening closed-chain stabilizi:ltion program .
The team physician could also consider injection
with anli-inflanmlatory medication. 1~he athleli
trainer should also recommend further modification
of the athlete's practice and conditioning program
to the a thlete and coach.
21-5 It is important for the athletic trainer to educate th
athlete as to which part of his hamstring has bee n
injured biomechanically and how long it will take
to rehabilitate. The athletic trainer should then
communicate a clear timelin e and progression 01
treatment and rehabilitaUon involving modali ties.
stretching. and strengthening. including open­
an d closed-chain strengthening exercises per­
formed in a high-intensity manner. The athlete
should start modalities with 24-hour compression.
 CHAPTER 21 Rehabilitation of Groin, Hip, and Thigh Injuries 525

a l. 199 1. i\bdomi­
gr oin pain in alh­
~me riclln Journal of
ilics in primary carl'.
filtl ti 01] of athletic ill­
,u is : los by.
~ ID ositis ossific am
Ph!lsicnl Tlzcmpy.
A realistic functiona l rehabilitation timetable
should be discussed with progression to full speed
and return to sport. The athlete should then
be participatin g ,in a hamstring maintenance in­
season program 1 or 2 days per week for injury
prevention.
21-6 The athlete should start modalities with 24-hour
compression. As soon as the athlete can tolerate it
(around days 1 to 3), isometric quadriceps setting
and pain-free active ROM lying supinc with the
knee bent ovcr the end of a table and lying pronc
should be started with ice. A clear progrcssion of
active range 01 motion to pain-free passive stretch­
ing and strengthening with the hip in extension
should be outlined for the athlete. Thc goal should
be full pain-free range of motion with the hip ex­
tended and full functional rehabilitation to [lrepare
the athlete for sport participation.

ring mnsde injury:

arrnup and fatigue.
111empy 16:12- 18.
ess Iractures in !\th­
kdicus: Postgradull1e

crcises, as well as a
rnp in g. The athlete
lays or more before
~ a Dd jumping.
the team physician
a1 pathologies. gen­
sorders, and pelvic
ian should then fo l­
ly. bone scan, MRJ.
Jetic trainer should
in strajn (and possi­
nd a stretching and
biLizaLion program.
, consider injection
alion. The athletic
irrtber modification
nditioning program

litOer to educate the

bam string has been
lOW long it will take
rainer should th en
and progression of
w olving moda:lities.
g. including open­
Un g exercises per­
laHner. The athlele
l -hou r compression.
 CHAPTER 22 some part of the .
chain, th eknee joi
........... ...................................................................................... ................................................... ... ...................................... ..... .............

absorption of these
Th e knee is c

Rehabilitation of Knee Injuries

William E. Prentice and three translal
James A. Onate hinge joinL]]] The
marily on the liga
lha l: surround the
provide stabilit.
motion: howe\'er
mediaJJy.
Movement be
the physiological
Study Resources • Recognize exercises that may be used lion, as weU as ar
To become more familiar with the knowledge and skllls to reestablish neuromuscular control. and glidin g. As l
necessary to design. implement. and docum ent therapeu­ gUdes and rolls an
tic rehabil.itation programs as identil1ed in the NATA Ath­ • Explain the rehabilitation progressions tibi a, gliding occ
rolling occurs _
letic Training Educational Competencies and Clinical for various ligamentous and meniscal
Proficiencies'Therapeutic Exercise content area. visit Axial rota tion
injuries.
Y\~h..~.co m / prentice 11 e. Also refer to the lab exer­
cises in the new Laboratory Manual and to eSims. which • Discuss the role of jump-landing train­
simu lates the athl etic training certil1cation exam, at
ing in preventing knee injuries.
www.mhh e.com/esims. For more online study resources,
visit our Health and Human Performance website at Thus. when weig
• Describe and explain the rationale for nally to ach ie\'e it.
www.mhhe. com/ hhp.
various treatment techniques in the gi\7 es a grea t deal
After Completion of This
management of injuries to the Wben weight be
an d externally r
Chapter, the Student Should
patellofemoral joint and the extensor
Be Able to Do the Following:
mechanism.
• Review the functional anatomy and
biomechanics associated with normal
function of the knee joint.
FUNCTI.ONAL ANATOMY
• Assemble the various rehabilitative accompanying
AND BIOMECHANICS The superficial
strengthening techniques for the knee.
The knee is part of the kinetic chain and is directly affect, eper capsular lie
including both open- and closed­
by motions and forces occurring in and being transmit1 ct of the Iigam
kinetic-chain isotonic. plyometric. and from the foot, ankle. and lower leg. Tn turn, the knee mu a r ligament and
isokinetic exercises. transmit forces to the thigh, hip, pelvis, and spine. I 12 A
normal forces that cannot be distributed must be absor~
• Identify the various techniques for re­ by the tissues. In a closed kinetic chain (CKC), forces m u.~
gaining range of motion. be either transmitted to proximal segments or absorbed
a more distal joint. The inability of this closed system l
dissipate these forces typically leads to a breakdown ir

526

 CHAPTER 22 RehabLlitatioa of Knee Injuries 527

some part of the system. Certainly. as part of the kinetic

Femur -;- -+-­ Medial condyle
chain. the knee Joint is susceptible to injury resulting from
of femur
absorption of these forces. Lateral condyle
of femur Posterior cruciate
The knee is commonly considered a hinge joint be­ ligament
cause its two principal movements are nexion and exten­ Anterior cruciate
~s
sion (Figures 22-1. 22-2). However. the knee is capable of Lateral
ligament
movement in six degrees of freedom-three rotations meniscus -+-f-t~-=5", M;::3If-+-Medial meniscus
and three translations-thus the knee joint is truly not a Lateral Medial collateral
collateral ligament
hinge joint. ll1 The stability of the knee joint depends pri­ ligament
marily on the ligaments. the joint capsule. and muscles -"';'---hlF---I--- Tibial tu berosi ty
Fibula
that surround the joint. The knee is designed primarily to
provide stability in weight bearing and mobility in loco­ """""'f---t-- Tibia

motion; however. it is especially unstable laterally and ANTERIOR VIEW

medially.
Figure 22-1 Anatomy of the knee. anterior view.
Movement between the tibia and the femur involves
the phYSiological motions of nexion. extension. and rota­
beused tion. as well as arthrokinematic rnotions including rolling
and gliding. As the tibia extends on the femur. the tibia
control. Femur ---j- -+-­
glides and rolls anteriorly. ff the femur is extending on the
gressions tibia. gliding occurs in an anterior direction. whereas
rolling oecu rs posteriorly. Lateral

meniscal Axial rotation of the tibia relative to the femur is an im­

Medial condyle
condyle
Anterior
portant component of knee motion. In the "screw home" Ligament r---"'dl-+-- cruciate
of Wrisberg -t-.....-....;.
mechanism of the knee. as the knee extends. the tibia ex­ ligament
lding train­ ternally rotates. Rotation occurs because the media'!
Medial meniscus -+.....~:::;;;!: ....e '!!5llt-t- Lateral meniscus
Posterior cruciate

ries. femoral condyle is larger than the lateral femoral condyle. ligament
Lateral
Thus. when weight bearing. the tibia must rotate exter­ "'-.Medial collateral collateral
tionale for nally to achieve full extension . The rotational component
ligament Fibula
Tibia -+--+­
les in the gi\fes a great deal of stability to Lhe knee b1 full extension.
the ''''hen weight bearing. the popliteus muscle must contract POSTERIOR VIEW
and externally rotate the femur to "unlock" the knee so
e extensor that nexion can occur.
Figure 22-2 Anatomy of the knee. posterior view.

Collateral Ligaments
The medial collateral ligament (MCL) is divided into two
parts. the stronger superficial portion and the thinner and
y weaker "deep" medial ligament or capsular ligament, with
its accompanying attachment to tbe medial meniscus. ] ro
The superficial position of the MCL is separate from the
:I is directly affected deeper capsular ligament at the joint line. The posterior as­
j being transmitted pect of the ligament blends into the deep posterior capsu­
urn. the knee must lar ligament and semimembranous muscle. Fibers of the
;. and spine. 1l2 Ab­ semimembranous muscle go through the capsule and at­
'Ii must be absorbed tach to the posterior aspect of the medial meniscus. pulling
i (CKC). forces must it backward during knee flexion. Thc MCt functions as the
lents or absorbed in primary static stabilizer against valgus stress. The MCL is
lis closed system to taut at full extension and begins to relax between 20 to 30
to a breakdown in degrees of nexion and comes under tension again at 60 to
70 degrees of t1exion. afthough a portion of the ligament
is taut throughout the rangeof motion. is.110 Its major pur­
pose is to prevent the knee from valgus and external rotat­
ing forces.
The medial collateral ligament was thought to be the
principal stabilizer of the knee in a valgus position when
combined with rotation. In the normal knee, valgus load­
ing is greatest during the push-off phasc of gait when the
foot is planted and the tibia is externally rotated relative to
the femur. It is now known that the anterior cruciate liga­
ment plays an equal or greater part in this function.!O(,
The lateral collateral ligament (LCL) is a round, fibrous
cord about the size of a pencil. It is attached to the lateral
epicondyle of the femur and to the head of the fibula. The
LCL functions with the iliotibial band, the popliteoLls ten­
don, the arcuate ligament complex. and the biceps tendons
to support the lateral aspect of the knee. The LCL is under
528 PART THREE The Tools of Rehabilitation
constant tensile loading. and the thick. firm coilllguration
of the ligament is well designed to withstand this constant
stress. 58 The lateral collateral ligament is taut during knee
extension but relaxed during flexion.
CLINICAL DECISION MAKING Exercise 22-1
A higb scbool football player sutTered an Isolated grade 2
sprain of his medial collateral Ugament 3 days ago. At the
emergency room. the X-ray result was negative and he
was gil'ell a slraigbt-Ieg immobiUzer and crutches. He
was instructed to begin walking after 1 week and return
to play wben the pain subsides. He bas never before sus­
tained a knee Inlury and is having dJfficulty regaining
pain-free range of motion. He has been referred to the
ath.letic trainer In tbe local sports medicine clinic. What
can tbe athletic lrainer do to help Increase range of mo­
tion In the athlete's injured leg?
Capsular Ligaments
The deep medial capsular ligament is divided into three
parts: the anterior. medial. and posterior capsular liga­
ments. The anterior capsular ligament connects with the
extensor mechanism and the medial meniscus through
the coronary ligaments. It relaxes during knee extension
andl tightens during knee flexion . The primary purposes of
the medial capsular ligaments are to attach the medial
meniscus to the femur and to allow th e tibia to move on the
meniscus inferiorly. The posterior capsular ligament is
called the posterior oblique ligament. it attaches to the
posterior medial aspect of the meniscus and intersperses
with the semimembranous muscle. Along with the MCL.
the pes anserinus tendons. and the semimembranosus. the
posterior oblique ligament reinforces the posteromedial
joint capsule.
The arcuate ligament is formed by a thickening of the
posteriorlateral capsule. Its posterior aspect attaches to
the fas cia of the popliteal muscle and the posterior horn
of the lateral meniscus. This arcuate ligament and the il­
iotibial band. the popliteus. the biceps femoris. and the
LCL reinforce the posteriorlateral' joint capsu le.
The iliotibial band becomes taut during both knee ex­
tension and flexion. The popliteal muscle stabilizes the
knee during fl exion and. when contracting. protects the
lateral meniscus by pulling it posteriorly. The biceps
femoris muscle also stabilizes the knee laterally by insert­ The Functiol
ing into the fibular head. iliotibial band. and capsule.
Collectively th e qu
tendon . the palell.
Cruciate Ligaments tensor mechanism
sion by lengthen
Th.e anterior cruciate ligament prevents the tibia fro m muscle. II di~tribur
moving anteriorly during weight bearing . stabilizes the by increasing the,
knee in full extension. and prevents hyperextension . It a nd the femur. '" I
also stabilizes the tibia agains t excessive internal rota­ [r iction. Tracking
tion and serves as a secondary restraint for valgus / varu the quadriceps IT'
stress with collateral ligament damage. The anterior remora:l condyles.
cruciate ligament works in conjunction with the thigh During full e
muscles. especially the hamstring muscle group. to sta­ a nd proximal to L
bilize the knee joint. there is tibial
During extension there is external rotation of th lrochlea . i\t 30 - t
tibia during the last 15 degrees of the anterior crucial :; 0 degrees an d C"
ligaments unwinding. in full extension the anterior cru­ rochlea. At 90
ciate ligament is tightest. and it loosens during flexion . 1ioned :l aterall): \'
When the knee is fully extended. the posterolateral por­ patella has mo\ ed
tion of the anterior cruciate ligament is tight. In flexio n
the posterolateral fibers loosen and the anteromedi al
fibers tighten. Muscle Actio
Some portion of the posterior cruciate Ligament is ta Ul
throughout lhe full range of motion. As the femur glides
on the tibia. the posterior cruciate ligament. becomes ta Ul
and prevents further gliding. In general. the posterior cru­
ciate ligament prevents excessive internal rotation. Hyper­
extension of the knee guides the knee in flexion. and acts
as a drag during the initial glide phase of flexion.
Menisci
,If requircmen
The medial and lateral menisci function to improve the sta­ lTluscles that are In
bility of the knee, increase shock absorption, and distri b­ but ath letic trai n
ute weight over a larger surface area. The menisci help to
sta biUze the knee. specifically the medial meniscus. when
the knee is flexed at 90 degrees. The menisci transmit one­
half of the contact force in the medial compartment and
even a higher percentage of the contact load in the lateral
compartment.
During flexion the menisci move posteriorly, an d
during extension they move anteriorly. primarily due Lo
attachments of the medial meniscus to the semimem­
branosus, and the lateral meniscus to lhe popliteus ten­
don. During internal rotation the medial menisc u
moves anteriorly relative to the medial tibial platea u
and the lateral meniscus moves posteriorly relative to the
lateral tibial pLateau. In internal rotation the movemen ts
are reversed.
 CHAPTER 22 RehabilitaLion of Knee Injuries 529

nerally by insert­ The Function of the Patella The iliotibial band on the lateral side primarily func­
and capsu le. tions as a dynamiC lateral stabi lizer and weak knee
Collectively th e quadriceps muscle group. the quadriceps 11exo r.
tendon. the patella . and the patellar te ndon form the ex­
tensor mechanism . The patella aids the knee during exten­
sion by lengthening the lever arm of the quadriceps REHABILITATION TECHNIQUES
It tbe tibin fron muscle. [t distributes the compressive stresses on the femur
ng. stabilizes the by increasing th e contact area betwee n the patellar tendon Range-of-Motion Exercises
·perextension. It and th e femur. ~~ It also protects the patellar tendon against
i\'e internal rotn­ friction. Tracking lVithin this groove depends on the pLlIl of After injury to th e knee. some loss of motion is li ke ly.
for valgus/ varm the quadriceps muscle. patellar tendon. depth or the Tbis loss ca n be ca used by th e effects of the injury. th e
Ige. The anterio~ ifemoral condyles. and shape of the patella. trauma of surgery. or the effecls of immobil iza tion .
)n with the thigh During full extension the patelln lies sligh tly latera l Waiting for li ga me nts to heal co mpletely is a luxury that
--Ie group. to sta- and proxima l to the trochlea. I\t20 degrees of kn ee flexion cannot be afforded in an effective rehabilitation pro­
t here is tibial rotation. nnd tbe patella moves into the gram. Ligamenls do not hea l completely for 18 to 24
II rotation of th e trochlea. At 30 degrees the patel la is most prominent. At months, yeL periarticular t iss ue changes can begin
I a nterior cruciate .30 degrees and more the patella moves deeper into the within 4 to 6 wee ks of imOlobilizaLion. i6 Th is is mCirked
I the anterior cru­ troc h'lea. At 90 degrees the patella again becomes posi­ histologically by a decrease in water co nten t in co llage n
DS during flexion. tioned laterally. When knee l1exion is 1 35 degrees. the and by an increase in collagen cross-linkage. 56 The initi­
)()stero'lateral por­ patell a has moved laterally beyond lhe trochlea .HS at ion of an early range of motion progrClm can minimize
is light. In flexi on these harmful changes (Figures 22-3 .through 22-17).
the anteromedial Controlled movement shou ld be initiated early in th e re­
Muscle Actions
lu~ ligament is tau
covery process and progress bnsed on h eaHng con­
For the knee to funcLion properly. numerous muscles mLlst straints and patient to le ran ce toward a normn l range of
the femur glid work together in a highly complex and coordinated fash­ approximately () to 130 degrees.
ment becomes tau­ ion. Knee movemt~nt requires various lower-ex tremity P itfalls th al ca n slow or prevent regaining normal
~. the posterior r ­ muscles to act as agonists. ill1tagonists. synergists. stabiliz­ range of motion include imperfect surgical tec hnique (i m­
al rotation. Hrper­ ers. and neutralizers. in order to act as force-couples to proper plncement of an anterior cr uciate replacement ).
in ne.
ion. and a produce (orce. reduce (orce. and dynam ica lly sta bil ize the development of jOint capsu le or ligament con traclure. and
l[ nex ion. knee.20 Traditional rehabilitation has focused on ll ni pla­ muscu lar resislance caused by pain. 39.so.63 The surgeon
nar force prodLlction movements. ye t a thletic movement must address motion lost from technique. but the athletic
demands required multi planar [orce w ith various mu sc u­ trainer can successfu lly dea l with motioll lost frolll soft tis­
lar reljuirements. Following is a list of knee act ions and lh e sue contracture or musc ular resista nce.
to impro\'e the: muscles that a re involved in lhe agonist movement action.
rion. and distr ­ but athletic trainers also need to take into account the var­
he menisci help ious muscle demands for proper movem en t production.
Knee flexion is executed by the biceps femoris. semi­
tendinous. semimembranous. gracilis. sartorius. gas­
trocnemius. poplite us. and plantaris muscles.
Knee extension is execu ted by the ljundriceps muscle oJ'
the thigh. consisting of three vasti- t'he vas tus m ed i­
alis. vastus la tera lis. and vastus intermedius-and by
th e rect us femoris.
External rotation of the tibia is controlled by the biceps
femoris. The bony anatomy also produces external tib­
ia l rotatio n as the knee moves into extension.
Interna l rotation is accomplished by the popliteus.
semilendinous. semimem branous. sartorius. and gra­
cilis muscles. Rotation of the tibia is limited and can
occur only when the knee is in a flexed position . Figure 22-3 Active ass istance knee slides on tCible.
5 30 PART THREE The Tools of Rehabilitntion

Figure 22-8
reight a round the

Figure 22-4 i\nive assistive knee slides use the good

leg supporting the injured knee to regain flexion a nd
extension .

Figure 22-5 WaLl slides are don e to regai n flexion an~

extension .

Figure 22-6 Active assistive knee slides on wall. Figure 22-7 Knee extension with rhe fool supported
on a rolled -up towel is used to regain knee extension.
 CHAPTER 22 Rehabilitation of Knee tnjuries 531

Figure 22-8 Knee extension in prone with an ankle

weight around the foot is used to regain extension.

Figure 22-9 Groin stretch. ivluscles: adductor magnus.

longus. and brevis; pectineus; gracilis.

Figure 22-10 lIioLibial band stretch . The iliotibial band

may be stretched in a variety of ways that use a scissor­
ing position with extreme hip adduction. The major prob­
lem with these techniques is the lack of stabilization )1'
the pelvis and th ' rcrore loss 01' stretch force transmission
aiD flexion and
to the iliotibial ban"l. To maximize the stretch. the pelvis
must be manually stabilized to prevent lateral pelvic lilt. If
the tensor fa scia lata portion is tight. the hip should be
flexed. abdu cted. extended . and adducted. in sequence. to
position the tel1Selr fasc ia lata fibers directly over the
trochanter (rather than anterior to it) to produce maxi­
mal stretch 9

foot supported
ee extension.

Figure 22-11 Kneeling thrusts. Muscles: rectus

femoris.
532 PART THREE The Tools or Rehabilitation

Figure 22-13 Side-lying knee extensor stretch using

spo rl co rd.
A

Figure 22-12 Knee extensors stretch. Muscles:

qU<ldriceps.
Figure 22- J4 Knee flexors stretch. Muscles: ham­
strings. i\iote: Externally rotated ti bia stretch es the St'llll­
membranous a nd semi tendin ous: internally rotated li b,
stretches the biceps femoris.

""Jve menl , has a

in g PNF strctcr
pri ate Lherapc
a Lion . etc.). Yfl

Strengthening
primary goal in _­
~a lstrengtJ, to In
long with the r

Figure 22-15 Kn ee flexor stretch using sport cord. Figure 22-16 Knee rIexor stretch against lVall.

A B
Figure 22·17 An kle plantarflexors stretch. Muscles: A, gastrocnemius. B, soleus.
To effecti vely alleviate lost motion. the cause of the
limitation must be identified. An experienced athletic
trainer can detect soft-tissue resistance to motion by the
quality of the feel of th e resistance at the end of the range.
Musc ular resistance. which restricts normal physiological
movement. has a firm end feel and can best be treated by
using PNF stretching technique in combination with ap­
propria te thera peutic modalities (heat. ice, electrical stim­
ulation. e tc.) .90
Strengthening Exercises
A primary goal in knee rehabili tati on is lhe return of nor­
mRI strength to the musculature ~, urrollnding the knee.
Along with the return of muscular strength, it is also im­
porUmt to improve muscul ar endurance and power. 94
It is critically im portant to understand that strength
wilt be gained only if the muscl e is subjected to overload.
gainst wall. However. it is (liso essential to remember that healLng tis­
ClL'\PTER 22 Rehabilitation of Knee Injuries 533
sues ca n be further damaged by overloading the injured
structure too aggreSSively. Especially during the early
phases of rehabilitation . muscular overload needs to be
carefully applied to protect the damaged structures. The
recovering knee needs protection , and the high-resista nce,
low-repetition program design ed to strengthen a healthy
knee can compromise the integrity of the injured knee. os
The strengthening phase of rehabilitation must be gently
progressive and will generally progress from isometric to
isotonic to isokinetic to plyometric to functional exercise.
For years, open-kinetic-chain exercises were the treat­
ment of choice. However. more recently closed-kinetic­
chain exercises have been widely used and recommended
in the rehabilitation of the injured knee. Closed-kinelic­
chain exercises may be safely introduced early in the
rehabilitation process for virtually all tY[Jes of knee in­
jury.1 3.2 7.99.l Oa. 109 Closed-kinetic-chain activities may in­
volve isometric, isotonic, plyometric, and even isokinetic
techniques.
534 PART THREE The Tools of Rehabilitation

In the past fe\-\: years. the debate o\ler using opeo­ CKC exercises m ay be best for preparing a n athlete for
kin eti c-cha in (OKC) versus closed-kinetic-ehain (CKC) competition whe n dy namic stability and fUl1ctionalmol'e­
exercises for knee rehabilitation has esca lated. especially ment technique are vital to injury pre ven tion . However.
with regard to ACL postsurgical rehabilitation.14·IOl . lIl~ specific isolated contractions of certain muscles or muscle
Rece nt biomechanical investigations have demonstrated groups may dem and the use of speCific OKC muscle­
that OKC exercises in crease anterior tibial translation strengthening exercises. Clinicians sh ould take into con­
forces during isokineUc knee extension exercises. Ln con­ sideration the most current biomechanical data tc.
trast, CKC squat exercises decrease forc e production. h7 establish th e appropri a te exercise protocols for vari oU:o
Resea rch on knee muscle activity while performing OKe kn ee ailments and stages of rehabilitation.
and e Ke exercise experiments has shown that. overall.
OKe exercises generate more rectus femoris aetivily and
CKe exercises more vastus m edi a lis and laleralis acliv­ CLINICAL DECISION MAKING Exercise 22-2
ity. l 8 Th is suggests that OKC exercises may be bellcr for
a thletes with isolated rect us femoris weakness a nd eKe A high school wrestler suffers from an terior knee pain.
exercise may be better for vasli musc ulature strengthen­ The athlete has 110 history of pre\'ious knee problt'ms and
ing. particularly pathologies involving the patel'lofemoral ca n't recall any specific mechan ism of injury. He com­
join t. Tibiofemoral compressive forc es also were reporLed plains of increased pain whenever pressure is applied to
to be greatc'r in eKe exercises th a n in OKe exercises. the tibial tubercle region and is baving extrt'me dimculty
with the squat producing th e most compressive for ce . fin ishing practice. How should the athletic trainer man­
Another biomechanical investigation h7 also supports age this condition?
this data a nd h8 s shown that eKe exercises increase
compressive forces and co-contraction. whereas OKC ex­
ercises at the sa me angles increase sh ea r force and pro­
vide less co-contraction. Isotonic Open-Kinetic-Chain Exercises
Current rese8rch has looked at both the force and the
strain on the cr uciate ligaments during common rehabil­
itation exercises. An investigation on AC I. strain in vivo
indicated increased ACL strain during CKe squat from 45
degrees to fuJI extension. OKC kn ee extension demon­
strate d a similar pattern. producing ACL strain between
30 degrees and full extension. ' Exercises producing the
lowest ACL strai n include mostly h amstring activity,
quadriceps contraction at knee angles greater than 60
degrees. and isotonic knee flexi o n-extension angles be­
tween 3:> and 90 degrees. i Patell ofemoral force during
isometric knee ex tension has been shown to be greatest
ncar full exlension. However, during dynamic OKC knee
extension. maximum patellofemora l fo rce occurs with
60 to SO degrees of knee f1exion. 1N This information sug­ Figure 22-18 Hip abduction. Used to strength c!'
gests that dynamic knee extension exercises should be gluteus medius an d tensor fascia lata. which share
done at lower (0 10 60 degrees ) or higher (HO to 90 de­ common tendon. the iliotihial band. The iliotibia l b
grees) knee ranges when patellofemoral stress is a pri­ serves as a weak knee tle)(Or and helps to provide
m a ry concern. laterally. Weight may be above knce as well.
 CHAPTER 22 Rehabilitation of Knee Injuries 535

ing an athlete for

runclional more­
c ntion. Howel'er.
usdes or muscle
fi e OKC muscle­
uld take into cnn­

for various
n.

Exercise 22-2

Figure 22-19 Hip adduction. Used to strengthen the Figure 22-20 Quad sets are done b:ometrically with
adductor magnus, longus. and brevis: pectineus. gracilis. the knee in full extension to help the athlete relearn how
The gracilis is the only one of the hip adductors to cross to contract the quadriceps following injury or surgery.
the knee joint. Weight placed above knee eliminates the
U'eme diflkulty
gracilis.
l trainer man-

in Exercises

Figure 22-21 Straight leg raising is done early in the

rehabilitation for active contraction of the quadriceps. Figure 22-22 Knee flexion. Primary muscles: biceps
femoris. semimembranous. semitendinoLls. Secondary
strengthen the muscles: gracilLs. gastrocnemius. sartorius. popliteus.
Iwhich share a Note: Biceps femoris is best strengthened with tibia rotated
Iheiliotibial baml externally: semimembranous and semitendinous muscles
i to provide stability arc best strengthened with tibia rotated internally.
\\'e11.
Figure 11-13 Knee ex tension. Primary muscles: rcctus
femoris, vastus la tera lis, vastus in termedia lis, vast us
medialis.

Figure 11-17
cps ecccnlTica

Figure 11-14 Ankle plan tarJ1exion standing on box.

Prim ury muscles: gast rocnem ius und soleus .

Closed-Kinetic-Chain Strengthening Exercises

Figure 11-15 Minisquat performed in 0 to 40 degrees Figure 11-16 Standi ng wall slides are done to
ra nge. strengthen the quadriceps.
 Figure 22-27 Lunges are dooe Lo strenglhen qu adri­
ceps eccentrica lly.
Figure 22-28 Lun ges performed at different angles of
the "clock face." .\Ilaintain a good sq uat position in each
directi on.
tan ding on bm, .
leus.

Figure 22-29 Leg-press exercise. The seCtt may be ad­

justed to whatever knee joint angle is appropriate.

Hgure 22-30 Lateral step-ups as well as forward step­

,a re done to ups may be done using different steppin g heights. Retro
step downs s ho u Id emphasize eccentric quadriceps con trol.
538 PART THREE The Tools of Rehabilitation

:'i gure 22-3-1

Figure 22-31 Terminal knee extensions using surgica l tubing resistance ror strengthen­
ing primarily the vastus medialis. athlete t.

Figure 22-32 Slide board exercises are used in side-to­ Figure 22-33 The Fitter is userul in sidc-to-side I'unc­
side training. The "squat." position should be emphasized. tional training.
 figure 22-35 Stationary bicycling is good for regain­
ing ROM. with seat adjusted to the appropriate height.
and also for maintaining cardiorespiratory endurance.
figure 22-34 Stairmaster stepping machine allows
the athlete to maintain con tant contact with the tep.

Plyometric Exercises

n side-to-side func-
Fignre 22-36 Box jum ps. Emphasize proper jump­
loading technique.
540 PART THREE The Tools of Rehabilitation

Isokinetic E~

·f
'- ~

A B
~
,-­

gUrf
ouadricCD
Figure 22-37 A, Single-leg. a nd B, do ubl e-leg bounding hops.

Figure 22-41 1
the ank le joinl aou
ten neglected.

Figure 22-38 Rope skipping is a plyomeLric exercise

that is also good for improving cardiorespiratory
endu rance.
 CHAPTER 22 Rehabilitation of Knee Injuries 541

Isokinetic Exercises

Figure 22-40 Knee flexion sel-llp to strengthen the

hamstrings.

Figure 22-39 Knee extension set-up to strengthen the

quadriceps.

Figure 22-42 Biodex manufactures an isokinetic

Figure 22-41 Tibial rotation is done with resistan ce at closed-chain exercise devi ce.
the ankle jOillt and is an extremely important. though of­
len neglected, aspect of knee rehabilitation.
Exercise to Reestablish Neuromuscular Control

A
Figure 22-43 BAPS board exercise. A. Standing.
B, Silting.
Figure 22-45
mini tra mp ror rr

Figure 22-44 'vliniLramp provides an unstable base oj

support to wh ich other funcli onal plyometric activities
may be added.
 CHAPTER 22 Rehabilitation of Knee Injuries 543

Figure 22-45 A foam pad is more cost-effective than a Figure 22-46 Biofeedback units can be used to help
minitramp for providing an unstable surface. the athlete learn how Lo fire a specific muscle or muscle
group.

a n unstable base of
ometric activities Figure 22-47 The athletic trainer can emphasize good Hgure 22-48 FASTEX is a useful device for functional
technique with the aid of a video monitor. neuromuscular training.
544 PARTTHREE The Tools of Rehabilitation
Figure 22-49 Speed and agility drills done on a speed
ladder are important components for functional activities
prior to return to play.
(Photo Courtesy Perform Beller Cranston Rl)
Joint Mobilization Techniques
Joint capsule or ligamentous contractures have a leathery
end feel and might not respond to conventional simple
passive. active-assistive. and active motion exercises. l9 These
contracLures can limit the accessory motions of tbe joint.
and until the accessory motions are restored . conventional
exercises will not produce positive results. Accessory mo­
tions in th e knee joint must occur between the patellCl and fe­
mur. the femur and tibia, and the tibia and fibula . Restriction
in any or all of these accessory motions must be add_ressed
early in the rehabilitation program.
edial CoIIat
Figure 22-50 Running progression exercises demon­
strating proper running technique should go from
marching. to skipping. to high knees. to alternate-leg
bounding, to pivoting and culting.
(Photo Courtesy Perform Beltl:T Cranston RI)
Figure 22-51 !\ knee il1lmobili~er CCln be used for c
fort following injury.
Mobilization of a knee thClt is restricted by soft-tis:
con_strainLs may be Clccomplished by specifically app!) -~
graded oscillCltions to the restricted sort tissue as discu«'
in Chapter 14 (see Figures 14-55 through 14-(1). In
ing so, the athletic trainer is addressing a specil1c li mit. _ '.he treatment
structure rather than assau.lting the entire joint \' ~y p ically grade
a "crank till you cry" technique. At'ter th e release of repair the to rn li <­

soft-tissue contracture, accessory motion should improve,
and so should physiological motion,
REHABILITATION TECHNIQUES
FOR LIGAMENTOUS
AND MENISCAl INJURIES
Medial Collateral Ligament Sprain
Pathomechanics, The MeL is the most commonly
injured ligament in the knee. 7S About 63 percent of MeL
sprains occur at the proximal insertion site on the femur.
Individuals with proximal injuries tend to have more stiff­
ness but less residual laxity than those with injuries nearer
the tibial insertion. Tears of the medial meniscus are occa­
sionally associated with grades 1 and 2 MCL sprains but al­
Rfl most never occur with grade 3 sprains,
Diagnosis of MCL spnlins can usually always be made
by physical evaluation and do not generally require MRl.
The grade of ligament injury is usually determined by the
amount of joint laxity. In a grade 1 sprain the MCL is t.en­
der due to microtears, but has no increased laxity and there
is a firm end point. A grade 2 sprain involves an incomplete
tear with some increased laxity with valgus stress at 30 de­
grees of Ilexion and minimal laxity in full extension, yet
there is still a firm end point. There is tenderness to palpa­
tion. hemorrhage. and pain on valgus stress test. A grade 3
sprain is a complete tear with significant laxity on valgus
stress in full extension. No end point is evident. and pain is
generally less than with grades 1 or 2. Signit1cant laxity
with valgus stress testing in full extension indicates injury
to the medial joint capsule and to the cruciate ligaments .'l
Injury Mechanism, An MeL sprain usually always
occurs with contact from a laterally applied valgus force to
the knee that is sufl'icient to exceed the strength of the lig­
ament. This is especially true with grade 3 sprains, Very
rarely, an MeL sprain can occur with noncontact and re­
sult in an isolated MeL Lear. TL has also been suggested that
the majority of grade 2 spra ins occur through indirect ro­
tational forces associated with valgus movement of the
knee, 99 The athlete will usually explain that the knee was
hit on the lateral side with the foot planted. and that there
was immediate pain on the media l side of the knee that felt
ie cd by soft-tissue more like a "pulling" or "tearing" than a "pop." Swelling
it1cally applying occurs immediately, and SOGle ecchymosis likely will ap­
tissue as discussed pear over the site of injury within 3 days.
ugh 14-61).rndo­ Rehabilitation Concerns. Since the early 19905,
a a speciflc limiting the treatment of MCL sprains has changed conSiderably.
ent ire joint with Typically grade 3 MCL sprains were treated surgically to
'r the rele.ase of the repair the torn ligamen t and then immobilized for 6 weeks.
CHAPTER 22 Rehabilitation of Knee Injuries 545
However, several studies have demonstrated that treating
patients with isolated MCL sprains non-operatively with
immobilization is as elTecLive as trea ling them surgically.
regard less of the grade of injury, the age of the paLienl. or
the activity revel. i l This is especially true with isolated Mel,
tears wh ere the ACL is inlacLI.1 07 Athletes with a com­
bined MCL-ACL injury wiJl most likely have an ACL recon­
struction without MeL repair, and this procedure appears
to provide sufficient functional stability. Three con ditions
must be met for healing to occur at the MCL: (1) the liga­
ment fibers must remain in continuity or within a well­
vascularized soft-tissue bed. (2) there must be enough
stress to stimulate and direct the healing process. and
(3) th ere must be protection from harmful stresses! 10
'W ith grade 2 and 3 sprains there will be some residual
laxity beca use the ligament has been stretched . but this does
not seem to have much effec t on knee fun ction. Patients
with grade 1 and 2 sprains may be treated symptomatically
and may be fully weight-bearing as soon as tolerated. It is
possible that an athlete with a grade 1 and occasionally
even a grade 2 sprain can continue to play. With grade 3
sprains the athllete should not be allowed to play and a re­
hablLitative brace should be worn for 4 to 6 weeks set from 0
to 90 degrees to control valgus stress (Figure 22- 51).
Rehabilitation Progression, Initially, cold. com­
pression, elevation, and elecLrical stimulation ca n be used
to control swelling. inllarnmation, and pain , JL may be nec­
essa ry to have the athlete on crutches initially, progressing
to full weight bearing as soon as tolerated, The athlete
should lise crutches lInLiI (1) full extension without an ex­
tension lag ca n be demonstraLed. and (2) the athlete can
walk normally without gait devidtion. Por patient comfort,
a knee immobilizer may be worn for a few days to a week
following injury with grade 2 sprains requiring 7 to 14
days in either an immobilizer or a brace.
The athlete with a grade 1 sprain can, on the second
day following injury. begin quad sets (figure 20-20) and
straight leg raising (Figure 22-21). Early pain-free range­
of-motio n exercises should be inco rporated with grade 1
sprains, whereas grade 2 sprains may require 4 to 5 days
for inflammation to subside. With grade 1 a nd 2 sprains,
the aLhlete may begin by doing knee sUdes on a treatment
tabl e (Figure 22-3), wall slides (Figure 22-5 ), active assis­
tive slides (Figure 22-4, 22-6). o[ riding an exercise bike
with the seat adjusted to the appropriate height to permit
as much knee llexion as can be tolerated (Figure 22-35),
As pain subsides and ROM improves, the athlete may in­
corporate isotonic open-chain flexion and ex1e nsion exer­
cises (Figures 22-22, 22-23). but the athlete should
concentrate on closed-chain strengthening exercises. as tol­
erated. throughout the rehabilitation process (Figures 22-25
546 P.A..RTTHREE The Tools of Rehabil itation

REHABILITATION PLAN
ISOLATED GRADE 2 MCl INJURY IN COLLEGIATE
CRITERIA FO R Ii
FOOTBAll PLAYER
1. Pain, innamrn~
2. Lower-extreill\
INJURY SITUATION A 20-year-old collegiate footb a ll offensive lineman sustain ed an isolated 3. Core stability
grade 2MCL spra in 2 days ago. H'e has been expe riencing localized pain al ong the medial ilS­ 4. Biomech anic<I ' "
pect of the knee and has been unable to ambulate without the <lid of crutches. He wishes to 5. The athlete rc
parlici pa te in the homecoming game in 4 weeks. DISCUSSION Qr
1. VVhat other an
SIGNS AND SYMPTOMS 'I'he athlete complains of pain in the medial aspect of the knee when
2 . What is th e
he aUempls to bear weight. Pain is increased during the valgu s stress test, and a soft end point
3. Describe the
is felt. During palpation th ere is noticeable pain on the superior border of th e MCL; this in­
4. Explain the

reases wh en the knee is passive ly f1 e)(ed and extended. There is mod(~rate discoloration and
iured kn ee.

swelling arong the medial aspect of knee extending down into th e lower ex tremity.
~. Describe the
MANAGEMENT 'PLAN The goal is to redu ce pain initially and increase pain-free range of mo tion. may be usedd

PHASE ONE ACLITE II\;FLAMMATOIW STi\CE

GOALS: 1vloduJate pain and begin appropri ate ra nge-of-motion exercises
Estimated Length of Time (ELT): Day 1 to Day 4
10 22-3 5). FUllet!
Ice aod electrical stimulation arc applied to decrease pain. Anti-infla mmatory medications can help reduce th e amOU nl
of swell ing; also apply a compression wrap. Tbe athlete is restricted from practice for a few weeks and instructed to per­ should be incorporil
form rehabUitation in the athletic trainin g room during the mornin g rehabilitation hours. He is fitted \\"it11 a protective ( reasing as the at
knee brace, an d he is instructed to increase bearing weight while crutch walking. Range-of-moUo n exercises-wall through 1:J"2J I.
slides. pron e hangs, and table glides-are beg un. Quadriceps strengthenin g begins with isometric exercises using qua d engage in plyom
setting, short arc motions. and complete range-of-motion exercises as tolerated. Leg abduction exercises and positions 22- 38) a nd fu ne r
that increase valgus stress sholJld be avoided . Hamstring and gastrocnemius/soleus Ilexibility shou ld be emphasized. stability of th e k
sprain th e at h lclt:
PHASE TWO FIBROBI,/\STIC-REPAIR ST;\CE in 3 to 5 weeks.
GOALS: In crease leg strength and improve J'lexibilily
With a grade 3
Estimated Length of Time (ELT): Days 5 to 14
2 to 3 weeks with
lce and electrical stimulation ll1ilY be continued as needed. Crutch walkillg should be eliminated. and the protective
and at 0 to 90 dt:=­
knee brace may be discontinu ed except when th e athlete is performin g dynami c active exercises. j\ggrcssive quadriceps/

hamstring stretching exercises should be used as tolerated. Isometric an d isotonic strengthening exercises should concen­
ercises may be per'
trate on tl'le entire lower-extremity ch ain and include dynamic motions as tolerated. Controlled closed-kin eti c-chain exer­
remain non- weigl,,.
cises, par ti cularly minisquats and step-ups. should be recommended and performed as tolerated. Aquatic exercise (walk . jog.
The strengt heni ng
and swim) should be emp hasized as tolerated, while avoiding increased valgus st ress on the knee. Function a l activities th at
1 and 2 spraim.
emphasize core stability (thigh, trunk, and hip musculature) should begin ollce the athlete is ab le to do them without pain.
months . 14 . I O,
Fitness levels must be ma inta ined. by using either an upper-extremity bicycle ergometer or aquaU c exercise.

PHASE THREE MATIJRATION-REMODElJN(; S'I';\(;E

GOALS: Complete elimination of pain and I'ull retUflJ to activity
Estimated Length of Time (ELT): Day] S to full return
The athlete should be gradually wea ned from wearing the protective brace while reh abilita ting. but en cou raged to w'car
a medi a l supportive brace during footb all activ ities. The athlete s hould be observed and m onitored closely prior to full re­
turn to play to evaluate any biomechanical deformities in technique that may IDe a result of th e injury. \ 'ideotape repl ay
may be useful for analyzing technique and gail prior to and after re turn to practice and should be eva 'l uated by the ilth­
letie trainer and/ or coach for possible compensations that may lead to addition a l problems. Th e athlete must continue
his strengthening and flexibility routine and incorporate function al tasks specific to his sport and positi on to increase
strength, speed, power. and agility.
 CHAPTER 22 Rehabilitation of Knee Injuries 547

R E H A B I LIT A T ION P LAN (CONT'D)

CRITERIA fOR RETURNING TO COMPETITIVE FOOTBALL

1. Pain, inllammation, and discoloration are eliminated in the lower extremity during all movement tasks.
2. Lower-extremity strength is good, especially in the quadriceps.
3. Core stability (thigh, trunk, and hip musculature) SLrcngth is good.
4. Biomechanical movement techniques are good.
5. The athlete l'eels ready to return to play and has regained coniidence in the injured knee.
DISCUSSION QUESTIONS
1. What other anatomic structures can potentially be disturbed if return to play activity is resumed too early?
2. What is the estimated total healing time for partially torn medial collateral ligament tissue?
3. Describe the characteristics of the protective knee 'brace used during footbaU activities.
4. Explain the possible biomechanical movement strategies that may be utilized as compensation techniques for the in­
jured knee.
). Describe the potential sport/ position demands imposed on this football offensive lineman and funcliOllal exercises that
may be used during the rehabilitation process.

to 22-35). Functional PNF patterns stressing tibial rotation
should be incorporated for strengthening, with resistance in­
~ns tructed to per­
creasing as the athlete becomes stronger (see Figures I 5-14
\' it h a protective
through 15-21). As strength improves the athlete should
rcises-wall
engage in plyometric exercises (Figures 22-36 through
cises using quad
22- 38) and functional activities to enhance the dynamic
and positions
stability of the knee (sec Chapter 17). With a grade 1
be emphasized.
sprain the athlete should be ab .~e to return to fulll activity
in 3 to 5 weeks.
With a grade 3 sprain the athlete will 'be in a brace for
2 to 3 weeh with the braced locked from 0 to 45 degrees,
protective and at 0 to 90 degrees for another 2 or 3 weeks, during
which time isometric quad sets and SLR strengthening ex­
in~quadriceps/
hould concen­ ercises may be performed as tolerated. 14 The athlete should
remain non-weight-bearing with crutches for 3 weeks.
The strengthening program should progress as with grade
1 and 2 sprains. with return to activity at about 3
months. 14 .1O ;
Criteria for Return. The athlete may return to activ­
itywhen (1) they have regained full ROM, (2) they have equal
bilateral strength in k.nee flexion and extension, (3) there is
no tenderness. and (4) they can successfully complete func­
tional performance tests such as hopping, shuttle funs, cari­
couraged to wear oca, and co-contraclion tests.
sel ' prior to full re­
>'. \ 'ideotape replay
Lateral Collateral Ligament Sprains
Iluated by the a1h­
.l must continue Pathomechanics. Fortunately. Lhe lateral aspect of
;ition to increase the knee is well supported by secondary stabi'lizers. Iso­
lated injury to the LCL is rare in athletics, and when it does
occur it is critical to rule out other ligamentous injuries.~~
,\!jost LCL sprains in the athletic population result from a
stress placed on the laLeral aspect of the knee. Isolated
sprain of the LCL is the least common of all knee ligament
sprains. n LCL sprains result in ;lJ5wption at the .fibular
head either with or withou t avulsion in approximately 75
percent of cases, with 20 percent occLIrring at the femur,
and only 5 percent as midsubstance tears. lOG ]t is not un­
common to see associated injuries of the peroneal nerve,
because the nerve courses around the head of the fibula. A
complete disruption of the LCL often invo'lves injury to tbe
posterolateral joint capsule as well as the PCL and occa­
sionaUy the ACL.24 ; 8.6
The extent of laxity determines the severity of the in­
jury. In a grade 1 sprain the LeL is tender due to microtears
with some hemorrhage and tenderness to palpation. How­
ever. there is no increased laxity and there is a firm end
point. A grade 2 sprain invo'lves an incomplete tear with
some increased laxity with varus stress at 30 degrees of
Ilexion and minimal laxity in full extension, yet there is still
a firm end point. There is tenderness to palpation. hemor­
rhage, and pain on a varus stress test. A grade 3 sprain is a
complete tear with signil'icant laxity on varus stress in 30
degrees of Ilexion and in full extension when compared to
the opposite 'knee. ~o end point is eVident, and pain is gen­
erally less than with grades 1 or 2. Significant laxity with
varus stress testing in full extension indicates injury to the
posterolateral joint capsule, the peL. and perhaps the ACL.
Injury Mechanism. An isolated LCL injury is almost
always the result of a varus stress applied to the medial
548 PART. THREE The Tools of Rehabilitation
aspect of the knee. Occasionally a varus stress may occur
during weight bearing when weight is shifted away from the
side of injury, creating stress on the lateral structures. 55
Athletes who sustain an LCL sprain will report that they
heard or felt a "pop" and that there was immediate lateral
pain. Swelling will be immediate and extra-articular with
no jOint effusion unless there is an associated menicus or
capsular injury.
Rehabilitation Concerns. Athletes with grade 1
and 2 sprains that exhibit stability to varus stress may be
treated symptomatically and may be full weight bearing as
soon as tolerated . For patient comfort a knee immobilizer
may be worn for a few days to a week following injury.
However, the use of a brace is not necessary. It is possible
that an athlete with a grade 1 and occasionally even a
grade 2 sprain can continue to play. With grade 2 and 3
sprains there will be some residual laxity, because the liga­
ment has been stretched. Grade 3 sprains may be managed
non operatively with bracing for 4 to 6 weeks limited to 0 to
90 degrees of motion. However, grade 3 MCL tears with as­
sociated ligamentous injuries that result in rotational in­
stabilities are usually managed by surgical repair or
reconstruction . This is certainly the case if the athlete has
chronic varus laxity and intends to continue participation
in athletics. or if there is a displaced avu lsion.
Rehabilitation Progression, The rehabilitation
progression following LCL sprains should follow the same
course as was previously described for MCL sprains. In the
case of a grade 3 LCL sprain that involves multiple liga­
mentous injury with associated instability that is surgi­
cally repaired or reconstructed, the athlete should be
placed in a postoperative brace with partial weight bearing
for 4 to 6 weeks. At 6 weeks a rehabilitation program in­
volving a carefully monitored, gradual, sport-specific
functional progression should begin. In general the at hlete
may return to full activity at about 6 months. 55
Criteria for Return, The athlete may return to activ­
ity when (1) they have regained full ROM, (2) they have equal
bilateral strength in knee flexion and extension, and (3) they
can successfully complete functional performance tests such
as hopping, shuttle runs. carioca, and co-contraction tests,
as described in Chapter 17.
Anterior Cruciate ligament Sprain
Pathomechanics. The ACL is perhaps the most
commonly injured ligament in the knee. In simple terms,
the ACL functions as a primary stabilizer to prevent ante­
rior translation of the tibia on the fixed femur and poste­
rior tran.slation of the femur if the tibia is IIxed as in a
closed chain. It also serves as a secondary stabilizer to pre­
vent external and internal rotation as well as valgus and
varus stress. It works in conjunction with the posterior
cruciate ligament to contro l the gliding and rolling of the
tibia on the femur during normal flexion and extension.
limiting hyperextension. The twisted configuration of the
fibers of the ACL causes the ligament to be under some de­
gree of tension in all positions of knee motion. with lesser
tension present at 30 to 90 degrees55 . 56.5~
Injury to the ACLmost often occurs as a result of sport­
related activities that place significant stress on the knee
joint, as in cutting or lumping. 5i It appears that females
tend to have a higher incidence of ACL injury than
males. 51 There seems to be some evidence that individuals
with a narrow intracondylar notch width may be at
greater risk for ACL injury. 64. 101 This is particularly evident cus, originally
in athletes with noncontact injuries. It has also been sug­ triad ... 81
gested that poor conditioning results in increased physio­ ACL Injur)
[ogicallaxity, although this has never been demonstrated for anterior crUL
experimentally. in the literat ure.
Tears of the ACL occur in the midsubstance of the lig­
amentabout 75 percent of the time, with 20 percent of the
tears at the femur and 5 percentat the tibia. 38 As with MCL
and LCL sprains, the severity of the injury is indicated b)
the degree of laxjty or instability. A grade 1 sprain of the
ACL results in partial microtears with some hemorrhage.
but there is no increased laxity and there is a firm end
point. A grade 2 sprain involves an incomplete tear with
hemorrhage, some loss of fUllction . and increased anterior
translation, yet there is still a firm end point. A grade 2
sprain is paioful. and pain increases with LacJlman's and
anterior drawer stress tests.
A grade 3 sprain isa complete tear with significant lax­
ity with Lachman 's and anterior drawer stress tests. There
is also rotational instability as indicated by a positive pivot
shift. No end point is evident. Th e athlete will most often
report feeling and hearing a "pop" and a feeling thaI the
knee "gave out." There is significant pain initially. but pain
decreases substantially within several minutes. With a
complete ACL tear, insignificant hemarthrosis occun
within 1 to 2 hours.
The term IIlIt erior cruciate defiCient kn ee refers to a
grade 3 sprain in which there is a complete tear of th
ACL. It is generally accepted that a torn ACL will n
heal. 10 1 An ACL-delkient knee will exhibit rotational in­
stability that may eventually cause functional disabili ty ir
the athlete. Additionally, rotational instability can lead l
tears of the meniscus and subsequent degen erat h
changes in the Joint.
Injury Mechanism. The ACL can be injured in Sn ·
eral different ways. One common mechanism of injury in­
volves a noncontact injury twisting motion in which lh
 CHAPTER 22 Rehabilitation of Knee [njuries 549

:11 as valgus amI foot is planted and the athlete is attempting to change di­ Biomechanical risk factors. The knee is only one
Ith the posterior rection , creating deceleration, valgus stress, and external
rotation of the knee. Occasionally the mechanism of in­
part of the kinetic chain; therefore, the roles of the trunk,
hip, and ankle may have importance to ACL injury risk.
h d rolling of the
and extension. jury involves deceleration, valgus stress, and internal rota­ The conference ag,reed that common biomechanical fac­
Iguration or the tion.! J J Knee hyperextension combined with internal tors in many ACL injuries include impact on the foot rather
t' u nder some de­
rotation can also produce a tear of the ACL. Investigations than the toes during landing or wben changing directions
lion. with lesser concerning the effect of quadriceps contraction on ACL while running, awkward body movements, and biome­
tears are still inconclusive, yet clinical incidents have been chanical perturbations prior to injury. The common at-risk
la result of' sport­ reported. Additionally, the stop-jump landing phase of situation for noncontact ACL injuries appears to be decel­
css on the knee movements (e.g .. pivoting, jumping, stopping) has been eraUon, which occurs when the athlete pivots, changes di­
~ar that females
considered to also produce ACL injury. 62 rection, or lands from a jump. The group also noted that
It is possible that the ACL can be torn with contact in­ neuromuscular factors (e.g .. joint stiffness, muscle activa­
~ L injury than
~ that individuals
volving a valgus force that can produce a tear of the ACL tion latencies, muscle recruitment patterns) are important
'dth may be at and MCL, and possibly a detachment of the medial menis­ contributors to the increased risk of ACL injuries in fe­
licularlyevident cus, originally described by O'Donohue as the "unhappy males and appear to be the most important reason for the
triad." S! differing ACL injury rates between males and females. The
also been sug­
creased physio­ ACL Injury Risk Factors, Numerous risk factors fmal factor stated was that strong quadriceps activation
~n demonstrated
for anterior cruciate ligament injury have been presented during eccentric contraction was considered to be a major
in the literature. 3.12.49.5Ul. l l Motivated by concern for the factor in ACL injury.
~ ance of the lig­ high incidence of anterior cruciate ligament injuries oc­ ACL Injury Prevention Programs: Prehabilita­
20 percent of the curring in 15- to 25-year-old athletes , a workshop was tion Programs. Prehabilitation is the concept of estab­
a . 38 As with MCL held in Hunt Valley, Maryland, in 1999 consisting of 22 lishing proper movement abilities prior to injury through
, is indicated by orthopedic physicians, family physicians, athletic trainers, the use of reha'bilitation and training concepts. Numerous
1 sprain of the physical therapists, and biomechanists in an attempt to programs have 'been developed, worldwide, that attempt to
me hemorrhage. reach a consensus on developing prevention strategies for reduce the number of ACL ligament injuries, especially in
lere is a firm end ACL injures.-lO The consensus of the Hunt Valley Confer­ the young female athletic population, utilizing the concept
m plete tear with ence was that ACL risk factors are multifactorial, with four of prehabilitation. 15 .-l 6 .S4 Even though the exact mecha­
creased anterior distinct areas of risk factors: environmental. anatomic, nisms of ACL injury have not been scientifically confirmed
point. A grade 2 hormonal, and biomechanical. and agreed upon, the numerous theories concerning bio­
Lachman's and Environmental risk factors. At present, there is mechanical and neuromuscular aspects have prOVided the
no evidence that knee braces prevent ACL injuries. In­ foundation for limited success in the early development of
rh significant lax­ creasing the shoe-surface coeffiCient of friction may im­ ACL injury prevention programs.
stress tesls. There prove performance, but it may also increase the risk of Griffis et a!., reported an intervention plan conducted
by a positive pivot injury. The conference recommended further investigation by Henning in 1989 that consisted of training techniques
'le will most often
of the shoe-surface interaction as a modifiable risk factor. (e.g., verbal cues, videotape slides, and physical practice)
a feeling that the Anatomic riskfactors. The conference decided that and demonstrated an 89 percent decrease in ACL injury in
[l initially. but pain
there was a great amount of information on femoral inter­ Division I basketball players over a 2-year span!1.4 5 An in­
minutes. Wit.h a condylar notch size, ACL size, and lower-extremity vestigation conducted by Caraffa et a!. established prelimi­
narthrosis occurs anatomic alignment (e.g., Q-angle, pronation, and tibial nary data revealing that proprioceptive balance training
torsion) as they related to ACL injury, but that, because of may reduce ACL injuries in semiprofessional soccer play­
knee refers to a the difficulty of obtaining valid and reliable measurements, ers. Caraffa et a!. found that a proprioceptive balance board
mplete tear of the no consensus on their role in ACL injury could be reached. training program performed during the preseason signifi­
orn ACL will not Hormonal risk factors. The group decided that cantly reduced the incidence of ACLinjuries to 0.15 (10 in­
ibit rotational in­ there was no consensus that sex-speciOc hormones playa juries per 300 players) per team per year as compared to a
.t ional disability in role in the increased incidence of ACL injury in female ath­ nontraining incidence rate of 1.15 (70 injuries per 300 play­
ability can lead to letes, but they encouraged further research in this area. ers) in the nontrained group.16 Hewett et a!. investigated the
ent degenerative Additionally, the consensus was that hormonal interven­ effects of plyometric training programs on reducing possible
tion for ACL injury prevention was not justifiable and that risk factors that predispose individuals to increased ACL in­
n be injured in sev­ no evidence warranted modiOcation of activity or restric­ jury. 46 Utilizing a variety of intervention methods (weight
anism of injury in­ tion from sport for females at any time during the men­ training, landing instructional cues, stretching, and plyo­
tion in which the strual cycle. metric training) to inl1uence jump-landing k,i nematics and
550 PART THREE The Tools of Rehabilitation
kinetics in adolescent athletes, they found that peak land­
ing forces from a volleyball block jump decre_ased 22 per­
cent, and knee adduction and abduction moments
decreased approximately 50 percent. 4 6 Hewett et al. also
conducted a much larger (n= 1263) prospective investiga­
tion on the effect of their neuromuscular training on inci­
dence of serious knee injury in female athletes. 47 A limited
number of serious knee injuries (n = 14) occurred, yet
they found a statistically significant difference in the inci­
dence rate for trained female athletes compared to the rate
for untrained female athletes. Untrained fema'/e athletes
had a 3.6 times higher incidence of knee injury as com­
pared to the female athletes who had had neuromuscular
training.
A clinical program, intended to reduce the incidence of
noncontact lower-extremity injury, was instituted at the
University of North Carolina during the off-season train­
ing programs of the women's basketball and volleyball
teams. The noncontact lower-extremity injury prevention
plan k4 piloted in the spring and summer of 20Cll is a mul­
tilevel training program consisting of strength, balance,
and jump-landing technique training. The program's
main purpose is to inlluence an athlete's ability to jump
and land properly to potentially reduce acute and chronic
non contact lower-extremity injuries.
The premise of the NC-LEIPP program is based on the
folloWing concepts: preseason technique screening, jump­
landing occurs in all functions (e.g" running, pivoting,
and jumping), and a Single-leg concept of athletic move­
ment that states that most athletic tasks are performed
during a single-leg stance.
The NC-LEIPP program is based on qual'ity and tech­
niq ue of movements performed in moderately large groups
(11= 10 to 30) and then further speciflc imervention plans
implemented in small dyad groups (/1=2 to 4). The concept
is to create overall group strategies that can then be specif­
ically modified to individual movement characteristics
during small dyad training stations. NC-LEIPP is primarily
focused on the jiUlnp-landing instruction for sport- and
position-specinc tasks. The jump-landing technique is the
main focus of the truining program and is based on the use
of verbal cues, observational modeling, videotape feed­
back, and physical practice. Four verbal cues are stressed
during the program: (1) "Soft knees" (1'anding with knee
flexion to absorb impact forces), (2) "Load hips" (hip flex­
ion to aid in impact absorption), (3) "QUiet sound," and
(4) "Toe-to-heel" (landing on forefoot and rolling into heel
contact). Data resulting from the implementation of the
clinical program is still quite limited. thus only clinical an­
ecdotal reports are supportive of the program's success.
Rehabilitation Concerns. After the diagnosis of
injury to the ACL, the athlete, the physician, the athletic
trainer, and the athlete's family are faced with various construction. \\1
treatment options. The conservative approach is to allow ment is sutured i
the acute phase of the injury to pass and Lo then imple­ ligament. or the I
ment a vigorous rehabilitation program. If it becomes ap­ of an avulsion ini
parent that normal function cannot be recovered with rect repair of an t
rehabilitation, and if the knee remains unstable even with resul t. 1 In the ca
normal strengthening and hamstring retraining, then re­ mented with aD i
constructive surgery is considered. For a sedentary indi­ construction, wn
vidual. this approach may be acceptable, but most athletes direct repair.9
prefer a more aggressive approach. Surgical recol
The older and more sedentary the indiVidual, the less extra-articu'l ar or
appropriate a reconstruction. This individuaJ may not have articu lar recon SlI
the inclination or the time for an extensive rehabilitation lies outside of tht
program and may not be greatly inconvenienced by some can affect the m
degree of knee instability. Conversely. the ideal patient is a mimics normal .\
young, motivated, and skilled athlete who is willing to make most commorur
the personal sacrifices necessary to successfully complete tive in reducin g
the rehabilitation process. Wilk and Andrews state that any in anterolateral r.
active individual with a goal of returning to stressful pivot­ the normal biome
ing activities should undergo surgical ACL reconstruc­ articular recons\l"1
tion. 109 Thus, successful surgical repairireconstruction of mild to modera Le
the ACL-deficien! knee largely depends upon patient scl.ec­ of choice in pa nel"
tion. 5h The following would be indications for deciding to of time and reso
surgically repairireconstruct the injured knee: tion. Sh The rehab
The ACL-injured individual is highly athletic.
The injured person ,is unwilling to change their active
lifestyle.
There is rotational instability and a feeling of the knee
"giving way" in normal ac(oivities.
There is injury to other ligaments and / or the menisci.
There are recurrent effusions. Bone-patellar ten
There is failure at rehabilitation and instability after the art. using b
6 months of intensive rehabilitation. Sf, while semitendin
Surgery is necessary to prevent the early onset of de­ tendon allografts
generative changes within the knee . i 8 syn thetic replac
In the case of a partially LOrn ligament, the medical able results. The
community is split on a treatment approach. Some feel
thaI: a partially damaged ACt is incompetent. and the
knee should be viewed as if the ligament were completel}
gone. Others prefer a prolonged initial period of immobi­
lization and limited motion , boping that the ligament w ill
heal and remain functional. Decisions to treat a patielll
non operatively should be based on the individual's prein­
jury status and willingness to engage only in activit ie
such as jogging, swimming. or cycling that will not plac,
the knee at high risk.79 This is clearly a case where t h~
athlete may wisely seek several opinions before choos i n~
the treatment course.
The most widely accepted opinion seems to be tha,
when more than one major ligament is disrupted al!
there is functional disability, surgery is indicated. Th
surgical approach to ACL pathology is either repair or p'­

ed with various construction . With a surgical repair. the damaged liga­
i>roach is \0 allow ment is sutured if the tear is in the midsubstance of the
Dd to then imple- ligament, or the bony fragment is reattached in the case
If it becomes ap­ of an avulsion injury. However. it is generally felt that di­
)C recovered with rect repair of an isolated ACL tear will tend to have a poor
,n table even with result. l In the case of suturing, the repair may be aug­
~training, then re- mented with an internal splint or au extra-articular re­
a sedentary indi­ construction, which seems to be more successful than a
, but most athletes direct repair. 96
Surgical reconstruction is performed using either an
dividual. the less extra-articular or an intra-articular technique. An extra­
ual may not have articular reconstruction involves taking a structure that
h'e rehabilitation lies outside of the joint capsule and moving it so that it
enicnced by somc can affect the mechanics of the knee in a manner that
~
ideal patient is a mimics normal ACL function. The iliotibial band is the
is willing to 111<1](C most commonly used structure. This procedure is effec­
cess(ully complete tive in reducing the pivot shift phenomena that is found
~ews state that any in anterolateral rotational instability but cannot match
Ig to stressful pivot­ the normal biomechanics of the ACL. 56 . 68 Isolated extra­
J I\CL reconstruc­ articular reconstructions can be effective in patients with
rtreconstruction of mild to moderate instability. Also it may be the treatment
upo n patient selec­ of choice in patients who cannot afford the commitment
:an for deciding to of time and resources for an intra-articular reconstruc­
:I 1."O ee: tion. 56 The rehabilitation after an extra-articular recon­
I) athletic, struction is aggressive and permits an earlier return to
change their active functional activities. but as an isolated procedure it is not
recommended for high-level athletes.
I feeling of the knce Intra-articular reconstruction involves placing a
structure within the knee that will roughly follow the
md/or the menisci. course of the ACL and will functionally replace the ACL.
Bone-patellar tendon-bone grafts are the current state of
md instability after the art, using human autografts/aliografts,27.31.S6.94.109
,n,;6 while semitendinosis or gracilis autografts and Achilles
Ie early onset of dc­ tendon allografts have been used. 57 Procedures that use
e_' synthetic replacements have generally not produced favor­
ament, the medical able results. The major problem with an autograft is avas­
pproach. Some feel cularity of the tissue, which results in a progressive
:ompetent, and thc decrease in strength of the graft. resulting in possible fail­
ent were completely ure. 31 The main problems with allografts are disease trans­
~ period of immobi­ mission, and rejection of the tissue. It has been
lat the ligament will demonstrated that at 6 months postsurgery, allografts
1 to treat a patient show a prolonged inflammatory response and a more sig­
individual's preLn­ nificant decrease in their structural properties. 57 Rehabili­
ge only in activities tation following an allograft reconstruction should be less
g that will not place aggressive than with an autograft reconstruction. ss
'Iy a case where the Surgical technique is crucial to a successful outcome.
.011S before choosing Improper placement of the tendon graft by only a few mil­
limeters can prevent the return of normal motion.
Dn seems to be thal In cases where there is reconstruction of the ACL
'nt is disrupted anc along with a repair of a torn meniscus, the time required
r~' is indicated. Tht for rehabilitation will be slightly longer. This will be dis­
i either repair or rc­ cussed in detail in the section on meniscal injury.
CHAPTER 22 Rehabilitation of Knee Injuries SS I
Rehabilitation Progression.
Nonoperatille rehabilitation. H the ACL-deficient
knee is to be treated nonoperatively, it is critical to rule out
any other existing problems (torn meniscus. loose bodies,
etc.) and correct those problems before proceeding with re­
habilitation. 79 Initial treatment should involve controlling
swelling, pain, and inflammation through the use of cold,
compression. and electrical stimulation. If necessary, the
knee can be placed in an immobilizer for the first few days for
comfort and minimal protection, with the athlete ambulat­
ing on crutches until they regain full extension and can
walk without an extension lag. The athlete can begin im­
mediately following injury with quad sets (Figure 22-20)
and straight leg raising (Figure 22-2 1l to regain motor
control and minimize atrophy. Early pain-free range of mo­
tion exercises using knee slides on a treatment table (Figure
22-3). wall slides (Figure 22-5) , active assistive slides
(Figure 22-4, 22-6), or riding an exercise bike with the seat
adjusted to the appropriate height to permit as much knee
fleXion as can be tolerated (Figure 22-35).
As pain subsides and ROM improves, the athlete may in­
corporate isotonic open-chain flexion and extension exer­
cises (Figure 22-22 and 22-23). With open-chain
strengthening exercises, it has been recommended that ex­
tension be restricted initially to 0 to 45 degrees for as long as
8 to 12 weeks (6 to 9 weeks being a minimum) to minimize
stress on the ACL. 79 Strengthening exercises should be em­
phasized for both the hamstrings and the gastrocnemius
muscles (Figure 22-24), which act to translate the tibia pos­
teriorly, minimizing anterior translation. Closed-chain
strengthening exercises (Figures 22-25 through 22-35) are
thought to be safer because they minimize anterior transla­
tion of the tibia. Closed-chain exercises are used to regain
neuromuscular contro'l by enhancing dynamic stabilization
through co-contraction of the hamstrings and quadriceps
(Figures 22-43 to 22-46). Closed-chain exercises also mini­
mize the possibility of developing patellofemoral pain, A
goal of these strengthening exercises should be to achieve a
quadriceps/ hamstring strength ratio of 1: 1.
It is important to incorporate PNF strengthening pat­
terns that stress tibial rotation (see Figures] 5-14 through
15-21). These manually resisted PNF patterns are essen­
tially the only way to concentrate on strengthening the ro­
tational component of knee motion, which is essential to
normal function of the knee. Unrortunately many of the
more widely known and used rehabilitation protocols fail
to address this critical rotational component.
The use of functionnl knee braces for an athlete with ei­
ther a partial ACL tear or an ACL-dellcient knee is contro­
versial (Figure 22-52 ). These braces have not been shown
to control translation, especially at functional loads. s.90
However, there may be some benefit in terms of increased
552 PART THREE The Toob of Rehabilitation
Figure 22-52 f\ functional knee brace can provide
some protection 1O the injured knee.
joint position sense. throllgh stimulation of cutaneous sen­
sory receptors. that may enhance both conscious and sub­
conscious awareness of the existing injury.b;
[t is incumbent on the athletic trainer to counsel the
athlete with regard to the precautions that must be exer­
cised when engaging in physical activity with an ACL­
deficient knee. Nonoperative treatment is appropriate for
an individual who does not plan on engaging in the types
of activities that can pOLcntially create stresses that can
furLher damage the supporting structures of that joint. If
the patient is noL Willing to make lifestyle changes relative
to those activities. then surgical intervention may be a
better treatment alternative.
CLINICAL DECISION MAKING Exercise 22-3
A soccer player ha~ suITered an isolated grade 2 sprain of
his anterior cruciale ligament. At this point the physician
feels that surgery is not required and decides to try to reha­
bilitate the athlete's knee and have him return to practice.
It is Ilkely that when he retums to full activity, the athlete
will experience some feeling of instability when stopping.
starting. and pivoting. \Vhat can the athletic trainer rec­
ommend to the athlete to help him mininlize these feelings
of instability and to prevent additional injury to the ACL?
Surgical reconstruction. There is great debate as matures. It hash...
the course of rehabilitation follOWing ACIL reconstruction. r a 10 mm CC~tI"
Traditionally, rehabilitation has been conservative. and '1lately 10 7 pen
there are a great number of physicians and athletic Lraine been predicted _
who maintain this basic tradiLional phllosophy.2i.Si> HOI\ ­ m onths. 56 perl
ever, in recent years the Lrend has been to become morc ag­ fllO nths. 18 Str
gressive in reh abilitation of the reconstructed ACT {he period of g
prirnar,uy as a result of the reports of success by ShelbourIlt' - J 6 weeksJ. ~
and Nitz.JOoThis has been referred to as an acceleraLed pro­ Lhatthe surgira
toco1. They have demonstrated that this program returns ",u nd, the gra
the patient to normal function early. results in fewer "urgery. so rehat'
patellofemoral problems, and reduces the number of sur­ process. Also it
geries to obtain extension, all without compromising stabU­ program mi n im
ity.lOOThe accelerated rehabilitation protocol is not wiLhom non of func tion
its detractors. Some clinicians feel that it places too much COIl trolling !
stress on vulnerable tissues and that there are not sufficicn goal is to miniIr
scientific data to justify Lne protocol :31.8o.87.109 pression. an d e,
There is now such a variety of accelerated and non ac­ used for this pu
celerated programs LhaL the difference between "tradi­ hi bit firing of lb
tional" and "accelerated" has been blurred. Depending OD Bracil7g_ The
the injury. many factors-such as type of athlete. time and most often,
athleLic season-have been driving the rehabiliLati on degrees passi\-c
process to a greater extent than science-based outcomes. frrst2 weeks IF.:
More studies need to be conducted to better predict the ideal
rehabilitation protocol, yet individual differences may never
allow for a single protocol to be uLilized for all athletes.
The traditional protocol emphasizes the follOWing:
Slow progression to regain flexion and eXLension
Partial- or nonweighL-bearing postoperatively
Closed-chain exercises at 3 to 4 weeks postoperative!) tion process. II
Return to activit.y at 6 to 9 months2 5.31.1 09
The accelerated protocol emphasizes tbe following:
Immediate motion. including full extension
Immediate weight bearing within tolerance
Early closed-chain exercise for strengthening and ne u­
rom uscular con trol
ReLurn to activiLy at 2 months and to competition at 1:
to 6 months lOO minimal swellin"
Preoperative period. Regardless of the various recom­ eeps stren gth II
mended time frames for rehabilitation. the rehabilitati\' take anywh ere [r'
process begins immediately follOWing injury in what b ~ Range of In
been referred to as the preoperative phase. There is genera; immediately. So
agreement that surgical reconstruction be delayed u l1li
pain, swelling. and inflammation have subsided and range
of motion, quadriceps muscle control. and a normal gai~
pattern have been regained during this preoperative pha
This appears to occur at about2 to 3 weeks postinjUTy.H '
It a1so appears that delaying surgery decreases the inci­
den ce of postoperative arthrofibrosis. 9R
Postoperative period. Perhaps the single most importanr
rehabilitation consideration postoperatively has to do wit
Lhe initial strength of the graft and how the graft heals an
 CHAPTER 22 Rehabilitation of Knee Injuries 553

:reat debate as to matures. It has been demonstrated that the tensile strength
. reco nstruction. of a 10 mm centrallhird patellar tendon graft is approxi­
n ervative. and mately 107 percent of the normal ACL initially, and it. has
, athletic trainers been predicted thal the strength is at S 7 percent at 3
o phy. E~6 Ho\\"­ mon ths, 56 percent at 6 months, and 87 percent at 9
be ome more ag­ monlhs. 1H Slress on th e graft should be minimized during
nstructed ACL. the period of graft necrosis (6 weeks ). revascularization
. by Shelbournc (8-16 weeks), and remodeling (1 h weeks).1119 Assuming
accelerated pro­ thal the surgical techniq ue for reconstrucNon is technica lly
program returns sourtd, the graft is at its strongest immediately following
re 'ults in fe wcr surgery, so rehabilitation can be very aggressive early in th e
~ number of sur­ process. Also it appears that an aggressive rehabilitation
Ilpromising stabU­ program minimizes complications and maxLmizes restora­
- I is not without tion of function following ACL reconstruction.»
places too mu ch Controlling swelling. Immediately following surgery, the
~ are not suf!lcien t goal is to minimize pain and swelling by using cold, com­
- 109 pression , and electrical stimulation . A Cryo-cuff is widely Figure 22-53 In a rehabilitative brace the range of
mlted and nonac­ used for this purpose. Significant swelling can initially in­ movement can be restricted and changed whenever
• between "tradi­ hibit firing of the quadriceps. appropriate.
red . Depending on Bracing. The athlete is placed in a rehabilitative brace
or athlete, time of and most often locked in either full extension, 11111 or 0 to 90 prone leg hangs (Figure 22-8). Exercises to main tain full ex­
the rehabilitation degrees passive with 40 to 90 degrees active Rm"I. for the tension should be emphasized throughout the rehabilita­
-based outcomes. fITS! 2 weeks (Figure 22-53). The brnce wUI be worn fOf 4 lion process. Active knee extension should be limited to 60
r predict the ideal to 6 weeks, or until knee flexion exceeds the Hmits of the to 90 degrees to mmUllize anterior tibial
brace, and may be removed for exercise and for bathing. translation ,whereas knee flexion should reach 90 degrees

~
re nces may never
r a ll athletes. Shellbourne and Nitz recommend that a knee immobilizer by the end of the second week. Full flexion (135 degrees)
th e following: be used for the fir st 2 weeks but that at the end of the Ilrst should be achieved at 5 to 6 weeks. Once knee flexi on
nd ex tension week the athlete be fitted for a functional brace, which reaches 100 to 110 degrees, the athlete may begin station­
lpe ratively should be worn for [Jrotection throughout the rehabilita­ ary cycling to help with regaining ROM (Figure 23-35).
'k postoperatively tion process. lOll There does not appear to be a general co n­ During the second week the athletic trainer should
" 11 10 9 se nsus among physicians as to the value of wearing a Leach the athlete self-mobilization tec hniques for the
the following: functional brace during return to activity. This decision patella (see F,i gure 14-58). Restriction of patellar molion
(tension should be made 011 an indi vidual basis. can interfere with regaining both flexion and extension.
olerance Weight bearing. Generally the athlete is placed on T he grade of mobilizatio n used should be based on the de­
'!!,the ning and neu- crutches either with 50 percent weight bearing. R7 or pro­ gree of ,i nflammation. and should avoid creating addi­
gressed to full weight bearing as tolerated 1011 for .the first 2 tiona 'l pain and swelling. 91
Lo competition at S weeks. The athlete can gel off the crutches when there is Strellg/hellillg. Initially, strengthening exercises should
minimal swelling. no extension 'lag, and sufficient quadri­ avoid placing high levels of stress on the graft. Quad sets
.he various recom­ ceps strength to allow for nearly normal gait. This may (Figure 22-20) and sLTaight leg raises (Figure 22-21) USing
I. the rehabilitati\'E~ take anywhere from 2 to 6 weeks. co-contraction of the hamstrings should begin immediately
in jury in what has Rarrge of motion. Range-of-motion exercises can begin to prevent shutdown of the quadriceps. Progressive resistive
iSe. There is general immediately. Some c1i.nicians advocate the judicious use of exercise can begin during the second week for hamstrings
m be delayed unt il contwuoLls passive motion (CPM) machines. which may be (Figure 22-22). hip addll.c tors (Figure 22-l9). hip abductors
bsided and range applied immediately after surgery (Figure 22_54).72.80,82.9; (Figure 22-18), and gastrocnemius muscles (Figure 22-24).
. nd a normal gail while others prefer that the athlete engage in active range­ Strengthening exercises lor a(J of these muscle groups. par­
preoperative phase. of-motion exercises as soon as possible (Figures 22-3 ticularly emphasizing strengthening of the hamstrings,
'eeks postinjurs,.44,9> through 22-8). Certainly, current research is sparse regard­ should continue throughout rehabilitation.
decreases the inci­ ing the efficacy of CPM. The rationale and biomechanical advantages (or using
In their accelerated rehabilitation program, Shell­ cIosed-kinetic-c hain strengthening exe rcises in the reha­
19le most important bourne and Nitz emphaSize the importance of early restora­ bilitation of various knee injuries was discussed in detail in
lively has to do with tion of fuJI knee extension. lOG Full extension can be achieved Chapter 12. When using the diHerent closed-kinetic-chain
,\' the graft heals and USing knee extension on a rolled-up towel (Figure 22-7) or exercises, it is essential to emphasize co-contraction of the
554 PART THREE The Tools of Rebabilitation

on a treadmill car
forward walki n,
in!!,. Swimming i
weeks. Stair clim
ing can begin a
for progressing .
months in th e a
closer to 6 mom h
Functional Cr,
gressively incor
occur during nor­
tivities in a CO(1
22_50). 14 .29 ExerL
ping. carioca. shl.
ping. and co-coo·
described in Cha
more traditional ~
about 4 mODth
they may begi n a
Movement Tf
the rehabilita tion
evaluating mO\·c
sations or problem
figure 2 2 ·54 A CPM device may be lIsed to help regain ROM. creased risk for AC
patterns utilized
and jump-landj(1
hamstrings, both to stabilize the knee and to provide a P I\TF strengthening patterns that stress tibial rotation throughout the r­
posterior translational force to counteract th e a nterior may also be used. These manually resisted PKF patterns the injured at hlcl,
shear force created by the quadriceps during kn ee exten­ are essentially th e only way to concentrate on strengthen­ ure 2 3~47). It ha
sion. Once ITexion reaches 90 degrees. which sh o uld ing th c rotational component of knee motion, which is es­ back cao help lc:
generally be in 1 io 2 weeks, the athlete can begin closed­ sential to normal function of the knee. Because the PNF technique and re
kinelic-chain minisquals in the 40 to 90 degrees range patterns Clrc dODe in an open kinetic chain, they should in­ Performance test~
(Figure 22-25), lateral step-ups (Figure 22-30), standing volve only active contraction through Lhe functional ability to rega in 11"
wall slides (Figure 22-26) or leg press (Figure 22-29). moveme.nt pattern. Progressively resisted patterns can be performance was
Open-kinetic-chain quadriceps strengthening exer­ used beginning at about') months (see figures] 5-14 reinjury or comlXl
cises should be completely avoided in t he early ~ ta ges of re­ through 15-21). previously existed
habilitation, due to the anterior sh ear forces. which are Reestablishing l1elll"OlJ1l1SClII(lr (0I1lro1. Along with the been developed. th",
greatest from 30 degrees of flexion to full extension. I low­ early controlled weight beuring and closed-chain exer­ and the athletic IT:
ever. at some point in the later stages of rehabilitation, cises timt act to stimulate muscle and jOint mechanore­ tbe rehabilitation
open-kinetic-chain quadriceps stren gtJlening exercises cepLors, seated RAPS board exercises to reestablish
may be safely incorporated (Figure 22- 2 3). balance and neuromuscular control should also begin
It should be recmphaslhed that the graft is at its wea.kest carly in the rehabilitation process (Figure 22-438). Bal­
between weeks il to 14. during Lhe period of revasculariza­ ance training using a standing BAPS board (Pigure 22­
lion. Therefore caution sbould be exercised relative to 43 ;1), and lateral shifting for strengthening and agility
strengthening exercises during this period. The accelerated using the Fitter (Figure 22-33), may be incorporated a: recommendatio O!;:
program bas recommended that isokinetic tesiing begin at 6 wccks. Shell bourne amj
about 2 months. Other programs recommend that testing be CardiorcspimlGrV cnilurance. Cycling on an upper­ Andrews an d \\
delayed unli14 or :; months. This should be done only using extremity ergometer may begin during the first week. C~­ Fu and lrrga ng­
an antishear de,rice with a 20-degrec ter minal extension c'ling on a stationary bike can begin as early as possibl Campbell Cli nic­
block. b o .Y'! Isokinetic strengthening exercises lTl ay be salCly when the athlete achieves about 100 to J 10 degrees of Paulos and Sler
incorporated at about 4 months (Figures 22- 39 lo 22-42 ). flexion (Figure 22- 35). Walkillg with I'ull wejght bearing Kerlan and J

on a treadmj\l can usually begin at about 3 weeks. using
forward walking initially then progressing to rclro walk­
ing. Swimming is considered to be a safe activity at 4 to 5
weeks. Stair climbing (Figure 22- 34) or cross-country ski­
ing can begin as early as wcek 6 or 7. RecommcndaLions
for progressing to jogginglrunn ing arc as early as 4
months in the accelerated program bIlt arc more often
closer to 6 months.
Functional training. Funclional training shonld pro­
greSSively incorporate the stresses. strains. and forces that
occur during normal running. jumping. and pivoting ac­
tivities in a controlled environment (figures 22-49,
22_50).14.29 hercises such as single- and double-leg ho p­
ping. carioca. shuttle runs, vertical jumpin g, rope ski p­
ping. an d co-contraction activities, most o r which we re
described in Chapter 17. should be incorporated. In th e
more lraditional pmgrams th ese activities may begin at
about 4 months. although ill the accelerated progra m
they may begin as early as 5 or 6 weeks.
Movement Technique Assessment Throughout
the rehabilitation process the athletic tminer should be
evaluating movement' technique to discern if any compen­
sations or problems exist. One current theory attribu tes in­
creased risk for ACt injury to the biomcchanical tec hnique
patterns utilized by individuals when running. pivoting.
and jump-landing. 6 1.84 Prior to return to play and
ere libial rotation throughout the rehabilitation process. motion analysis of
- led PNF pallerns the injured athlete's movements should be monitored (Fig­
rate on strengthen­ ure 23-47). It has been shown that videota pe replay feed­
Doti on. which is eS­ back can help teach the athlete proper jump-landing
~_ Because the PNF technique and reduce possible deleterious forces. 76.83.89
ain . they sho uld in­ Performance tests are vilalto assess the injured athlete's
gh the functiona l ability to regain movement times, bUl analysis of holV the
ed patterns can be performance was conducted is also vital in preventing
Figures 1 5- H reinjury or compensatory problems. If poor tec hnique
previously existed or poor compensatory techniques have
I. Al ong with the been developed, then the predisposition for inj ury remains
closed-chain exer­ and the athletic trainer has missed a critical final step of
Ii joint mechanore­ the rehabilitation process.
es to reestablish Criteria for Return. Physicians lypically have
hould also begiI~ varying criteria for full relUrn of lb . athlete foll owing in­
gu re 22-4381. Bal­ jury to the anterior cruciale. Perhaps the greatest variabil­
board (Figurc 22­ ity exists in the recommended lime frames for full return.
lhe ning and agilit . Among the more widely used protocols are the following
I be incorporated at recommendations:
Shellbourne and Nitz-4 to 6 monlhs
-n g on an upper­ Andrews and Wilk-3 to b months
g the first week. Cy­ Fu and Irrgang- 6 to 9 months
a" early as possible Campbell Clinic-6 to 12 months
p to 11 0 degrees 0 Paulos ami Stern- 9 months
I fu ll weight bearing Kerlan and Jobe- 9 month s
CHAPTER 22 Rehabllitalion of Knee Injuries 555
In general the f()llowing criteria appear to be the most
w ielely accepted: (1) t\o joint effusion, (2) full ROM, (3) iso­
kinetic testing ind,i eall's that strength of the quadriceps
and hamslrings are at R5 to 100 percent of the uI1invo!ved
leg. (4) satisfactory ligament stability tesling using a KT­
1000 arth.rometer. 2 (5) successful progressioIl from walk­
ing to runnin g. and (6) slIccessful performance during
runctio n al testing (hop tes ts, agility runs. etc.).
Posterior Cruciate Ligament Sprains
Pathomechanics. Isol a ted tears of the poslerior
cruciate liga ment (PCL) are not common but certainly do
occur in a thlet's. It is more likely that the pCL is injured
concurrentl w ith the ACL. MCL, LCL, or menisci. The PCL
is th e stron gest ligament in the knee and runctions with
th e ACL to control the rolling and gliding or the
libiofemoral joint and has been called the primary stabi­
lizer of the knee. More specifically t he PCL preven ts 85 to
90 percent or Lh' posterior tra nsla tio nal force of the tibia
o n the femur. This is evident in the PCL-def1c1ent knee
when. u pon descending an incline, the force of gravity
works to increase the anterior gUde of th e femur on the
tibia ; without the pe L the femur will sublux on 111e tibia
from midslance to toe-off. where the quadriceps are less ef­
fective in controlling the anterior motion of the femur on
the tibia. 697l
The majority (70 percent) of PCL tears occur on the
tibi a. while 15 percent occur on femur and 15 percent are
lI1idsubstance te ars . I O~ Tn the PCL-deficlent knee there is
a n increased likelihood of men iscus lesions and chondral
defc "ts. most olten involving the medial side. 36
The extent of la xity determines the severity of the in­
jury. In a grade] sprain the PCI. is tender due to microtears
wit h some hemor rhage and tenderness lo palpation. How­
ever. l.here is n o increased laxity and there is a firm end
poin l. A grade 2 prain involves an incomplete tear with
some increased laxity in a positive posterior drawer test,
yet there is still a firm end poin l. There is tenderness to pal­
palion. hem orrha ge. an d pain on posterior drawer test. A
grade 3 sprain is a co mplele tear with significant posterior
la o Ity in poste ri or dralVer. posterior sag. and reverse pivot
:;hif tests when compared to the opposite knee. No end
point is evident. and pain is generally less than with grades
lor 2.
Injury Mechanism . in athletics, the most com­
mon mechanism of in jury to tbe PCL is with the knee in a
position of forced hypcrflexi on with the foot plantar
flexed. The PCL can also be injured when the tibia is forced
posteriorly on the fixed femur Of the femur is forced ante­
riorly on the fixed tibia. oS It is also possible to injure the
556 PA.Rl'THREE The Tools or Rehahilitation

peL when tbe knee is h)7perl1exed aod a downward force bilitative process. the rate of progression limited only by
is applied to the thigh. pain and swelling. leg. The team
Forced hyperextension will usually result in injury to The 8thlete can begin immediately foIlowing injury return to pIa)
both the peL and the ACL. rr an anteromedial force is ap­ will'! quad sets (Figure 22-20) and straight leg raising (Fig­ strength are
plied to a hyperextended knee. the posterolateral joint: cap­ ure 22-21) to regain motor control and minimize atrophy. use of the leg ..
sule may also be injured. If enough valgus or varus force is Early pain-free range-of-motion exercises can begin using kick. What sh:
applied to the fully extended knee to rupture either collat­ knee slides on a treatment table (Figure 22-3), wall slides bility in the in;
eral ligament. it is possible that the PCL may also be torn. (Figure 22-5). active assistive slides (Figure 22-4.22-6), or
The athlete will indicate that they felt and heard a riding an exercise bike with the seat adj usted to the appro­
"pop" but will often feel that the injury was minor and that priate beight to permit as much knee flexion as can be tol­ Surgical n ,
they can return to acUvity immediately. There will be mild erated (Figure 22-35). Hamstring exercises should be maturation a nd t
to moderate swelling within 2 to 6 hours. avoided initially to minimize posterior laxity. been document
Rehabilitation Concerns. Perhaps the greatest NonoperaUve rehabilitation should focus primarily on graJls. The cou r ~
concern in rehabilitating an athlete with an injured peL is quadriceps strengthening. As pain subsides and ROM im­ construction of ..
the fact tbat the arthroi<inematjcs of the joint are altered. proves, the atblete may incorporate isotonic open-chain mended rebabil
and this change ran event ually lead to degeneration of both extension exercises (Figure 22-23). vVlth open-chain Clancy has perhar
tbe medial comp8rtment and the patellofemoral joint. 5i quadriceps strengthening exercises, it has been recom­ constructions
The decision as to whether the PCL-delkient knee is mended that extension be restricted initially in the 45 to Immediatel)
best treated non operatively or surgically is controversial. 20 degrees range to avoid developing patcllofemoral pain and swelling
This is primarily due to the relative lack of data-based in­ ,0
pain . It has also been recommended that quadriceps cal stimulatio n.
formation in the literature regarding the normal history of strength in the PCL-deficient knee be greater than LOO this. The athlete
PCL tcars. Many athletes with an isolated peL tear do not percent of the uninjured knee. particularly in athletes at­ locked in 0 deg
seem to exhibit functional performance limitations and can tempting to· fully return to sport activity.s5 week (Figure 12­
continue to compete athletically. while others occasionally Open-chain hamstring strengthening exercises using may be unlocked
are limited in performing normal daily activities. Ib knee flexion that increase posterior translation of the cises. The brace
Parolie and Bergfeld reported a more than 80 percent tibia should be avoided. Posterior tibial translation can be
success rate with nonoperalive treatment. ~; On the other minimized by strengthening the hamstrings using open­
hand. Clancy reported a high incidence of femoral chain hip extension lVith the knee fully extended (see soon as possib k .
condylar articular injury involving degenerative cbanges Figure 2l-28E). Closed-chain exercises (Figures 22-2:; 6 weeks until the;
that may eventually result in arthritis in patients 4 years through 22-35) that use a co-contraction of the quadri­ Quad sets (Fig
after PCL injury. Thus surgical reconstruction has been ceps to reduce posterior tibial translation and also to min­ ure 22-21) done in
a dvocated. IY . 71 imize the possibility of developing patellofemoral pair sisted exercise c.
It is generally felt that the surgical treatment of PCL may safel» be used to strengthen the hamstrings. hip adductors t F.
Lenrs is technically difficult. Surgery to reconstruct a PCL­ The use of functional knee braces for an athlete with a 22-18). After sur~
deficient knee is most often indicated with avulsion in­ PCL-deficient knee is generally not recommended, becauSe' portant to limi t h;
juries. Reconstructive procedures using the semitendinous functional braces are designed primarily for ACL-deficienl translational ror'
tendon, the tendon of th e medial gastrocnemius. the knees. However. there may be some benefit in terms of in­ hamstrings should
AchUles tendon, the patellar ten don. or synthetic material creased joint position sense. through stimulation of cuta ­ to place stress on
to replace the lost PCL have been recommended. i5 Both neous sensory receptors, that may enhance both conscio exercises from 0 t
autografts and allografts have been used. and subconscious awareness of the existing injury. fi, sisted terminal kn
Rehabilitation Progression. Because of the tendency toward progressive degeoer also be used (Fi gu
Nonoperative rel.abilitution. If the PCL-deflcient tion of the medial aspect of the knee with a PCL-deDcien Along with t.h
knee is to be treated nonoperatively, initial treatment knee, it is incumbent on the sports therapist to counsel tho. closed-chain cxer,
should involve controlling swelliog, pain, and inl1amma­ patient to avoid repetitive Clctivities that produce pai n
tlion through the use of cold, compression, and electrical swelling."
stimulation. If necessary, the knee can be placed in an im­
mobilizer for the first few days for comfort and [!1.inimal CLINICAL DECISION MAKING Exercise 22-4 lion process (Fig
protection, with the athlete ambulating on crutches until Cycling on a sta
they regain full extension and they can walk without an A high school football kicker suffered an isola ted grade 2 the athlete achi C\

~xtcnsion lag. Because there is often little functionallimi­ spmin of his posterior cruciatc ligament in his nonkicking I Figure 22- 35 1. \\

tation. the athlete may progress rapidly through the reha­ treadmill can begi"'


limited only by
leg. The team physician has decided to allow the player to
return Lo play once pain-free range of motion and
fo llowing injury
strength are regained. The atblete hab regained complete
1l lcg raising (Fig­
use of the leg, except he feels unstable when planting to
~nimize atrophy.
kick. What should the athletic lrainer do to increase sta­
r an begin using
bUlly in the injured leg durin g the kicking maneuver?
12-3). wall slides
r 22-4,22-6), or
Isled to the appro­
-io n as can be tol­ Surgicld rellabilitation. The time frame for the
~rci es should bc maturation and healing process for a PCL graft has not
ity. been documented in the literature, as it has been for ACL
lOc us primarily on grafts. The COLlrse of rehabilitation following surgical re­
d s and ROM iOl­ construction of the PCL is not well defined, and recom­
t nic open-chain mended rehabilitation protocols are difficua to fInd.
With open-chain Clancy has perhaps the largest study of operative PCL re­
has been recom­ constructions using a patellar tendon grafl. r9
itia lly in the 45 to Immediately follOWing surgery, the goal is to minimize
og patellofemoral pain and swelling by using cold. compression. and electri­
kl that quadriceps cal stimLllation. A Cryo-cuff may be used to accomplish
greater than 10U this. The athlete is placed in a rehabilitative brace and
larly in athletes at- locked in 0 degrees of extension at all times for the first
week (Figure 22-52). During the second week the brace
g exercises using may be unlocked for ambulation and passive ROM exer­
ra nslation of the cises. The brace will be worn for 4 to 6 weeks until the ath­
tra nslation can be lete can achieve 90 to 100 degrees of t1exion. Generally the
rings using open­ athlete is placed on crutches with full weight bearing as
Jly extended (see soon as possible. but they should stay on crutches for 4 to
(Pigures 22-25 6 weeks until they can achieve fuU extension.
i n of the quadri­ Quad sets (Figure 22-20 ) and straight leg raises (Fig­
I and also to min­ ure 22-21) done in tbe brace can begin al2 to 4 weeks. Re­
sisted exercise can begin during the second week for
hip adductors (!Figure 22-19) and hip abductors (Figure
22-18). After surgical reconstruction of the peL. it is im­
mended. because portant to limit hamstring function to reduce the posterior
lIy for ACL-deficienc translational forces. 09 Strengthening exercises for the
efIt in terms of in­ hamstrings should be avoided initially because they tend
lim ulation of cuta­ to place stress on the graft. At 4 to 6 weeks. closed-drain
a nce both conscious exercises .from 0 to 45 degrees of flexion are initiated. Re­
. g injury."; sisted terminal knee extensions in a closed chain should
rogressive degenera­ also be used (Figure 21-31).
L,'ilh a PCL-defIcient Along with the early controlled weight bearing and
rapist to COllnsel the closed-chain exercises begun at about 6 weeks which act
hal produce pain or to stimulate muscle and jOint mechanoreceptors, seated
BAPS board exercises to reestablish balance and neuro­
muscular control shouId also begin early in the rehabilita­
Exercise 22-4 tion process (Figure 22-43B).
Cycling on a stationary bike can begin at 6 weeks when
isolated grade 2 the athlete achieves about 100 to 110 degrees of t1exion
in his nonkicklug (Figure 22- 3.5). Walking with full weight bearing on a
treadmill can begin when the athlete has no extension lag
CH.AP'lliR 22 Rehabilitation of Knee [njuries 557
and has sufficient quadriceps strength to allow for nearly
normal gait. Progressing to jogging/running is generally
not recommended until 9 months. tunctional training
should progressively incorporate the stresses. strains. and
forces that occur during normal running. jumping, and
pivoting activities in a controlled environment (see Figures
23-49.23 =.50).
Criteria for Return. In generallhe following crite­
ria for return appear to be the most w idely accepted:
(1) There is no joint effusion. (2) There is full ROM. (3) Iso­
kinetic testing indicates that strength of the quadriceps
greater than 100 percent of the uninvolved leg. (4) The
athlete has made successful progression from walking to
running. (5) The athlete has successful performance dur­
ing functional testing (hop tests. agility runs. etc.).
Meniscal Injury
Pathomechanics. The menisci aid ,in joint lubrica­
tion, help distribute wcight-bearing forces, help increase
joint congrucncy (which aids in stability). act as a second­
ary restraint in checking tibiofe01oral motion, and act as a
shock absorber1 5. hb
Thc medial meniscus has a much higher incidence of
injury than the latera'! meniscus. The higher number of
medial meniscal 'lesions may be attributed to the coronary
ligaments that attach the meniscus peripherally to the
tibia and also to the capsular ligament. The lateral men is­
cus docs not attach to the capsular ligament and is more
mobile during knee movement. Because of the attachment
to the medial structures. the medial meniscus is prone to
disruption from valgus and torsional forces.
A meniscus tear can result in immediate joint-line
pain localized to either the medial or the lateral side of
the knee. Effusion develops gradually over 48 to 72
hours, although a tear at the periphery might produce a
more acute hemarthrosis. [nilially pain is described as a
"giving-way" feeling, but the knee may be "locked" near
full extension due to displacement or the meniscLis. A
knee that is locked at 10 to 30 degrees of nex,i on may in­
dicate a tear of the medial meniscus. while a knee that is
locked at 70 degrees or more may indicate a tear of the
posterior portion of the lateral meniscus. 2 3 A positive Mc­
Murray's test usually indicates a tear in the posterior
horn of the meniscus. The knee that is locked by a dis­
placed meniscus may require unlocking with the ath'lete
under anesthesia so that a detailed examination can be
conducted. If discomfort, disability. and locking of the
knee continue, arthroscopic surgery may be required to
remove a portion or the meniscus. If the knee is not
locked but shows indications of a tear, the physiCian
558 PART THREE The Tools of Rehabilitation
might initially obtain an MRI. A diagnostic art hroscopic
examination may also be performed . Diagnosis of men is­
cal injuries should be made immediately after the injury
has occurred and before muscle guarding and swelling
obscure the normal shape of the knee.
Injury Mechanism. The most common mecha­
nism of meniscal injury is weight bearing combined with
internal or external rotation while extending or flexing the
knee. l7 A valgus or varus force sufficient to cause disrup­
tion of the MCL or LCL also might produce an ACL tear as
well as a meniscus teas. A large number of medial menis­
cus lesions are the outcome of a sudden. strong. internal
rotation of the femur with a partially flexed knee while the
foot is firmly planted, as would occur in a cutting motion.
As a result of the force of this action, the mediaJ meniscus
is detached and pinched between the femoral condyles.
MeniscallesiQns can be longitudinal, oblique, or trans­
verse. Stretching of the anterior and posterior horns of the
menisc,~s can prod~ce ~ \7e ~~caJ-longitudinal or "bucket­
handle tear. A longltudmal ~r can also result from force­
fully extending the kllee froll!l a flexed position while the
femur is internally rotated. During extension the medial
meniscus is suddenly pulled back, causing the tear. In con­
trast, the lateral meniscus can sustain an oblique tear by a
forceful knee extension with the femur externally rotated.
Rehabilitation Concerns. Quite often in the ath­
letic population, the choice is to initially treat meniscus
tears conservatively. taking a "wait and see" approach. Oc­
casionally the athlete will be able to complete the compet­
itive season by simply ';dealing" with the associated
symptoms of a torn meniscus, with the idea that the prob­
lem will be taken care of surgically at the end of the sea­
son. rn some individuals the symptoms may resolve so that
there is no longer a need for surgery.
The problem is that once a mcniscal tear occurs, the
ruptured edges harden and can eventually atrophy. On oc­
casion. portions of the meniscus may become detached
and wedge themselves between the articulating surfaces of
the tibia and femur, imposing a chronic locking, "catch­
ing," or "giving way" of the joint. Chronic meniscal lesions
can also display recurrent swelling and obvious muscle at­
rophy around the knee. The athlete might complain of an
inability 10 perform a full squat or to change direction
quickly when running without pain, a sense of the knee
collapsing. or a "popping" sensation. Displaced meniscal
tears can eventually lead to serious articular degeneration
with major impairment and disability. Such symptoms and
signs usualIy warrant surgical intervention.
Three surgical treatment choices are possible for the
athlete with a damaged meniscus: partial menisectomy,
meniscal repair. and meniscal transplantation. It was not
too long ago that the accepted surgical treatment for a torn MeniscaJr,
meniscus involved total removal of the damaged menis­ involves the use •
cus. However, total menisectomy has been shown to cause channels drilled if
premature degenerative arthritis. With the advent of the insertion of a '
arthroscopic surgery, the need for total meniscectomy has scopic surgery fo...
been virtually eliminated. rn surgical management of ated capsular
meniscal tears, every effort should be made to minimize complication s i
loss of any portion of the meniscus. Rehabilitati
The location of the meniscal tear often dictates transplant requi.fe.
whether the surgical treatment will involve a partial meni­ more prolonged ..;
sectomy or a meniscal repair. Tears that occur within the Athlete it is esse::
inner third of the meniscus will have to be resected be­ endurance con
cause they are unlikely to heal, even with surgical repair. period of immob
due to avascularity. Tears in the middle third of the menis­ rehabUitaUve bra
cus and, particularly, in the outer third. may heal well fol­ is perhaps the ill
lowing surgical repair because they have a good vascular The athlete is ~
supply. Partial menisectomy of a torn meniscus is much full extension for
more common than meniscal repair. to prevent fl exi
Rehabilitation Progressions. this period, there
Nonoperative management. If a consensus deci­ Submaximal iso
sion is made by the physician. the athlete, and the athletic formed in the bra
trainer to treat a meniscus tear nonoperatively, the athlete
may return to full activity as soon as the initial signs and
symptoms resolve. Rehabilitation efforts should be di­
rected primarily at minimizing pain and controlling
swelling in addition to getting the athlete back to func­
tional activities as soon as possible. Generally the athlete
may require 3 to 5 days of limited activity to allow for res­
olution of symptoms.
Partial menisectomy. Postsu.rgical management for
a partial menisectomy that is not accompanied by degener­
ative change or injury to other ligaments initially involves
controlling swelling, pain , and inflammation through the
use of cold, compression, and electrical stimulation. The
athlete should ambulate on crutches for 1 to 3 days, pro­
gressing to full weight bearing as soon as tolerated until re­
gaining full extension and walking without a limp or an
extension lag. Early pain-free range-of-motion exercises us­
ing knee slides on a treatment table (Figure 22-3), wall slides
(Figures 22-5), active assistive slides (Figure 22-4 and
22-6), and stationary cycling (Figure 22-35) can begin im­ strengthening ex
mediately along with quad sets (Figure 22-20) and straight mechanical im pac
leg raising (Figure 22-21), which are used to regain motor protocols for oth
control and minimize atrophy. As pain subsides and RO~I
improves, the athlete may incorporate isotonic open- and must be incorpora
closed-chain exercises (Figures 22-22). Functional activity Merriscal lra
training may begin as soon as the athlete feels ready. rt is not either a:JIogral't
uncommon in the athletic population for functional activity mended. 1 >.l 04 A ILrl
training to begin within 3 to 6 days after a partial menisec­ procedures have
tomy, although it is more likely that full return will require
about 2 weeks.

atment for a torn Meniscal repair. The repair of a damaged meniscus
damaged men is­ involves the use of absorbable sutures, vascular access
1 shown to cause
channels drilled from vascular to nonvascular areas, and
the advent of the insertion of a fibrin clot. Ii Rehabilitation after arthro­
leniscectomy has scopic surgery for a partial menisectomy with no associ­
management of ated capsular damage is rapid. and the likelihood of
lade to minimize complications is minimal.
Rehabilitation after either meniscal repair or menicus
,r often dictates transplant requires that joint motion be limited and thus is
,-ea partial meni­ more prolonged than for a partial menisectomy. For the
occur within the athlete it is essential that some type of cardiorespiratory
o be resected be­ endurance conditioning be incorporated throughout the
.h surgical repair. period of immobilization. Because of the limitation of the
hird of the menis­ rehabilitative brace. usc of an upper-extremity ergometer
may heal well fol­ is perhaps the most effective way to maintain endurance.
a good vascular The athlete is placed in a rehabilitative brace locked in
neniscus is much full extension for the first 2 wceks, both for protection and
to prevent flexion contractures (Figure 22-53). During
this period, there is partial weight bearing on crutches.
a consensus deci­ Submaximal isometric quad sets (Figure 22-20) are per­
:e. and the athletic formed in the brace along with hip abduction and adduc­
'atively. the athlete tion strengthening exercises (Figures 22-18,22-19).
Ie initial signs and For weeks 2 to 4. motion in the brace is limited to 20 to
1ft should be di­
90 degrees of flexion, and for weeks 4 to 6, motion is lim­
I and controlling
ited in the 0 to 90 degrees range. Hip exercises and isomet­
~ete back to func­
ric quad sets should continue. Range-of-motion exercises
nerally the athlete using knee slides (Figure 22-3), wall slides (Figure 22-5),
ity to allow for res­ and active assistive slides (Figure 22-4,22-6), should all be
done in the brace within the protected range. Partial
:al management for weight bearing on crutches should progress to full weight
bearing after 6 weeks.
Ipanied by degener­
I - initially involves At 6 wecks the brace can be removed and the knee re­
nation through the habilitation progressions described above may be incorpo­
al stinlUlation. The rated , as tolerated by the athlete, to regain full range of
:>r 1 to 3 days. pro­ motion and normal muscle strength. Generally the athlete
lS tolerated until re­
can return to full activity at about 3 months.
,thout a limp or an If an athlete has had an ACL reconstruction ,in addi­
Illotion exercises us­ tion to a meniscal repair. the healing constraints associ­
l re 22 -3). wall slide~ ated with meniscal repair must be laken into consideration
(Figure 22-4 and in the rehabilitalion plan JO , Range-of-molion exercises.
2-35) can begin im­ strengthening exercises, and weight bearing all have some
12-20) and straight mechanical impact on the meniscus. If the rehabilitation
(sed to regain motor protocols for other [,jgamenl injuries are more aggressive
~ subsides and ROi\! or accelerated, the guidelines for meniscus repair healing
~ isotonic open- and must be incorporated into the treatment plan.
I. Functional activity Melliscal transplant. Meniscal transplants using
~e feels ready. Itis not
either allografts or synthetic material have been recom­
or functional activity mended.3i.104 Although reports of the efficacy of these
ler a partial menisec- procedures have been inconsistent,23 generally the prefer­
I return will require ence seems to be an aiiograft using bone plugs and sutur­
ing to the capsule at the periphery of the graft.) 5 Mcnlscal
CHAPTER 22 Rehabilitation of Knee Injuries SS9
transplants are markedly less common than either meni­
sectomy or repair.
It is recommended that follOWing transplantation. a re­
habilitative brace be locked in full extension for 6 weeks.
The brace may be unlocked during this period to allow pas­
sive range-of-motion exercises in the 0 to 90 degrees
range. Isometric quad sets and hip exercises are performed
throughout this 6-week period. Also only partial weight
bearing on crutches is allowed.
At 6 weeks the brace is unlocked, and there should be
progression to full weight bearing. Use of the brace may be
discontinued at 8 weeks or whenever the athlete can
achieve full extension, flexion to 100 degrees, and a nor­
mal gait. 55 At that point progressive strengthening, range
of malian, and functional training techniques as described
previously can be ,i ncorporated when appropriate. Full ro­
turn is expected in 9 to l2 months.
Criteria for Return. Time frames required for full
return follOWing nonoperalive management, partial meni­
sectomy, meniscal repair, and meniscal transplant were
discussed previously. Generally, with meniscus injury, the
athlete may return to activity when (1) sll'eiling does not
occur with activity, (2) full ROM has been regained.
(3) there ,is equal bilateral strength in knee flexion and ex­
tension. and (4) the athlete can successfully complete
functional performance tests such as hopping, shuttle
runs, carioca, and co-contraction tests.
REHABILITATION TECHNIQUES
FOR PATELLOFEMORAL AND
EXTENSOR MECHANISM
INJURIES
Complaints of pain and disability associated with the
patellofemoral joint and the extensor mechanism are ex­
ceedingly common among the athletic population. The ter­
minology used to describe this anterior knee pain has been
a source of some confusion and thus requires some clarifi­
cation. At one time, it was not uncommon for every athlete
who walked into a sports medicine clinic complaining of
anterior knee pain to be diagnosed as having cOlldromalacia
patella. However, there can be many other causes of ante­
rior knee pain. and chondromalacia patella is only one 01
these causes. The term patellofemoral arthralgia is a catchall
term used to describe anterior knee pain. Chondromalacia
patella. along with patellofemoral stress syndrome, patellar
tendinitis, patellar bursitis, chronic patellar subluxation.
acute pateHar dislocation, and a synovial plica. are all con­
ditions that can cause anterior knee pain. The treatment
and rehabilitation of athletes complaining of anterior knee
560 PART THREE The Tools of Rehabilitation
pain can be very frustrating for the athletic trainer. The
more conservative approach to treatment of patellofemoral
pain described below should be used initially. If this ap­
proach fails. surgical intervention may be
required.
Patellofemoral Stress Syndrome
Pathomechanics. Athletes presenting with patel­
lofemoral pain typically exhibit relatively common symp­
toms. 33 They complain of nonspecific pain in the anterior
portion of the knee. It is difficult to place one finger on a
specific spot and be certain that the pain is there. Pain
seems to be increased when either.ascending or descend­
ing stairs or when moving from a squatting to a standing
position. Athletes also complain of pain when sitting for
long periods of time-this has occasionally been referred
to as the "moviegoer's sign ." Reports of the knee "giving
away" are likely. although typically no instability is associ­
ated with this problem. When evaluating the pathome­
chanics of the patellofemoral joint. the athletic trainer
must assess static alignment. dynamic alignment. and
patellar orientation.
Static alignment. Static stabilizers of the patel­
lofemoral joint act to maintain the appropriate alignment
of the patella when no motion is occurring (Figure 22-5 5).
The superior static stabilizers are the quadriceps muscles
(vastus latera lis, vastus intermedius, vastus medialis. rec­
tus femoris). Laterally. static stabilizers include the lateral
reHnaculum. vastus lateralis. and iliollbia;1band. Medially,
the medial retinaculum and the vastus medialis are the
static stabilizers. Inferiorly. the patellar tendon stabilizes
the patella .
Dynamic alignment. Dynamic alignment of the
patella must be assessed during functional activities. It is
Lateral retinaculum
Vastus lateralis .t r .~~ Medial retinaculum
,..._..
Vastus medialis
Iliotibial band
Figure 22·55 Static and dynamiC patellar stabilizers.
critical to look at the tracking of the patella from an ante­
rior view during normal gait. Muscle can trol should be ob­
served while the athlete engages in other functional
activities, including stepping. bilateral squats, or one­ Val~
legged squats. vee­
A number of different anatomical factors can affect fO!
dynamic alignment. It is essential to understand that both
static and dynamic structures must create a balance of
forces about the knee. Any change in this balance might
produce improper tracking of the patella and
paEeliofemoral pain.
Increased Q-angle. The Q-angle (Figure 22- 5 6) is formed
by drawing a line from the anterosuperior iliac spine to the
center of the patella. A second line drawn (rom the tibia]
tubercle to the center of the patella that intersects the first Figure 22-57
line forms the Q-angle. A normal Q-angle falls between 10 when the quadri
to 12 degrees in the male and 15 to 17 degrees in the fe­
male. Q-angle can be increased by lateral displacement of
the tibial tubercle, external tibial torsion, or femoral neck
anteversion. The Q-angle is a static measurement and
might have no direct correlation with patellofemoral
pain. 32 However. dynamically this increased Q-angle may
increase the lateral. valgus vector force. thus encouraging
lateral tracking. resulting in patella femoral pain 6l (Figure
22-57).
A-angle. The A-angle (Figure 22-58) measures the
patellar orientation to the tibial tubercle. It is created by
Figure 22-58
\
active electromvi
tion. In individ ual~
cally active, an
capabilities. 93 The
of the femoral nen
Figure 22-56 Measuring the Q-angle. gle motor uni t. :; ill
 CHAPTER 22 Rehabilitation of Knee Injuries 561

Ua from an ame­ lateralis (VL) ratio has been shown to be 1: 1.92 However. in
01 ho uld be ob­ indiv.iduals who complain of patellofemoral pain the
VMO:VL ratio is less than 1:1.
uats. or OO/"­ Val'gus Vastus lateralis. The vastus lateralis interdigitates with
vector . -........ fibers of the superflcial lateral retinaculum. Again. if this
tor can affec
force retinaculum is tight or if a muscle imbalance exists be­
. land that both
tween the vastus lateralis and the vastus medialis with the
ale a balance I
lateralis being more active, lateral tilt or tracking of the
balance might patella may occur dynamically. 32
patella and Excessive pronation. Excessive pronation may resullL
from existing structural deformities in the foot. With over­
2 2-56) is for:med pronation there is excessive subtalar eversion and adduc­
r ilia spine to the tion with an obligatory internal rotation of the tibia,
;n from the tibial increased internal rotation of the femur. and thus an in­
intersects the fi r l f'igure 22-57 A lateral valgus vector force is created creased lateral valgus vector force at the knee that encour­
e fall between 10
when the quadriceps is contracted. ages lateral tracking.39 Various structural deformities in
- degrees in the fe­ the feet that can cause knee pain should be corrected bio­
displacement 0 mechanically according to techniques recommended in
. or femoral neck Chapter 24 .
ea urement and Tight hamstring muscles. Tight hamstring muscles
th patellofemoraJ cause an increase in knee flexion. When the heel strikes
I'd Q-angle m a~ the ground, there must be increased dorsiflexion at the
Inferior
thus encouragin g pole ----;~~ talocrural joint. Excessive subtalar joint motion may occur
ra! pain o3 (Figure A angle to allow for necessary dorsiflexion. As stated prev,iously,
Tibial

this produces excessive pronation with concomitant in­

tubercle

.- ) measures he creased internal tibia.1 rotation and a resultant increase in

Ie. It is created by
Figure 22-58 Measurement of the A-angle.
the intersection of lines drawn bisecting the patella longi­
tudinally and [rom .the tibia 'l tubercle to the apex of the in­
ferior pole of the patella . An angle of 35 degrees or greater
has been correlated with pate'llofemoral pathomechanics,
resulting in patellofemoral pain. 4
Iliotibial band. The distal portion of the iliotibial band
interdigitates with both the deep transverse retinaculum
and the superficial oblique retinaculum. As the knee
moves into flexion, the iliotibial band moves posteriorly,
causing the patella to tilt and track laterally.3 J
Vastus medialis oblique insufficiency. The vastus medialls
oblique (VMO) functions as an active and dynamic stabi­
llzer of the patella. Anatomically it arises from the tendon
of the adductor magnus Y Normally, the VMO is tonically
active electromyographically throughout the range of mo­
tion. In indiv.iduals with patellofemoral pain, it is phasi­
cally active, and it tends to lose fatigue-resistant
capabilities 93 The VMO is innervated by a separate branch
of the femoral nerve; therefore it can be activated as a sin­
Igie. gle motor unit. s In normal individuals the VMO to vastus
the lateral valgus vector force.
Tight gastrocllemius muscle. A tigh t gastrocnemius mus­
cle will not allow for the 10 degrees of dorsiflexion neces­
sary for normal gait. Once again this produces excessive
subtalar motion , increased internal tibial rotation, and in­
creased lateral valgus vector force. l9
Patella alta. In patella alta, the ratio of patellar tendon
length to the height of the patella is greater than the nor­
mall: I ratio. In patella alta the length of the patellar ten­
don is 20 percent greater than the height of the patella.
This creates a situation where greater Ilexion is necessary
before the patella assumes a stable position within the
trochlear groove, and thus there is an increased tendency
towar!ilateral sub'luxation. s3
PateUa baja is a condition in which the patel1a lies infe­
rior to the normal pOSition and may also restrict knee flex­
ion range of motion. Knee injuries (e.g. , patellar tendon
rupture, ACL reconstructions using quadriceps tendon)
may cause a patella baja ·c ondition. Aggressive joint mobi­
!\ization and soft-tissue manipu1lation is important to
prevent these conditions from occurring postinjury.
Strengthening exercises are also necessary to establish in­
creased patellar stabilization dur,i ng range of motion.
Patellar orientation_ Patellar orientation is the po­
sitioning of the patella relative to the tibia. Assessment
562 PART THREE The Tuols of Rehabilitation

REHABILIT A TION PLAN

PATELLOFEMORAL PAIN IN A HIGH SCHOOL
knee pain. Videolai
VOLLEYBALL PLAYER
activities . Tbe ath
game demands lh
INJURY SITUATION i\ 16-year-old high school female volleyball player complains or pain in her left anterior knee. She has insert. It may be n
been experiencing this pain for several weeks. At first. pain was present only during and immediately after practice, but season and possib' .
lately her knee seems Lo ache all the time. Her pain has increased to the point where she now CRITERIA FOR I
has dilTiculty compleling a practice session. 1. Pain is c1im.ina
2. There is good
SIGNS AND SYMPTOMS The athlete complains of pain in the anterior aspect of the knee while
3. QuadriccpsstT,
walking, running, ascend.ing and descending stairs, or squalling. Pain is increased during the
4 . Core stability
patellar grind test. During palpation there may be pain on the inferior border of the patella or
5. Biomechan ica
when the patella is compressed within the femoral groove while the knee is passively flexed
6. The ath'l ete f4
and extended. She has tightness of the hamstrings, an increa sed Q-angle, excessive pronation
DISCUSSION Q
in her left foot, and weakness in her vastu s medialis obliques (VMOs).
1. What other faL
MANAGEMENT PLAN The goal is to reduce pain initially and then identify and correct faulty 2. What therape
biomechanics thai may collectively con tribute to her anterior knee pain. 3. Describe th e c
4. WiI'! m edi cal
PHASE O NE AClJTE INFL,\MMATORY STACE 5. Explain th t' \! < ~
GOALS: Modulate pain and begin appropriate st.rengthening exercises
Estimated Length of Time (ELT): Day 1 to Day 4
Use ice and electrical stimulation to decrease pain. II' there appears to be inflammation, anti-inflammatory medications
may be helpful. McConnell taping should be used 10 try to correct any patellar malalignment th at may exist The athlete
may need to be restri cted from practice for a few days: at least reduce th e amount of lower-extremity activity, which ma~
should be done II
be exacerbating her condition. ;\n ortl10tic in sert should be constructed to correct any excessive pronation during gait.
components ShOll
Quadriceps strengthening should begin with isometric exercises using quad setting. short arc motions, and complete
orientation: glide.
range-of-motion exercises from 90 degrees of f1exion to full extension . None of the isometric exerciscs shou1ld increase
Glide cOl11pont'r'
her pa.in level; if they do , they should be eliminated and pain-free exercises should be incorporated.
medial deviat ion
PHASE TWO FIBROBLASTIC-REPAIR STi\(~E groove of the fem
GOALS: fn Crl!3Se VMO strength and improve hamstring flex,ibility
:ally and dyn ami
Estimated Length of Time (ELT): Days 5 to 14
of a positive latera..
Ice and electrical stimulation may be continued. McConnell taping technique should also be continued with clay-to-da',
Tilt cOmpOlll'1ll
reassessment of its effectiveness. Biofeedback may help the athlete learn to contract the VMO beller. The effectiveness of
height of the moo
the orthotic should be reassessed, and appropriate correction adjustments should be made. Aggressive hamstring­
la r border. Figure
stretching exercises should be used. Quadriceps strengthening should conce ntrate on V1VfO activation and progress frou:
a teral tilt.
isometrics to full-range isotonics as soon as full-range-of-motion resisted exercise no longer causes pain. Closed-kinetic­
Rotational CO/II,
chain exercises, particul a rly minisq,uats and step-ups, shou ld be recommended. The athlete may resume practice, but
ing the deviation
activiiil!S that seem to increase pain should be modit1ed or replaced with alternative activities. Functional activities th ai
[ro m superior pole t,
emphasi%c core stability (thi'gh, trunk, and hip musculature) should be emphasized once pain-free activities are con­
l he femur. The pOin
ducted. Fitness levels must be maintailled using stationary cycHng, aq,uatic exercises, or other nonballislic types of aer
. ferior pole is mon
bie exercise that do not increase kn ee pain.

Allteroposteri(lr
I PHASE THREE IVIATlIRJ\TfON-REMODELINC STACE a teraJIy to determ­
GOALS: Complete elimination of pain and full return to activity patellar pole to the
Estimated Length of Time (ELT): Week 3 to FuU Return
The athlete should be gradually weaned form !\1cCon neJI taping. It may be helpful for the alhlcte to wear a neopren e
sleeve during ac tivity for jOint warming and psychological support. The athlete should be observed and monitored
closely prior to fuJI return to play, 10 evaluale any biomechanical deformities in technique tbat may contribute to her
 CHAPTER 22 Rehabilitation of Knee Injuries 563

R E H A B I LIT A T ION P LAN (CONT'DI

knee pain. Videotape replay may be useful for gait analysis consisting of walking, running. pivoting, and jump-landing
activities. The athlete must continue her strengthening and flexibility routine. taking into consideration any practice or
game demands that may impose too much of an overload. The athlete should now be fully accustomed to the orthotic
rior knee. She h a_ insert. It may be necessary to continue to use alternative fitness activities that reduce the strain on her knee during the
afler practice. but season and possibly indefinitely.
CRITERIA FOR RETURNING TO COMPETITIVE BASKETBALL
1. Pain is eliminated in squatting and in ascending or descending stairs.
2. There is good hamstring flexibility.
3. Quadriceps strength is good. especially the VMO.
4. Core sta bility (thigh, trunk, and hip musculature) strength is good.
5. Biomechanical gait techniques arc good.
6. The athlete feels ready to return to play and has regained confidence in the injured knee.
DISCUSSION QUESTIONS
1. What other factors can potentially contribute to patellofemoral pain?
2. What therapeutic modalities might potentially be used to control pain?
3. Describe the characteristics of the orthotiC that might be used to correct excessive pronation.
4. Will medications help in managing this problem?
5. Explain the McConnell taping technique that would likely be used to correct this problem .

alOry medications
. exist. The athlete
lCtivity. which ma~ should be done with the athlete in supine position. Four
alioo during gail. components should be assessed when looking at patellar
.. an d complete A
orientation: glide, tilt, rotation, and anteroposterior tilt.
- -hould increase
Glide component. This component assesses the lateral or
medial deViation of the patella relative to the trochlear Medial Lateral
groove of the femur. Glide should be assessed both stati­
cally and dynamically. Figure 22-59 provides an example
of a positive lateral glide. B
Tilt component. Tilt is determined by comparing the
:=d with day-to-day
height of the medjal patellar border with the lateral patel­
he effectiveness of
lar border. Figure 22-60 shows an example of a positive
h amstring- Figure 22-59 Positive lateral glide. A, Normal posi­
lateral till.
r. a nd progre.ss from
Rotatiollal component. Rotation is identified by assess­
tioning, B, Positive lateral glide component.
UrI. Closed-kmctlc­
ing the deviation of the longitudinal axis (a line drawn
une practice, but

~
from superior po'le to inferior pole) of the patella relative to
na l activities that
the femur. The point of reference is the inferior pole. If the A
ivit ies arc con­
inferior pole is more lateral than the superior pole, a posi­
llii. tic types of aero­
tive external rotation exists (Figure 22-61).
Anteroposterior tilt component. This must be assessed Medial Lateral
laterally to determine if a llne drawn from the inferior
~
~I
patellar pole to the superior patellar pole is parallel to the B
long axis of the femur. If the inferior pole is posterior to the
"ear a neoprene

d monitored
Figure 22-60 Positive lateral tilt. A, Normal position­
ontribulc to her
ing, B, Positive lateral tilt component.
564 PART THREE The Tools of Rehabilitation

Rehabilit adol
chain exercises li
tact. With closed
knee flexion clem
_ Patellofemoral knee increases. n
£ LJl I. joint reaction lar tendon tensi<
A B force creased fleXi on rr
PFJRF as flexi on
uted over a larger
the increase in C(Y.
pears that closed­
era ted by the pale
exercises.
Normal External rotation Closed-kineuL'
Figure 22-63 Patellofemoral joint reaction forces
Figure 22-61 Positive external rotation. A. Normal po­ (PFJRF). in Chapter 1 2. I,.. .
sitioning. B. Positive external rotation. minisquats from
from 0 to 60 de
an 8-inch step tn~
Superior
22-34), a stationlL
cises (Figure 21-3':
amples of clo
that may be used
Regaining II
tracking. TW,
A B Lateral Medial proach is based
pist, Jenny McC
by stretching the
lar orientation. an
\1NIO contraction.
St retching.
Normal Positive AlP sign
figure 22-64 Compression force and contact stress. structures im'oh
Figure 22-62 Positive inferior anteroposterior tilt. Even though compression forces increase wiLh increasing
A. Normal positioning. B. Positive inferior knee flexion , the amount of contact stress per unit area
anteroposterior tilt component. decreases.

superior pole. the athlete has a positive anteroposterior tilt
component (Figure 22-62).
Rehabilitation Concerns. Traditionally, rehabili­
tation techniques for athletes complaining of
patellofemoral pain tended to concentrate on avoiding
those activities that exacerbated pain (for example, squat­
ting or stair climbing), occasional immobilization, and
strengthening of the quadriceps group using open­
kinetic-chain exercises. The current treatment approach
has a new direction and focus that includes strengthening
of the quadriceps through closed-kinetic-chain exercise,
regaining optimal patellar positioning and tracking, and
regaining neuromuscu:ar control to improve lower-limb
mechanics.
Strengthening techniques. Earlier in this chapter,
closed-kinetic-chain exercises were recommended for
strengthening in the rehabilitation of ligamentous knee
injuries. These same exercises are also useful in the reha­
bilitation of patello(emoral pain, not because anterior
shear is reduced but because of how they affect
patellofemoral jOint reaction force (PFJRF).
More traditional rehabilitation techniques focused on
reducing the compressive forces of the patella against the
femur and reducing PFJRF. PFJRF increases when the an­
gIe between the patellar tendon and the quadriceps tendon
decreases (Figure 22-63). PFJRF also increases when the
quadriceps tension increases to resist the flexion momen t l·omparison .
created by the lever arms. PFJRF can be minimized by max­ It should be
imizing the area of surface contact of the patella on the fe­ plain of patellofem
mur. As th e knee moves into greater degrees of flexion, the entation compon
area of surface contact increases, distributing the force orientation can be L
assOCiated with increased compreSSion over a larger area Correction of patel
(Figure 22-64), minimizing the compressive forces per plished by using p
unit area. 38 mechanically corr.
 CHAPTER 22 Rehabilitation of Knee Injuries 565

Rehabilitation techniques involving closed-kinetic­

chain exercises try to max,imize the area of surface con­
tact. With closed-kinetic-chain exercises, as the angle of
knee flexion decreases, the flexion moment acting on the
)"loral
knee increases. This requires greater quadriceps and patel­
lion lar tendon tension to counteract the effects of the in­
creased flexion moment arm, resulting in an increase in
PFJRF as flexion increases. However, the force is distrib­
uted over a larger patellofemoral contact area, minimizing
the increase in contact stress per unit area. Therefore it ap­
pears that closed-kinetic.-chain exercises may be better tol­
erated by the patellofemoral joint than open-kinetic-chain
exercises.
Closed-kinelic-chain exercises were discussed in detail M
.':lion forces
in Chapter 12. In the case of patellofemoral rehabilitation,
minisquats from 0 to 40 degrees (Figure 22-25), leg press
from 0 to 60 degrees (Figure 22-29), lateral step-ups using
an 8-inch step (Figure 22-30), a stepping machine (figure
22-34), a stationary bike (Figure 22- 35), slide board exer­
cises (Figure 22- 32), and a Fitter (Figure 22-33) are aU ex­
amples of closed-kinetic-chain strengthening exercises
that may be used in patellofemoral rehabilitation.
Regaining optimal patellar positioning and
tracking. This second: goal in our current treatment ap­ Figure 22-65 Application of base tape.
Medial proach is based on the work of an Australian physiothera­
pist, Jenny McConnell .17.74 This goal can be accomplished
by stretching the tight lateral structures, correcting patel­ the orientation of the patella, the tape provides a pro­

) lar orientation, and improving the timing and force of the

VMO contraction.
longed stretch to the soft-tissue structures that affect patel­
lar movement.
Stretching. Successfully stretching the tight lateral Taping should be done using two separate types of highly
structures involves a combination of both active and pas­ adhesive tape available from several different manufactur­
sive stretching techniques. Active stretching techniques ers. A base layer using white tape is applied directly to the
with increasing skin from the lateral femoral condyle to just posterior to the
per unit area include mobilization techniques as discussed in Chapter
14. Specific techniques should involve medial patellar medial femoral condyle, making certain that the patella is
glides and medial patellar tilts along the longitudinal axis completely covered by the base layer (Figure 22-65) . This
of the patella (see Figure 14-58). Passive stretch is accom­ tape is used as a base to which the other tape is adhered to
useful in the reha­
plished through a long-duration stretch created by the use correct patellar alignment. The glide component should al­
~ because anterior
of very speCific taping techniques to alter patellar align­ ways be corrected frrst, followed by the component found to
how they affect
ment and orientation. be the most excessive. If no positive glide exists, begin ",rjth
).
Correcting patellar orientation. After a thorough assess­ the most pronounced component found.
~ niqlles focused on
ment of patel ofemoral mechanics as described earlier, the The glide component should always be corrected with
patella against the
sports therapist should have the athlete perform an activ­ the knee in full extension. To correct a positive lateral glide,
ases when the an­
ity that produces patellofemoral pain, sl1ch as step-ups attach the tape one thumb's breadth from the lateral patel­
~ quadriceps tendor:
or double- or single-leg squats to establish a baseline for lar border, push the patella medially, gather the soft tissue
crcases when the
comparison. over the medial condyle, push toward the condyle, and ad­
the flexion momen:
It should be stressed that not all individuals who com­ here to the medial condyle (Figure 22-66).
minimized by max­
The tilt component should be corrected with the knee
~e pa tell a on the fe­ plain of patellofemoral pain exhibit a positive patellar ori­
entation component. In athletes who do, patellofemoral flexed 30 to 45 degrees . To correct a positive lateral tilt,
:grees of flexion, th c­
orientation can be corrected to some degree by using tape. from the middle of the patella pull medially to lift the lat­
ib uting the force·
Correction of patellar positioning and tracking is accom­ eral border. Again , gather the skin underneath , and ad­
n over a larger area
plished by using passive taping of the patella in a more bio­ here to the medial condyle (Figure 22-67).
~p ressive forces per
mechanically correct pOSition. In addition to correcling
566 PART THREE The Tools of Rehabilitation

One piece of j
\ simultaneously. ~
"" along with ao at
" taping procedlln!

I
~ L
tape should be ~
After this ta
I
reassess the aeil
many cases the ~
n

..

~~~
immediatelv.
~ •
If I
palella is taped m

\ '\ l'.\~\
tape should be"
lelic trainer sh
and tighten the
It is importa
M forces acting on
, --- f knee jOint. Tapiu

\
eral pull on the
in the force and'
result in altera u,
Interestingly. a
patellar tapiog r,
Figure 22-68 Taping to correct positive external
pain, but radi og
rotation.
vealed no change
Figure 22-66 Taping to correct positive lateral glide. rotational aogles.
socia ted with
Reestablis' .
\
\
,
""

+ M
As mentioneu
should be 1:1. [n.
than 1:1 with pa
focus on select!
training the VMO
, part of the at h!
\
\ manually stroking:
\ back. are reco
biofeedback un it c
electromyographie
Figure 22-69 Taping to correct positive inferior an­ romuscular conlT
Figure 22-67 Taping to correct positive laterallile. teroposterior tilt. timing for the firin
The VMO is a
patella both static
The rotational component is corrected in 30 to 40 To correct a positive anteroposterior inferior tilt. tive throughout th
degrees of flexion. To correct a positive external rota­ place the knee in full extension. Adhere a 6-inch strip of be directed toward
tion, from the middJe of the inferior border puLl upward tape over the upper half of the patella, and press directly traction both cone,
and medially whilc rotating the superior pole externally posterior, adhering wilh equal pressure 00 bolll side the range of moli
(Figurc 22-68). (Figure 22-69) . ductor magnus ten

One piece of tape can be used to correct two components
simultaneously. For example, when correcting a lateral glide
along with an anteroposterior inferior tilt, follow the same
taping procedure for the glide component except that the
tape should be applied to the upper half of the patella.
After this taping procedure, the athletic trainer should
reassess the activity that caused the athlete's pain. In
many cases the athlete will indicate improvement almost
immediately. rf not. the order of the taping or the way the
patella is taped may have to be changed considerably. The
tape should be worn 24 hours a day initially. and the ath­
letic trainer should instruct the athlete in how to adjust
and tighten the tape as necessary.
It is important to understand that taping changes the
forces acting on the patella and thus the kinematics of the
knee joint. Taping essentially attempts to decrease the lat­
eral pull on the patella. When combined with an increase
in t.he force and liming of the VMO contraction, this will
result in alteration of the balance of forces on the patella.
Interestingly, a study by Bockrath et al. demonstrated that
patellar taping reduced pain in patients with anterior knee
\e xternal pain, but radiographic studies before and after taping re­
vealed no change in patellolemoral congruency or patellar
rotational angles. Hence the reduction in pain was not as­
sociated with positional change of the patella. 10
Reestablishing neuromuscular control. Establish­
ing neuromuscular control involves improving the timing
and force of VMO contraction. It is perhaps most ,i mportant
for the athletic trainer to emphasize the quality rather than
the quantity of the contraction .This means that training the
VMO should concentrate more on motor skill acquisition
than on strengthening activities. Strengthening shoulcl oc­
cur concomitantly with improvement in motor skill.
As mentioned previously the VMO:VL strength ratio
should be 1:1. rn athletes who have a VMO:VL ratio of less
than 1:1 with patellofemoral pain, training efforts should
focus on selectively strengthening the VMO. rsolating and
training the VMO selective'ly requires concentration on the
part of the athlete. Techniques of facilitation, such as
manually stroking or taping the VMO or the use of biofeed­
back, are recommended. The use of a dual-channel
biofeedback unit capable of monitoring both VMO and VL
electromyographic activity can help the athlete gain neu­
romuscular control over both the force of contraction and
ilive inferior an­
timing for the firing of the VMO.
The VMO is a tonic muscle that acts to stabilize the
patella both statically and dynamically, so it should be ac­
lerior inferior ttlt tive throughout the range of motion. Training goals should
e re a 6-inch strip be directed toward increasing the force of the VMO con­
la . and press directl. traction both concentrically and eccentrically throughout
ure on both sid ­ the range of motion. Because the VMO arises from the ad­
ductor magnus tendon, adduction exercises may be used to
CHAPTER 22 Rehabilitation of Knee Injuries 567
facilitate VMO contraction. 'rhe VMO should be trained to
respond to a new length-tension relationship between the
agonist (VMO) and the antagonist (VL).
Several sources have indicated that the VMO has a sep­
arate nerve supply from the rest of the quadriceps, al­
though this is in our opinion somewhat debatable.4.12.JO
Nevertheless, assuming this is the case, then the athlete
should be taught to nre the VMO before the V1. Neuro­
muscular control of the VMO firing should help the athlete
maintain appropriate patellar alignment.
VMO exercises should concentrate on controlling the
fIring of the VMO. Exercises should be performed slowly
and with concentration to selectively activate muscles. The
sports therapist should address concentric and eccentric
control in a variety of functional tasks and positions. Min­
isq uats, step-ups or step-downs, and leg presses are good
exercises lor establishing concentric and eccentric control.
Training on a BAPS board DynaDisc, Bosu Ba'Iance Trainer,
or Extreme Balance Board (see Figures 8-20 through 8-25
and Figure 22-43) is useful for proprioceptive training. It is
extremely important to concentrate on VMO control dur­
ing gait-training activities.
Criteria for Return, Taping should continue
throughout the V1'1O training period. Again, tape should
initially be worn 24 hours a day. The athlete may be
weaned from tape progre~sively when he or she demon­
strates VMO control. Examples of functiona l criteria for
weaning would be when the athlete can keep the VMO ac­
tivated for 5 minutes durIng a walking gait and when the
athlete can fire the VMO either before or simultaneously
with the vastus lateralis consistently in step-downs for 1
minute. At this point, tape may be left off every third day
for 1 week, then every second day for 1 week, then worn
only during activity. and finally worn only if pain is pres­
ent. Taping can be eliminated altogether when the athlete
can perform step-downs for 5 minutes wHh appropriate
timing and when she or he can sustain a quarter to a half
squat for 1 minute without VMO loss.
Chondromalacia Patella
Pathomechanics and Injury Mechanism, Chon­
dromalacia patella can occur either as a consequence of
patellofemoral stress syndrome or from a direct impact to
the pate'lla. It is a softening and deterioration of the artic­
ular cartilage on the back of the patella that has been de­
scribed as undergoing three stages: swelling and softening
of the articular carti'lage, nssuring of the softened articu­
lar cartilage, and deformation of the surface of the articu­
lar cartilage caused by fragmentation. IS
The exact cause of chondromalacia is unknown. As
indicated previously, abnormal patellar tracking could be a
568 PART THREE The Tools of Rehabilitation

major etiological factor. However, individuals with normal Criteria for Return, As lo ng as the athlete can tol­ knee may be
track ing have acquired chondromalacia, and some indi­ erate the pain and discomfort that occurs with chondro­ swelling but also r
viduals with abnormal tracking are free of it. ll malacia patella , they ca n continue to train and compete. has been strei ch
The athlete may experience pain in the anterior aspect Again the key is essentially to "play games" with this con­ swelling the kn
of the knee while walking, run n ing, ascending and de­ dition, training normally when there is no pain and back­ There may also ~
scending stairs, or squatting. There may be recurrent ing off wben the knee is painful. tubercle wh ere tt>
swelling around the kneecap and a grating sensation ligament) attache'
when l1exing and extending the knee. There may also be Acute patellar
crepitation and pain during a patellar grind test. During CLINICAL DECISION MAKING Exercise 22-5
foot is planted a~
palpation there may be pain on the inferior border of the on the medial su
patella or when the patella is compressed within the A triathlete has been complain ing of knee pain for several
months. She has 110 previous history of a knee injury, but
Ilaterally. The a
femoral groove while th e knee is passively l1exed and ex­ episode. The ath
tended. Degenerative arthritis occurs on the lateral facet of her training regimen is intense. invoh'ing 3 hours of
training each day. A physician diagnosed her with chon­
function , pain . a
the patella, which makes contact with the femur when the in an abnormal
athlete performs a full squaL l1 Degeneration first occurs in droma lacia patella. She has been referred to the athletic
mediately red uc!'
the deeper portions of tb e articular cartilage. followed by trainer for evaluation and rehabiUtation. What can the
athlelic trainer do to help reduce the athlete's symptoms
sure on the patel
blistering and fissuring that stems from the subchondral possibLe. If a per
bone and appears on the surface of the patella.)] ·15 and signs?
a general a nCSlh
Rehabilitation Concerns. Chondromalacia patella of the joint hema'
is initial'ly treated conservatively USing the same rehabilita­ mobilized. A flI"s'­
tion plan as was described for patellofemoral stress syn­ associated with _
drome. 73 If conservative measures fail to help, surgery may Acute Patellar Subluxation chondral fracture
be the only aJternative. Some of the follOwing surgical or Dislocation Thus some p hy~
measures have been recommended: ll realignment proce­ lioll follOWing pa.
dures such as lateral release of the retinaculum; moving Pathomechanics. The pateHa, as it tracks superi­ Rehabilitati
the insertion of the vastus medialis muscle forward; shav­ orly and inferiorly in the femoral groove, can be subject to Chronicpa
ing and smoothing the irregular surfaces of the patella direct trauma or degenerative changes, leading to chronic chronically su bl
and/or femoral condyle; in cases of degenerative arthritis, pain and disability.4 ~ Of major importance among athletes each of the poten
removing the lesion through drilling; elevating the tibial are those conditions that stem from abnormal patellar dividually or coli
tubercle; or, as a last resort, completely removing the tracking within Lhe femoral groove. Improper patellar
patella. tracking leading to patellar subluxation or dislocation can
Rehabilitation Progression. Chondromalacia resu'it from a number of biomechanical factors, including
patella is a degenerative process that unfortunately does femoral anteversion wit.h increased internal femoral rota­
not tend to get better or resolve with time. There are times tion ; genu valgum with a concomitant ,i ncrease in the
when the knee is painful and other times when it feels all Q-angle: a shallow femoral groove: rIat lateral femoral stress to the pate
right. Perhaps the key to managing chondromalacia is to condyles; patella afta ; weakness of the vast us medialis Particular altt;
maintain strength of the quadriceps muscle group and in muscle relative to the vast us lateralis: ligamentous laxity the quadriceps t
particular the VMO. Closed-chain exercises are recom­ with genu recurvatum; excessive external rotation of the strengthening th
mended because they tend to decrease the patellofemoral tibia; pronated feet: a tig.ht lateral retinaculum; and a adductors (['igun.
joint reaction forces. The athlete must be consistent in patella with a positive lateral tilt. Each of these factors was 22-24); streteilln
these strengthening efforts. discussed in detail earlier in this chapter. binalion of palelJ
Irritating activities that tend to exacerbate pain, such Injury Mechanism. When the athlete plants the and medial pat ellar,
as stair climbing, squatting. and long periods of sitting, foot. decelerates, and Simultaneously cuts in an opposite patella as well as 5
should be avoided. Isometric exercises or closed-chain iso­ direction from the weight-bearing foot. the thigh roUltes 22-10) and biceps
tonics performed through a pain-free arc to strengtben the internally while the lower leg rotates externally, causing a recling patellar oli
quadriceps and hamstring muscles should be routinely forced knee va lgus. The quadri ceps muscle attempts to pull eular control by .
done. The use of oral a nti-inflammatory agents and small in a straight line and as n result pulls the patella laterally. VMO contraction.
doses of aspirin may help to modulate pain. Wearing a creating a force that can su blux the patella. As a rule, dis­ If the athlet e d
neoprene knee sleeve helps certain athletes but does ab­ placement takes place laterally, wilh the patella sh ifting the athletic train~
solutely nothing for others. Use of an orthotic device to over the lateral condyle. subluxation rema.·
correct pronation and reduce tibial torsion is helpful in A chronically subluxing patella places abnormal stres vention may be n
many instances. on the patellofemoral joint and the medial restraints. 'r hl' the lateral relinacw

knee may be swollen and painful. Pain is a result of
swe'lling but also results because the medial capsular tissue
has been stretched and torn. Because of the associated
swelling the knee is restricted in nexion and extension.
There may also bc a palpable tenderness over the adductor
tubercle where the medial retinaculum (patellar femoral
ligament) attaches.
Acute patellar dislocation most often occurs when the
ERn:ise 22-5
foot is planted and there is contact with another athlete
on the medial surface of the patella. forcing it to dislocaLe
laterally. The athlete reports a painful "giving way"
episode. The athlete experiences a complete loss of knee
function. pain. and swelling. with the patella remaining
in an abnormar lateral position. A physician should im­
mediately reduce the dislocation by applying mild pres­
sure on the patella with the knee extended as much as
possible. If a period of time has elapsed before reduction.
a general anesthetic may have to be used. Arter aspiration
of the joint hematoma. ice is applied. and the joint is im­
mobilized. A first-time patellar dislocation is sometimes
associated with loose bodies from a chondral or osteo­
chondral fracture as well as articular cartilage lesions.
Thus some physicians advocate arthroscopic examina­
tion following patellar disiocation Y7
Rehabilitation Progression.
Chronic patellar subluxation_ Rehabilitation for a
ding tochr
chronically subluxing patella should focus on addressing ued. the athlete should wear a neoprene knee sleeve with a
-e among atWe
each of the potentia:! biomechanical factors that either in­ lateral horseshoe-shaped felt pad thaL helps the patella
bn r mal patel
r dividually or collectively contribute to the pathomechan­ track medially (Figure 22-70). This support should be
Improper patel r ics. It is important to regain a balance in strength of all
or dislocation Ca!" musculature associated with the knee joinl. Postural
facto r. includin=o malalignments must be corrected as much as possible.
nal r moral rota­ Shoe orthotic devices may be used to reduce foot pronation
1 inc rease in lh and tibial ,i nternal rotation. and subsequently to reduce
al lateral fem or stress to the patellofemoral joint.
e a tus media\' Particular attention should be given to strengthening
ligamentous la:";l_ the quadriceps through closed-kinetic-chain exercises;
nal rotation of lh . strengthening the hip abductors (Figure 22-] 8). hip
-elinaculum: a nd adductors (Figure 22-19). and gastrocnemius (Figure
of these factors \\"a 22-24); stretching the tight lateral structures using a com­
r. bination of patellar mobilization glides (see Figure 14-51\)
athlete plants the and medial patellar ti.lts along the longitudinal axis of the
ru ts in an opp il
patella as wei! as stretching for the iliotibial band (Figure
L the thigh rotal ­ 22-10) and biceps femoriS (Figures 22-13. 22-14); cor­
~uer nally. causin g recting patellar orientation; and establishing neuromus­
scle attemDts to pu.. cular control by improving the timing and force of the
the patella latera U~ ViVlO contraction.
lelia. As a rule. di. · If the athlete does not respond to extensive efforts by
Lhe patella shulio::­ the athletic trainer to correct the pathomechanics and
subluxation remains a recurrent problem. surgical inter­
c s abnormal stre' vention may be necessary. However. a surgical release of
edial restraints. The the lateral retinacular ligaments does not appear to be a
CHAPTER 22 Rehabilitation of Knee Injuries 569
particularly effective procedure and should be done only
after fa ilure of more conservative treatment.
Acute patellar dislocation_ In th e case of acute
patellar dislocation. following reduction the knee should
be placed in an immobilizer immediately. and it is recom­
mended that it remain in place for 3 to 6 weeks with the
athlete ambulating on crutches until rega ining full exlen­
sion and walking without an extension lag. The athlete
can begin immediately follOWing Lhe dislocation with iso­
metric quad sets (Figure 22-20) and straight leg raising
(Figure 22-21). always paying close attention to achieving
a good contraction of the VJ\llO. Early pain-free range-()f~
motion exercises including knee slides on a treatment table
(Figures 22- 3). waH slides (Figures 22-5). or active ass is­
tive slides (Figures 22-4 and 22-6) can be used.
As pain subsides and ROM improves. the athlete should
incorporate closed-chain strengthening exercises (Figures
22-25 through 22-35) to minimlze stress on It he
pateUofemoral joint. Strengthening shoul.d be directed to­
ward increasing the force of the VMO contraction both
concentrically and eccentricaUy throughout the range of
motion . Neuromuscular control of the VMO firing should
help the athlete maintain appropriate patellar alignment.
It is also important to concentrate on VMO control during
gait-training activities.
After 3 to fJ weeks when immobilization is diseontiIl­
worn while running or performing in sports.
Criteria for Return. The athlete should have good
quadriceps strength and shou'ld be able to demonstrate
VMO control during functional activities. Examples of
functional criteria would be when the athlete ca n keep the
VMO activated for 5 minutes during a walking gait and
when the athlete can nre the VMO either before or simulta­
neously with the vastus lateralis consistently in step-downs
for 1 minute. The athlete should be able to perform step­
downs for 5 minutes with appropriate {iming and sustain a
quarter to a half squat for 1 minute without VMO loss.
Patellar Tendinitis (Jumper's Knee)
Pathomechanics and Injury Mechanism.
Jumper's knee occurs when chronic inl1ammation devel­
ops in the pate'flar tendon either at the superior patellar
pole (usually ref'erred to as quadriceps tendinitis ). the tib­
ial tuburcle. or most commonly at the distal pole of' the
patella (patellar tendinitis). It usually develops in athletes
involved in activities that require repetitive jumping;
hence the name. Point tenderness on the posterior aspect
of the inferior pole of the patella is the hallmark of patellar
570 mRT THREE The Tools of Rehabilitation
Figure 22-70 A brace that can help limit patellar dis­
location and/ or sublux[Jtion should h[Jve a felt horseshoe
applied laterally.
tendinitis . This condition is fell to be related to the shock­
absorbing function (an eccentric contraction) that the
quadriceps provides upon landing from a jump. Initially
the athlete complains of a dull [Jching pain after jumping
or running following repetitive jumping activities. Pain
usuaUy dis[Jppears with rest but returns with activity. Pain
becomes progressively worse until the athlete is unable to
continue. There are also reports of difnculty in stair climb­
ing and un occasional feeling of "giving way."
Reha bilitation Concerns. Because jumper's knee
involves a chronic innammation. rehabilitation strategies
may ta ke one of two courses. The athletic trainer may
choose to use traditional techniques designed to reduce
the infiammaUon. which include rest. anU-innammaLory
mediC<.ltiol1. icc. and ultrasound. Another. more aggressive
approa ch would be to usc a transverse friction massage
technique designed to exacerbate tbe acute inflammation.
so tbat the healing process is no longer "stuck" in the
inflammatory-response phase a_nd can move on to the
l'ibrobl astic-repair phase. The technique involves a 5- to
'I-minute friclion massage at the inferior pole of the patella
in a direction perpendicular to the direclion of the tendon
llbers. performed every other day for approximately 1
week. During this treatment. all other medicative or
modality efforts to reduce inflammation should be elimi­
nated. It is our experience that if pain is not decreased af­
ter 4 or 5 treatments it is unlikely that this technique will
resolve the problem.
Ruptures of the patellar tendon are rare in young ath­
letes but increase in incidence with age. A sudden power­
fu l contraction of the quadriceps muscle with the weight
of th e body applied to the affected leg can cause a rupture
uf the patellar tendon. 112 The rupt ure may occur to the
quadriceps tendon or to the patellar tendon. Usually rup­
ture docs not occur unless there has been a prolonged pe­
riod of innammation of the patellar tendon that has
weakened the tendon. Seldom docs a rupture occur in tbe
middle of the tendon: usually the lendon is torn from its at­
tachment. The quadriceps tendon ruptures from the supe­
rior pole of the patella. whereas the patellar tendon
ruptures from the inferior pole of the patella . A rupture of
the patellar tendon usually requires surgical repair.
Rehabilitation Progression. Regardless of which
of the two treatment approaches is used. once the problem
begins to resolve. the athlete should engage in a thorough
warm-up prior to activity. Initially. jumping and running
activities should be restricted. Strengthening of the quadri­ Figure 22-71
ceps is critical, during rehabilitaLion. Success has been re­ lete muving sl o\\ .
porLed using eccentric strengthening exercises for both the return.
quadriceps and th ~ ankle dorsiflexorsY·iH.77 Curwin and
Stanish have th eorized that (1 graded program of eccentric
stress wilL stimulate the tendon to heal. 22 They feel that rest tendinitis (Fig ure
does not stimuJate healing. while low- to moderate-level ec­ of this strap in n
centric exercise will. Their program consists of five parts: another.
warm-up. stretching. eccentric squatting. stretching. and Injection of (
ice. (d2 The eccentric squats. called drop squats. are per­ l1ammat ioll is n
formed with the athlete moving slowly from standing to a weaken the ten dt:~
squat position and return. To increase stress. the speed of lar tendon ruprur.
the drop is increased until a mild level of pain is experienced One vital pi,
(Figure 22-71). The goal is to perform 3 sets of 10 repeti­ often been ignor l'd
tions at n speed that causes mild pain during the last set. by the injured a
The presence of mild pain is indicative of the mild stress. arises in individua
Jensen and DiFabio have suggested treating patellar (e.g.. volleyball. ba
tendinitis with a program of isokinetic eccentric quadri­ the jump-landin g [I
ceps training iY (Pigure 22-39). The program begins with f muscular stren gth
sets of 5 repetitions at 30 degrees per second 3 times per are often assessed
week. progressing over an 8-week period to 4 sets or 5 rep­ menl techniqu e ~
etiUons each at 30. 50. and 70 degrees per second. 59 Vig­ An at.hlete v"ho ha:
orous quadriceps and hamstring stretching precede an d lar contribution
follow each workout (Figures 22-12. 22-14). and injury from
The lise of a tenodesis strap or brace worn about the instructional feed
patellar tendon has also been recommended for patellar bal cues has been
 CHAPTER 12 Rehabilitation of Knc(' jnjuries 571

. T 'f, .-.

Figure 22-72 A tenodesis strap can be used to help

control patella r tendinitis .

with jump-landing. thu s possibly redUCing the risk of

jump-landing injuries. 76.S3.H9 Tnstruction in proper land­
ing technique mu st be sport- a nd position-specific and
should include a combLnation of videotape replay from
the athletic trainer (Figure 22-47) to provide specific reed­
back (e.g.. land with t\Vo feet. feet shoulder-width apart.
,1l1d bend Lo absorb impact) und verbal cues (e.g .. soft
Figure 22-71 Drop squats are performed with the ath­ knees. load hips, quiet so und. and toe-to-heel land­
lele moving slowly [rom standing to a squat position and ing). 46.7(,.MJ. 4 .89 Improving sofL-tissue structures sur­
return. rounding the injured joint is necessary, but poor
jump-landing technique will constantly eXilcerbate the
tendinitis problem.
tendinitis (Figure 22-72). It appears that the effectiveness Criteria for Return. The athlete may return to
of this strap in reducing pain varies from one athlete to full activity when pain has subsided to the point where he
of five parlS: another. or she is capable of performing jumping and running ac­
ng. tretehing. and Injection of cortisone into the tendon to reduce in­ tivities without increased swelling or exacerbation of
bp quats, are per­ flammation is not recommended because it wil l tend to pain. There should be normal strength in the quadriceps
fr m standing to a weaken the tendon and can predispose the athlete to patel­ bilaterally.
tress. the speed of lar tendon rupture.
pain is experienced One vital piece of the rehabilitation process that has
3 sets of 10 repet!­ orten been ignored is the jump-landing technique utilized CLINICAL DECISION MAKING Exercise 22- 6
du ring the last Sf't. by the injured ath lete. 2 J.75.84 Patellar tendinitis often
of the mild stress. arises in individuals who jump a lot during sport activities A high ~chooll'ollc.vball player has been complaining ur
_ treating patellar (e .g.. vol leyba ll . basketball. and soccer), yet the analysis of patellar tendon pain for 2 weeks follOWing the start or
eccentric quadri­ the jump-landing technique is overlooked. Assessment of preseason practice. She complains of sharp shooting pain
=-ram begins with 6 muscular strength. flexibility, and neuromuscular control in the inferior pole of the patellar tendon region dW'ing
. econd 3 times per are often assessed properly, but the contribution or move­ jumping activities. with increased pain during the plyo­
pd to 4 sets of :> rep- ment technique assessment is the final piece of the puzzle. metric conditioning program conducted at the end of
per second. 59 Vig­ An athlete who has sufficient muscular and neuromuscu­ each practice. Shl' has tried to cont inue playing. but now
Itc hing precede and lar contributions to joint stability. can get joint overload she is noticeably limping. The roach has told ber to dis­
~ 1-14). and injury from poor jump-landing technique. The use of continue practice <md see the athletic trainer. How ,houl.1
tace worn about the instructional feedback such as videotape replay and ver­ the atbletic trainer [millage this condition?
/TIended for patellar bal cues has been shown to reduce the forces associated
572 PARTTHREE The Tools of Rehabilitation

Bursitis of immobilization in a knee splint. Tf necessary the athlete The athlete has
should walk on crutches until they have regained quadri­ swelling over the
Pathophysiology. Bursitis in the knee can be acute, ceps control and can ambulate without a (.imp. The com­ letes with iliolibia
chronic. or recurrent. Although anyone of the numerous pression wrap should be applied from the foot upward to tory of troch ame:
knee bursae can become inflamed. anteriorly the prepatel­ the middle of the thigh in a manner that maintains con­ at the origin 8l
lar, deep inl'rapatellar. and suprapatellar bursae have the sta_nt pressure on the bursa. The leg should be elevated as Leg len gth
highest incidence of irritation in sports. The pathophysio­ much as possible. The athlete should begin with quad sets fasciae latae and,
logical reaction that occurs with bursitis follows the nor­ (Figure 22-20) and straight leg raising (Figure 22-21) , strings and Quade
mal course of thc inflammatory response as described in both to maintain function of the quadriceps and to use ac­ leading to incre
Chapter 2. tive muscle contractions to help facilitate resorption of cord can indh'id
Swelling patterns can often help differentiate bursitis fluid, On the second day, the athlete may begin ROM exer­ the iliotibial ban
from othcr conditions in the injured knec. With bursitis, cises doing knec slides on a treatment table (Figure 22- 3), detect tightlle~
swelling is localized to the burs<J. For example. prepatellar wall slides (Figure 22-5), or active assistive slides (Figures Injury l\lec
bursitis results in localized swelling above the knee thal is 22-4. 22-6), The compression wrap should be left in place associated with r
ballollable. Tn thc more severe cases it may seem to extend until there is no evidence of fluid reaccumulation. training t echniq~.
over the lower portion of the vastus medialis. Swelling is Occasionally. a ph)7sician may choose to aspirate the lar surfaces (suer
not intra-articular. and there may be some redness and in­ bursa to relieve the pressure and speed up th e recovery pe­ ning. or ru nn" •
creased tempcrature. Tn acute prepatellar bursitis the riod. [f so it is essential to take necessary precautions to bUilding up 10
range of motion of the knee is not restricted exccpt in the prevent contamination and subsequent infection. If infec­ athletes who do r
last degrees of flexion when pain-producing pressure is felt tion does occur. it shou ld be treated with antibiotics. RehabiUtad
in the bursa. whereas a true hemarthrosis or synovitis of [n cases of chronic bursitis, thc techniques for control­ treatment for iii
thc knee joint most frcquently shows a more significant ling swelling listed above should be used. A comprcssion reducing the local
limitation of terminal flexion and extension 01 the joint. J J wrap needs to be worn constantly. Unfortunatcly there will ultrasound, and
Injuries to the ligaments of the knee and also fractures generaIry not be complete resolution . Chronic bursitis be­ bilitation should
of the patella may occur along with acute prepatellar bur­ comes a recurrent problem with thickening of the bursa chanical facto
sitis. Patellar fractures can occur l'rom a direct blow to the and reaccull1ulation of fluid. Tn these cases injection with
patella with the knee held in flexion. A violent contraction a corticosteroid or surgical excision of the bursa may be
of the quadriceps mechanism can also produce transverse necessary. flexion contra
patellar fracturcs, which should be ruled out with radi­ Criteria for Return. The athlete may return to full stretching of the
ographs. fnfectiol1 of the infrapatellar bursa can be simi­ activity when there is no reaccumulalion of fluid folloWing the tensor fasci
larly difficult to diagnosis because of its deep location. Tt is their exercises , when tbere is full ROi\!L and when there is shown in Figure
a rare condition and requires aspiration for diagnosis. normal quadriceps control. motion.
Swelling posteriorly in the popliteal fossa does not nec­ During n or
essarily indicate bursitis but could instead be a sign of
Iliotibial Band Friction Syndrome internal rot ation
Baker's cyst. A Baker's cyst is connected to the joint, which this pronatlon an",
swells because of a problem in the joint and not due to bur­ Pathomechanics. The iliotibial band is a tendinous 4 to 6 weeks of l.
sitis. A Baker's cyst is often asymptomatic, causing little or extension of the fascia covering the gluteus maximllS and trol tbe symptom
no discomfort or disability. tensor fascia e latae muscles proximally: it attaches distally
Injury Mechanism. The cause of prepatellar bursi­ at Gerdy 's tuberclc on the proximal portion of the lateral
Us can involve either a single trallma. as would occur in tibial. As the athlete flexes and extends the knee. the ten­
falling on a flexed knee, or it can result from repetitive don glides anteriorly and posteriorly over the lateral
crawling or kneeling on the knee. as would occur in femoral condyle. This repetitive motion, as typically occurs tion massage u
wrestling. Acute or posttraumatic inflammation is not un­ in runners, may produce irritation and inflammation of appears to be eHi
common. The prepatellar bursa ls more likely to become the tendon. syndrome. A ::i - to
inflamed from continued kneeling. whereas the deep infra­ niotibial band friction syndrome involves localized ial band ovcr th e la
patellar becomes irritated from repetitive stress to the pain about 2 cm above the joint line over the latera l pendicular to the
pClteLiar tendon. as is the case in jumper's knee. femoral condylc when the knee is in 30 degrees of flexion . done cvery other
Rehabilitation Concerns and Progression. Pain appears to radiate toward th.e lateral join t line an this treatment. all
Acult' prepatellar bursitis should be treatec! conservatively. down toward the proximal tibia . becoming increasingly se­
and rehabilitation should begin with ice. compression. vere as the athlete continues to run. Eventually it become
anti-inflammatory medication, and possibly a brief period so symptomatic that the activity must be discontinued.

SM) th athle
The athlete has tenderness. crepitus. and an area of res ume running but should avoid prolonged workou ts
~ain d qu adri­ swelling over the la teral condyle. In some instances ath­
limp. he COID­
letes with iliotibial ba.nd fri cLion syndrome also have a his­ sary to run on the side of the road. it is essential that th e
... foo t upward l
tory of trochanteric bursitis and pain along the iliac crest patien t a ltern ate sides of the road during workouts.
maintains con­ at the origin at the tensor fasciae latae.
be elevated a_ Leg length discrepancies. contractures of the tensor
\\ith quad se ­ rasciae latae and gluteus m ax imus. tightness of the ham­
figure 2 2-21 strings and quadriceps. genu varum. excessive pronation
an d to use ae­ leading to increased inLerna t tibial torsion. and a light heel
cord can individually or collectively increase the tension of
the iliotibial band across th e femoral condyle. Ober's test to
detect tightness in this muscle group will be positive.
Injury Mechanism. As is the case in many injuries
associated with -running. th ere is often a history of poor
training techniques that may include running on irregu­
lar surfaces (such as on the side of Lhe road) , downhiU run­
ning. or running long dista nces without gradually
building up to that level. Symptoms frequently develop in
athleLes who do not have an adequate stretching program.
Rehabilitation Concerns and Progression. Initial
lreatment for iliotibial band friction syndrome is directed at
. . compression reducing the local inflammatory reaction by using rest. ice.
unately there wiU ultrasound. and oral anti-inflammatory medications. Reha­
o nie bursitis be­ bilitation should focus on correcting the underlYing 'biome­
g of the bursa chanical factors that may cause the problem. if Ober's test is
injection wit h positive. stretching exercises to correct this static contracture
bursa may bc should be used (Figure 22-10) . Some athletes also have hip
flexion contractures with a positive Thomas test and require
~ may return to fu ll stretching of the iliopsoas and tihe anterior capsule. as well as
of fluid following the tensor fasciae latae. Myofascial release stretching as
an d when there i shown in Figure 6-SA also helps reduce pain and increase
motion.
During normal gait, pronation leads to an obligatory
internal rotation of the tibia. Orthotics may help reduce
Idrome
this pronation and relieve symptoms at the knee. Generally
band is a tendinous 4 to 6 weeks of conservative treatment is required to con­
tc uS maximus ami trol the symptoms of iliotibial band syndrome. While con­
: it attac hes dis wily servative treatment is usu ally effecLive in controlling
n io n of the lateral symptoms. occasionally cases of iliotibial band syndrome
the knee. the ten­ do not respond and require surgical treatment.
I} over the lateral As was the case with patellar tendinitis. transverse fric­
~. s typically occur~ tion massage used to increase the inflammatory response
D inl1arnmation of appears to be effective in treating iliotibial band friction
syndrome. A 5- to 7-minute friction massage to the iliotib­
~ involves localized ial band over the laLeral femoral condyle in a direction per­
e over the lateral pendicular to the direction of th e Lendon fibers. should be
o degrees of flexion. done every other day for approximately 1 week. During
te ral joint line and this treatment. all other medica tive or modality efforts to
ping increasingly se­ reduce inflammation should be eliminated .
'entually it becomes Criteria for Return. When the local tenderness
~ l be discontinued. over the lateral epicondyle has subsided, the athlete may
CHAPTER 22 Rehabilitation of Knee Injuries 573
and runn ing on hills and irregular surfaces. If it is neces­
Shorten ing the stride and applying ice after running may
also be beneficial.
Patellar Plica
Pathomechanics. A plica is a fold in the synovial
lining of the knee that is a remnant from the embryologi­
cal development within the knee. The most common sy n­
ovial fold is the infrapatellar plica. which originates from
the .infrapatellar fat pad and extends superiorly in a fanlike
marmer. The second most common synov1ial fold is th e
suprapatellar plica. located in the suprapatellar pouch.
The lea st common. but most subject to injury. is th e
mediopatellar plica. which is bandlike. begins on the me­
dial wall of the knee jOint. and extends downward to insert
into the synovial tissue that covers the infrapatellar fat
pad. 9 The medipate\!lar plica can bowstrtng across the an­
teromedial femoral condyle, impinging between the artic­
ular cartilage an d the medial facel of the patella with
increasing flexion . A plica is often associated with a torn
meniscus , patellar malalignment. or osteoarthritis. Be­
cause most synovial plicae are pliable. most are asympto­
matic; however. the mediopatellar plica may be thick.
nonyielding. and fibrotic. causing a number of symptoms.
Injury Mechanism. The athlete mayor may not
have a history of knee injury. If symptoms are preceded by
trauma. it is usu ally one of blunt force such as falling on the
knee or of tvvisting with the foot planted, either of which
can lead to inflammation and hemorrhage. Inl1ammations
leads to fibrosis and thickening with a loss of extensibility.
As the knee passes 15 to 20 degrees of flexion. a snap
may be felt or heard . Internal and external tibial rotation
can also produce this snapping. The mediopatellar plica
can snap over the medial femoral condyle. contributing
to the development of chondromalacia. 9 A major com­
plaint is recurrent episodes of painful pseudolocking of
the knee when sitting for a period of t ime. Such charac­
teristics of locking and snapping could be miSinterpreted
as a torn meniscus. The athlete complains of pain while
ascending or descending stairs or when squatting. Unlike
meniscal injuries. there is little or no swelling and no lig­
amentous lax ity.
Rehabilitation Concerns and Progression. Ini­
tially. a plica should be treated conservatively to control
inl1arnrnation with rest, anti-inna mmatory agents. and
local heat. If th e plica ,is associated with improper patel­
lar tracking. the pathomechanics should be corrected as
574 PART THREE The Tools of RehabiJitation
previously discussed. If conservative treatment is unsuc­
cessful. the plica may be surgically excised. usualIy with
good results. 26
Criteria for Return. The athlete can return to full
activity when she or he can perform normal functional ac­
tivities with minimal or no pain and without a recurrence
of swelling.
Osgood·Schlatter Disease
Pathomechanics and Injur)' Mechanism. Two
conditions common to the immature adolescent's knee are
Osgood-Schlatter disease and Larsen-Johansson disease.
Osgood-Shlatter disease is characterized by pain and
swelling over the tibial tuberosity that increases with ac­
tivity aod decreases with rest. Traditionally Osgood­
Schlatter disease was described as either a partial avulsion
of the tibial tubercle or an avascular necrosis of the same.
Current thinking views it more as an apophysitis charac­
terized by pa in at the attachment of the patellar tendon at
the tibial tubercle with associated extensor mechanism
problems. The most commonly accepted cause of Osgood­
Schlatter disease is repeated stress of the patellar tendon at
the apophysis of the tibial tubercle. Complete avuJsion
of the patellar tendon is a uncommon complication of
Osgood-Schlatter disease.
Summary
1. To be effective in a knee rehabilitation program. the
athletic trainer must have a good understanding of the
functional anatomy and biomechanics of knee joint
motion.
2. Techniques of strengthening involving closed-kinelic­
chain. isometric, isotonic, isokinetic, and plyometric
exercises are recommended after injury to the knee be­
cause of their safety and because they are more func­
tionalthan open-chain exercises.
3. Range of motion may be restricted either by lack of
physiological motion. which may be corrected by
stretching. or by lack of accessory motions, which
may be corrected by patellar mobilization techniques.
Constant passive motion may be used post.operatively
to assist the athlete in regaining range of motion.
4. PCL, MCL. and LCL injuries are generally treated non­
operatively. and the athlete is progressed back into ac­
tivity' rapidly within their limitations.
5. The current surgical procedure of choice for ACL re­
construction uses an intra-articular patellar tendon
graft.
This condition I1rst appears in adolescents and usually
resolves when the athlete reaches the age of 18 or 19. The
References
ol1'ly remnant is an enlarged tibial tubercle. Repeated irri­
tation causes swelling. hemorrhage, and gradual degener­ 1. Anderson. c..
ation of the apophysis as a result of impaired circulation. laled and com
The athlete complains of severe pain when kneeling, up study. Ami'"'
jumping, and running. There is point tenderness over the 2. Anderson. :\
anterior proximal tibial tubercle. menled eva!
arthromeler
Larsen-Johansson disease. although much less com­
20:135-40 .
mon. is similar to Osgood-Schlatter disease. but it occurs at
3. Arendt. E.. J.
the inferior pole of the patella. As with Osgood-Schlatter
disease, the cause is believed 10 be excessive repeated strain
on the patellar tendon . Swelllng, pain, and point tender­ 4.
ness characterize Larsen-Johansson disease. Later, degen­
eration can be noted during X-ray examination.
Rehabilitation Concerns and Progression. 5. Basmajian . J.
Management is usually conservative and includes the fol­ Lions r{'veaIn.
lOWing: Stressful activities are decreased until the apophy­ Wilkins.
6. Bennet , j .. and
seal union occurs. usually within 6 months to 1 year; ice is
of anterior
applied to the knee before and after activities; isometric
Science in SjXPt.
strengthening of quadriceps and hamstring muscles is 7. Beynnon. B. r.
performed; and severe cases may require a cylindrical cast.
Treatment is symptomatic with emphasis on icing,
quadriceps strengthening. hamstring stretching. and ac­ 8.
tivity modi.fication. Only in extreme cases is immobiliza­
tion necessary.
9.
6. Recent trends in rehabilitation after ACL reconstruc­
tion arc toward an aggressive, accelerated program
that emphasizes immediate motion, immediate weight 12.
bearing, early c1osed-cha.in strengthening exercises,
early return to activity, and jump-landing training.
7. The current trend in treating meniscal tears is to sur­
the anterior
gically repair the defect if possible or perform a partial
alld Sports Ph
menisectomy arlhroscopically. Repaired menisci
J 4. Brotzman . B.
should be immobilized NWB for 4 to 6 weeks. pedic relwbilir,
8. It is critical to assess the mechanics of the 15. Calliet. R. 19
patellofemoral joint in terms of static alignment, dy­
namic alignment. and patellar orientation to deter­
mine what specifIcally is causing pain.
9. Rehabilitation of patellofemoral pain concentrates on soccer: A pr
strengthening the quadriceps through c1osed-kinetic­ ing. Knee 511
chain exercises, regaining optimal patellar positioning 17. Cavenaugh . J. :
gery. In Knee
and tracking. and regaining neuromuscular control to
York: Chure
improve lower-limb mechanics.
18. CJancy. w.. D..
 CHAPTER 22 Rehabilitation of Knee Injuries 575

n ts and usuaUy
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SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES
22-1 The athletic trainer should recommend that the
athlete remove the straight-leg immobilizer and be­
gin crutch walking while bearing weight on the in­
jured leg as tolerated. Range-ol~motion exercises
that emphasize pain-free movement should be insti­
tuted. Stationary bicycling for range-or-motion
purposes can be initiated as tolerated. Isometric
strengthening exercises should avoid increased MCL
pain and leg abduction movements that place the
knee in a valgus pOSition causing strain on the MCL.
22-2 The athletic trainer should recommend that the
athlete reduce competition for a {'ew days to allow
for the reduction of inflammation. The ath'lete
should start ice treatments following physical activ­
ity and initiate strengthening and stretching of the
quadriceps and h amstring musculature. A protec­
tive kneepad will help alleviate contact pressure
when the athlete returns to play, and the athlete
should continue with ice, stretching, an.d strength­
ening exercises follOWing return to activity. '! 'he ath­
letic trainer should continue to monitor of signs and
symptoms, to avoid escalation of knee problems
that may require casting or surgical intervention.
22-3 It is important to understand that once a ligament
has been sprained, the inherent stability provided
to the jOint by that ligament has been lost and will
never be totally regained. Thus, the athlete must
rely on the other structures that surround the joint,
the muscles and their tendons, the help provide sta­
bility. It is essel1tial {'or the athlete to work hard on
strengthening exercises for all of the muscle groups
that playa role in the function of th e knee jOint.
22-4 The athletic trainer should continue with range-of­
motion and strengthening activities of the quadri­
ceps and surrounding musculature. The athletic
ligament rehabilitation, edited by R. Engle. New York:
ChurchiJi Livingstone.
Chi
112. Woo. S. L.. R. E. DcbaskL J. D.. Witbrow. and M. A. Janausbek.
1999. BIomechanics of knee ligaments. flmericnlllolimni oj
Sports Medicine 27(4):533-43.
113. Woodall. W.. and J. Welsh. 1991. A biomecbanical basis for
rehabilitation programs involving tbe knee joinl.lollrnal oj
IRe
OrtllOpaeriic and Sports P/lysicnl Therapy ll( 11): 5 3 5.
114. Zarins. B" and D. Fish. 1995. Knee ligament injury. In The
loIVe/' extremity and spine in sports medicine, cdited by J.
LeJ
Nicholas. and E. Hershman. SI. Louis: Mosby. Chri st~,
trainer should start introducing dynamic stability
exercises (e.g., low-level plyometrics. single-leg
static and dynamic exercises, and proprioception
training) that mimic th e planting aspect of the StJ
kicking maneuver. A prophylactic knee brace may To become mon."
also aid in stability and should not impair the ath­ necessary to d
lete because it is the nonkicking leg.
22-5 The athletic trainer should recommend shorter the
training sessions; in particular, the running phase
of training should be limited. Isometric exercises wWIV.mhhc. c
that are pain-{'ree to strengthen tbe quadriceps and
hamstring muscles can be used initially, progress­
ing to closed-chain strengthening exercises. Oral
anti-inflammatory agents and small doses of as­
pirin may help control swelling and reduce pain.
Pain might also be reduced by wearing a neoprene
sleeve and an orthotic device that corrects prona­
tion and reduces tibial torsion.
22-6 Following an initial evaluation that indicates infra­
patellar tendinitis, acute care for the athlete should
be application of ice. Rehabilitation should consist
of llexibility and strengthening exercises for the
quadriceps and hamstring musculature. while not
causing increased patellar tendon pain. A jump­
landing videotape analysis probably will reveal
poor landing technique, with the knees in full ex­
tension and a hard landing sound that indicates in­
creased landing forces . A tendinosis strap may b~
recommended, but strengthening and proper
jump-landing technique should be emphasized.
The athletic trainer should discuss with the coach
reducing plyometric exercises to two or three time,
per week and beginning each session with a revie\'.
of proper jump-landing technique.
 gle. :\ew York: Chapter 23
~ !. A. Janaushek.
c\m ericQn Joumal of
Rehabilitation of Lower­
ent injury. In Tile
Leg Injuries

Line. edited by J.
Christopher J. Hirth

dy n amic stability
etrics, single-leg
d proprioception
g aspect of the Study Resources • Identify common causes of various
knee brace may To become more familiar with the knowledge and skills lower-leg injuries and provide a ration­
I impair the ath­ necessa ry 1.0 design, implement. and document therapeu­
ale for treatment of these injuries.
tic rehabilitation programs as identified in the :\,AIII Illh­
"'.
flIIle nd shorter the Ietie Training filil m tional Competencies and Clinimi • Discuss criteria for progression of the
e running phase Projlciellcies 'Thera peulic Exercise content area , vi sit
rehabilitation program for variolls
metric exercise~ w\\'\\'.mhhe,CQ!.n / prenticel!.l;.. Also refer to tbe lab exer­
e q uadriceps and cises in the new Laboratory Manual and to eSims, which lower-leg injuries.
initially. progress­ simulates the athletic training ccrlineation exam, at
II'ww,mhhe.com /csims. For more online study resources,
• Describe and explain the rationale for
g 'Cfcises. Oral
rn a II doses of as­ visit our Hea lth and' Human Performance website at variOllS treatment techniques in the
~ an d reduce pain . www.mhhe.com/hhr. management of lower-leg injuries.
a ring a neoprene
&at corrects prorta­ After Completion of This

Chapter, the Student Should

at indicates infra­ Be Able to Do the Following:

- lhe athlete should FUNCTIONAL ANATOMY

'on should consist • Discuss the functional anatomy and AiN D BIOMECHANICS
g exercises for the
biomechanics of the lower leg during
ul ature, while not The Jowcr lcg consists of the tibia and fIbula and four
~o n pain. A jump­
open-chain and weight-bearing activi­ muscular compartments that either originate on or tra­
iobably will reveal ties such as walking and running. verse various points along these bones. Distally the tibia
~e knees in full ex­ and fibula articu late with ,he talus to form the talocrural
r d lhal indicates in­ • Identify the various techniques for regain­ joint. Because of the close approximation of the talus
rnosis strap may be ing range of motion. including stretching within the mortise, movement of the leg will be dictated
nin g and proper by the foot. especially upon ground contact. This be­
exercises and joint mobilizations.
ld be emphasized . comes ~mportant when examining tbe effects of repeti­
russ with the coach • Discuss the various rehabilitative strength­ tive stresses placed upon the leg with excessive
~ two or three time ening techniques. including open- and
compensatory pronation secondary to various structural
_ ion wit h a review lower-extremity malalignments. 74 .7 ; Proximally the tibia
lue. closed-chain isotonic exercise. balcillcel articulates with the femur to form tbe tibiuremoral joint
proprioceptive exercises. and isokinetic ex­ as well as serving as an attachment site for the patellar
ercise for dysflillction of the lower leg. tendon, the distal soft-tissue component of the extensor
mechanism. The lower leg serves to trammit ground

579
580 PART THREE The Tools of Rehabilitation Isotonic O}i

reaction forces to the knee as well as rotatory forces prox­ tarflexion of the foot. Functionally these muscles are re­
imally along the lower extremity that may be a source of sponsible for acting eccentrically controlling pronatio n of
pain. especially with athletic activities. S4 the subtalar joint and internal rotation of the leg in the
midstance phase of gait and activated concentrically dur­
ing the push-off phase of gai1. 2 [J.;1
Compartments ot the Lower Leg
All muscles work in a functional integrated fashion in
which they eccentrically decelerate. isometrically stabi­
lize. and concentrically accelerate during movement. 49 REHABILITATION TECHNIQUES
The muscular components of the lower leg are divided FOR THE LOWER LEG
anatomically into four compartments. Tn an open-ki­
netic-chain position. these muscle groups are responsible Strengthening Techniques
for movements of the foot primarily in a single plane. Figure 23 -3
When the foot is in contact with the ground. these mus­ position. Used
cus longus. an .
cle-tendon units work both concentrically and eccentri­
units after a pt'
cally to absorb ground reaction forces. control excessive
movements of the foot and ankle to adapt to the terrain.
and. ideally. provide a stable ba se to propel the limb for­
ward during wall<ing and running.
The anterior compartment is primarily responsible
for dorsillexion of the foot in an open-kinetic-chain po­
sition. FunctionaLly these muscles are active in early
and midstance phase of gail. with increased eccentric
muscle activity directl)7 after heel strike to control plan­
tarfiexion of the foot and pronation of the forefoot. 20
EMG studies have not.ed that the tibialis anterior is ac­
tive in more than 85 percent of the gait cycle during
running. ;2 Figure 23-1 AR01\J[ ankle plantarflexion. Used to acti­
The deep posterior compartment is made up of the vate the primary and secondary ankle plantarflexor
Figure 23-5
tibialis posterior and the long toe flexors and is responsi­ muscle-tendon units after a period of immobilization or
tubing. Used l
ble for inversion of the foot and ankle in an open kinetic disuse. This eXercise can be performed in a supportive
a nd second a r~
chain. These muscles help control pronation at the sub­ medium such as a whirlpool.
oneals. flexor f:­
talar joint and internal rotation of the lower leg. 2o .s2 and tibialis
Along with the soleus. the tibialis posterior will help de­ cise will also p
celerate the forward momentum of the tibia during mid­ load on the Ad
stance phase of gait.
The lateral compartment is made up of the peroneus
longus and brevis. which are responsible for eversion of
the foot in an open kinetic chain. Functionally the per­
oneus longus plantarflexes the first ray at heel off. while
the peroneus brevis counteracts the supinating forces of
(

the tibialis posterior to provide osseous stability of the

subtalar and midtarsal joints during the propulsive
phase of gait. This is a prime example of muscles work­
ing synergistically to isometrically stabilize during
movement. EMG studies of running report an increase in
peroneus brevis activity when the pace of running is in­
creased. 52 Figure 23-2 AROM ankle dorsiflexion. Used to activate
The superficial posterior compartment is made up of the tibialis anterior. extensor hallicus longus. and exten­ Figure 23-7
the gastrocnemius and soleus muscles. which in open­ sor digitorum longus muscle-tendon units after a period ing. Used to isol
kinetic-chain position are responsible primarily for plan­ of immobilization or disuse. eluding the Li bla
flexor digitoru m
 Isotonic Open-Kinetic-Chain Exercises.
UES
Figure 23-3 AROM ankle inversion start position/end
position. Used to Clcthrate the tibialis posterior. flexor halll­
eus ,l ongus. a nd flexor digitorum long us muscle-tendon
units after a per,iod of immobilization or disuse.
Figure 23-5 RROM an lde plHntarnexion with rubber
tubing. Used to strengthen the gastrocnemius. soleus.
and secondary ankle plantarflexors. including the per­
oneals. llexor hallicus longus. flexor digilorum longus,
and tibialis posterior. in an open-chain fashion. This exer­
cise will also p1ace a con trolled concentric and eccentric
load on the Achilles ten don.
o . sed to ae[i\'aL
,ongus. and exten ­ Figure 23-7 RROM ankle inversion with ru bber tub­
mits after a period ing. Used to isolate a nd strengthen the ankle inverlers. in­
cluding the tib ialis posterior, flexor hallie us longus, and
flexor digitorum long us, in an open-chain fashion.
Figure 23-4 AROM a nkle eversion start position/end
position. Used to aetivMe the peroneus [angus and brevis
muscle-tendon units after a period of immobilization or
disuse.
Figure 23-6 RROM ank le dorsiflexjon with rubb er tllb­
ing. Used to isolate and streng then the ankle dorsifiJ exors.
including th e libiaHs an terior. extensor hallieus longus.
a nd extensor digitorum 'l ong us, in an open-chain fashi on.
Figure 23-8 RROl'..1 ankle eversion with rubber tubing.
Used to isolate and strengthen th e ankle everlers, includ­
ing the peroneus longus and peroneus brevis. in ao open­
chain fashion.
 (

Figure 23-9 AROM toe ilexion / ext"ension. Used to acti­

t

vate the long toe Hexers. extensors. and foot intrinsic

musculature. This exercise wiU also help to improve the
tendon-gliding ability of the extensor hallicus longus. ex­
tensor digitorum longus. l1exor hallicus longus. and
ilexor digitorum longus tendons after a period of
immobi lization.
Figure 23-12 Two-legged heel raise. Used to
strengthen the gastrocnemius when the knee is extended Figure 23-1-1
and the soleus when the knees are l1exed. The flexor halli­ dorsiflexion/ pI.;:
cus longus. flexor digitorum longus. tibialis posterior. and ankle dorsinex·'·
peroneals will also be activated during this activity. The chain position.
ath lete can modify concentric and eccentric activity de­
pending on the type and severity of the condition. For ex­

..
ample. if an eccentric load is not desired on th e involved
side. the ath lete can raise up on both feet aJld lower down
011 the uninvolved side until eccentric loading is tolerated
Qnthe involved side.

Figure 23-10 Towel-gathering exercise. Used to

strengthen the foot intrinsics and long toe l1exor and ex­
tensor muscle-tendon units. A weight can be placed on
the end of the towel to require more force production by
the muscle-tendon unit as ROM and strength improve.

Closed-Kinetic-Chain Strengthening Exercises.

Figure 23-13 One-legged heel raise. Used to

strengthen the gastrocne mius and soleus muscles when
the knee is extended and flexed. respectively. This can be
used as a progression from th e two-legged heel raise.

Figure 23-11 Heel raises. Used to strengthen the gas­

trocnemius musculature and will directly load the
Achilles tendon with a percentage of the ath lete's body
weight depending on the angle of the carriage relative to
the ground.
 CHAPTER 23 Rehabilitation of Lower-Leg Injuries 583

Figure 23-14 Seated closed-chain ankle Figure 23-15 Seated closed-chain ankle
- ee is extended
dorsil1exion/plantarl1cxion I\ROM. Used to activate the inversion/eversion ,\J.{O iVI. sed to activate the ankle
T he l1exor hall i­
ankle dorsil1exorlplantarl1exor musculature in a closed­ inverter/everter musculCiture in a closed-chain position.
llis posterior. and
chain position .
. activity. The
ri activity de­
·ond ition . for ex­
on the involved
l a nd lower down
rdin g is tolerated

muscles when
This can be

Figure 23-16 Stationary cycle. Used to reduce impact Figure .2.3-17 Stair-stepping machine. Used to progres­
weight-bearing forces on the lower extremity while a lso sively load the lower extrem ity in a closed-kinetic fashion
maintaining cardiovascular J1tness levels. as well as maintain and improve cardiovascular fitness.
584 PART THREE The Tools of Rehabilitation

Stretching Exercises Exercises tel

Figure 23-18 Ankle plantarfiexion towel stretch. Used to stretch the gastrocnemius when the knee is extended and
the soleus when Lhe knee is flexed . The Achilles tendon will be stretched with bath pasitions. The athlete ca n hald the
stretch for 20 to 30 secands. Figure 23-22
tivity. Used to a
prove balance a

A B

Figure 23-] 9 A, Standing gastracn emius stretch. Used to stretch the gastrocnemius muscle. The Achilles tendan will
also be stretched. The stretch is held far 20 to 30 secands. B, Standing saleus stretch. Used ta stretch the saleus muscle.
The Achilles tendon will alsa be stretched. The stretch is held for 20 ta 30 seconds.

Figure 23-21 Kneeling ankle darsiflexar stretch. L

Figure 23-20 Standing ankle dorsiflexar stretch. Used to stretch the extensar hallicus langus. extensar digito
ta stretch the extensor hallicus lang us. extensar digila­ langus. tibi alis anteriar. and anteriar ankle capsule. T
rum langus. tibialis anterior. and anteriar ankle capsule. an aggressive stretch that can be used in the later stagl
The stretch is held for 20 to 30 seconds . rehabilitation ta gain end-ROM ankle darsiflexian.
 CHAPTER 23 Rehabilitation of Lower-I.e Injuries 585

Exercises to Reestablish Neuromuscular Control

i extended and
e can hold the
Figure 23-22 Slanding double-leg balance board ac­
tivity. Used to activate the lower-leg musculature and im­
prove balance and proprioceplioll in the lower extremity.
Hgure 23-23 Slnnding single-leg balance board activ­
ity. Used to activate the lower-leg musculalurc and improve
bafance and proprioception in the involved extremily.

Figure 23-24 Static Single-leg standing balance pro­

gression. Used to improve balance and proprioception of
the lower extremity. This activity can be made more diffi­
cult with the follOWing progression: (a) Single-leg stand.
e. ~ ensor digitoru m eyes open; (b) single-leg stand, eyes closed; (c) singkl-leg
n kle capsule. This is stand, eyes open, toes extended so only the heel and
the later stages ()'f melalarsal heads are in contact with the ground:
lor iOexion. (d) Single-leg stand, eye ' closed, toes extended.
 586 PART THR EE The Tools of Rehab ilitation

Exercises

iii
A B

~- ..
f'
-~
c

Figure 23-25 Single-leg sta nding rubber-tubi ng kicks. Used to improve muscle activation of the lower leg to maintain
sin gle-leg stan ding on the involved extremity while kicking against the resistance 01" the rubber tubing. A, Ex tension.
B, Flexion. C, Adduction. D, Abdu ction.

Figure 23-26
to reduce impaCi
tremity while m
a nd runnin g form
 CHAPTER 23 Rehabilitation of Lower-Leg fnjuries 587

Exercises to I mprove Cardiorespiratory Endurance

cr leg to maintain
\ . E.xte nsion. igure 23 ·27 pper-body ergometer. Used to maintain
cardiovascular fitness when lower-extremity ergometer is
con traindicated or too difficu lt for the athlete to use.

Figure 23-26 Pool running with flot(l[ion device. l:sed

to reduce impact weight-bearing forces on the lower ex­
tremity while maintaining cardiovascu lar iltness I('vel
and running form.

Figure 23·28 Exe rcise sandals (OPTP. ,\:iinneapolis.

MN ). Wooden sanda ls with a rubber hemis phere located
centrally on the plantar sLlrface.
588 PARTTHR EE The Tools of Rehabilitation

---
-
Figure 2 3-32
Figure 2 3-30 Exercise sanda ls sidestepping. Used to hance bal an ce
n hance balance an d proprioception in the frontal plane. the foot inlriJ)si
Increases muscle activity of the lower-leg muscula ture the gluteals. The
figure 2 3-29 Exercise sandal forward and backward and foot intrinsics. The athlete moves directly to the left ture and avoi d
walking. Used to enhance balance and proprioception or right along a straight line with the toes pointed cise promote
a nd increase muscle act ivity in the foot intrinsics. lowe r­ forward. period of tim~ .
leg muscul ature. and glu tea ls. The at hlet e t,lkes sm a ll
steps forward and backwcLrd.

Figure 23-3] Exercise sa nda ls butt kicks. Used to pro­

mote balance a nd proprioception along with increased Figure 2 3-34
muscle ac tivity of the fool intrinsics. lower-leg muscu la­ han cc balan ce. pr
ture. an d gluteals. Th is exc rcise enhan ces Single-leg tivity. The a thlete I
stan ce in the exercise sanda ls . ball to th e ath letic
left of right.
- Figure 2 3· 3 2 Exercise sandals high knees. Used to en­
pping. Used to hance balance and proprioception and muscle activity of
e frontal plane.
Figure 23·3 3 Exercise sandals Single-leg stance. Used
the foot inlrinsics. lower-leg musculature. and especially to enhance balance. proprioception. and muscle activity
• m usculatlJre the glutcais. The athlete shou ld maintain Clll upright pos­ in the entire lower extremity. This exercise is the most de­
tly to the left
ture and avoid trunk Oex ion with hip Oexion. This exer­ manding in the exercise sandal progression.
. pOinted
cise promotes Single-leg stance progressioll for a short
period of time.

Figure 23-35 Achilles tendon eccentric muscle load­

ing. Used to enhance gastrocnemius (knee straight) and
ti k . Used to pro­ soleus (knee bellt) strength and achilles tendon tensile
, wit h increased Figure 23-34 Exercise sandal ball catch. Csed to en­ strength. The athlete uses the uninvolved side to elevate
'er-leg muscula­ hance balance. proprioception. and lower-leg muscle ac­ onto Lheir toes and then places all weight on toes of the
re single-leg tivity. The athlete focuses on catching and throwing the involved side to eccentrically lower. Initially the athlete
ball to the athletic trainer while moving laterally to the lowers to the step and then progresses below the level of
left of rig h l. the step. Extra weight can be added via a backpack.
590 P't-\RT THREE The Tools of Rehabilitation

cle flexibility. st;

volved lower ~...
The athletic trair
mands that \ \ilJ
competition and
ingly. Upon cast
defiCits. This can
in a supporli\'e r::
23-1 to 23-4 . .::
stiffness can
to any joint
14-(8). rt is
foot and anlJe
massage. Streo~
cle firing, stren!;
Figure 23-36 Short foot concept. Csed to enhance and strengthen the foot intrinsic muscles. The athlete is instructed
to shorten the foot from front to back while keeping the toes straight. The metatarsal heads should stay in contact with 23-10 to 23- 13
the ground. The athletic trainer can palpate the foot intrinsics and will notice a raised longitudinal arch with a flexible proved witb ,I
foot type. The shortened foot should be maintained at all times while in the exercise sanda ls. board actlviti~
endurance can
swimming and P'
REHABILITATION TECHNIQUES combination of rotatory and compressive forces can be tionary cycli ng
manifested in sports when an athlete's foot is planted and (Figures 23- 16
FOR SPECIFIC :INJURIES the proximal segments are rotated with a large compressive a lso an excelle
force. An example of this could be a football running back
Tibial and Fibular Fractures attempting to gain more yardage while an opposing player
is trying to tackle him from above the waist and applying a
Pathomechanics.The tibia and fibula constitute the superincumbent compressive load. If the athlete's foot is
bony components of the lower ·leg and are primarily re­ planted and immovable and N1e lower extremity is rotated.
sponsible for weight bearing and muscle attachment. 'fhe the superincumbent weight of the defender may be enough
tibia is the most commonly fractured long bone in the to cause a fracture in the tibia. A fibular fracture may ac­
body, and fr actures are usually the result of either direct company the tibial fraG'ture.
trauma to the area or indirect trauma such as a combina­ Rehabilitation Concerns. Tibial and fibular frac ­
tion rotatory/ compressive force. fractures of the fibula are tures are usually in1mobilized and placed on a restricted
usually seen in combination with a tibi al fracture or as a weight-bearing status for a period of time to facilitate frac­
result of direct trauma Lo the area. Tibial fractures will ture he.aling. Immobilization and restricted weight bearing
present with immediate pain. swelling, and possible defor­ of a bone, its proximal and disttll joints. and surrounding
mity and can be open or closed in nature. Fibular fractures muscnlature will lead to functional deficits once the frac­
alone are usually closed and present with pain on palpa­ ture is healed. Depending on the severity of the fracture,
tion and with ambulaUon. These fracLures should be there a lso may be postsurgical considerations such as an
treated with immediate medical referral and most likely a incision and hardware within the bone. Complications fol­
period of immobilization and restricted weight bearing for lowing immobilihation include joint stiffness of any joints
weeks to possibly months. depending 011 the severity and immobilized, muscle atrophy of the lower leg and possibly
involvement of the injury. Surgery such as open reduction the proximal thigh and hip musculature, as well as an perform the she
with internal fixation (OIUF) of the bone, usually of the abnormal gait pattern. Bullock-Saxton demonstrated progressed to \\c
tibia, is common . changes in gluteus maximus EMG muscle aclivation after short steps (Figu
Injury Mechanism. The two mechanisms of a trau­ a severe ankle sprain.' ) Proximal hip muscle weakness is sume a good upri
matic lower-leg fracture arc either a direct insll'lt to the bone magnified by the immobility and non-weight-bearing ac­ 1nitiall)' the athl
or indirectly through a combined rotatory/compressive lion that accompanies lower-leg fractures. It is important while acclimati ng
force. Direct impact to the long bone, such as from tI projec­ that the athletic trainer perform a comprehensive evalua­ athlete appears
tile object or the top of a ski boot, can produce enough dam­ tion of the athlete to de termine all potential rehabilitation forward walki ng. I
aging force to fracture a bone. lndirect trauma from a problems, including range of molion. joint mobility. mus­ sion. See Tabl e 13
 CHAPTER 23 Rehabilitation of Lower-Leg Injuries 591

cle flexibility, strength and endurance of the entire in­ • TAB LE 23-1 Exercise Sandal Progression
volved lower extremity. balance, proprioception and gait.
The athletic trainer must also determine the functional de­ 1. Walking in place
mands that will be placed on the athlete upon return to 2. Forward/backward walking-small steps
competition and set up short- and long-term goals accord­ 3. Sidestepping
ingly. Upon cast removal it is important to address ROM 4. Butt kicks
deficits. This can be managed with PROM/ AROM exercises 5. High knees
in a supportive medium such as a warm whirlpool (Figures 6. Single-leg stance-lO to 15 seconds
23-1 to 23-4, 23-9, 23-14, 23-15 , 23-18 , 23-20). JOint 7. Ball catch-sidestepping
stilTness can be addressed via joint mobilization 8, Sport-specifIc activity
to any joint that was immobilized (Figures 14-6] to • Each activity can be performed for 30 to 60 seconds
14-68). It is possible to have post-traumatic edema in the with rest between each activity.
foot and ankle after cast removal that can be reduced with • All exercises should be performed with short-foot
massage. Strengthening exercises can help facilitate mus­ and good standing posture except where sport­
cle firing. strength, and endurance (Figures 23-5 to 23-8, specific activity dictates otherwise.
23-10 to 23-13). Balance and proprioception can be im­
proved with single-leg standing activities and balance
board activities (Figures 23-22 to 23-25). Cardiovascular
endurance can be addressed with pool activities including The exercise sandals offer an excellent means of ,facili­
swimming and pool running with a flotation device. sta­ tating ,lower-extremity musculature that can be affected by
':e forces can be
tionary cycling, and the use of an upper-body ergometer tibial and fibular fractures. Bullock-Saxton noted in­
t is planted and
(Figures 23-16, 23-17, 23-26. 23-27). A stair stepper is creased gluteal muscle activity with exercise sandal train­
large compressive
also an excellent way to address cardiovascular needs as .ing after 1 week. 14 Myers also demonstrated increased
all running back
well as lower-extremity strength. endurance. and weight gluteal activity, especially with high-knees marching in
an opposing player
bearing (Figure 23-17) . the exercise sandals." Blackburn has shown itlcreased ac­
'5t and applying a
Once the athlete demonstrates proficiency in static bal­ tivity in the lower-leg musculature, specifically the tibialis
e athlete's foot is
ance activities on var,ious balance modalities, more dy­ anterior and peroneus longus. while performing the exer­
rrremity is rotated.
namic neuromuscular control activities can be cise sandal progression activities. 1 I The lower-leg muscu­
r may be enough
introduced. Exercise sandals (OPTE Minneapolis) can be lature is usually weakened and atrophied. from being so
fracture may ac-
incorporated into rehabilitation as a closed-kinetic-chain close to the trauma. The exercise sandals olTer an excellent
functional exercise that places increased propriocepUve means of increasing muscle activation of the lower-leg
I and fibular frac­
demands on the athlete. The exercise sandals are wooden musculature in a functional weight-bearing manner.
Iced on a restricted sandals with a rubber hemisphere located centrally on the Rehabilitation Progression. Managcment of a
e to faci'litate frac­ plantar surface (Figure 23-28). The athlete can be pro­ post-immobilization fracture will require good conununi­
ted weight bearing gressed into the exercise sandals once they demonstrate cation with the physician to determine progression of
. and surrounding proflciency in barefoot single-leg stance. Prior to using the weight-bearing status, any assistive devices to be used dur­
J'icits once the frac­ exercise sandals the athlete is instructed in the short-foot ing the rehabilitation process. such as a wall;.er boot. and
' t ~, of the fracture. concept-a shortening of the foot in an A-P direction any other pertinent information that will influence the re­
rations such as an while the long toe flexors are relaxed, thus activating the habilitation process. It is important to address ROM defIcits
1'. Complicatioos fol­
short toe flexors and foot the intrinsics 36 (Figure 23-36) . immediately with AROM, passive stretching. and skilled
tiffoess of any joints Clinically the short foot appears to enhance the longitudi­ joint mobilization . Isometric strengthening can be initi­
\' r leg and posSibly nal and transverse arcbes of the foot. Once the athlete can ated and progressed to isotonic exercises once ROM has
1 reo as well as an perform the short-root concept in the sandals, they are been normaHzed. After weight-bearing status is deter­
xtoo demonstrated progressed to walking in place and forward waUdng with mined, gait training to normalize walking should be initi­
se le activation after short steps (Figure 23-29). The athlete is instructed to as­ ated. Assistive devices should be utilized as needed.
I muscle weakness is sume a good upright posture while training in the sandals. Strengthening of the involved lower extremity can be in­
I-weight-bearing ac­ Initially the athlete may be limited to 30 to 60 seconds corporated into the rehabilitation process. especially for
u res. It is important while acclimating to the proprioceptive demands. Once the the hip and thigh musculature. It is important for the ath­
mprehensive evalua­ athlete appears safe with walking in place and small-step letic trainer to identify and address this hip muscular
ential rehabilitation forward walking. they can follow a rehabilitation progres­ weakness early on in rehabilitation through open- and
. joint mobility, mus­ sion. See ',j'able 23-1 and Figures 23-30 to 23-34. closed-chain strengthening. Balance and proprioceptive
592 PART THREE The Tools of Rehabilitation
exercises can begin once there is full pain-free weightbear­
ing on the involved lower extremity.
A~ ROM, strength, and walking gait are normal.ized.
the athlete can be progressed to a walking/jogging pro­
gression and a sport-related functional progression. It
must be realized that the rate of rehabilitation progression
will depend on the severity of the fracture. any surgical in­
volvement, and length of immobilization. The average
healing time for uncomplicated nondisplaced tibial frac­
tures is 1() to 13 weeks: for disp laced. open. or commin­
uted tibial fracture. it is 16 to 211 weeks.hl
Fibula.r fractures may be immobilized for 4 to 6 weeks.
Again an open line of communicaLion with the physician
is required to facilitate a safe rehabilitation progression for
the athlete.
Criteria for Fut! Return. The following criteria
should be met prior to the return to full activity: (1) full
RCn,r and strength. compared to the uninvolved side:
(2) normalized walking, jogging, running gait: (3) ability
to hop for endurance and 90 percent hop for distallce as
compared to the uninvolved side, without complaints of
pain or observable compensation: and (4) successful com­
pletion of a sport-specil1c fun ctional test.
CLINICAL DECISION MAKING Exercise 23-1
An athlete 8 weeks after tibial fracture presents 10 the
train ing room, An X ray reveals excellent bony healing,
The cast was removed today. and the physician would like
him to begin rehabilitation . The evaluation reveals mod­
erate atrophy of tbe lower leg and quadriceps muscula­
ture, along with severe restriction in foot and ankle )oJnl
range of moti()n. Galt abnormalities are also present.
Muscle lesting reveals Significant weakness throughout
the enUre lower extremlty. What rehabilitation exercises
could this athlete start with to address some or his or­
thopaedk problems?
Tibial and Fibular Stress Fractures
Pathomechanics. Slress fractures of the tibia and
f1bula are common in sports. Studies indicate that stress
fractures of the tibia occur a t a higher rate than those of
the f1bula. 7.8 .44 Stress fractures in the lower leg are usually
the result of the bone's inability to adapt to the repetitive
loading response during training and conditioning of the
athlete. The bone attempts to adapt to the applied loads ini­
tially through osteoclastic acLivity. which breuks down the
bone. Osteoblastic uctivity, or the laying down of new
bone. will soon foHO\\!.5l.71 rr the applied loads are not re­ subtalar joint 10
duced during this process, structural irregularities will de­ alignments suc~
velop within the bone, which will further reduce the bone's femoral ante\'er--;
ability to absorb stress and will eventually lead to a stress affect the leg dw
fracture 8 .26 might become a (
Repetitive loading of the lower leg with weight-bearing duration, an d l'"
activity such as running is usually the cause of tibial and time. 29 .7) In crea·
fibular stress fractures. Romani reports that repetitive m e­ muscle-tendo n
chaniea lloading seen with the initiation of a stressful ac­ applied load. II
tivity may cause an ischemia to the afrected bone. if> He fractures of the .
reports that repetitive loading may lead to temporary oxy­ from the same pr
gen debt of the bone, which signals the remodeling process of repetitive jum:
to begin . 56 Also. microdamage to the capillaries further re­ may playa grea'
slricts blood flow, leading to more ischemia. which again perpronat ion ca'
triggers the remode'iing process-leading to a weakened crowned road. s
bone and a setup for a stress fracture. i~ running on a
Stress fractures in the tibial shaflmainly occur in the will tend to inerf',
midanterior aspect and the posteromedial aspect. 7.44.53. 7l closer to the in
Anterior tibial stress fractures usually present in athletes also playa role
involved in repetitive jumping activities with localized pain activity of th e
directly over the midanterior tibia. The athlete will com­ on the bone m
plain of pain with activity that is relieve.d with rest. 'fhe ture. l] 1'niinin
pain can affect activities of daily living (ADLs) if act.ivity is a long with IV
not modined. Vibration testing using a tuning fork will re­ problems. j~ alb
produce the symptoms. as wiII hopping on the involved ex­ lies, diet. bone
tremity. i\ triple-phase technet.iuIT1~ 9 bone scan can ial w idth., a nd
confirm the diagnosis faster than an X ray, as it ('[111 take a
minimum of 3 weeks to demonstrate radiographic
changes.'1.53 71 Posteromedial tibial pain usually occurs
over the distal one-third of the bone with a gradual onset
of symptoms.
Focal point tenderness on th e bone will help differen­
tiate a stress fracture from medial tibial stress syndrome cycling and ru
(MTSS), which is located in the same area but is more dif­
fuse upon palpation . The procedures listed above wiJI be
positive and will implicate the stress fracture as the small but stali
source of pain. Fibular stress fractures usually occur in oble capacity wI"
the distal one-third of th e bone with the same sympto­ ular runnin g. : :
matology as for tibial stress fractures. Although less com ­ bike. 12 These au
mon, stress frac Lures of the proxim a l fibula are noted in and frequen c\­
the literao[ure . 44 . b9 . ~2 et a!. note th aI
Injury Mechanism, Anterior tibial stress fractures
are prevalent in athletes involved with jumping. Several
authors have noted that the tibia will bow anteriorly with
the convexity on the anterior aspect. I S . i l.)47 l This places
the anterior aspect of the tibia under tension. which is less
than ideal for bone healing. which prefers compressive
forces. Repetitive jllmping will place greater teosion on important. For
this area, which ha s minimal musculotendinous support type will req uire
and blood supply. Other biomechanical factors may be in­ ties. A pes pl anus
volved, including excessive com pensatory pronation at the

subtalar joint to accommodate lower- extremity structural
alignments such as forefoot varus, tibial varum, and
femoral anteversion. This excessive pronation might not
affect the leg during ADLs or with moderate activity. but
might become a factor with increases in training intensity,
'ght-bearul: duration , and frequency, even with suffiCient recovery
of tibial time.29 .73 Increased training may affect the surrounding
repetitin' muscle-tendon unit's ability to absorb the impact of each
a me fu. applied load. which places more stress on the bone. Stress
ed bone.~ fractllres of the distal posteromedial tibia will also arise
from the same problems as listed above, with the exception
of repetitivc jumping. Exccssive compensatory pronalion
may playa greater role with this type of injury. This hy­
perpronation can be accentuated when running on a
crowned road, such is the case of the uphill leg. 37 Also,
funning on a track with a small radius and tight curves
Iv occur in t
will tend to increase pronatory stresses on the leg that is fractures of the mid anterior tibia can take much longer.
lal ~pect.'A~- ­ closer to the in side of the track. \7 Excessive pronation may
esent in athle also playa role with flbular stress fractures. The repeated
th localized pam activity of the ankle everters and calf musculature pulling
athlete will om· on the bone may be a source of this type of stress frac­
w ith re l. Th . ture. \ J Training errors of increased duration and intensi ty
DIs) If a cti\'it) along with worn out shoes wUl only accentuate these
ning fork will r . problems. \7 Other fact ors, including menstrual irregulari­
n lh involved e. ­ ties. diet, bone density, increased hip external rotation, tib­
bone scan car­
ial width, and calf girth. have also been identi fied as venous blood pressu re produces a positive piezoelectric ef­
rar. as it can take
contributing to stress fractures .s .2R fect that stimulates osteoblastic activity and facilitates frac­
"CIte radiograph'
Rehabilitation Concerns. Immediate elimination ture healing. 81 Rettig et ai. used rest from the olTending
in usua lly oc UI"" of the offending activity is most importallt. The athlete
tb a gradual on. must be educated on the importance of this to prevent fur­
ther damage to the bone. Many a thletes will express con­
Ie \\ ill help differen· cerns about fitness level with loss of activity. Stationary
al st ress s ' ndrom~ cycling and running in the deep end of the pool with a flota­
area bu t is more dif· tion device can help maintain cardiovascular fitness (Fig­
Ii ted above will be ures 23-16, 23-26). Eyestone et al. have demonstrated a
fracture as tb l.' small but statistically significant decrease in maximal aer­
usually occur if' obic capacity when water running was substituted for reg­
the samc sympt(}­ ular running. 22 This was also true with using a stationary
\It hough less COill­ bike. 21 These authors recommend that intensity, duration,
fib ula are noted ir. and frequency be equivalent to regular tra ining. Wilder
et al. note that water provides a resistance that is propor­
ibia l stress fract ur tional to the effort exerted. 7R These a uthors found that ca­
lh jumping. Severa dence, via a metronome. gave a quanlilaUve external cue
bow a nteriorly with tha t with increased rate showed high correlation with
,51. 54 .7l This plac heart rate. 78 Nonimpact activity in the pool or on the bike
ension , which is Ie will help maintain Iltness and allow proper bone healing.
pre fers compressh Proper footware that matches the needs of t he loot is also
. greater tension 0 important. For example, a high arched or pes cavas loot
Ilotendinous suppor type will require a shoe with good shock-absorbing quali­
'al fa ctors may be in­ ties. A pes planu s foot type or more pronated foot will re­
ILOry pronation at t he quire a shoe with good moUon control characteristics. A
CHAPTER 23 Rehabilitation of Lower-Leg Injuries 593
detailed biomec hanical exam of the lower extremity both
statically and dynamically may reveal problems that re­
quire the use of a custom foo t orthotic. Stretching and
strengthening exercises ca n be incorporated in the rehabil­
itation process. The use of ice and electrical stimulation to
control pain is also recommended. The utilization of an Air­
cast with athletes who have diagnosed stress fractures has
produced positive res ults. J 9 Dickson et aI. speculate that the
Aircast unloads the tibia and fibula enough to allow heal­
ing of the stre,ss fracture with continued participation. 19
Swenson et al. reported that athletes with tibial stress frac­
tures who used an aircast returned to full unrestricted ac­
tivity in 2] ± 2 days: athletes who used traditional regimen
returned in 77 ± 7 days. 72 Fibular and posterior medialtib­
ial stress fractures wiill usually heal without residual prob­
lems if the above-mentioned concerns are addressed. Stress
and residual problems might exist month s to years after th e
initial diagnosis, with attempts at increased activ­
it y.18.1I.\ l.54 Initial treatment may include a short leg cast
and non-weight-bearing for 6 to 8 weeks. Batt et al. noted
that use of a pneumatic brace in those individuals allowed
for return to unrestricted activity. an average of 12 months
from presentation. 4 The proposed hypoth esis for use of a
pneu matic brace is that elevated osseous hydrostatic and
activity as well as electrical stimulation in the form of a
pulsed electromagnetic field for a period of 10 to 12 hours
per day. The authors noted an average of 12. 7 months from
the onset of symptoms to return to full activity with this
regimen. 54 They recommended Llsing this program for 3 to
6 months before considering surgical intervention. 54
Chang et. al. noted good to excellent results with a surgical
procedure involving intramedullary nailing of the tibia
with individuals with delayed union of this ty pe of stress
fracture. 1R Surgical procedures involving bone grafLing
have also been recommended to improve healing of this
type of stress frac ture.
Rehabilitation Progression. After diagnosis of
the stress fracture. the athlete may be placed on crutches.
depending on the amount of discomfort with ambulation .
Tee and electrical stimulation can be used to reduce local
inflammation and pain. The athlete can immediately be­
gin deep-water running with the same training parame­
ters as their reg ular regimen if th ey are pain-free.
Stretching exercises for the gastrocnemius-soleus musc u­
lature can be performed 2 to 3 t.imes per day (Figure
23- J 9). Isotonic strengthening exercises with rubber tub­
ing can begin as soon as tolerated on an evcry-other-day
594 PART THREE The Tools of Rehabilitation
basis, with an increase in repetitions and sets as the ath­
letic trainer sees fit (Figures 23-5 to 23-8). Strengthening
of the gastrocnemius can be dOl1e initially in an open
chain and eventually be progressed to a closed chain (Fig­
ures 23-5, 23-12. 23-13). The athlete should wear sup­
porlive shoes during the day and avoid shoes with a heel.
which can cause adaptive shortening of the gastroc-soleus
complex and increase strain on the healing bone. Custom
foot orthotics can be fabricated for motion control in order
to prevent excessive pronaUon for those athletes that need
it. Foot orthotics can also be fabricated for a high arched
foot to increase stress distribution throughout the plantar
aspect of the whole foot versus the heel and the metatarsal
heads. Shock-absorbing materials can augment these or­
thotics to help reduce ground reaction forces. The exercise
sandal progression can also be introduced to help facilitate
lower-leg muscle activity and strength (Figures 23-29 to
23-34 and 23-36). As the symptoms subside over a period
of 3 to 4 weeks and X rays confirm that good callus forma­
tion is occurring. the athlete may be progressed to a walk­
ing/jogging progression on a surface suitable to that
athlete's needs. The athlete must demonstrate pain-free
ambulalion prior to initiating a walk/jog program. A qual­
ity track or grass surface may be the best chOice to begin
this progression. The athlete may be instructed to jog for
1 minute, then walk for 30 seconds for 10 to 15 repeti­
lions. This can be performed on an every-other-day basis
with high-intensity liang-duration cardiovascular train­
ing occurring daily in the pool or on the bike. The athlete
should be reminded that the purpose of the walk/jog pro­
gression is to provide a gradual increase in stress to the
healing bone in a controlled manner. If tolerated. the jog­
ging time can be increased by 30 seconds ever)7 2 to 3
training sessions untU the athlete is running 5 minules
without walking. The above progression is a guideline and
can be modified based on individual needs.
Romani has developed a three-phase plan for stress
fracture management. i6 Phase 1 focuses on decreasing
pain and stress to the injured bone while also preventing
deconditioning. Phase 2 focuses on increasing strength,
balance, and conditioning. and normalizing function,
without ao increase in pain. After 2 weeks of pain-free ex­
ercise in phase 2. running and functional aclivities 01
phase 3 arc introduced. Phase 3 has functional phases and
rcst phases. During the functional phase. weeks 1 and 2,
running is progressed ; in the third week, or rest phase,
running is decreased. This is done to mimic the cyclic fash­
ion of bone growth. During the flrst 2 weeks. as bone is re­
sorbed. running will promote the formalion of trabecular
channels: in the third week. while the osteocytes and pe­
riosteum are maturing, the impact loading of running is
removed. 56 This cyclic progression is continued over sev­
eral weeks as the athlete becomes able to perform sport­ cipitating tra uma
speCific activities without pain. iii which acute c
Criteria for Full Return. The athlete can return minimal to mode.
to full aclivity when (1) there is no tenderness to palpa­ properly, it can lee;
tion of the affected bone and no pain of the affected area athlete.2J.SO Again
with repeated hopping. (2) plain mms demonstn:lte good fIrm the di agnosf
bone healing, (3) there has been successful progreSSion of treatment of ('r
a graded return to running with no increase in symp­ ICCS) is acti\'ity­
toms. (4) gastroc-soleus flexibility is within normal lim­ consistently at a ­
its, and (5) hyperpronation has been corrected or complains of a 51
shock-absorption problems have been decreased with the affected CO!!!,..,:
proper shoes and foot orthotics if indicated. (6) All mus­ the activity. Stu
cle strength and muscle length issues of the involved ler,ior compar
lower extremity have been addressed. presentation of·
CLINICAL DECISION MAKING Exercise 23-2 using a slit ca
mental preSSlW
A freshman cross-country athlete presents with localized
d1e follOWin g in
posterior medial shin pain. She notes a gradual onset in
of CCS: (1) pren
the last :2 weeks with an increase in her training volume. (2) 1 minute
She has been training primarily on concrete and asphalt.
and also on trails wet from excessive rainfall. What advice
can the athletic trainer give this athlete to help her elimi­
na te this problem?
Compartment Syndromes
Pathomechanics and Injury Mechanism. Com­
partment syndrome is a condition in which increased pres­
sure. within a fixed osseofascial compartment, causes
compression of muscular and neurovascular structures
within the compartment. As compartment pressures in ­
crease, the venous outflow of fluid decreases and even tu­
ally stops, which causes further fluid leakage from the
capillaries into the compartment. Eventually arterial blooc!
inflow also ceases secondary to rising intracompartmenta.
pressures. 76 Compartment syndrome can be diVided im
three categories: acute compartment syndrome, acute ex­
ertional compartment syndrome, and chronic compar.­
ment syndrome. Acute compartment syndrome ocr
secondary to direct trauma to the area and is a medi
emergency.l7.70.7h The athlete will complain of a det:t'­
seated aching pain, tightness, and swelling of the invoh ponding to a
compartment. Reproduction of the pain wiLl occur \\ cio[omy report
passive stretching of the involved muscles. Reductio n inj ury. 64 i\lichelf
pedal pulses and sensory changes of the involved nen'c l more pron e 10 th
be present but arc not reliable signs. 7h.Ho IntracoOl pG.-­ lbey did not res
mental pressure measurements will conftrll1 the diagn
Emergency fasciotomy is the del1nitive treatment. Acu te ....­
ertional compartment syndrome occurs without an} p-.

) perform sport­ cipitating trauma. Cases have been cited in the literature in
which acute compartment syndrome has evolved with
llete can return rr
minimal to moderate activity. not diagnosed and treated
ern ess to paJpa­ properly, it can lead to a poor functional outcomes for the
lhe a rfcc ted a rea athlete.2>.XO Again intraeompartmental pressures will con­
~mo nstrate good fIrm the diagnosis, with emergency fasciotomy being the
ul progression of treatment of choice. Chronic compartment syndrome
r ase in symp­ (CCS) is aCUvity-related in that the symptoms arise rather
.hill normal lim­ consistently at a certain point in the activity. The athlete
~n corrected or complains of a sensation of pain, tightness. and swelling of
decreased with the affected compartment. which resolves upon stopping
lted . (6) All muS­ the activity. Studies indicate that the anterior and deep pos­
of the invol ved terior compartments are usually involved."·1 5.61.71. 79 Upon
presentation of these symptoms, intracompartmental pres­
sure measurements will further defIne the severity of the
condition. Pedowitz et al. have developed modif1ed criteria
Exercise 23-2 using a slit catheter measurement of the intracompart­
m ental pressures. These authors consider one or more of
'ith localized the following intramuscular pressure criteria as diagnostic
ual onset in
of CCS: (1) preexercise pressure greater than 15 mm Hg. ac tivity of the deep posterior comparlment. which is highly
ming \'olume.
(2) 1 minute postexercise pressure of 30 mm Hg, (3) a active in controlling pronation during running. i1 Cardio­
e and asphalt.
5-minute postexercise pressure greater than 20 mm Hg. 50 vascular Htness can be maintai ned and improved with sta­
. What advice Rehabilitation Concerns. Management of CCS
elp her elimi­ is initially conservative with activit.y modification , ic ing,
and stretching of the anterior compartment and
gastrocnemius-soleus complex (Figures 23-21 to 23-23).
A lower-quarter structural exam along with gait analysis
might reveal a structural variation that is causing exces­
sive compensatory pronation and might benefIt from the
-chanism. Com­ use of foot orthotics and proper footwear. These measures
h increased pres­ will not address the issue of increased compartment pres­
Ipar tment. causes sures with acUvity. though. Cycling has been shown to be
asc ular structures an accep table alternative in preventing increased anterior
nen t pressures in­ compartment pressures when compared to running and
~ea ses and eventu­ can be utilizcd to maintain cardiovascular fItness. 2 If con­
lea kage from the servative measures fail, fasciotomy of the affected com­
a lly arterial blood partments has produced favorable results in a return to
tracompartmental higher level of ac Uvity. 55.SV6.79
n be divided into The athlete should be cou nseled regarding the out­
-ndrome, acute ex­ come ex pectations after fasciotomy for CCS. Howard re­
hronic compart­ ported a clinically significant improvement in 81 perce nt
syndrome occurs of the an terior/ lateral releases and a 50 percent improve­
and is a medical me nt in deep posterior compartm en t releases with CCS. 35
P1plain of a deep­ Slimmon et a!. noted that 58 percent of the subjects re­
lin g of the involved sponding to a long-term (allow-up study for CCS fas­
Lin will occur with ciotomy reported exercising at a lower level than before the
les. Reduction in injury. 64 Micheli et al. no ted that female athletes may be
~ in volved nerve can more prone to this co ndition and that for reaso ns unclear
- ~."o Intracompart­ th ey did not respond 10 the fasciotomy as well as their male
[lfi rm the diagnosis . counterparts. 45
reatment. Acute ex­ Rehabilitation Progression. Following fascioLomy
r without any pre- for CCS, the immediate goals are to decrease postsurgical
CHAPTER 23 Rehabilitation of Lower-Leg fnjuries 595
pain, swelling with RICE, and assisted ambulation wi th tbe
use of crutches. After suture removal and soft-tissue heal­
ing of th e incision has prog ressed, AR..OM and flexibility ex­
ercises should be initiated (Figures 23-1 to 23-4.23-18 to
23-21) . Weight bea ring will be progressed as .ROM im­
proves. Gait training should be incorporated to prevent ab­
normal movements in the gait pattern secondary to joint
and soft-tissue stiffness or muscle guarding. A.ROM exer­
cises should be progressed to open-chain exercises with
rubber tubing (Figures 23-510 2.3-8). Closed-kinetic-chain
activities can also be initiated to incorporate strength. ba'l­
ance, and proprioception that may have bcen affected 'by
th e surgical procedure (Figures 23-12 to 24-1 S. 23-22 to
23-25). Lower-ex tremity structurar variaUons that lead Lo
excessive compensatory pronation during gait should be
addressed with foot orthotics and proper shoeware after
walking gait has been normalized. These measures should
help control excessive movements a t the subtalar
joint/lower leg and thus theoretica lly decrease muscular
tionary cycling and running in the deep end of a pool wilh
a flol ation device (Figures 23-16. 23-26). When ROM,
slrength, and walking gait have norm al ized. a walking /
jogging progression ca n be initialed.
Criteria for Returning to I:'ull Activity. The ath­
lete may return to ~ull activity when (1) the re is normal­
ized ROM a nd strength of the involved lower leg, (2) there
are no gait deviations with walking. jogging, and running.
and (3) the athlete has completed a progressive
jogging/ running program with no complaints of CCS
symptoms. It sh ould be noted that a thletes undergoing an­
terior comparlment fasciotomy may not return to futI ac­
tivity for 8 to 12 weeks after surgery, while athletes
undergoing deep posterior co mpartmenl fasciolomy may
not return lIntii 3 olo 4 months posl surgery. l9 .5R
CLINICAL DECISION MAKING Exercise 23-3
A rema le lacrosse athlete has been diagnosed with ante­
rior com partment syndr me. he pr senLS to the athletic
train ing room for recommendation on reha bilitation ex­
ercises and activity modification prior to attempts at sur­
gery. Prior to being diagnosed. the athlete had been
running long distances on an urban. hill course for con­
ditioning. She has a history of lower-extremity muscu­
loskeletal dysfunction. Including decreased ne~ibllity and
'xcessive pronation . List and discuss recommendatlons
the atWeti tralner an give to this athlete to alleviate the
symptoms of anterior ompartrnent syndrome.
596 PART'l'HREE The Tools of RehabililOtion
Muscle Strains
Pathomechanics. The majority of muscle strains
in the lower leg occur in the medial head of the gastrocne­
mius at the musculotendinous junction. 27 The injury is
more common in middle-aged athletes and occurs in ac­
tivities requiring ballistic movement such as tennis and
basketball. The athlete may feel or hear a pop as if being
kicked in the back of the leg. Depending on the severity of
the strain. the athlete may be unable to walk secondary to
decreased ankle dorsiOexion in a closed kinetic chain
which passively stretches the injured muscle and causes
pain during the push-olI phase of gait. Palpation will elicit
tenderness at the site of the strain. and a palpable divot
may be present. depending on the severity of the injury
and how soon it is evaluated.
Injury Mechanism. Strains of the medial head of
the gastrocnemius usually occur during sudden ballistic
movements. A common scellario is the athlete lunging
with the knee extended and the ankle dorsif1exed. The an­
kle plantarOexes. in this case the medial head of tbe gas­
trocnemius. are activated to assist in push-off of the foot.
The muscle is placed in an elongated position and acti­
vated in a very short period of Lime. This places the mus­
culotendinous junction of the gastrocnemius under
excessIve tensile stress. The muscle-tendon junction. a
transition area of one homogeneous tissue to another. is
not able to endure the tensile loads nearly as well as the ho­
mogeneous tissue itself. and tearing of the tissue at the
junction occurs.
Rehabilitation Concerns. The initial manage­
ment of a gastrocnemius strain is ICE. It is important for
the athlete to pay special attention to compression and el­
evation of the lower extremity to avoid edema in the foot
and ankle. which can further limit ROM and prolong the
rehabilitation process. Gentle stretching of the musc\e­
tendon unit should be i.nitiated early in the rehabilitation
process (Figure 23-1 il). Ankle plantarOexor strengthening
with rubber tubing can also be initiated when tolerated
(Figure 23-5). Weight bearing may be limited to an as­
tolerated status with crutches. The fool/ankle will prefer a
plantarflexed position. and c1osed-kinetic-chain dorsiOex­
ion of the foot and ankJe. which is required during walk­
ing. will stress the muscle and cause pain. Pulsed
ultrasound can be utiJized early in the rehabilitation
process and eventllally progressed to continuous ultra­
sound for its thermal effects. A stationary cycle can be used
for an active warm-up as well as cardiovascular i1tness. A
heel lift may be placed in each shoe to gradually increase
dorsiOexion of the foot and ankle as the athlete is pro­
gressed off crutches. Standing. stretching and strengthen­
ing can be added as soft-tissue healing occurs and ROM
and strength improve. Eventually the athlete can be pro­ Medial Tibii
gressed to a walking /jogging program and sport-speciflc
activity. It is important that the athlete W<lrm up and Pathomec
stretch properly before activity. to prevent reinjury. (MTSS) is a co
Rehabilitation Progression. Early management of the dist<ll two-,
a medial head gustrocnemius strain focuses on reduction of tibia. 1 6 . 6~ Th
pain <lnd swelling with lCE und modified weight bearing.
The athlete is encouraged to perform gentle towel stretch­
ing for the affected muscle group several times per d8y (Fig­
ure 23-Ul). AROM of the foot and ankle in all planes will
also facllitate movement and act to stretch the muscle (!lig­
ures 23-l to 23-4). With mild muscle strains. the athlete
may be off crutches and performing standing cull' stretches
and strengthening exercises by about 7 to 10 days with u
normal gait pattern (Figures 23-12. 23-13. 23-19). lvlod­
crate to severe strains may Luke 2 to 4 weeks before nor­
mal.ization of ROM and gait occur. This is usually due to the
excessive eden18 in the foot and ankle. Strengthening can
be progressed from open- to closed-chain activity as soft-tis­
sue healing occurs (Figures 23-l4. 23-15. 23-22 te
23-25). As walking gait is normalized. the athlete is en­
couraged to begin a graduated jogging program in which
distance and speed are modulated throughout the progres­
sion. Most son-tissue injuries demonstrate good healing b~
14 to 21 days poslinjury. In the case of mJlLl muscle strain.
as the athlete becomes more comfortable with jogging a nd
running. plyometric activities can be added to the rehabi li ­
tation process. Plyometric activities should be introduced ill
a controlled fashion with alleast ] to 2 days of rest bet we
activities to allow for muscle soreness to diminish. As th
athlete adapts to the plyometric exercises. sport-speciliL
training should be added. Care should be taken to save suG­
den. ballistic activities for when the athlete is warmed u
and the gastrocnemius is well stretched.
Criteria for Full Return. The <lthlet c may returr
to full activity when the fo!.lowing criteria have been mt"
(1) full ROM of the foot and ankle. (2) gnstrocnemit:.
strength and endurance that are equallO the uninvoh
side. (3) ability to walk. jog, run. and hop on the invol n~
extremity without any compensation. and (4) successfl
completion of a sport-specific functional progression \\;
no residual calf symptoms.
CLINICAL DECISION MAKING Exercise 23-4
A male tennis player presents to the training room with
medial ca U' pain while playing tennis. He noted a sudden
onset of pain while serving. List stretching and strength­
ening exercises in a progressive order that the athletic
trainer could provide to the athlete.

e can be pro­ Medial Tibial Stress Syndrome
qx>rl- ped fie
rm up and Pathomechanics. Medial tibial stress syndrome
ur~ '. (MTSS) is a condition that involves increasing pain about
'1agement of the distal two-thirds of the posterior medial aspect of the
reductio n of tibia.l MbThe soleus and tibialis posterior have been impli­
ghl bearing. cated as muscular forces that can stress the fascia and pe­
r: \'el tretc h­ riosteum of the distal tibia during rurwing activities.2.25.61
per day (Fig­ Tn a cadaveric dissection study, Beck and Osternig impli­
planes \\ill cated the soleus as the major contributor toMTSS and not
Ie IFi ­ ~he tibialis posterior.' Magnusson et al. noted reduced
bone mineral density at the site of MTSS but could not as­
certain whether this was the cause or the result. 41 Bhatt
reported abnormal histological appearance of bone and
periosteum in long-standing MTSS. 10 Pain is usually dif­
fuse about the dista l medial tibia and the surrounding soft
tissues and can arise secondary to a combination of train­
ing errors, excessive pronation, improper shoeware, and
poor conditioning level. 16 .bl Initially. the area is diffusely
tender and might hurt only after an intense workout. As
the condition worsens, daily ambulation may be painful
and morning pain and stiffness may be present. Rehabili­
tation of this condition must be comprehensive and ad­
dress several factors , including musculoskeletal. training,
and conditioning, as well as proper shoeware and or­
thotics intervention.
Injury Mechanism. Many sources have linked ex­
cessive compensatory pronation as a primary cause of
MTSS. 16.15.bI.6h Bennett et al. reported that a pronatory foot
type was related to MTSS. The authors noted that the com­
bination of the athlete's sex and navicular drop test meas­
ures provided an accurate prediction for the development of
rvrrss in high school runners.9 Subtalar joint pronation
serves to dissipate ground reaction forces upon foot stdke in
ma~ return order to reduce the impact to proximal structures. If prona­
been m tion is excessive or occurs too quickly or at the wrong time
in the stance phase of gait, greater tensile loads wm be
placed on the muscle~tendon units that assist in controlling
this complex triplanar movement. 30.74 Lower-extremity
structural variations sllch as a rearfoot and forefoot varus
can cause the subtalar joint to pronate excessively in order
Lo get the medial aspect 0[' the forefoot in contact with the
ground for push-off. 6b The magnitude of these forces will
increase during running, especially with a rearfoot striker.
Sprinters may present with similar symptoms but with a
different cause, that being overuse of the plantar11exors
secondary to being on their toes during their event. Train­
ing surfaces including embankments and crowned roads
can place increased tensile loads on the distal medial tibia,
and modifications should be made whenever possible.
Rehabilitation Concerns. Management of this
condition should include physician referral to rule out the
CHAPTER 23 Rehabilitation of Lower-Leg (njuries 597
possibility of stress fracture via the use of bone scan and
plain films. Activity modification along with measures to
maintain cardiovascular fitness are set in place immediately.
Correction of abnormal pronation during walking and
running can be addressed with antipronation taping and
temporary orthotics to determine their effectiveness. Vi­
cenzino et al. reported that these measures were helpful in
controlling excessive pronation. 77 H the above measures
are helpful, a custom foot orthotic can be fabricated.
Masse' Genova noted that foot orthotics signifIcantly re­
duced maximum calcaneal eversion and cakaneal ever­
sion at heel rise with abnormal pronaters during treadmill
walking. 4J Proper shoeware, especially running shoes
with motion control features. can also be very helpful in
dealing with MTSS. While the above-mentioned meamres
provide passive support to address abnormal pronation,
exercise sandals may provide a dynamic approach to man­
aging excessive pronation issues. Michell et al. noted a
trend in reduced rearfoot eversion angles in 2-D rearfoot
kinemat,ics during bar.efoot treadmill walking with abnor­
mal pronaters who trained in the exercise sandals for 8
weeks. 46 The subjects also demonstrated improved balance
in a sing,le-leg stance and subjectively noted improved foot
functionY' These improvements might be due to increased
muscle activity of the foot intrinsics via the short-foot con­
cept and increased activity of the lower-leg musculature
that may assist in controlling pronation. Also, the exercise
sandals appear to place the foot in a more supinated posi­
tion, which may enhance the cuboid pulley mechanism
and its effects on the fUllction of the first ray during the
push-off phase of gait. 34 Ice massage to the affected area
may help reduce localized pain and in11ammation. A 11exi­
bility program for the gastrocnemius-soleus musculature
should be initiated.
CLINICAL DECISION MAKING Exercise 23-5
A ronner athlete who is currently tralnlng for a lO-K race
present to the athletic training room with .. hln splints."
She run during her lunch hour in an urban area, and
over the past}. weeks she has doubled her mileage. which
has not allowed her time to stretch after training. She
notes Lhat her running shoes afe about 1 year old. What
advice can the athletic trainer give to this individual?
Rehabilitation Progression. Running and jump­
ing activities may need to be completely eliminated for the
fITst 7 to 10 days after diagnosis. Pool workouts with a 110ta­
tion device will help maintain cardiovascular fitness during
the healing process. Gastrocnemius-soleus 11exibility is
598 PART'FHREE The1bols of Rehabilitation
improved with static stretching (Figure 23-19). Ice and
electrical stimulation can be used to reduce inflammation
and modulate pain in the early stages. As the condition im­
proves. general strengthening of the ankle musculature
with rubber tubing can be performed along with calf mus­
cle strengthening (Figures 23-5 to 23-8,23-12,23-13).
These exercises may cause muscle fatigue but should not
increase the athlete's symptoms. The exercise sandal pro­
grcssion can be introduced to enhance dynamic pronation
control at the foot and ankle (Table 23-1) (Figures 23-29 to
23-34,23-36). An isokinetic strengthening program of the
ankle inverters and everters can be utilized to improve
strength and has been shown to reduce pronation during
treadmill running H (see Figures 24-24). As mentioned
previously. it is imperative that all structural deviations that
cause pronation be addressed with a foot orthotic or at least
proper motion-control shoes. As pain to palpation of the
distal tibia resolves, the athlete should be progressed to a
jogging/running program on grass with proper footwear.
This may involve beginning with a 10- to IS-minute run
and progressing by 10 percent every week. In the case of
track athletes, a pool or bike workout can be implemented
for 20 to 30 minutes after the run to produce a more de­
manding workout. The athlete needs to be compliant with
a gradual progression and should be educated to avoid do­
ing too much. too soon, which could lead to a recurrence of
the condition or possibly a stress fracture.
Criteria for Returning to Full Activity. The ath­
lete may return to full activity when (1) there is minimal to
no pain to palpation of the affected area, (2) all causes of
excessive pronation have been addressed with an orthotic
and proper shoeware, (3) there is sufflcient gastrocnemius­
soleus musculature fleXibility, and (4) the athlete has suc­
cessfully completed the gradual running progression and a
sport-speciOc functional progression without an increase
in sym ptoms.
CLINICAL DECISION MAKING Exercise 23-6
An athlete presents to the training room from the physi­
cian with a referral to fabricate orthotics for abnormal
pronation. List some possi ble structural causes of abnor­
mal pronation the at hletic trainer can look for during the
evaluation.
Achilles Tendinitis
Pathomechanics. Achilles tendinitis is an inflam­
matory condition that involves the Achilles tendon and /or
its tendon sheath. the paratenon. Often there is excessive
ten sUe stress placed on the tendon repetitively, as with run­
ning or jumping activities, that overloads the tendon, espe­
cially on its medial aspect. 48.60 This condition can be divided
into Achilles paratenonitis or peritendinitis, which is an in­
flammation of the paratenon or tissue that surrounds th • •,:111
tendon, and tendinosis, in which areas of the tendon con­
INJURY SlTU,
sist of mucinoid or fatty degeneration with disorganize
present for th
collagen. 60 The athlete often complains of generalized pai n
Ding. and im
and stiffness about the Achilles tendon region, which when
ing down
localized is usually 2 to 6 cm proximal to the calcanea'l' in­
sertion. Uphill running or hill workouts and interval train­ SIGNS AND
ling will usually aggravate the conrution. There may be ial varum. Hh
reduced gastrocnemius and soleus muscle flexibility in gen­ lion and int
eral that may worsen as the condition progresses and adap­ slight th ick
tive shortening occurs. Muscle testing of the above muscles cancal insen
may be within normal limits, but painful and a true deOcil ga.strocnemi
may be observed when performing toe raises to fatigue as demons lrall~
compared to the uninvolved extremity.
Injury Mechanism. Achilles tendinitis will often
present with a gradual onset over a period or time. Initially
the athlete might ignore the symptoms, which might pres­
ent at the beginning of activity and resolve as the activity
progresses. Symptoms may progress to morning stiffne
and discomfort with walking after periods of prolonged sit­
ting. Repetitive weight-bearing activities, such as running
or early-season conditioning in which the duration and in­
tensity are increased too quickly with insufficient recovery
time, will worsen the condition. Excessive compensatory
pronation of the subtalar joint with concomitant internal
rotation of the lower leg secondary to a forefoot varus, tib­
ial varum, or femoral anterversion will increase the tensile
load about the medial aspect of the Achilles tendonY'f,I
Decreased gastrocnemius and soleus complex flexibility
can also increase subtalar joint pronation to compensate
for the decreased dosed-kinetic-chain dorsiflexion needed
during early and midstance phase of running. If th.e athlete PHAS E
continues to train, the tendon wiII become further inflamed
GOALS: Incr
and the gastrocnemius-soleus musculature will become
less ef11cient secondary to pain inhibition. The tendon may
be warm and painful to pal'pation, as well as thickened.
which may indicate the chronicity of the condWon. Crepi­
tace may be palpated with AROM plantar and dorsillexion
and pain win be elicited with passive dorsiflexion.
Rehabilitation Concerns. Achilles tendinitis can
be resistant to a quick resolution secondary to the slowe
healing response of tendinous tissue. It has also been
noted that an area of hypovascularity exists within th e PHAS E
tendon that may l'urtber impede the healing response. It is GOALS:
important to create a proper healing environment by rc­
ducing the offending activity and replacing it with an ac­
tivity that wil! reduce strain on the tendon. Studies ha\ L
shown that the achilles tendon force during running ap­
 CHAPTER 23 Rehabilitalion of Lower-Leg Injuries 599

ely. as with run­

D tendon. espe· REHABILITATION PLAN
10 can be divided
i. whicb is an in"
ACHILLES TENDINITIS
II surrounds the
!he tendon con­
INJURY SnuATlON A 17-year-old male lacrosse player presents with pain in his right achilles. He notes Ilhat the pain has been
im disorganized present for the past week. secondary to an increase in preseason conditioning that has ,included long runs on asphalt, hill run­
generalized pain
ning. and interval training on the track. He currently has morning stiffness and pain with walking, especially up hiUs and go­
ion. which when
ing down stairs. The athlete is concerned that the pain will affect his conditioning for the season. which wiLl start in 3 woeks.
the calcaneal in­
Id interval train­ SIGNS AND SYMPTOMS The athlete stands in moderate subtalar joint pronation with mild tib­
I. There may be ial varum. His single-leg stance balance is poor. with an increase ,in subtalar joint (STn prona­
n xibiUty in gen­ tion and internal rotation of the entire lower extremity. Observation of the tendon reveals
~esses and ada(J­ slight thickening. Palpation reveals mild crepitus with pain 4 centimeters proximal to the cal­
Ie above muscles caneal insertion on the medial side of the tendon. ROM testing reveals tightness in both the
wd a true deficit gastrocnemius and soleus musculature versus the uninvolved side. A 6-inch lateral step-down
to fatigue as demonstrates restricted c1osed-kinetic-chain ankle dorsil1exion that is painfull, with compen­
sation at the hip to get the opposite heel to touch the ground. The athlete is able to perform 10
hollis will often heel raises on the right with pain and 20 on the left without pain. Walk.ing gait reveals in­
Iof time. InitiaHy creased pronation during the entire stance phase of gait. A .12-degree forefoot varus is noted
rhich might pres· on the right with the athlete in a prone STJ neutral position.
, as the activity
om ing stiffness MANAGEMENT PLAN The goal is to decrease pain, address the issues of abnormal pronation, and provide a protected envi­
f prolonged sit­ ronment for the tendon to heal. Eventually address range-of-motion and strength deficits that are preventing the athlete
5\! h as running
from fUl1ctioning at his expected level.
' duration and in­ PHASE ONE /\ClITE \NFLA I\ ;lMX('ORY ST!\(;E
llfficient recovery
GOALS: Modulate pain, address abnormal pronation, begin appropriate therapeutic exercise.
e compensatory
Estimated Length of Time (ELT): Day 1 to Day 4
:omitant internal
Use ice and electrical stimulation to decrease pain. NSAIDs could help reduce inl1ammation. A foot orthotic could be fab­
_ foot varus, tib­
ricated to address the excessive pronation. which may be placing increased tensile st.ress on the medial aspect of the
!CreaSe the tensile
achilles tendon. A heel lift could be built into the foot orthotic. It might be recommended that the ath.lete wear a motion­
. 1 tendon. lJ. r,(l
control running shoe to address pronation and provide a heel lift. The athlete couId begin gentle, pain-free towel stretch­
p!ex L1exibility
ing for the gastrocnemius and soleus musculature several times per day. Conditioning could be done in a pool or on a
[0 compensate
bike.
. exion neede
g.lf the athlet PHASE TWO
l' fur ther inL1amed
GOAl,S: Increase gastrocnemius-soleus l1exibility. gain strength. and improve singte-Ieg stance (SLS) balance and SLS
ure will become closed-kinetic-chain functional activity.
The tendon may Estimated Length of Time (ELT): Days 5 to 14
~eU as thickened. As signs of inl1ammation decrease, the use of ultrasound could be introduced, first at a pulsed level and then at a contin­
~ condition. Crepi­ uous level. Stretching could be progressed to standing on a flat surface. Strengthening could be started with isometrics
~ an~ dorsillexion and progressed to open-kinetic-chain isotonics with rubber tubing. As the athlete improves. standing double-leg heel
6nexlon. raises can be introduced. Single-leg stance activity could be added. focllsing on control of the lower extremity. especially

~
tendinitis cal foot pronation and Ilower-leg internal rotation. Conditioning at the end of this stage could be upgraded to weight­
ry to the slower bearing activity. such as the elliptical trainer with the foot flat on the pedal, avoiding ankle plantarl1exion.
It has also been
exists within th PHASE THREE J\L\Tl l RXI'ION-REMOJ)EI .I NC S'l'!\CE
. g response. [t is GOALS: Complete elimination of pain and full return to activity
ironment by re­ Estimated Length of Time (ELT): Week 3 to Full Return
As range of motion and strength improve, the athlete could be progressed to gastrocnemius-soleus stretching on a
slant board and single-leg heel raises, with an increased focus on eccentric loading 01 the involved side. Dynamic muscle
'ng running ap-
(cont'd)
600· PART THREE The Tools of Rehabilitation

improve fitn
R E H A B I LIT A T ION P LAN (CONT'D) cular fitness ca
ming.! ! Fina ll~
loading via double-leg hopping on a yielding surface such as jumping rope for short periods of time could be added. ;\ nature of th f.> ,
running program on a flat. yielding surface such as grass or track could be initiated with good running shoes and the l'oot tions for a saff.> rf
orthotic in place. The program should be sport-specific and initially should be done every other day to allow the tcndon to Criteria for
recover. A sport-specific functional program could also begin when straight running and sprinting arc tolerated by the to full activi ty
athlete. Other forms of conditioning could also be continued to maintain ntness levels. Achilles taping may be of benel1t symptoms \\<ilh
when the athlete returns to !:raining on a daily basis to reduce excess load to the tendon over the next several weeks. sport-related a .
CRITERIA FOR RETURNING TO COMPETITIVE LACROSSE durance are
1. No pain with walking. ADLs. and running. and (3) all con
2. Gastrocnemius-soleus nexibility and streugth are equal to the uninvolved extremity. corrected d wi r~
3. Improved SLS balance. closed-kinetic-chain func[.ion (step-down. squat, lunge). proper shoewa
DISCUSSION QUESTIONS
1. Why would an orthotic be helpful in this case? Achilles Tet
2. \'11hy would closed-kinetic-chain activities such as a SLS and reach and a step down be painful and limited with this
condition? Pathomech
3. Explain what training errors may have caused this condition to arise with this athlete. 'l argest tendon
4. Explain what intrinsic factors may have contributed to this condition occurring with this athlete. force [rom tbe
5. Explain why an achilles tendon taping would benel1t this athlete during his sporting activity. the calcaneus.
end of stance
weight. Do RupllIr'
an area 2 to
which has been
proaches 6 to 8 times body weight. (;0 Addressing structural pronation or supination should be addressed with a cus­
faults that may lead to excessive pronation or supination tom foot orthotic. Placing a heel lift in the shoe or building
should be done through proper shoeware and foot orthotics it into the orthotic can reduce stress on the Achilles tendon
as well as f1exibility exercises for the gastrocnemius-soleus initially but should be gradual'ly reduced so as not to cause
complex. Soft-tissue manipulation of the gastrocnernius­ an adaptive shortening of the muscle-tendon unit. Gentle
soleus with a foam roller can be helpful prior Lo stretching. pain-free stretching can be performed several times per da~
Modalities such as ice can help reduce pain and inf1ammation and can be done after an active or passive warm-up with
early OD. and ultrasound can facilitate an increased blood exercise or modalities such as superficial heat or ultra­
f10w to the tendon in the later stages of rehabilitation. Cross­ sound (Figures 23-18. 23-19). Open-kinetic-ehain
friction massage may be used to breal< down adhesions that strengthening with rubber tubing can begin early in the
may have formed during tbe healing response and further im­ rehabilitation process and should be progressed to closcd­
prove the gliding ability of the paratenon. Strengthening of kinetic-chain strengthening in a concentric and eccentric
the gastrocnemius-soleus musculature must be progressed fashion utilizing the athlete's body weight with modifica­
carefully so as not to cause a recurrence of the symptoms. tion of sets. repetitions. and speed of exercise to intensif}
Lastly a gradual progression must be made for a safe return to the rehabi litation session (Figures 23- 5. 23-12. 23- .13
activity to avoid the condition's becoming chronic. Recent studies have reported excellent results with the u!
Rehabilitation Progression. Activity modifka­ of eccentric training of the gastrocnemius-soleus muscu­
tion is necessary to allow the Achilles tendon to begin the lature with chronic achilles tendinosis over a ] 2 week pe­
healing process. Swimming. pool running with a notation riod. ] The athlete should be progressed to a regimen
device. stationary cycling. and usc of an upper-body er­ isolated eccentric loading of the achilles tendon using
gometer (UBE) are all possible alternative activities l'or car­ body weight (Figure 23-35). A walking-jogging progr~­
diovascular maintenance (Figures 23-16. 23-26. 23-27). sion on a nrm but forgiving surface can be initiated when
It is important to reduce stresses on the Achilles tendon the symptoms have resolved and ROM. strength. en·
that may occur with daily ambulation. Proper footwear durance. and nexibility have been normalized to the un in­ cessive subtalar
with a slight heel lilt such as a good running shoe. can re­ volved extremity. The athlete must be reminded that thi> ing this loss.
duce stress on the tendon during gait. Structural biome­ progression is designed to improve the affected tendon' tendinitis sym
chanital abnormalities that manifest with excessive ability to tolerate stress in a controlled fashion and not I this is not al \\'a~

improve Iltness level. Studies have shown that cardiovas­
NT'D) cuJar t1tness can be maintained with biking and swim­
mingY Fina'lly it is important to educate the athlete on the
nature or the condition in order to set realistic expecta­
be added. A
tions for a safe return without recurrence of the condition.
~n('s and the root
Criteria for Full Return. The athlete may return
\\' the tendon to
to full activity when (1) there has been full resolution of
Icrated by the
symptoms with ADLs and minima l or no symptoms with
a~ be of benefit
sport-related activity, (2) ROM, strength. flexibility. and en­
>ral weeks.
durance arc equal to the opposite uninvolved extremity.
and (3) all contributing biomechanical faults have been
corrected diuring walking and running gait analysis with
proper shoeware and/or custom root orthotics .
Achilles Tendon Rupture
l li mited with this
Pathomechanics. The Achilles tendon is the
largest tendon in the human body. It serves to transmit
force from the gastrocnemius and soleus musculature to
the calcaneus. Tension through the achilles tendon at the
end of stance phase is estimated at 250 percen t of body
weight. bO Rupture of the Achilles tendon usually occurs in
an area 2 to 6 cm proximal to the calcaneal insertion.
which has been implicated as an avascular site prone to de­
res cd with a cus­ generative changes. 17.11. 38 The inj u ry presen ts after a sud­
le shoe or building den plantarflexion or the ankle, as in jumping or
he Achilles tendon accelerating with a sprint. The athlete will often feel or
d 0 as not to cause hear a pop and note a sensation o[ being kicked in the back
endon unit. GenLle o[ the leg. Plantarflexion of the ankle will be painrul and
~n~ ral times per day limited but still possible with the assistance or the tibialis
'ive warm-up with posterior and the peroneals . A pa'lpable derect will be noted
I 'ial heat or ultra­ along the length of the tendon. and the Thompson test will
pen-Kinetic-chain be positive. The athlete will require the use o[ crutches to
gin early in the continue ambulation without an obvious limp.
rogressed to closed­ Injury Mechanis-m. Achilles tendon rupture is
'ntric and eccentric usually caused by a sudden [orcerul pl,antarl1ex,ion of the
ight with modifica­ ankle. it has been theorized that the area or rupture has
~. ercise to intensify undergone degenerative changes and is more prone to rup­
-5 .23-12.23-13). ture when placed under higher levels or tensile load­
results with the use ing. 33 .48.59.60 The degenerative changes may be due to
nius-soleus muscu­ excessive compensatory pronation at the subtalar joint to
; over a 1 2 week pe­ accommodate ror structural deviations or the rorefoot.
;e to a regimen of rearfoot, and lower leg during walking and running. This
h.iJ les tendon using pronation can place an increased tensile stress on the me­
n g-jogging progres­ dial aspect of the Achilles tendon . Also. a chronica'ily in­
III be initiated when flexible gastrocnemius-soleus complex will reduce the
mM. strength, en­ available amount of dorsiflexio n at the ankle joint. and ex­
malized to the unin­ cessive subtalar joint pronation will ass ist in accommoda t­
• reminded that this ing this loss. The above mechanisms may result in
tJ arfected tendon's tendinitis symptoms that precede th e tendon rupture. but
d ras h ion and not to this is not always the case. Fatigue or th e deconditioned
CHAPTER 23 Rehabilitation of Lower-Leg Injuries 601
athlete or weekend warrior rn ay also contribute to tendon
rupture. as well as improper warm-up prior to ballistic ac­
tivities such as basketball or racquet sports. J1
Rehabilitation Concerns. After an Achilles ten­
don rupture. the qu es tion o[ surgical repair versus cast im­
mobilization will arise. Celli et al. report that surgical
repair of the tendon is recommended to allow the athlete
to return to previOUS levels or ac tivity. Ii Surgica l repair of
the Achilles tendon may require a period of immobiliza­
tion for 6 to 8 weeks to allow for proper tendon heal ­
ing.lS.33.42 The deleterious effects or this Icngthy
immobilization include muscle atrophy. joint sti[rness in­
duding intra-articular adhesions and capsular sti ffness of
the involved joints. disorganization of the ligament s ub­
stance. and possible disuse osteoporosis o[ the bone.) \ Iso­
kinetic strength deficits [or the ankle plantarllexors.
especially at lower speeds. have been documented with pe­
riods of cast immobilization for 6 weeks 411 Steele et al.
noted signifLcant defiCits isokinelically of ankle plan­
tarflexor strength after 8 weeks or ,immobilization 6R These
authors [eel that the primary limiting factor that influ­
ences runctional outcome might be the duration of post­
surgical immobilization. 6H Several studies have been done
lIsing early control'led ankle motion and progre 'sive
weight bearing without immobilization. 3.1 5.31.4 2.h o. h i. h7 It is
important not only to regain full ROM without harming
the repair, but also to regain normal muscle fun ction
through controlled progressive strengthening. This ca n be
performed through a variety o[ exe rcises. including iso­
metrics, isotonics . and isokinetics (Figures 23- 1 to 2 3-1 3).
Open- and closed-kinetic-chain aGtivities ca n be incorpo­
rated into the progression to gradually increase weigbt­
bearing stress on the tendon repair as well as to improve
proprioception (Figures 23-11, 23-14. 23-15. 23-22 to
23-25). Cardiovascular endurance can be maintained
with stationary biking and pool running with a Jlotation
device. Gait normalization for waHdng and running can be
perrormed using a treadmi'll.
Rehabilitation Progression. It is important for
the athletic trainer to have an open line o[ communication
with the physician in charge or the surgical repair. Deci­
sions about length and type o[ immobilization. weight­
bearing progression. allowable ROM. and progressive
strengthening should be thoroughly discussed with the
physician. ExceUent results have been reported with early
and controUed mobilization with the use o[ a splint that a'l­
lows early plantarflexion ROM and that slowly increases
ankle dorsiflexion to neutral a nd full dorsiflexion over a
6- to 8-week period of time. l i II More recent studies
have noted excc.llent ,functionall res ults with early weight
bearing and ROM. Aok.! et al. reported a full return to
602 PAR'I'THREE The Tools of Rehabilitation
sports activity in .13.1 weeks. l Controlled progressive
weight bearing based on percentages of the athlete's body
weight can be done over a 6 to 8 weeks postoperatively,
with full weight bearing by the end of this time frame. Dur­
ing the early stages of rehabilitation. ICE is used to de­
crease swelling. A variety of ROM exercises are done to
increase ankle ROM in all planes as well as initiate activa­
tion of the surrounding muscles (Figures 23-1 to 23-4,
23-9,23-10,23-14,23-15 . 2 3-18,23-20) . By 4 to 6
weeks postoperatively, strengthening exercises with rub­
ber tubing can be progressed to dosed-chain exercises uti­
lizing a percentage of the athlete's body weight with heel
raises on a Total Gym apparatus (Figures 23-5, 23-8,
23-11). It is important to do more concentric than eccen­
tric loading initially. so as not to place excessive stress on
the repair. Gradual increases in eccentric loading can oc­
cur from 10 to 12 weeks postoperatively. Also at this time.
isokineUc exercise can be introduced with submaximal
high-speed exercise and be progressed to 10IVer concentric
speeds gradu a lly over time (see Figures 24-24 and 24-25 ).
By 3 months, rull-weight-bearing heel raises can be per­
formed (Figures 23-12. 23-l3). At the same time a walk­
ing/ jogging program can be initiated. Isokinetic strength
testing can be done between 3 and 4 months to determine
if any deficits in ankle plantarOexor strength exist (sec Fig­
ure 24-24). The number of Single-leg heel raises per­
formed in a speCified amount of time as compared to the
uninvolved extremity can also be utilized to determine
functional plantarOexor strength and endurance. Sport­
related functional activities can be initiated at 3 months
along with a progressive jogging program. A full return to
unrestricted athletic activity can begin after 6 months,
once the athlete successfully meets all predetermined
goa ls.
Criteria for Full Return . The athlete can return to
full activity after the following criteria have been met:
(1 ) full AROM of the invohred ankle as compared to the un­
involved side, (2) isokinetic strength of the ankle plan­
tarf1exors at 90 to 95 percent of the uninvolved side, (3) 90
to 9:; percent of the number of heel raises throughout the
full ROM in a 30-second period as compared to the unin­
volved side. and (4) the ability to walk. jog, and run with­
out an observable limp and successful completion of a
sport-related functional progression without any Achilles
tendon irritation.
Retrocalcaneal Bursitis
Pathomechanics. The retrocalcaneal bursae is a
disc-shaped object that lies bet ween the Achilles tendon
and the superior tuberosity of the calcaneus. 1 2·~() The ath­
lete will report a gradual onset of pain that may be asso­ Criteria for I
ciated with Achilles tendinitis. Careful palpation anterior criteria need to rn
to the Achilles tendon will rule out involvement of the
servabJe sweUin
tendon. Pain is increased with AROM/ PROM ankle dorsi­ the area at rest
flexion and relieved with plantarflexion. Depend,i ng on
the severity and swelling associated. it may be painful to
walk. especially when attempting to attai.n full closed­ Summary
kinetic-chain ank le dorsiflexion during the midstance
phase of gait.
Injury Mechanism. Loading the foot and ankle in
repeated dorsiflexion. as in uphiJll running. can be a cause
of this copdition. When the foot is dorsiflexed. the distance
between the posterior/ superior calcaneus and the Achilles
tendon will be reduced. resulting in a repeated mechanical
compression of the retrocalcaneal bursae. Also. structural
abnormalities of the foot may lead to excessive compensa­
tory movements at the subtalar joint, which may cause
friction of the Achilles tendon on the bursae with running.
Rehabilitation Concerns. Because of the close
proximity of other structures. it is important to rule out
involvement of the calcaneus and Achilles tendon with
careful palpaLion of the area. Rest and activity modifica­
tion in order to redu ce swelling and inflammation is nec­
essary. If walking is painful . crutches with weight bearing
as tolerated is recommended for a brief period. Gentle but
progressive stretching and strengthening should be added
as tolerated, with care being taken not to increase pain
with gastrocnemius-soleus stretching (Figures 23-5.
23-12. 23-l3. 23-18. 23-19). If excessive compensatory
pronation is noted during gait analysis. recommendations
References
on proper foot ware should be made. especially in regard to
the heel counter. and foot orthotics should be considered. 1. Alrredson. H
Rehabilitation Progression. The early manage­ eccentric ca'
ment of this condiLion requires all measures to reduce pain lendinosis.
360-6 6.
and inllammation including ice. rest rrom offending activ­
2.
ity. proper shoeware. and modified weight bearing with
crutches if necessa ry. Cardiovascular fitness can be main­
tained with pool running with a Ilotation device. Gentle
stretching of the gastrocnemius-soleus needs to be intro­
duced slowly. because lhis will tend to increase compres­ 4.
sion of tbe retrocalcaneal bursae. As pain resolves and
ROM and walking gait are normalized, the athlete may be­
gin a progressive walking/ jogging program. The athlete 5.
can progress back to activity as the condition allows . Heel
6.
lifts in both shoes may be necessary in the early return to
activity. with gradual weaning away from them as
AROM/ PROM dorsillexion improves. The condition may
allow full return in ] 0 days to 2 weeks if treated early 7.
enough. rr the condition persists. 6 to 8 weeks of rest. ac­
tivity modificaLioo. and treatment may be needed before a
successfu l result is attained with conservative care.
 CH APTER 23 Rehabilitation of Lower-Leg Injuries 603

at may be as so­ Criteria for Return to fulJ Activity. The following llexion AROM and normal pain-free strength of the gas­
pat ion anterior criteria need to met before return to fuJI aclivity: (1) no ob­ trocnemius and soleus musculature, and (3) normal and
I\' ment of the servable swelling and minimal to no pain to palpation of pain-free walking and running gail.
)~ I ankle dorsi- the area at rest or after daily activity. (2) full ankle dorsi-
Depending on
ay be painful to
ai n full closed­
Summary
tbe mids1ance

lOt and ankle in 1. Although some injuries in the region of the lower leg 5. Rehabilitation of medial tibial stress syndrome must
" can be a cause are acute. most injuries seen in an athletic population be comprehensive and address several factors. includ­
,ed . the distance result from overuse, most often [rom running. ing musculoskeletal. training , and conditioning, as
an d the Achilles 2. Tibial fraclures can create long-term problems for the well as proper shoes and orthotics intervention .
ned mechanical athlete if inappropriately managed. Fibular fractures 6. Achilles tendinitis will often present with a gradual
Also. structural generaJry require much shorter periods for immobi­ onset over a period of time and may be resistant to a
ive compensa­ lization. Treatment of these fractures involves immedi­ quick resolution secondary to the slower healing re­
Wc h may cause ate medical referral and most likely a period of sponse of tendinolls tissue,
e with running. immobilization and restricted weight bearing. 7. Perhaps the greatest question after an Achilles tendon
!ie of the close 3. Stress fractures in the lower leg are usually the result rupture is whether surgical repair or castimmobiliza­
ta ltl to rule out of the bone's inabi lity to adapt to the repetitive loading .lion is the best method of treatment. Regardless of
I tendon wi th response during training and conditioning of the ath­ treatmen t method, the time required for rehabilitation
clivit)' modiftca­ lete and are more likely to occur in the tibia. is significant.
mmation is nec­ 4 . Chronic compartment syndromes can occur from 8, With retrocalcaneal bursitis the athlete will report a
) weight bearing acute trauma or repetitive trauma of overuse. They gradual onset of pain that may be associated with
!riod. Gentle but can occur in any of the four compartments, but are Achilles tendinitis. Treatment should include rest and
-hould be added most likely in the anterior compartment or deep poste­ activity modification in order to reduce swelling and
to increase pain rior compartment. inllammation .
IFigures 23-5.
ompensatory
~o nU11endations References
:ialJ}' in regard to
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! arJy manage­
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-es to red uce pain 360-66. 810-17.
I offending acliv­
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can be main­

r.
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34. Hirth, C, 2001. Rehabilitation strategics in the mana.rJcl1lPllt oj Disorders .,
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35. Howard. J.. N. Mobtadi. and J. Wiley 2000. Eva luation of out­ crileri a rl
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36. Janda, v.. and M. VaVrova. 1990. Sensor!l motor stimulation Stressfra
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38. Karjalain e n, I~, H. Aronen, H. Pihlajamaki. et al. 1997. Mag­ 53. Reeder. .\(
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39. Kohn, H. 199 7. Shin pain and compartment syndromes in
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40. Leppilahti, J.. P. Siira, H. Vanharanta, et al. 1996. Isokinetic
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41. Magnusson, H.. N. Westlin , F. i\yqvist. et al. 2001. Abnor­ 56.
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29(6) :712-15. 57.
42. Mandelbaum, B.. M. Myerson, and R. Forster. 1995. Achilles
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43. Masse' Genova, J.. and M. Gross. 2000. Effect' of foot ort holics
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 CHAPTER 23 Rehabilitation of Lower-Leg Injuries 60S

-'laking the diag­ 47. Myers. R .. D. Padua. W. Prentice. et a\. 2002. Electromyo­ 63. Simon, R. 1995. The tibial and fibular shaft. In Emergency or­
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,I. 2000. Effects of 62. ShwayhaL. A.. J. Linenger. L. Hofher. et al. 1994. Profiles of jotlrnalof Sports Medicine 21(1 ):45-48.
oliOI! and post llml exercise history and overuse inj uries among United States 79. Wiley, J.. D. Clement. D. Doyle. et al. 1987. A primary care
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606 PARTTI-IREE The Tools of Rehabilitation
80. Willy, C.. B. Becker, and H. Evers. 1996. Unusual develop­
ment of acute exe.rtionul compartment syndrome due to de­
layed diagnosis: A case report. Illtcmational Joumal of Sports
Medicine 17(6):4S8-hl.
81. Whitelaw. G., M. Wetzler, A. Levy, et al. 1991. A pneumatic
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Orthopaedics 270:301-5.
SOLUTIONIS TO CLINICAL DECISION MAKING EXERCISES
23-1 AROM exercises for the foot and ankle in a warm
whirlpool would assist in addressing ROM deficits
and muscle activation issues of the lower leg. Spe­
cific joint mobilization exercises for the foot and an­
kle would also bc indicated. Stretching of the
gastrocnemius-soleus complex would [llso work on
ankle ROM and flexibiUty issues. Addressing weak­
ness of the proximal hip and thigh musculature via
quadriceps and gluteal setting, along with four­
direction straight leg raises (SLR), would assist in
dealing with lower-extremity disuse atrophy. Gait
training emphasizing normal lower-extremity me­
chanics with assisted weigl'lt bearing and the use of
crutches would be recommended. Most of these ac­
tivities could be performed by the athlete several
times per d[lY on his own.
23-2 The athletic trainer should refer the athlete to a
physician to rule out a str·ess fracture. Depending
on the severity, an assistive device such as crutches
may be warranted. Application of a pneumatic
splint may assist in pain reduction and healing. Ice
and electrical stimulation would be helpful for pain
reduction. Training modifications including swim­
ming, deep-water running, and cycling would be
benefiCial. Proper running shoes that meet the
needs of the athlete's foot type would be helpful not
only for running but for ADLs. The athlete should
be encouraged to train on a more yielding surface
than concrete. Lastly, educating the athlete and
coach regarding bone remodeLing relative to in­
creases in training volume would be helpful in de­
vising a return-to-activity plan.
23-3 Clinically, the athletic trainer should address the
potential ca uses of excessive compensatory prona­
tion. This can include gastrocnemius-soleus
stretching, fabrication of a foot orthoses, and mo­
tion-control running shoes. Addressing any my­
ofasci a I restrictions via soft-tissue mobiLization
may provide some help. Conditioning on the bike
and in the pool, along with nonimpact activity on a
82. Yasuda, T.. K. Miyazaki. K. Tada, et a!. 1992. Stress fracture of to alio
the right distal femur foHowing bilateral fractures of the prox­ training
imal fibulas : A case report. American Journal of Sports Medi­
during U'
cine 20 (6):771-74.
stretchiD
symptom
educat
volume a
week in'
Runom
also hetp
Stairmaster or elliptical machine, would be appro­ stretchin.
priate. The athlete needs to be counseled about the muscula:.
nature of the condition and what types of Illness 23-6 Several
training, training intensity and training surface cated in _
may affect the condiUon. Conditioning on a flat, letic traic
yielding surface would reduce stress to the anterior
compartment musculature. Also, conditioning
that is more sport-specific (e.g., shorter runs vs.
long-distance running) may also benefit.
23-4 Once the initial pain and inflammation have sub­
sided, the athlete could begin AROM ankle dorsi­
flexion with the knee straight. stressing the
involved muscle. Seated towel stretching of the gas­
trocnemius is next and could be progressed to
standing calf stretching wilh the knee extended.
l.astly, performing the same stretch on a slant
board would place the most tensile stress on the
medial head of the gastrocnemius muscle.
Strengthening can begin with submaximal, pain­
free isometric plantarflexion, progressing to maxi­
mal isometric strengthening. Isotonics can be
introduced with manua l resistance and progressed
to concentric and eccentric isotonics with rubber
tubing. The athlete Can then be progressed to
weight-bearing double-leg heel raises (co ncentric
and eccentric) and then single-leg heel raises (con­
centric and eccentric) . Single-leg eccentric lower­
ing with body weight will place th e greatest tensile
load on the muscle. Dynamic muscle loading can
be initiated with jumping rope. Multidirectional
double-leg hopping can be progressed to multidi­
rectional Single-leg hopping on the involved side.
The athlete can be progressed to plyometrics with
two legs and then lo the involved leg at various
hei ghts.
23-5 The athlete appears to have medial tibial stress syn­
drome. The increase in her training volume, along
with running on nOllyieldillg surfaces, may be the
primary cause of the problem. She should be coun­
seled to reduce her training volume and frequency
 CHAPTER 23 Rehabllitation of Lower-Leg Injuries 607

-rre s fracture of to allow for soft-tissue healing. Nonimpact cross­
ures of the prox­ training would help her maintain her fitness level
of -ports .V/edi­ during this time. New running shoes along with a
stretching program would be beneficial. When the
symptoms have decreased, the athlete should be
educated to return to 50 percent of her training
volume and increase by about 10 to 15 percent per
week initially so as to not provoke the condition.
Running on softer surfaces than concrete would
also help reduce impact loading. A regimented
u ld be appro­ stretching program of the gastrocnemius-soleus
led about the musculature would also be helpful.
23-6 Several structural alignment issues could be impli­
cated in excessive pronation. In standing, the ath­
letic trainer could look for a leg length discrepancy.
The longer leg will attempt to shorten and equal
out the pelvic heights. which can increase prona­
tory forces in the 10IVer extremity. Femoral antever­
sion can be observed if the patella appear to be
facing inlVard and can be conllrmed with the ath­
lete prone on the table. Tibial varum and external
tibial torsion can also be observed and measured in
standing and silting. respectively. The fOOL will most
likely compensate with excessive pronation if these
structural variations are present. Assessing rear­
foot and forefoo t position in a prone pOSition will
usually reveal a rearfoot varus or valgus and most
likely a forefoot varus when the subtalar jOint is
placed in a neutral position.

tressing the
hi ng of the gas­
progressed to
mee extended .

r-ssing to maxi­
• t nics can be
and progressed
ic with rubber
progressed to
a (concentric
I heel raises (con­
centric lower­
Ie greatest tensile
ele loading can
,r ultid irectional
~ssed to multidi­
e involved side.
plyometrics with
• leg at various

II tibial stress syn­

ng volume, along
faces, may be the
e should be coun­
ne and frequency
 CHAPTER 24 The relath'ely
.................................................................... .......................................................................................................................................... .
only two mO\'c
ca use the tal us b
stable position 01
Rehabilitation of Ankle this position the
contact with lhe

andl Foot Injuries olio gripping it

plantarOexion.
contact with th
Skip Hunter ating a less stab
William E. Prentice The lateral
tally so that lh
ankle is m ore
talocrural joint
50 degrees of p.
normal foot req
degrees of d
mal gait.
Study Resources • Explain the biomechanical examina­ Talocrural
To become more familiar with the knowledge and skills tion of the foot.
necessary to design, implement. and document therapeu­
tic rehabilitation programs as identified in the NATA Ath­ • Demonstrate techniques for orthotic
letic Training Educational Competencies and Clinical fabrication.
Projlciencies ' Therapeutic Exercise content area , visit
www.mhhe.com/ prenHcell e. Also refer to the lab exer­ • Break down problems associated with
cises in the new Labora tory Manual and to eSims, whi ch the foot and the treatment options for
simulates the athletic training certification exam, at
www.m hhe.com/esims. For more online study resources,
each.
visit our Health and Human Performance website at
www.mhhe. com/ hhp.

After Completion of This

FUNCTIONAL ANATOMY
Chapter, the Student Should
AND BIOMECHANICS
Be Able to Do the Following:

• Review the biomechanics and func­ The Talocrural Joint

tional anatomy of the foot arid ankle. The ankle joint, or ta locrural joint, is a hinge joint that !.
formed by an articular facet on the distal extremity of lh
• Identify the various injuries that occur tibia. which articulates with the superior articular surface
at the ankle joint. (troch lea) of th e talus: the medial malleol us. which artic­
ulates with th e medial surface of the trochlea of th e tal u
• Recognize the various treatment op­ and the lateral malleolus. which articulates with the la, ­
tions for rehabilitating an ankle sprain. eral surface of the trochlea. The ax is of motion of th Lat
talocrural joint passes transversely through the body talocalca n
• Analyze the effect of forefoot varus. the talus. This bony arrangement forms \Vhat is referred 1

<J
forefoot valgus. and rearfoot varus on as the ankle mortise. 67
The talus provides a !.ink between the lower leg an d tl­
the foot and lower extremity. tarsus. The talus, the second largest tarsal and the mai
weight-bearing bone of the articulation, rests on the calc..­
neous and articulates with the lateral and medial mall figure 24-1
608

 CHAPTER 24
The relatively square shape of the talus allows the ankle
only two movements: dorsiflexion and plantarflexion. Be­
cause the talus is wider anteriorly than posterioriy, the most
stable position of the ankle is with the loot in dorsiflexion. In
this position the wider anterior aspect of the talus comes in
contact with the narrower portion lying between the malle­
oli, gripping it tightly. By contrast, as the ankle moves into
plantarllexion. the wider portion of the tibia is brought in
contact with the narrower posterior aspect of the talus. cre­
ating a less stable position than in dorsifiexion. b7
The lateral malleolus of the fibula extends I~urther dis­
tally so that the boney stability of the lateral aspect of the
ankle is morc stable than the medial. Motion at the
talocrural joint ranges from 20 degrees of dorsillexion to
50 degrees of plantarflexion depending on the athlete. A
normal foot requires 20 degrees of plantar flexion and 10
degrees of dorsiflexion with the knee extended for a nor­
mal gait.
ina­ Talocrural Joint Ligaments. The ligamentous
support of the ankle consists of the articular capsule, three
lateral ligaments. two ligament:; lhat connect the tibia and
rthotic fibula. and the medial or deltoid ligament (Pigure 24-1).
The three lateral ligaments are the anterior talofibular. the
posterior tatofibular, and the calcaneol1bular. The anterior
iated \Ivith and posterior tibiol1bular ligaments hold the tibia and
I1bula and form the distal portion of the interosseus mem­
Iptions for brane. The thick deltOid ligament provides primary resist­
ance to foot eversion. A thin articular capsule encases the
ankle joint.
lalocrural Joint Muscles. The muscles passing pos­
terior to the lateral malleolus wd! produce ankle plantar
flexion along with Loe extension. Anterior muscles serve to
dorsil1ex the ankle and to produce toe flexion. The anterior
muscles include the extensor hallucis longus, the extensor
digitorum longus, the peroneus tertius, and the tibialis an­
terior. The posterior muscle group falls into three layers: at
~inge joint that is
~ e. tremity of the A 8
.~ar ticular surface Anterior
Ius , which artic­ tibiofibular
Posterior
b lea of the talus:
tibiofibular
fales with the lat­
Posterior
pr motion of the
talofibular
bugh the body of
,'b at is referred to IW'I;""""'----r-r- Calcaneofibular
, lower leg and lhe
~I and the main
rests on the calc a­
id medial malleoli. Figure 24-1 Ligaments of the talocrural joint. A, Lateral aspect. B, Medial aspect.
Rehabilitation of Ankle and Foot Tnjuries 609
the superflcial! layer is the gastrocnemius; the middle layer
includes the soleus and the plantaris; and the deep layer
contains the tibialis posterior. the flexor digitorum longus.
and the l1exor hallucis longus. A7
The Subtalar Joint
The subtalar joint consists of the articulation between the
talus and the calcaneus''} (Figure 24-2). Supination and
pronation are normal movements that occur at the subta­
lar jOint. These movements are triplanar movements, that
is. movements that occur in all three planes sinlUitane­
ously.22.oRM In weight bearing, the subtalar joint acts as a
torque convertor to translate the pronation/supination
into leg rotaLion. 82 .<J! The movements of the talus during
pronation and sLlpination have profound effects on the
lower extremity both proximaUy and distally.
When weight 'bearing, in supination the talus abducts
and dorsiflexes on the calcaneus while the calcaneus in­
verts on the talus. The foot moves into adduction, plan­
tarllexion, and inversion. Conversc!y, when weight
bearing in pronation, the talus adducts and plantarflexes
while the calcaneus everts on the talus. The foot moves
into abduction, dorsillexion, and eversion. 22 .55
The Midtarsal Joint
The midtarsal joint consists of two distinct joints: the cal­
caneocuboid and the talonavicular joint. The midtarsal
joint depends mainly on ligamentous and muscular ten­
sion to maintain position and integrity. Midtarsal joint sta­
bility is directly related to the position of the subtalar joint.
If the subtalar joint is pronated, the talonavicular and cal­
caneocuboid joints become hypermobile. If the subtalar
joint is supinated. the midtarsal joint becomes hypomo­
bile. As the midtarsal joint becomes more or less mobile. it
Posterior
talotibial
Posterior
talocalcaneal
 610 PART THREE The Tools of Rehabilitation

TIbia --+-+
A
-+--/1- Fibula
Lo~,
Fibula
Navicular B

Cuneiforms
d I Calcaneus c
Calcaneus Pe
Metatarsals
Metatarsals Phalanges
Figure 24-2 Bones of the foot. A, Medial aspect. B, Lateral aspect. 1st & 5
Figure 24-4

affects the dista l portion of the foot because of the articu­ Talus adducts/plantar flexes
lations at th e tarso metatars al joint. 5~
Effects or Midtarsal Joint Position during
+
Foot muscles fire out of sync
Pronation. During pronati on. the talus adducts and

plantarl1exes and makes the joint articulations of the

+
midtarsal joint more congruous. The lon g axes of the
Lower extremity internally rotates
ta lonavicular and calcaneocuboid joints are more paral­

lel and thus allow more motion. The resulting foot is of­

+
Midtarsal jOint hypermobile
ten referred to as a "loose bag of bones." 11.75

As more motion occurs at the midtarsal joint. the

+
Cuboid pulley is less efficient
lesser tarsal bones. particularly the firs t metatarsal and

flrst cuneiform. become more mobile. These bones com­

+
prise a functional unit known as theflrst ray. ",,lith prona­
Peroneal tendon less functional
tion of the midtarsal joint. the flrst ray is more mobile

because of its articulations with that joint. ;~ The flrst ray

+
First ray hypermobile
is a'lso stabilized by the attachment of the long peron eal

ten don. which attaches to the base of the flrst metatarsal.

+
The long peron eal tendon passes posteriorly around the
2nd & 3rd metatarsals bear too much weight
base of the lateral malleolu s an d then through a notch in

the cuboid to cross the foot to the first metatarsal. The

+ Together with
Metatarsals splay apart
cub oid functions as a pulley to increase the mechanical ad­
tarsal intcrrelaLi
vantage of the peroneal tend on. Stability of the cuboid is
+ function of the
Bunio ns, fractures , callouses
essential in this process. In the pronated position, the

cuboid loses much of its mechanical advantage as a pulley; Figure 24-3 The effects of a forefoot varus.
therefore the peroneal tendon no longer stabilizes the fIrst
ray effectively. This condition creates hypermobility of the concerned with
first ray and increased pressure on the other metatarsals lesser surface areas of both joint articulations to become the peroneus Ion
(Figure 24-3). congruous. 74 Also the lon g axe.s of th e joints become more aspect of the fir<
Effects or Midtarsal Joint Position during oblique. Both allow less motion to occur at this joint, mak­ foot , stability of
Supination. During supination , th e talus abducts and ing the foot very rigid and tight. Since less movement oc­ relative position
dorsLl1exes. which raises the level of the talonavicular joint curs at the ca lcaneocuboid joint, the cuboid become5 The Mth metata
superior to th at of the calca neocuboid joint a nd allows hypomobile. The long peroneal tendon has a greater moves indepeod
 CHAPTER 24 Rehabilitation of Ankle and Foot Injuries 611

Talus abductsJdorsiflexes duction and inversion: conversely. in dorsif1exion it moves

Lower extremity externally rotates
t Biomechanics of Normal Gait
B Midtarsal joint hypomobile
t in running can be divided into two phases. The nrst is the
Calcaneu~ Cuboid pulley is less mobile
t swing or recovery phase. This represents the time imme­
Peroneal tendon held more rigid
boid
t tbe body to a position in front of the body in preparation
First ray hypomobile
t The foot's function during the support phase of run­
1st & 5th metatarsals bear most weight
Figure 24·4 The effects of a forefoot valgus.
amount of tension since the cuboid has less mobility and
thus wil.[ not allow hypermobility of the first ray. In this
case the majority of the weight is borne by the first and
fifth metatarsals (Figure 24-4 ).
The Tarsometatarsal Joint
The tarsometatarsal joint is comprised of the cuboid: nrst,
second. and third cuneiforms: and the bases of the
metatarsal bones. These bones allow for rotational forces
when engaged in weight-bearing activities. They move as
~al a unit, depending on the pOSition of the midtarsal and sub­
talar joints. A'lso known as the Lisfrancs' joint, the tar­
somet.atarsaljoint provides a locking device that enhances
foot stability.
.ch weight
The Metatarsal Joints
Together with subtalar. talonavicular. and tarsometa­
tarsal interrelationships, foot stabilization depends on the
function of the metatarsal joints. The first metatarsal
s bone. along with the first cuneiform bone, forms the nrst
us. r ay. The first ray moves independently from the other
metatarsal bones. As a main weight bearer. the nrst ray is
concerned with body propulsion. Stabi\jzation depends on
lations to become the peroneus longus muscle that attaches on the medial
in rs become more aspect of the nrst ray. As with the other segments of the
at this joint. mak­ foot. stability of the fLrst metatarsal bone depends on the
s movement oc­ relative position of the subtalar and talonavicular joints.
cuboid becomes The fifth metatarsal bone, like the nrst metatarsal bone,
,n has a greater moves independently. In plantarf1exion it moves into ad­
the foot into abduction and eversion. 3b
The action of the lower extremity during a complete stride
stance. or support. phase. which starts with initial con­
tact at heel strike a11d ends at toe-off. The second is the
diately after toe-off in which the leg is moved from behind
for heel strike.
ning is twofold. At heel strike. the foot acts as a shock ab­
sorber to the impact forces and then adapts to the uneven
surfaces. At push-off. the foot functions as a rigid lever to
transmit the explosive force from the lower extremity to
the running surface. In a heel-strike running gait, initial
contact of the foot is on the lateral aspect of the calcaneus
with the subtalar joint in supination. 4
At initial contact, the subtalar joint is supinated. As­
sociated with this supination of the subtalar joint is an
obligatory external rotation of the tibia. As the [(Jot is
loaded. the subtalar jOin t moves into a pronated position
until the forefoot is in contact with the running surface.
The change in subtalar motion occurs between ,inWal heel
strike and 20 percent into the support phase of running.
As pronation occurs at the subtalar joint, there is obliga­
tory internal rotation of the tibia. Transverse plane rota­
tion occurs at the knee joint because of this tibial
rotation. 4 Pronation of the foot unlocks the midtarsal
joint and allows the foot to assist in shock absorption and
[0 adapt to uneven surfaces. It is important during initial
li mpact to reduce the ground reaction forces and to dis­
tribute the load evenly on many different anatomica l
structures throughout the foot and leg. Pronation is nor­
mal and allows for this distribution of forces on as many
structures as possible to avoid excessive loading on just a
few structures. The subtalar joint remains in a pronated
position until '5 '5 to 8'5 percent of the support phase with
maximum pronation is concurrent with the body's center
of gravity passing over the base of support. G7
The foot begins to resupinate and wiB approach the
neutral subtalar position at 70 to 90 percent of the sup­
port phase. In supination the midtarsal joints are locked
and the foot becomes stable and rigid to prepare for push­
off. This rigid position allows the foot to exert a great
amount of force from the lower extremity to the running
surfaceY
612 PART'J'HREE The Tools of Reh abilitation

REHABILITATION TECHNIQUES
Stretching Exercises

Figure 24-5 Seated BAPS board exercises are an Figure 2"*-8

AROM exercise that are usefu I in regaining nor mal
ankle motion.

A
l'igure 2"*-9

Figure 24-6 Standing ankle plantarf1exors stretch.

Figure 24-7 Seated ankle plantarf1exors stretch using A, Gastrocnemi.us. B, Soleus. C, Stretching may also be
a towel. done using a slant board.
 CHAPTER 24 Rehabilitation of Ankle and Foot Injuries 613

A B

Figure 24·8 Ankle dorsillexors stretch [or the anterior tibialis. A. Standing. B. Kneeling.

A B c
Figure 24·9 Plantar fascia stretches. A. Manual. B. Floor stretch. C. Prostretch.

tor . stretch.
" may also be
Strengthening Exercises Isotonic S

Isometric Strengthening Exercises.

Hgure 24- 1 5
longus. bre\

Figure 24-10 Isometric inversion ClgClinst a stelble re­ Figure 24-11 fsometric eversion against a stable re­
sistance. used to strengthen the posterior tibialis. flexor sistance. I ised to strengthen the peroneus longus. brevis.
digitorum longus. and l1exor halli cus longus. tertius, and extensor digitorum longus.
A

Figure 24-12 Isometric plantarl'lcxion against a stable

resistance. Used to strengthen the gastrocnemius. soleus,
posterior tibialis. flexor digitorum longus. flexor haHicus
longus. and plantaris.

Figure 24-14 Inversion exercise. A. Using a weight

Figure 24-13 fsometric dorsillexion against a stable cull B. Using resistive tubing. Used to strengthen the
resistance. Used to strengthen the anterior tibialis and posterior tibialis. flexor digitorum longus. and flexor
peroneus tertius. halliclls longus.
 Isotonic Strengthening Exercises.

A B

Figure 24-15 Eversion e)(ercise. A. Using a weighl curf. B. Us ing resislive lubing. Used lo sl rengthen the peroneus
longus. brevis, lerlius. and extensor di gilorum longus.

I a slable re-

I ngllS. brevis,

A B

Figure 24-16 Dorsiflexion exercise. A. ()sing a weight curf. B. Using resislivc tubing. Csed lo slrengthen the anterior
tibialis and peroneus lerlius.

f'igure 24-17 Plantarflexion exercise using surgical

tubing. Csed to strengthen the gastrocnemills, soleus,
a weight posterior tibialis, flexor digitorum longus. flexor halliclls
gthen the longus. and planturis. A. Body weight resisted. B. Using
, a.nd flexor surgical tubing.
 - ,
'I~~-
~,
I
-:..:::::- -~ ...
­
,F~
~{;-

.­
~-
Figure 24-18 .M ultidirectional Elgin ankle exercise r.

Figure 24-21

A B

Figure 24-19 Toe raises. Used to strengthen th e gastrocnemius. soleus. posterior t'ibialis. flexor digitorum longus.
flexor hallicLls longus. and plantaris. A, Extended knee strengthens the gastrocnemius. B, Flexed knee strengthens
the sole us.

Figure 24-22

A B

-
Figure 24-20 Towel-gatheri n g exercise. A, Toe Ilexion. Used Lo strengt hen the l1exo r digilorul1l longus and brevis.
lumbricales. and llexo( hallicus longus. B, Inversion / eversion exerci.ses. Used to strengthen the posterior tib ialis. flexor
digitorum longus. Ikxor hallicus longus. peroneu s longus. brevis. tertius. and extensor digitorulll long us. Figure 24-23
 CHAPTER 24 Rehabilitation of Ankle and Foot Injuries 617

Closed Kinetic Chain Strengthening Exercises. Isokinetic Strengthening Exercises.

Figure 24-21 Lateral step-ups.

Figure 24-24 [sokinetic inversion/eversion exer 'isc.

Used to improve the strength and clldurance of the ank le
inverters and everters in an open chain. Also can provide
ru m lo ngus. an objective measurement of muscular torque production.
e ngthens

Figure 24-22 Slide board exercises.

Figure 24-25 Isokinetic plantarl'lexion /dorsiflexion

exercise. Used to improve the strength and endurance of
1$ ane! brevis. the ankle dorsiflexors and piantarflexors in an open
r tib ialis, flexor chain. Also can provide an objeccive measurcmcn t of
1.'> . Figure 24-23 Shuttle MVP exercise m achine. torque production.
 PNF Strengthening Exercises.

A B
A

Figure 24-26 01 pattern movin g into fl ex ion . A, Sta rting position. ankle plantarnexed. root e\7ertcd. toes Ilexed .
Figure 24-2 9
B. Termin al pOSition. ankl e dorsin exed . foot inverted. toes extend ed. B. Terminal

Exercises ro

A B

Figure 24-27 01 pattern moving inlo ex le nsion. A. Starting posiLi on . <Ink lc dorSilkxcd. fool inverted, toes extended.
B. Termina l position, ankle plant a rn exed, foo t everted. toes rlexed.

A
A B

Figure 24-28 02 pattern moving in to flexion. A. Start ing positio n. an kle pla ntarflexed. fool inver ted. toes flexed .
B. Terminal. position, a nkl e dorsi rl excd, foo l everted. toes extended.
 HAPTER 24 Rehabilitation of Ailkle and Foot [ojuries 619

A B

Figure 24-29 02 patl to movlng into extension. A. Starling pO ' itlon. ankle dorsinexed. foot everted. loe extended.
B. Terminal po ition. ankl plantarflexed. foot inverted, loes flexed.

Exercises to Rce tabli h Neuromuscular Control.

A B c
Figure 24-30 Standing single-leg balance board activity. Used Lo activate the lower-leg 0111 clilature and improve ba l­
ance and proprioception of the involved extremity. A. BAP board. B. Rocker board. C. KAT sy tern.

:d. toes flexed .

620 PART THREE The Tools of Rehabilitation

Figure 24-3 ] Static single-leg standing balance pro­

gression. Used to improve balancc and proprioception of
the lower extrcmity. This activity can be made more difft­
cult with the following progression: (a) single-leg stand, Figure 24 -35
eyes open: (b) single-leg sland, eyes closed: (c) single-leg
stond, eyes open. toes extended so only lhe heel and
metatarsal heads <Ire in contact with the ground: (d) sin­ Figure 24-32 Single-leg stance on an unstable surface
Exercises t
gle-leg sland, eyes closed , loes extended. while performing function<ll activities .
Endurance

Figure 24-3 3 Single-leg standing rubber-tubing kicks.

Using kicks resisted by surgic<lltubing of the uninvolved Figure 24-34 Leg press.
side while weight bearing on the uninvolved side may en­
courage neuromuscular control. Figure 24-36
to reduce impac
tremity whil e m
and runnin g ro
 CHAPTER 24 Rehabilitation of Ankle and Foot injuries 621

Figure 24-37A Upper-body ergometer. Used to main­

tain cardiovascular Jltness when use of a lower-extremity
ergometer is contraindicated or too difncult for the ath­
lete to use.

Figure 24-35 Minisquals.

Exercises to Improve Cardiorespirator}'

Endurance.

Figure 2 4 -3 7 8 Stationary exerci se bike. Used to main­

tain cardiovascular utne s when lower-extremity weight
beuring is difncull.
Figure 24-36 Pool running with Ilotation devicc. lscd
to reduce impact weight-bearing forces on thc lower ex­
trcmity while maintaining cardiovascular l1tncss level
and running form.
622 PARTTl-IREE The Tools of Rehabilitation
REHABILITATION TECHNIQUES
FOR SPECIFIC INJURIES
Ankle Sprains
Pathomechanics and Injury Mechanism. Ankle
sprains are among the more common injuries seen in
sports medicine. 719 .9 ; Injuries to the ligaments of the an­
kle may be classil1ed according to either their 10catio11 or
the mechanism of injury.
Inversion sprains. An inversion ankle sprain that
results in injury to the lateralligamcnts is by far the most
common. The anterior talol1bular ligament is the weakest
of the three lateral ligaments. [ts major function is to stop
forward subluxation of the talus. It is injured in an in­
verted. plantarflexed. and internally rotated posilion. 44 "i
The calcaneol1bular and posterior ta'lol1bular ligaments
are also likely to be injured in inversion sprains as the force
of inversion is increased. Increased inversion force is
needed to tear the calcancol1bular ligament. BeCause the
posterior talol1bular ligament prevents posterior subluxa­
tion of the talus, its injuries are severe. such as is the case
,i n complete dislocations.'
Eversion sprains. The eversion ankle sprain is less
common than the inversion ankle sprain. largely because
of the boney and ligamentous anatomy. As mention previ­
ously, the Ilbular malleolus extends further inferiorly than
does the tibial malleolus. This. combined with the strength
of the thick deltoid ligament. prevents excessive eversion.
More often eversion injuries may involve an avulsion frac­
ture of the tibia before the deltoid ligament tears.u The
deltoid ligament may also be contused in inversion sprains
due to impingement between the Ilbular malleolus and the
calcaneous. Despite the fact that eversion sprains are less
common , the severity is such that these sprains may take
longer to heal than inversion sprains. hl
Syndesmotic sprains. Isorated injuries to the distal
tibiofel11oral joint are referred 10 as syndesmotic sprains.
The anterior and posterIor llbiul1bular ligaments are found
between the distal tibia and fibula and extend up the lower
leg as the interosseous ligament or syndesmotic ligament.
Sprains of the ligaments are more common than has been
realized in the past. These ligaments arc torn with in­
creased external rotational or forced dorsiflexion and are
often injured in conjunction wiLh a severe sprain of the
medial and lateral ligament complexes.'; Initial rupture of
the ligarnents occurs distally at the tibiot1bular ligament
above the ankle mortise. As the force of disruption is in­
ereased, the interosseous ligament is torn more proximally.
Sprains 01 the syndesmotic ligaments are extremely hard
to treat and often take months to heal. Treatments for thois
problem are essentially the same as for medial or lateral
sprains, with the difference being an extended period of
immobilization. Functional activities and return to sport
may be delayed for a longer period of time than for tbe in­
version or eversion sprains. A
Severity of the sprain. In a grade 1 sprain. there is
some stretching or perhaps tearing of the ligamentous
I1bers with little or no joint instability. Mild pain, little
swelling, and joint stiffness may be apparent. With a grade
2 sprain. there is some tearing and separation of the liga­
mentous t1bers and moderate instability of the joint. Mod­
erate to severe pain. swelling, and joint stiffness should be
expected. Grade 3 sprains involve total rupture of the liga­
ment, manifested primarily by gross instability of the joint.
Severe pain may be present initially. followed by little or no
pain due to tOLal disruption of nerve Ilbers. Swelling may be
profuse, and thus the joint tends to become very stiff some
hours after the injury. A grade 3 sprain with marked insta­
bility usually requires some form of immobilization lasting
several weeks. Frequently the force producing the ligament
injury is so great that other ligaments or structures sur­
rounding tJ1e joint may also be injured. With cases in whic h B
there is injury to mUltiple ligaments, surgical repair or re­
construction may be necessary to correct an instability.
Rehabilitation Concerns. During the initial
phase of ankle rehabilitation, the major goals are reduc­
tion of postinjury swelling. bleeding. and pain and pro­
tection of the already healing ligament. As is the case in
all acute musculoskeletal injuries. initial treatment efforts
should be directed toward limiting the amount of
swelling.68 This is perhaps more true in the case of ankle
sprains than with any other injury. Controlling initial
swelling is the single most important treatment measure
that can be taken during the entire rehabilitation process.
Mawdsley, Hoy, and Erwin found the t1gure-of-eight
method of measuring ankle edema to be reliable and
valid. There is no question that limiting the amount of
acute swelling can signilkantly reduce the time required partmentalize
for rehabilitation. Initia l management includes ice, com­ a nd bottom of
preSSion. elevation. rest. and protection. 24-38). Une\'en
Compression. Immediately following injury and
evaluation. a compression wrap should be applied to the
sprained ankle. An elastic bandage should be Ilrmly and
evenly applied wrapping distal to proximal. It is also rec­
ommended thatlhe elastic bandage be wet to facilitate the
passage of cold. To add more compreSSion. a horseshoe­
shaped felt pad may be inserted under the wrap over the !\.Inong these
area of maximum swelling. as a Josbt Pump
Following initial treatment, open Gibney taping may be Ice. Th e
applied under an elastic wrap to provide additional COIll­ documented in
 CHAPTER 24 Rehabilitalion of /\n kle and Foot Inj uries 623

UDeOiS for lh'­

sprain , there i
A
ligam ent u
'Id pa in . little
\" ith a grade
n of th e Ilga­
the joint. \od­
hould b

~ tion lasting

I repair or re­
instability.
B
g th' initial
Is are redu c'
pain and pro,
is the case in

e amount of
e ase of ankle

Figure 24-38 A. Correctly done open Cibney tape.

B. Closed Basketweave tape.
i the amount of pression and support. Care should be taken not to com­
c time req Llire partmentalize this treatment by placing tape across the top
'I udes icc. COIl1­ and bottom of the open area of the opcn Gibney (figure
24-38). Uneven pressure or uncovered areas over any part
g injury a nd of the extremity may allow the swelling to accumulate,
_ a pplied to the Other devices are available that upply externut com­
d be Ormly a nd preSSion to the ankle to control or reduce swelling. This
can be used both initially througho ut the rehabilitative
process. ~Iost of these usc either air or cold water within
an enclosed bag to provide pressure to reduce swelling.
le wrap over the Among these are intermittent compression devices such
as a fosbt Pump or a Cryo-cuff (figure 24-19).
y taping may be Ice. The use of ice on acute injuries has been well
additional com, documented in the literature. fee must initially be usee!
Hgure 24-39 A. Jobst intermittent air compression de­
vice. B. Cryo-cuff.
with compression, because ice used alone is not as crfec­
tive as icc used in conjunction with compression. so The
initial use of icc has its basis in constricting superficia l
blood now to prevent hemorrhage as well as in reducing
the hypoxic response to injury by decreasing cellular me­
tabolism. Long-term benef1ts may be from redLlction of
pain and guarding.h7 Carrick suggests the usc or ice [or a
minimu m of 20 minutes once every 4 waking hours. 1S Icc
should not be used longer than 30 minutes, especially
over superf1cial nerves such as the peroneal <Jnd ulnar
nerves: prolonged use of ice in such areus can produce
transient nerve palsy. 23
624 PART THREE The Tools of Rehabilitation

Current literature suggests that ice can be used during

all phases of rehabilitation,4 i but is most effective if llsed
immediately after injury,68 Ice can certainly do no harm if
used properly, but beat, if applied too soon after injury,
may lead to increased swelling, Often the switch from ice to
heat cannot be made for weeks or months. INJURY SITU
Elevlltion. Elevation is an essential part of edema on her right
control. Pressure in any vessel below the level of the heart prior 10 her
is increased . which may lead to increased edema. 14 Eleva­ ·prain. X fa..
tion allows gravity to work with the lymphatic system
rather than against it and decreases hydrostatic pressure SIGNS AND S
to decrease fluid loss and also assists venous and lymphatic lion o\-er the
return through gravity.oil Athletes with ankle sprains lar ti lt lest ­
Figure 24-40 Commercially available J\ircast ankle
should be encouraged to maintain an elevated position as stirrup, o degrees. e'\
often as possible. particularly during the first 24 to 48
MANAGEMENT PI
hours following injury. An attempt should be made to treat
ran ge-or-m
in the elevated position rather than the gravity dependent
position. Any treatment done in the dependent position
wiLl allow edema to increase,6s,iil Mjllljj
Rest. It is important to aKow the inflammatory GOALS: (
process to have a chance to accomplish what it is supposed :.stim aled
to during the first 24 to 48 hours before incorporating ag­ [;se PRJCE
gressive exercise techniques. However. rest does not mean 'he use of
that the injured athlete does nothing. Contralateral exer­
cises may be performed to obtain cross-transfer effects on
the muscles of the injured side.';!> Isometric exercises may
be performed very early in dorsiflexion. plantarflexion. in­
version. and eversion (Figures 24-10 through 24-13). PHAS E
These types of exercises may be performed to prevent atro­ fignre 24-41 Molded Hexnlitc ankle stirrup.
phy without fear of further injury to the ligament. Active
plantarflexion and dorsiflexion may be initiated early be­ The open Gibney wping technique also provides earh
cause they also do not endanger the healing ligament as medial and lateral protection while allowing plantarflex­
long as they are done in a paiD-free range. These active ion and dorsiflexion. in addition to being an excellen
planturfiexion and dorsiflexion exercises can be done mechanism of edema control (Figure 24-38). The use 0
while the athlete is iced and elevated, Inversion and ever­ prewrap may reduce skin irritation when tape is applied.
sion are to be avoided. because they might initiate bleeding Ricardo and others found that the application of prev.rrar
and further traumatize ligaments. before taping was as cffect~i vc in reducing inversion as t ap­
Protection. Several appliances are available to ac­ ing directly to the skin,72
complish this early protected motion. Quillen 69 recom­ Cross, Lapp. and Davis compared the effectiveness of a
mends the ankle stirrup. which allows motion in the number of commercial ankle orthoses and taping in re­
sagittal plane while limiting movement of the frontal stricting eversion and inversion. All of these support sys­
plane and thus avoids stressing the ligaments through in­ tems Significantly reduced inversion and eversion
version and eversion (Figure 24-40). Clasoe et al. found immediately after initial' application and after exerci se
that weight-bearing immobilization combined with an when compared to preapplication measures. Of the or­
early exercise program was effective treatment for Grade 2 thoses tested. taping provided the least support after exer­
ankJe sprains. ll Several commerCially available braces ac­ cise. ll Early npplication of these devices allows earl~'
complish this goal and also apply cushioned pressure to ambulation.
help with edema.S ! When a commerCially available prod­ Rehabilitation Progression. Tn the early phase of
uct is not feasible, a similar protective device may be fash­ rc"habilitation. vigorous exercise is dIscouraged. The in­
ioned from thermoplastic materinls such as Hexalite or jured ligament must be maintained in a stable position so
Orthoplast (Figure 24-4]), that healing can occur. Thus during the period of maxj-
 CHAPTER 24 Rehabilitation of Ankle and Foot Injuries 625

REHABILITATION PLAN
ANKLE SPRAINS

INJURY SITUATION i\ 30-year-old female recreational indoor soccer player attempted to cut
on her right ankle when ,he experienced a grade 1 ankle sprajn. The injury occurred 1 hour
prior to her arrival in the training room. Her local physician diagnosed a grade 1 ankle
sprain. X rays were negative.

SIGNS AND SYMPTOMS Physical findings include (1) mild swelling and tenderness to palpa­
tion over the anterior talol1bular ligament, (2) negative anterior drawer test. (3) negative ta­
lar tilt test, (4) I\ROM: dorsiflexion-O degrees, plantar l1exion-50 degrees, inversion­
ircasl a nkle
o degrees. eversion- 20 degrees.
MANAGEMENT PLAN Thc overall goal is to reduce inl1ammation initially. proceed through a
range-of-motion and strengthening program. address proprioceptive and neuromuscular control. and implement a re­
turn-to-sport program.

PHASE ONE
GOALS: Control pain . linlit swelling, regain range of motion.
Estimated Length of Time (ELT): Days 1 to 5
se PRJCE (protection. rest, ice, compression, and elevation) to address the symptoms of the acute inl1ammatory stage.
The usc of tape/ bracing allows early weight bearing while protecting the healing ligament from further motion exercises
may be begun stressing plantarl1exion and dorsiflexion . Inversion/eversion exercises should be avoided during this stage
to protect the healing ligament. Alternative forms or conditioning may be needed to maintain cardiovascular status dur­
ing the entire rehabilitation. This may include swimming, cycling, and upper body ergometer work.

Irrup. GOALS: Increase runge of motion in all planes, restore neuromuscular control, and restore proprioception.
Estimated Length of Time (ELT): Days 5 to 14
provides early PRICE may be continued to conlrol swelling and pain. Range-of-motion exercises should be performed in all planes.
ing plantarl1ex­ Strengthening exercises should address not only the musculature surrounding the ankle but also the intrinsic muscula­
ng a n excellent ture of the fool. full weight bearing should be encouraged as quickly as possible. f'ro priocep[jve cxercises should be begun
- 38) . The use of as early as tolerated. These exercises may be started as non-weight-bearing exercises and progress to exercises as strenu­
I ta pe is applied. ous as standing BJ\PS board exercises with perturbations.
Ilio n of prewra p
PHAS E THREE Mi\T[]RATION-REMO))ELI~C STACE
invers ion as tap-
GOALS: Elimination of swelling and pain, full range of motion, full strength, and restoration of proprioception. '{'hese

criteria are followed by a carefully instituted return-to-sport program.

Estimated Length of Time (ELT): Days 14 to 21

The athlete continues to perform all the strengthening, range-of-motion, and proprioceptive exercises. i\ gradual pro­

gression of walking to running to protection in the form of bracing, taping, and high-top shoes may be nceded to a llow

these steps to be taken. Once cutting und sprinting have been performed withoUl an antalgic gait. the athletc may be re­

turned graduaUy to sports.

IPP rt after exer­ DlSClJSSION QUESTIONS

allows early I. How might the rehabilitation progression change if the athlete had sustained a medial ankle sprain of the same
degree?

e early phase of
2. Describe a proprioceptive exercise progression for this patient.
luraged. The in­ 3. Whm steps can be taken to reduce the chance of reinjury for ankle sprains?

able position so
4. HolV might this athlete's recovery time change if the injury had been to the tibiofibular ligament and the interossells
period of maxi- membra lie?
626 PART THREE The Tools of Rehabilitation
mum protection following injury, the athlete should be ei­
ther non-weight-bearing or perhaps partial-weight-bear­
ing on crutches. Partial weight bearing with crutches
helps control several complications to healing. Muscle at­
rophy, proprioceptive loss. and circulatory stasis are all re­
duced when even limited weight bearing is allowed.
Weight bearing also inhibits contracture of the tendons,
which can lead to tendinitis. For these reasons, early am­
bulation. even if only touchdown weight bearing, is essen­
,0
tial. Aquatic therapy may be beneficial , in that it allows
light to moderate weight bearing in a gravity-reduced en­
vironment. 11 It has been clearly demonstrated that a heal­
ing ligament needs a certain amount of stress to heal
properly. Recent literature suggests that early limited stress
following the initial period of inOammation might pro­
mote faster and stronger healing. 8 .61 These studies found
that protected motion facilitated proper collagen reorien­
tation and thus increased the strength of the healing liga­
ment.
As swelling is controlled and pain decreases, indicating
that ligaments have reached that point in the healing
process at which they are not in danger from minimal
stress, rehabilitation can become more aggressive.
Range of motion. In the early stages of the rehabil­
itation, inversion and eversion should be minimized. Light
joint mobilization conceotrating on dorsinexion and plan­
tarOexion should be started first, 49 It can be accomplished
by manual joint mobilization techniques (see Figures
14-63 through 14-66) or through exercises such [IS towel
stretching for the plantarOexors (Figure 24-7) and stand­
ing or kneeling stretches for the dorsillexors (Figure 24-8).
Athletes are encouraged to do these exercises slowly, with­
out pain, and to use higb repetitions (two sets of 40).
As tenderness over the ligament decreases. inversion­
eversion exercises may be initiated in conjunction with
plantarOexion and dorsiOexion exercises. Early exercises
include pulling a towel from one side to the other by alter­
natively inverting and everting the root (Figure 24-208)
and alphabet drawing in an ice bath, which should be done
in capital letters to ensure that full range is used.
E~"ercises performed on a BAPS board, wedge board. or
KAT (Figure 24- 30) may be beneficial for range of motion.
as well as a beginning exercise for regaining neuromuscu­
lar control. 88 These exercises should at first be done seated.
progressing to standing (Figure 24-5). Initially the athlete
should start in the seated position with a wedge board in
the plantarOexion-dorsiOexion direction. As pain de­
creases andlligament healing progresses, the board may be
turned in the inversion-eversion direction. As the athlete
performs these movements easily, a seated BAPS board
may be used for full range-of-motion exercises. When
seated exercises are performed with ease, standing balance a ncing on a B.-\P
exercises should be initiated. They may be started on one a Bosu Balan ce T.­
leg standing without a board. The athlete then supports Figures 8-2 3 thr
weight with the hands and maintains balance on a wedge tially with SUPPl
boa.rd in either plantar(]exion-dorsiOexion or inversion­ cise, tbe athlc
eversion. Next. hand support may be eliminated while the controlling th
athlete balances on the wedge board. The same sequence is Other clo
then used on the BAPS board. The BAPS board is initially Leg presses (Fi" u'"
used with assistance from the hands. 'fhen balance is prac­ the involved leg
ticed on the BAPS board unassisted. proprioceptive rel
Vigorous heelcord stretching should be initiated as tion. adduction.
soon as possible (Figure 24-6). McCluskey, B'l ackburn. and while weight
Lewis;l found that the heelcord acts as a bowstring when strength (lnd pr
tight and may increase the chance of ankle sprains. ther free-stal1din e
Strengthening. Isometrics may be done in the four
major ankle motion planes, frontal and sagittal (figures -
24-10 through 24-14). They may be accompanied early in CLINICAL DE
the rehabilitative phase by plantarOexion and dorsiOexion
isotonic exercises. which do not endanger the ligaments A 21-year-o
(Figures 24-16.24-17). As the ligaments heal further and grade 21a
range of motion increases , strengthening exercises may be
begun in all planes of motion (Figures 24-14 and 24-15).
Care must be t.aken when exercising the ankle in inversion
and eversion to avoid tibial rotation as a substitute move­
ment. Pain should be the basic guideline for deciding when
to start inversion-eversion isotonic exercises. Light resist­
ance with high repetitions has fewer detrimental effects on
the ligaments (two to four sets of 10 repetitions). Resistive
tubing exercises, ankle weights around the foot. or a mul­
tidirectional Elgin ankle exerciser (Figure 24-18) are ex­
cellent methods of strengthening inversion and eversion.
Tubing has advantages ,jn that it may be used both eccen­
trically and concentrically. Isokinetics have advantages in
that more functional speeds may be obtained (Figures
24-24. 24-25). PNF strengthening exercises that isolate
the deSired motions at the talocrural joint can also be used
(Figures 24-26 through 24-29).
Proprioception and neuromuscular control. The
role of proprioception in repeated ankle trauma has been
questioned.12.14.2 6.28 'The literature suggests that proprio­
ception is certainly a factor in recurrent ankle sprains.
Rebman 70 reported that 83 percent of his patients experi­
enced a reduction in chronic ankle sprains after a program
of proprioceptive exercises. Glencross and Thornton 32
found that the greater the ligamentous disruption. the
greater the proprioceptive loss. Early weight bearing has
previously been mentioned as a method of reducing pro­ when run n ing
prioceptive loss. During the rehabilitation phase, standing for early ru nD In
on both feet with closed eyes with progression to standing swim vest th al
on one leg is an exercise to recoup proprioception (Figure rllns in place \\
24-31). This exercise may be followed by standjng and bal­ Proper run ning
 CHAPTER 24 Rehabilitation of Ankle and Foot fnjuries 627

-la nding balance ancing on a 13APS board (see Figure 22-43A). a Dynadisc, athlete is moved into shallow water so that more weight is
If -tarted on one a Bosu Balance Trainer or an Extreme Balance Board (see placed on the ankle. Progression is then made to running
te then sUpports Figures 8-23 through 8-25). which should be done lni­ on a smooth, nat surface. ideally a track. Initially the ath­
a nce on a wedge liaHy with support from the hands. As a final-stage exer­ lete should jog the straights and walk the curves and then
on or inversion­ cise, the athlete can progress LO free standing and progress to jogging the entire track. Speed may be in­
li nated while the controlling the board through all ranges (Figure 24- 30). creased to a sprint in a straight line. The cutting sequence
same seque!1ce is Other closed-kinetic-chain exercises may be beneficiaL should begin with circles of diminishing diameter. Cones
board is in itially Leg presses (Figure 24-34) and minisquats (Figure 24-35) on may be set up for the athlete to run figure eights as the next
1 balance is prac­ the involved leg wiU encourage weight bearing and increase eluting progression. The crossover or Sidestep is next. 1 The
proprioceptive return. Single-leg standing kicks using abduc­ athlete sprints to a predesignated spot and cuts or sidesteps
i be initiated as tion. adduction. extension. and flexion 01' the uninvolved side abruptly. When this progression is accomplished, the cut
'. Blackburn, and while weight bearing on the affected side will increase both should be done without warning on the command of an­
bowstring when strength and proprioception. This may be accomplished ei­ other person. Jumping and hopping exercises should be
1e sprains. ther [,ree-standing (Figure 24- 33) or on a machine. started on both legs Simultaneously and gradually reduced
do ne in the fOUF to only the injured side.
agitlal (FigLlfes The athlete may perform at different levels for each of
m panied carl} in CLINICAL DECISION MAKING Exercise 24-1
these functional sequences. One functional sequence may
an d dorsiflexion be done at half speed while another is done at full speed.
er the ligaments A 11-year-Qld recreational ba ketbaU playersuJTered a
An example of this is the athlete who is running full speed
heal further and grade 2 lateral ankle sprain last night. n is the third episode
on straights of the track while doing l1gure eights at only
e 'ercises may be of the same injury in 3 years. His Initial symptoms are lim­
half speed. Once the upper levels of all the sequences are
- H and 24-15). Ited swelling. pain. and loss of ROM. Tolar tilt and anterior
reached, the athlete may return to limited practice, which
nk le in inversion drawer lesting are withill normaillmits (Wf\'1 ). The athlete
may include early teaching and fundamental drills.
'ubstitute move­ states that previous rehabilitation included strengthening
Criteria for Full Return. Estimates are that 30 to
)r deciding when and ROM exercises. What type of additional rehabilitative
40 percent of all inversion injuries result in rein­
- . Light resist­ exercises can the athletic trainer suggest that might reduce jury.24.39.40.;2.7b In the past, athletes were simply returned
me ntal effects on the likelihood of this inlury recurring?
to sports once the pain was low enough to tolerate the ac­
crtions). Resistive tivity. Cross, Worrell, Leslie, et aI. found that self reported
Ie foot, or a muI­ measures of impairment correlated well with clinical
~ 2-1-] 8) are ex- Cardiorespiratory endurance. Cardiorespiratory measures of IimiLation in predicting th.e number of days to
n and eversion. conditioning should be maintained during the entire reha­ return to sport. 18 Returning to full activity should include
J d both eccen­ bi'litation process . Pedaling a stationary bike (Figure a gradual progression of functional activities that slowly
Ie advantages in 24-37 B) or an upper-exlremity ergometer (figure increase the stress on the Iigament. 4i The specific demands
)la ined (Hgures 24- 37 A) with the hands provides excellent cardiovascular of each individual sport dictate the individual drills of this
=i that isolate exercise without placing stress on the ankle. Pool running progression.
can also be used using a float vest and swimming are also good cardio­ It is most desirable to have the athlete return to sport
vascular exercises (Figure 14-36). without the aid 01' ankle support. However. it is common
r control. The Functional progressions. Functional progressions practice thaL some type of ankle support be worn initially.
r uma has been may be as complex or simple as needed . The more severe It appears that ankle taping does have a stabilizing effect
that proprio­ the injury, the more the need for a detailed functional pro­ on unstable ankles, 27.89 without interfering with motor
, an kle sprains. gression. The typical progression begins early in the reha­ performance. 25 .53 Nishikawa found thal application of an
f patients experi­ bilitation process as the athlete becomes partially weight ankle brace increased the excitability of the peroneus
I after a program bearing. full weight bearing should be started when am­ longus motoneuron. This ,i ncrease was attributed to a
~d Thornton lC bulation is performed without a limp. Running may be be­ number of mechanoreceptors, one of which was cuta­
disruption. the gun as soon as ambulalion is pain free. Pain-free hopping neous. McCluskey and others" suggest taping the ankle
gh t bearing has on the affected side may also be a guideline to determine and also taping the shoe onto the foot to make the shoe and
,r reducing pro­ when funning is appropriate. Exercising in a pool allows ankle function as one unit. High-topped footwear may fur­
phase, standing for early running. The athlete is placed in the pool in a ther stabilize the ankle. l5 Ricardo, Schulthics, and Soret
iou to standing swim vest thai supports the body in water. The athlete then found that high-top shoes reduced the rale of inversion.? I
~c plion (Figure runs in place without toucbing the bottom of the pool. If cleated shoes are worn, c1ea ts should be Oll tset along the
n ding and ba l­ Proper running form should be stressed. Eventually the periphery of the shoe to provide stability. 53 An Aircast or
628 PART THREE The Tools of Rehabilitation

some other supportive ankle brace can also be worn for tion until the fracture has healed. whereas displaced frac­ weight beartr.".
support as a substitute for taping (Figure 24-40). tures are treated with open reduction and iJlternal fi.xa­ ROM pla ntan.,:
l 'he athlete should have complete range of motion and tion. Undisplaced fractures are treated by casting in a short and shoul d be
at least 80 to 90 percent of preinjury strength before con­ leg wa lking cast for 6 weeks with early weight bearing. The strengthening
sidering a retum to the sport. 77 Finally, if full practice is course of rehabilitation fo'llowing this period of immobi­ At 6 wee:
tolerated without insult to the injured part. the athlete lization is generally the same as for ankle sprains. Folio\\'­ wafking braCt".
may return to competition. ing surgery for displaced or unstable fractures. the athlete more. Isome'
may be placed in a removable walking cast. However. it i can be perfo
essential to closely monitor lhe rehabilitative process to isotonic streng:
CLINICAL DECISION MAKING Exercise 24-2 make certain that the patient is compliant. II 24-17Jtb al
If an osteochondral fracture is displaced and there iSa can also be
A 19-year-old voUeyha ll player sprained her right ankle
fragment, surgery is required to remove the fragment. In Joint mobiliz<.
as she attempted to spike a baU at the net. The injury
other cases. if the fragment has 110t healed within a year su'lar tigh ln
mechanism was external rotation and forced dorsiflexion. surgery may be conSidered to remcJ\te the fragment. 3 3 cises to regain
Initial pain was between the tibia and fibula above the an­
Rehabilita tio n Progression. FollOWing open re­ can progre
kle mortise. extending between the tibia and llbula supe­
duction and in ternal fixation. a posterior splint with the 24-30 th roug.~
riorly halfway to the knee. What are the implications of ankle in neutral should be applied and the athlete should control conti:-_
these symptoms for the athletic trainer in asseSSing the
be non-weight-bearing for about 1 weeks. During this pe­ kinetic-chain
likelihood that the athlete will be ready for the conference
riod efforts should be directcd at controlling swelling an e 24-21 through .
championship in 2 weeksr
wound management. Criteria fOJ
At 2 to 3 weeks the athlete Illay be placed in a short leg of strength. n
walking brace (Figure 24-42) which allows for partial
Ankle Fractures and Dislocation
Pathomechanics and Injur}' Mechanism, When
dealing v"ith injuries to the ankle joint, the athletic trainer
must always be cautious about suspecting an ankle sprain
when a fracture might actually exist. !\ fracture of the
malleoli \Viii generally resull in immediate swelling. Ankle
fractures can occur from several mech,1l1isms that arc sim­ ~ndonspa
ilar to those for ankle sprains. In an inversion injury. me­ under the su
dialmaJieolar fractures are often accompanied by a sprain
of the la1.eralligaments of the ankle. A fracture of the lat­
eralmalleolus is often more likely to occur than a sprain if
an eversion force is applied to the ankle. This is due to the
fact that the latera l malleolus extends as I'ar as the distal
aspect or the talus. With a fracture of the lateral malleolus.
however, there may also be a sprain of the del toLd liga­
ment. Fractures result from either avu 'lsion or compres­
sion forces. With avulsion injuries it is often the injured
ligaments that prolong the rehabilitation period. l3
Osteochondral fractures are sometimes seen in the
talus. These fractures may also be rel'erred to as dome frac­
tures of the talus. Cenerally they will be either umllsplaced
fract ures or compression fractures. 31
While sprains and fractures are very common. disloca­
~iol1s in the ankle and foot arc rare. They 1110st often occur peroneal su bl
in conjunction with fractures and require open reduction tear, there \\iJ
and internal fixation. 77 and swelling
Rehabilitation Concerns, Cenerally. u ndisplaced During acLi\'e
ankle fractures should be managed with rest and protec­ Figure 24-42 Shorlieg walking brace. oneal tend on s m
 CHAPTER 24
weight bearing that should continue for 6 weeks. Active
ROM plantarflexion and dorsillexion exercises can begin
and should be done 2 to 3 times a day, along with general
strengthening exercises for the rest of the lower extremity.
At 6 weeks, the athlete can be weight bearing in the
walking brace. and this should continue for 2 to 4 weeks
more. Isometric exercises (Figures 24-10 through 24-13)
l. However. it b can be performed initially without th e brace, progressing to
tal ive process to isotonic strengthening exercises (Figures 24-14 through
l. B 24-17) that concentrate on eccentrics. Stretching exercises
ed and there is a can also be incorporated (HglHes 24-5 through 24-9).
the fragme nt. 1n Joint mobilizaNon exercises should be used to reduce cap­
ed w ithin a year. sular tightness (see Figures 14-63 through 14-68). Exer­
~ fragment. n cises to regain proprioception and neuromuscuIar control
can progress from sitting to standing as tolerated (Figures
24-30 through 24- 35). As strength and neuromuscular
control continue to increase, more functional closed­
kinetic-chain strengthening activities can begin (Figures
24-21 through 24-23).
Criteria for FuJI 'Return. Once near-normal levels
ced in a short leg of strength, flexibility. and neuromuscular control have
Ilows for partial been regained and the injured athlete has progressed
through an appropriate functional progression. full activ­
ity may be resumed.
Subluxation and Dislocation
of the Pe~neal Tendons
Pathomechanics. The peroneus brevis and longus
tendons pass posterior to the fibula in the peroneal groove
under the superior peroneal retinaculum. Peroneal ten­
don dislocation may occur because of rupture of the supe­
dor retinaculum or because the retinacuillm strips the
periosteum away from the lateral maHeollls, creating lax­
ity in the retinaculum. It appears that there is no anatomic
correlation between peroneal groove size or shape and in­
stability of the peroneal tendons. 4l An avulsion fracture of
the lateral ridge of the distal fibllia may also occur with a
subluxation or dislocation of the peroneal tendons.
Injury Mechanism. Subluxation of peroneal ten­
dons can occur from any mechanism causing sudden and
forceful contraction of the peroneal muscles lhal involves
dorsillexion and eversion of the fOOt. 11 This forces the ten­
dons anteriorly, rupturing th e retinaculum and potentially
causing an avulsion fraclure of the lateral malleolus. The
athlete will orten hear or feel a "pop." And differentiating
peroneal subluxation from a lateral ligament sprain or
tear, there witl be tenderness over the peroneal tendons
and swelling and ecchymosis in the retromalleolar area .
During acLive eversion th e fool subluxation of the per­
oneal tendons may be observed and palpated . This is easier
Rehabilitation of Ankle and Foot Injuries 629
to observe when acute symptoms have subsided. The ath­
lete will typically complain of chronk "giving way" or pop­
ping. If the tendon is dislocated on initial evaluation, it
should 'be reduced using gentle inversion and plantarollex­
ion with pressure on the peroneal tendon.'l l
Rehabilitation Concerns and Progression. Fol­
lowing reduction the athlete should be initially placed in a
compression dressing with a felt pad cut in the shape of a
keyhole strapped over the lateral malleolus. placing gentle
press ure on the peroneal tendons. Once the acute symp­
toms abate, the athlete should be placed in a short leg cast
in slight plantarllexion and non-weight-bearing for 5 to 6
weeks (Figure 24-42). Aggressive ankle rehabililation, as
previously described, is initiated after cast removal.
In the case of an avulsion injury or when this becom es
a chronic problem. conservative treatment is unlikely to be
successful and surgery is needed to prevent the problem
from recurring. A number of surgical procedures ha\le
been recommended, including repair or reconstruction of
the superior peroneal retinaculum. deepenin g of the per­
oneal groove, or rerouting the tendon . Following surgery,
the athlete should be placed in a non-weight-bearing short
leg cast for about 4 weeks. The course of rehabilitation is
similar to that described for ankle fractures with increased
emphasis on strengthening of the peroneal tendons in
eversion. 43
Criteria for Full Return. The athlete may return
to full activity at approximately 10 to 12 weeks as toler­
ated, when normal strength, ROM, and neuromuscular
control in the ankle joint are demonstrated .
CLINICAL DECISION MAKING Exercise 24-3
Following a recent grade 2 lateral ankle sprain. an athlete
bas begun to complain lhat be reels a "popping" sensa­
tion accompanied by "giving way" of the ankle. X rays
are negative. Examination reveals rull ROM. but there is
palpable tenderness and slight swelling over the posterior
aspect of the lateral malleolus. particularly in the retro­
malleolar area. What i the probable ca use of this "pop­
ping" and "giving way"?
Tendinitis
Pathomechanics and Injury Mechanism. In­
nammation of the tendons surrounding the ankle joint is
a common problem in athletes. The tendons most often
involved are the posterior tibialis tendon behind the me­
dial malleolus, the anterior tibialis under the extensor
630 PART THREE The Tools of Rehabilitation

retinaculum on the dorsal surface of the ankle. and the

peroneal tendons both behind the bteral malleolus and
at the base of the flfth metatarsal. s ; I
Tendinitis in these tendons may result from one spe­
cific cause or from a collection of mechanisms including
faulty foot mechanics. which will be discussed later in this
chapter: inappropriate or poor footwear that can create
faulty foot mechanics: acute trauma to the tendon: tight­
ness in the heel chord complex: or training errors. Train­
ing errors would inc.lude training at intensities that are too
high or too often ; changing training surfaces; or changes 1­
l;,
in activities within the training program. R5 Net..
Athletes who develop tendinitis are likely to complain
of pain with both active movement and passive stretching; Figure 24-+1
swelling around the area of the tendon dQe to inOam m a­ weight-bearir.,
tion of the tendon and the tendon sheath: crepitus on
movement: and stiffness and pain following periods of in­
activity but particularly in the morning.
Rehabilitation Concerns and Progression. In
the early stages of rehabilitation. exercises are used to pro­
duce increased circulation. The increased lymphatic Oow
facilitates removal of Ouid and the by-products of the in­
Oammatory process. and increases nutrition to the healing
tendon. Exercise should also be used to limit atrophy.
which can occur with disuse. and to minimize loss of
strength. proprioception. and neuromuscular conb"ol.
Rehabilitation should incorporate techniques that re­ Figure 24~43 IJow-dye taping for arch support.
duce or eliminat.e innammation. Tbese include rest. thera­ Neutra.
peutic modalities (ice. ultrasound. diathermy). and
anti-inflammatory medications. fIrst of all eliminate the inflainmatory response and then Figure 24-15
If faulty foot mechanics are a cause of tendinitis. it to begin tissue realignment and remodeling will not allo\\' weight-bear ~=
may be helpful to construct an appropriate orthotic devise the tendon 0(0 heat and can exacerbate the existing inflam­
to correct the biomechanics. Taping of the foot may also mation. The rehabilitation progression must be slow and
and get ioto a
help reduce stress on the tendons (Figure 24-43). controlled. with full return only when the athlete seems to
In many instances. if the mechanism that is causing be free of pain.
the irritation and inOammation of the tendon is removed.
and the inOammatory process is allowed to accomplish Excessive Pronation and Supination
what it is supposed to. the tendinitis will often resolve
within 10 days to 2 weeks. This is particularly true if rest Pathomechanics and Injury Mechanism. Often.
and treatmen t are begun as soon as the symptoms begin. when we hear the terms pro/lillian or wpil1ation. we auto­
Unfortunately, if treatment does not begin until the symp­ matically think of some pathological condition related to
toms have been present for severa'! weeks or even months, gait. It mus. be reemphasized that. pronation and supina­
as is most often the case. the tendinitis will take much Lion of the foot and subtalar joint are normal movements
longer to resolve. Long-standing inflammation causes the that occur during the support phase of gail. However. ;f
tendon to thicken and significantly increases the period of pronation or supination is excessive or prolonged. overuse
time required for that tendon to remodel. injuries may develop. Excessive or pro'l onged supination Or
Criteria for Full Return. In our experience. it is pronation at the subtalar joint is likely to rcsuH from some
beller to allow the athlete sufl1cient rest so that tendon structural or fUllctiona l deformity in the foot or leg. 'I'he
healing can take place. The rehabilitation phUosophy in structural deformity forces the sublalar joint to compen­
sports medicine ,is usually aggressive. but with tendinitis sate in a manner that will allow the weight-bearing sur­
an aggressive approach that docs not allow the tendon to faces of the foot to make stable contact with the groun d
 CHAPTER 24
o Neutral
Neutrdl Weight-bearing
Figure 24-44 Forefoot varus. Comparing neutml and
weight -bearing positions.
Weight-bearing
Figure 24-45 Forefoot valgus. Comparing neutral and
weight-bearing positions.
and get into a weight-bearing position. 'f'hus, excessive
pronation or supination is a compensaLion for an existing
structural deformity. Three of the most common struc­
tural deformities or the foot are a forefoot varus (E'igure
24-44), a forefoot valgus (Figure 24-45 ), and a rearfoot
varus (Figure 24-46).
Often. Structural forefoot varus and structural rearroot varus
deformities are usually associated with excessive prona­
tion. A structural forefoot valgus causes excessive supina­
tion. The deformities usually exist in one plane, but the
subtalar joint will interfere with the normal funct,i ons of
the foot and make it more difficult for it to act as a shock ab­
sorber, adapt to uneven surfaces, and act as a rigid lever for
upina ti on or push-off. The compensation, rather than the deformity it­
'u lt from some self. usually causes overuse injuries.
at or leg. The Excessive or prolonged pronation of th e subtalar joint
during the support phase of running is one of the major
causes of stress injuries. i Overload of specil1c structures
results when excessive pronation is produced in the sup-
Rehabilitation of Ankle and Foot Injuries 631
Weight-bearing
Figure 24-46 Rearfoot varus. Comparing neutral and
weight-bearing positions.
port phase or when pronation is prolonged into the propul­
sive phase of running. Excessive pronation during the sup­
port phase will cause compensatory subtalar joint motion
such that the midtarsa'l joint remains unlocked, resulting
in an exceSSively loose foot. There is also an increase in tib­
ial rotation, which forces the knee joint to absorb more
transverse rotation motion. Prolonged pronaNon of the
subtalar joint wiU not allow the foot to resupinate in time
to provide a rigid lever for push-off. resulting in a less pow­
erful and less efficient force. Thus various foot and leg
problems occur with excessive or prolonged pronation
during the support phase. These ,i nclude callus formation
under t.he second metatarsal. stress fractures of the second
metatarsal. bunions due to hypermobility of the first ray.
plantar fascitis, posterior tibial tendinitis, Achilles tendini­
tis, tibial stress syndrome, and medial knee pain.'
Several extrinsic keys may be observed that indicate
pronation?; Excessive eversion of the calcaneus during the
stance phase indicates pronation (Figure 24-47). Excessive
or prolonged internal rotation of the tibia ,is another sign of
pronation. This internal rotation can cause increased
symptoms in the shin or knee, especially in repetitive sports
such as running. A lowering of the medial arch accompa­
nies pronation. II may be measured as the navicular dil"fer­
entia!, 51 the difference between the height of the navicular
tuberosity from the Ooor in a non-weight-bearing position
and its height in a weight-bearing position (Figure 24-48).
Pronatory foot type as measured by a navicular drop test
has been identified as an accurate predictor for the devel­
opment of tibial stress syndrome. J8 As previously dis­
cussed, the talus plantarllexes and adducts with pronation.
It may be seen as a medial bulging of the talar head (Figure
24-49). This same talar adduction causes increased con­
cavity below th e lateral malleolus in a posterior view while
the calcnneus everts" (Figure 24-50).
At heel strike in prolonged or excessive supination,
compensatory movement at th e subtalar joint will not
632 PART THREE The Tools of Rehabilitation
Figure 24-47 Eversion of the calcaneus indicating
pronation.
Figure 24-48 Measurement of the navicular
differen tia!.
allow the midtarsal jOint to unlock, causing the foot to re­
main excessively rigid. The foot cannot absorb the ground
reaction forces as efficiently. Excessive supination limits
tibial internal rotation . Injuries typically associated with
excessive supination include inversion ankle sprains, tibial
stress syndrome, peroneal tendinitis, iliotibial band fric­
tion syndrome, and trochanteric bursitis.
Structural deformities originating outside the foot
also require compensation by the foot for a proper
weight-bearing position to be attained. Tibial varum is
the common bowleg deformity. 5 5 The distal tibia is medial
to the proximal tibial! (Figure 24-51). This measurement
is taken weight-bearing with the foot in neutral posi­
tion. l7 The angle of deviation of the distal tibia from a
perpendicular line from the calcaneal midl,i ne is consid­
ered tibial varum. 29 TibiaJ varum increases pronation to
Figure 24-49 Medial bulge of the talar head indicating
pronation.
Figure 24 - 5 1
Pronation Neutral Supination
Figure 24-50 Concavity below tbe lateral malleolus
indicating pronation.
allow proper foot function. 10 At heel strike the calcaneus
must evert to attain a perpendicular positioll.H 2
Ankle joint equinus is another extrinsic deformity that
may require abnormal compensation. H may be consid­
ered an extrinsic or intrinsic problem.
During normal gait. the tibia must move anterior to the
talar dome. 55 Approximately 10 degrees of dorsiflexion
are required for this movement" (Figure 24-52). Lack of
dorsiflexion may cause compensatory pronation of th
foot with resultant foot and lower-extremity pain. Often
this lack of dorsiflexion results from tightness of the poste­
rior leg muscles. Other causes include forefoot equinus. in cessively pro
which the plane of the forefoot is below the plane of the imply to carr.
rearfool. 55 It occurs in many high-arched feet. This defor­ t.he existi ng st"
mily requires more ankle dorsiflexion. VVhen enough dor­ ical an alysis
siflexion is not available at the ankle, the additiona tify those deforfT1.
 CHAPTER 24 Rehabilitation of Ankl.e and Foot fnjuries 633

Figure 24-53 Examination position for neutral

Figure 24-51 Tibial varum. or bow leg deformity. position.

movements. In the majority of cases faulty biomechanics

can be corrected by constructing an appropriate orthotic
device.
Despite arguments in the literature. the author has
found orthotic therapy to be of tremendous valuc in the
treatment of many lower extremity problems. This view is
Supination supported in the literature by several clinica~ sLudies. Do­
natelli et al. 22 found that 96 percent of thell' patients re­
al malleolus ported pain relief from orthotics and that 52 percent
would no t leave home wilhoutthe devices in theLr shoes .
McPoil. Adrian. and Pidcoe found that orthotics were an
important treatment for valgus forefoot deformities only. 54
~ the calcaneus Riegler reported that ~O percent of his patients experi­
ion . 2 enced at least a 50 percent improvement with orthotics. n
de formity that This same study reported improvements in sport perfor­
lIlay be consid­ mance wilh orthotics. Hunt reported decreased muscular
Figure 24-52 Ten degrecs of dorsitlexion is necessary activity with orthotics. l ? Oschendorff and Mattacola .
~ an terior to the for normal gait. fo und that molded orthotics reduced postural sway in fa­
of dorslnexion tigued ankles. 65
_4-52). Lack of The process for evaluating the foot biomechanically.
onation of the movement is required at other sites. slIch as dorsiflexion of for constructing an orthotiC device. and for selecting the
~ty pain. Orten the midtarsal joint and rotation of the leg. appropriate footwear is detailed below.
_ of the poste­ Rehabilitation Concerns. In individuals who ex­ Examination. The first step in the evaluation
foo t equin us. in cessively pronate or supinate. the goal of treatment is quite process is to establish a position of subtlliar neutral. The
be plane of the simply to correct the faulty biomechanics that occur due to athlete shou ld be prone with the dista l third of the leg
t. This defor­ the ex isting structural deformity. 1\n accurate biomechan­ hanging off the end of the table (Figure 24-53). A line
n enough dor­ ical analysis of the foot and lower extremity should iden­ should be drawn bisecting the leg from the start of the
the additional tify those deformities that requ 'ire abnormal compensatory muscu lotendinous junction of the gastrocnemius to the
634 PART'l'HREE The Tools of Rehabilitation
Figure 24-54 Line bisecting the gastrocnemius and
posterior caIcaneus.
distal portion of the caIcaneus Sf' (Figure 24-54). VVith the
athlete still prone, the athletic trainer palpates the talus
while the forefoot is inverted and everted. One finger
should palpate the talus at the anterior aspect of the fibula
and another finger at the anterior portion of the medial
malleolus (Figure 24-55). The position at which the talus
is equally prominent on both sides is considered neutral
subt.alar position: 2 Root, OrLen, and Weed / > describe this
as the position of the subtalar joint where it is neither
pronated or supinated. It is the standard position in which
the foot should be placed to examine deformities. 64 In this
position. the lines on the lower leg and calcaneus should
form a straight line. Any variance is considered La be a
rearfoot valgus or varus deformity. The most common de­
formity of the foot is a rearfoot varus deformity. 56 A devia­
tion of 2 to 3 degrees Ls normal. 9 !
Another method of determining subtalar neuLral posi­
tion involves the lines that were drawn previously on the
leg and back of the heel. "Vith the athlete prone. the heel is
swung into full eversion and inversion. with measure­
ments taken at each position. Angles of the two lines are
taken at each extreme. Neutral position is considered two­
thirds away from maximum inversion or one-third away
from maximum eversion. The normal foot pronat.es 6 to 8
degrees from neutra).l >For example. from neutral position
a foot inverts 27 degrees and everts 3 degrees. The position
Figure 24-55 Palpation of the talus to determine neu­
tral position.
at which this foot is neither pronated nor supinated is that
point at which the caIcaneus is inverted 7 degrees.
Oncc the subtalar joint is placed in a neutral position.
mild dorsil1exion should be applied while observing Ilw
metatarsal heads in relation to the plantar surface of the
calcaneolls. Forefoot varus is an osseous deformity in
which the medial metatarsal heads arc inverted in relation
to the plane of ["he calcaneus (Figure 24-44). ForefoOt
varus is the most common cause of excessive pronation.
according to Subotnick. sl Forefoot valgus is a position in
which the lateral metatarsals are everted in relation to the
rearfoot (Figure 24-45). These forefoot deformities are be­
nign in a non-weight-bearing position. but in stance the
foot or metatarsal heads must somehow get to the l100r to
bear weight. This movement is accomplished by the talus
rolling down and in and the calcaneus everting for a fore­
foot varus. For the forefoot valgus. the calcanells inverts
and the talus abducts and dorsil1exes. McPoil. Knech t. and
Schmit>6 rcport that forefoot valgus is the most common
forefoot deformity in their sample group. 1.
In a rearfoot varus deformity. when the foot. is in sub­
talar neutral position non-weight-bearing. t.he medial
metatarsal heads arc inverted as in a forefoot varus. and
the calcaneous is abo in an inverted pOSition. To get to
footl1at in weight bearing. the subtalar joint must pronate 2.
(Figure 24-46). lVlinimal osseous deformities of the lore­
foot have little effect on the function of the fool. Whe!) ei­
ther forefoot varus or valgus is too large. the foot
compensates through abnormal movements to bear
weight.
 CH/\PTER 24 Rehabilitation 0[' Ankle and root Injuries 635

Figure 24-57 Semirigid orthotics.

de termine neu­

Figure 24- - 6 Felt pads.

. upinated is that
- de grees.
ne utral position . Figure 24-58 Rigid orthotic.
Ie observing the Constructing orthotics. Almost any problem of
tar surface of thl' the lower extremity appears at one time to have been
ou deformity in treated by orthotic therapy. The use of orthotics in control 3. Functional or rigid orthoUcs are made from hard plas­
\\ efle d in [elaliOl of root deformities bas been argued for many tic and also require ncutral casting (Figure 24-58).
~4 -44). ForefooL years J · 1 1.1 7. HI.42.74.Hl.HI.91 The normal foot functions most These orthotics allow control for most overuse symp­
:e ive pronalio . efficiently when no deformities are present that predispose toms.
us is a position in it to injury or exacerbate existing injuries. Orthotics are Many athletic tra.i ners make a neutral mold. put it in a
i in relation to the used to control abnormal compensatory movements of the box. maH it to all orthotic labornlory. and several weeks
erormities are be­ foot by ';bringing the Ooor to the fool. "1 8 later receive an orthotic back in the mail. Others like to
but in slance the The foot functions most efficiently in neutral position. complete tbe entire orthotic from start to nnish, which re­
gel to the floor to By providing support so that the foot does not have to move quires a much more skilled technician than the mail-in
-hed by the talu" abnormally. an orthotic should help prevent compensa­ method. as well as approximately $I.()OO in equipment
\er ting for a f'orc­ tory problems. For problems that have already occurred. and supplies. The obvious advantage is cost if many or­
~ icaneus invert" th.e orthotic prov,ides a platform of support so that soft tis­ thotics are to be made.
Pail. Knecht, and sues can heal properly without undue strcss. No matter which method is chosen. the ftrst step is the
ihe most common Basically there <Ire three types of orthotics: 38,4g.sl fabrication of the neutral mold. done with the patient in
~ l. Pads and soft flexible felt supports (Pigure 24-')6). the same position used to determine sllbtalar neutral posi­
the fool is in su b­ T hese soft inserts are readily fabricated and are advo­ tion. Once subtalar neutral is found, three layers of plastcr
Iri ng. the media l cated for mild overuse syndromes. Pads are particu­ splints are applied to the plantar surface and sides of the
[efoot varus. an d larly useful in shoes. such as spikes and ski boots. that root (Figure 24-59). Subtalar neutral position is main­
)Osilion . To get to nrc too narrow to hold orthoties. tained as pressure is applied on the fifth metatarsal area in
inl must pronate 2. Semirigid orthotics made of' flcxible thermoplnstics. a dorsiflexion direction until the midtarsal joint is locked
mi tics of the forc­ rubber. or leather (Figure 24-57). These orthotics are (Figure 24-(0). This position is held until the plaster dries.
Lhe rool. Whell ei­ prescribed for athletes who ho:IVe increased symptoms. At this point the plaster cast may be sent out to have the or­
large. the foo t These orthotics are molded from a neutral casL. They thotic mnde or ilmay be finished (Figure 24-h 1). If it is
'ements to bear are well tolerated by athlctes whose sports require mailed out. the appropriate mcasurements of forefoot and
speed or jumping. rearfoot positions should be sent. along with any extrinsic
636 PART THREE The Tuols of Rehabilitation

Figure 24-62 Positive mold.

Figure 24-59 Three layers of plaster form neutral
mold.

Figure 24-63 Convection oven and grinder.

measurements. If the orthotic is to be fabricated in-house, Figure 24--65

the plaster cast should be liberally lined interiorly with talc tient sitling.
Figure 24-60 Mild pressure over the fifth metatarsal to or powder. Plaster of paris should then be poured into the
lock the midlarsal jOint. cast to form a positive mold of the foot (Figure 24-(2 ).
Many different materials may be used to fabricate an
orthotic from the positive mold. The author uses 1I8-inch
Aliplast (AHmed Inc., Boston) covering wilh a 1/ 4-inch
Plastazote underneath. A rectangular piece of each mate­
rial large enough to completely encompass the lower third
of the mold is cut. These two pieces are placed in a convec­
tion oven (Figure 24-63) at approximately 275°F, At this
temperature the two materials bond together and become
moldable in about 5 to 7 minutes. At this lime the ortholic
materials are removed from the oven. and placed on the
positive mold (Figure 24-64). Ideally a form or vacuum
Figure 24-61 Neutral mold. press should be used to form the orthotic to the mold. 3M
 CHAPTER 24
Figure 24-64 Orthotic material on the positive mold.
r.
Figure 24-65 Orthotic mold under the foot with pa­
-Iy \\it h tal tient sitting.
ured. into the
_ ~ -1-611.
fabri ale an Once cooled. the uncut orthotic is placed under the
__ 1 -inch foot while the athlete sits in a chair (Figure 24-65). Excess
material is then trimmed from the sides of the orthotic
with scissors. Any material that can be seen protruding
from either side of the foot should be trimmed (Figure
24-66) to provide the proper width of the orthotic. The
length should be trimmed so that the end of the orthotic
bisects the metatarsal heads (Figure 24-67). This style is
slightly longer than most orthotics are made. but the au­
thor has found that this length provides better comfort.38
Next a third layer of medial Plastazote may be gl ued to
the arch to fill that area to the fioor. Grinding begins with
RehabilitaLion of Ankle and FOOL [njuries 637
Figure 24-66 Trim excess material from orthotic.
Figure 24-67 The length of the orthotic should bisect
the metatarsal heads.
the sides of the orthotic. which should be gwund so that
the sides are slightly beveled inward (l'igure 24-61-l) to al­
low beller shoe fit. The boltom of the orthotic is leveled so
that the surface is perpendicular to the bisection of the cal­
caneus. Grinding is continued until very little Plastazote
remains under (he Aliplast at the heel. The forefoot is
posted by selectivc'ly grinding Plastazole just proximal (0
the metaLarsal heads. Forefoot varus is posted by grinding
more laterally than medially. Forefoot valgus requires
grinding more medially than laterailly. The final step is to
grind the distal portion of the orthotic so that only a very
638 PARl"l'HREE The Tools of Reh abil itation
Figure 24-68 Sides of the orthotic should be leveled
inward.
thin piece of Aliplast is under the area where the orthotic
ends. This prevents discomfort under the forefoot where
the orthotic stops. If the athlete feels that this (lre(l is a
problem. a full insole of Speneo or other materialm3Y be
used to cover the orthotic to the end of the shoe to elimi­
nate the drop off sQmetimes felt as the orthotic ends. Time
must be allowed for proper break-in. The athlete should
wear the orthotic [or 3 to 4 hours the first d(lY. 6 to i) h ours
the next day, and then all day on the third day. Sports ac­
tivities should be started with the orthotic only aner it has
been worn (Ill day for several d(l)7 s. l~
Shoe selection. The shoe is ono of the biggest con­
siderations in treating (l foot problem. HI Even a properly
made orthotic is less effective ir placed in a poorly con­
structed shoe.
As noted, pronation is a problem of hypcrmobiUty.
Pronated feet need stability and 11rmness to reduce this ex­
cess movemenl. Heseareh indicates that shoe compression
may act ualiy increase pronation. cQmpClrcd to biJrcfool.·l
The ideal shoe for a pronated foot is less nexible emd has
good rem-foot con tto!'
Conversely, supinated feet arc usu ;,ll ly vcry rigid. In­
creased cushion and nexibility benefit this type of fo ol.
Several construction factors may influence the firmness
and stability of a shoe. The basic form upon which a shoe
is built is called the last. 2 The upper is fitted onto a last in
severa l ways. Each method bas its own nexibility and con­
trol cllaracteristics. A slip-lasted shoe is sewn together like
a moccasin (Figure 24-(9) and is very flexibl e. Board­
lasting provides a piece of fiberboard upon which the up­
per is attached (Figure 24-70), which provides a vcry
firm. inflexible base for the shoe. ;\ combination-lasted
shoe is boarded in the back half of the shoe and slip-lasted
in the front (Figure 24-71). which provides n~arfoot sta­
bility with forefoot mobility. The shape of the last may also
be used in shoe selection. Most athletes with excessive
pronation perform better in a straight-lasted .G boe.2 that
is , a shoe in which the forefoot does not curve inward in
relation to tlle rearfoot. ~·1idsole design also affects the
stability of a shoe. The mid sole separates the upper from
the outsole. 11 Ethylene vinyl acetate (EVA) is one of the
most commonly used materials in the midsole. [,6 Often
denser EVA, which is colored differently to show that it is
denser, is placed under the medial aspect o[ the foot to
control pronation (Figure 24-72).
E
In an effort to control rearfoot movement. mallY shoe
manufacturers have reinforced the heel counter both in­
ternany and externally. often in the form of extra plastic
along the outside of the heel counter" (Figure 24·73).
Other factors that may affect the performance of a shoe arc
the outsole contour and composition, lacing systems, and
forefoot wedges.
Figure 24-69
Shoe \Ilcar pattcrns. Athletes with excessive pronation
often wear out the front of the running shoe under th e sec­
ond metatarsal (Figure 24-74). Shoe wear patterns arc
comlllonly misinterpreted by athletes who think they must
be pronators because they wear out the back outside edges
of their heels, Actually, most people wear out th e back out­
side edges of their shoes. Just before heelstrike, the anLerio:­
tibial muscle fires to prevent the foot from slapping for­
ward. The anlerior tibial muscle not only dorsillexes thL'
foot but also slightly inverts it, hence the wear pattern on
the back edge of the shoe. Tbe key to inspection of wear
patterns on shoes is observation of the heel counter and
the forefoot.
I CLINICAL DECISION MAKING Exercise 24-4
C]
A 14-year-old cross-country runner has been diagnosed Figure 24-70
with a second-metatarsal sLress fracture. After 8 weeks
she is ready to return to ru nning. Biomechanical exami­
nation of her foot shows a moderate forefoot varus defor­
mity. With weight bearing there is a marked navicular
differential and moderate calcaneal eversion. What shoe
characteristics might be desirable for this individual as
she returns to sport?
G
Stress Fractures in the Foot
Pathomechanics and Injury Mechanism, T he
most common stress fractures in the foot involve th e 0 3 \ ' ­
icular, the second metatarsal (Ma rch fracture), and th e di­
aphysis of the fifth metatarsal (Jones fracture) . Navicular
Figure 24- 7 ]
and second metatarsal stress fractures arc likely to occu"
witb excessive foot pronation , while mth metatarsal slre<;~
fractures tend to occur in a more rigid pes cavus fool.
 CHAPTER 24 RehabiliLation of Ankle and Foot Injuries 639

If ve inward in
a affects the
he upper from
is one of the
id ole. fih Often
• how that it is
of the foot to

nt. many shoe Sliplasted

,unter both in­
f extra plast ic
ig ure 24-73) .
ce of a shoe are
g systems. and

Figure 24-69 Slip-lasted shoe.

ive pronation
~ under the sec­
if pa tterns are
~ ink they must
Ik au tside edges
t the back ou t­
'e . the anterior
slapping for­
dorsillexes the
ear pattern on
~c tion of wear
Boardlasted
oel counter and

Figure 24-70 Board-lasted shoe.

Sliplasted
Boardlasted

:hanism. The
\'olve the nav­
ure) . and the di­
re) . Navicular
Figure 24-71 Combination-lasted shoe.
~ li kely to occur
etatars al stress
'av us foot.
640 PART THREE The Tools of Rehabilitation

Na"icular stress fractures. Tndividuals who exces­

sively pronate during running gait are likely to develop a
slress fracture of the navicular. Of the tarsal bones it is the
most likely to have a stress fracture.
Second metatarsal fractures. Second metatarsal
stress fractures occur most often in running and jumping
sports. As is the case with other injuries in the foot associ­
ated with overuse, the most common causes include rear­
foot varus and forefoot varus structural deformities in the
foot that result in excessive pronation. training errors,
changes in training surfaces, and wearing inappropriate
shoes. The base of the second metatarsal extends proxi­
Figure 24-72 EVA in a midsole. mally into the distal row of tarsal bones and is held rigid
and stable by the bony architecture and ligament support.
Tn addition. the second metatarsal is particularly subjected
to increased stress with excessive pronation, which causes aponeurosl
a hypermobiJe foot. Tn addition, if the second metatarsal is and the lon~
longer than the first. as seen with a Morton's toe, it is the­ selves to tht
oretically subjected to greater bone stress during running. the plantar a
A bone scan , as opposed to a standard radiograph, is fre­ bility of tht:
quently necessary for diagnosis. nal arch. "
Fifth metatarsal stressfractures. Fifth metatarsal
stress fractures can occur from overuse, acute inversion, or
high-velocity rotational forces. A Jones fracture occurs at
the diaphysis of the fifth metatarsal most often as a sequela
figure 24-73 External heel counter. of a stress fracture. 77 The athlete will complain of a sharp
pain on the lateral border of the foot and will usually re­
port hearing a "pop." Because of a history of poor blood
supply and delayed healing. a Jones fracture may result in
nonunion requiring an extended period of rehabilitation.
Rehabilitation Concerns. RehabiUtation efforts
.for stress fractures should focus 011 determining and allevi­
ating the precipitating cause or causes. Second metatarsal
stress fractures tend to do well with modified rest and nOI1­
weight-bearing exercises such as pool running (Figure
24-36). upper-body ergometer (Figure 24-37A ). or sta­
tionary bike (Figure 24-37B) to maintain the athlete's
cardiorespiratory fitness for 2 to 4 weeks. This is followed
by a progressive return to running and jumping sports
over a 2 or 3 week period using appropriately constructed
orthotics and appropriate shoes.
Stress fractures of both the navicular of the proximal
shaft of the l'ifth metatarsal usually require more aggres­
sive treatment, requiring non-weight-bearing short 'leg
casts for 6 to 8 weeks for nondisplaced fractures. With
cases of delayed union, nonunion , or especially displaced
fractures. both the Jones and navicular fractures require
internal fixation. with or without bone grafting. Tn the
Figure 24-74 Front forefoot of a running shoe sbow­ highly competitive athlete, immediate internal flxation
ing the typical wear pattern of a pronator. should be recommended.
 CHAPTEH 24 Rehabilitation of Ankle and Foot injuries 64 1

lalS who exces­ Plantar Fasciitis

'ly to develop a
~ bones it is the Pathomechanics. Heel pain is a very common
problem in the athletic and nonathletic population. This
md metatarsal phenomenon has been attributed to several etiologies. in­
Ig and jumping cluding heel spurs, plantar fascia irritation . and bursitis.
the foot associ­ Plantar fasciitis is a catchall term that is commonly used to
! include rear­ denote pain in the proximal arch and heel.
fo rmities in the The plantar fascia (plantar aponeurosis) runs the
rainjng errors, length of the sole of the foot. [t is a broad band of dense
~ inappropriate connective tissue that is attached proximally to the medial
extends proxi­ surface of the calcaneus. It fans out distally. with l1bers and
n d is held rigid their various small branches attaching to the metatar­
ament support. sophalangeal articulations and merging into the capsular
ligaments. Other I1bers. arising from well within the
Figure 24-75 Night splint for plantar fasciitis.
ul arly subjected
1 . which causes aponeurosis. pass between the intrinsic muscles of the foot
l d metatarsal is and the long flexor tendons of the sole and attach them­
n's toe, it is the­ selves to the deep fascia below the bones. The function of flexibility of the longitudinal arch, and lightness ot' the
luring running. the plantar aponeurosis is t() assist in maintaining the sta­ gastrocnemius-soleus unil. Wearing shoes wilhout suffi­
:liograph, is fre- bility of the foot and in secur,i ng or bracing the longitudi­ cient arch support, a lengthened stride during running,
nal arch. ~5 and running on soft surfaces are also potential causes of
Fifth metatarsal Tension develops in the plantar fascia both during ex­ plantar fasciilis.
l te inversion, or tension of the toes and during depression of the longitudi­ The athlete complains of pain in the anterior medial
Icture occurs at nal arch as the result of weight bearing. When the weight heel. usually at the attachment of the plantar fascia to the
fLeo as a sequela is principally on the heel, as in ordinary standing, the ten­ calcaneus that eventually moves more centrally into the
plain of a sharp sion exerted on the fascia is negligible. However, when the central portion of the plantar fascia. This pain is particu­
will usually re­ weight is shifted to the ball of the foot (on the heads of the larly troublesome upon arising in the morning or upon
_" of poor blood metatarsals), fascial tension is increased . In running, be­ bearing weight after sitting for a long period. However, the
re may result in cause the push-ofr phase involves both a forceful extension pain lessens after a few steps. Pain also will be intensil1ed
. rehabilitation. of the toes and a powerful thrust by the ball of the foot (on when the toes and forefoot are forcibly dorsirIcxed .
iJi tation efforts the heads of the metatarsals), fascial tension is increased Rehabilitation Concerns. Orthotic therapy is ve ry
in ing and allevi­ to approximately twice the body weight. useful in the treatment of this problem. The authors have
cond metatarsal Athletes who have a mild pes cavus are particularly found that soft orthotics in combination with exercises can
ed rest a nd non­ prone to fascial strain. Modern street shoes, by the nature Significantly reduce the pain level of these paUen ts. A soft
iU nning (Figure of their design , take on the characteristics of splints and orthotic works better than a hard orthotic. An extra-deep
1-1- 37 A), or sta­ tend to restrict foot action to such an extent that the arch heel cup should be bu-ilt into the orthotic. The orthotic
lin the athlete's may become somewhat rigid because of shortening of should be worn at all times. especially upon arising from
This ·is followed the ligaments and other mild abnormalities. The athlete, bed in the morning. Always have the athlete step into the
jumping sports when changing from such footwear into a flexible gym­ orthotic rather than ambulating barefooted.~
tely constructed nastic slipper or soft track shoe, often experiences trauma Use of a heel cup compresses the fat pad under the cal­
when the foot is subjected to stress. 92 Trauma may also caneous. providing a cushion under the area of irritation.
of the proximal result from running, either from poor technique or be­ When soft orthotics are not feasible. taping may reduce
Ire more aggres­ cause of lordosis. a condition in which the increased for­ the symptoms. A simple arch taping or alternative taping
'a ring short leg ward tilt of the pelvis produces an unfavorable angle of often allows pain-free ambulation. %
fractures. With foot-strike when there is considerable force exerted on the The use of a night splint to maintain a position of static
ecially displaced ball or the fool. stretch has also been recommended (figure 24- 75). In
ractu,r es require Injury Mechanism. A number of anatomical and some cases it may be necessary to use a short leg walking
grafting. In the biomechanical conditions have been studied as possible cast for 4 to 6 weeks.
lernal I1xation causes of pla ntar ,fasciitis . They inclucle leg length dis­ Vigorous heelcord stretching should be used. along
crepancy, excessive pronation of the sub talar joint, in- with an exercise to stretch the p'lantar fascia in the arch .
642 PART THREE The Tools of Rehabilitation

Exercises that increase dorsiflexion of the great toe also

may be of benefitlO this problem (Figures 24-14, 24-75).
Stretching should be done at least three times a day.
Anti-inflammatory medications are recommended.
Steroidal injection may be warranted at some point if
symptoms fail to resolve.
Criteria for Full Return. Managemcnt or plantar
fasciitis will generally require an extended period of treat­
l11ent. It is not uncommon for symptoms to persist for as
long as 8 to 12 weeks . The athlete's persistence in doing
the recommended stretching exercises is critical. In some
cases, particularly during a competitive season, the athlete
may continue to train and compete if sy mptoms and nsso­
ciated pain are not prohibitive.
Figure 24-7 7

CLINICAL DECISION MAKING Exercise 24-5 A bunion

ties of th e gn:
A 30-year-old lennls coach bas complained or morning
tendern ess.
heel pain for severa l weeks. The pain began after chang­
of the hen d 0
Ing to a very fl exible shoe during training. His pain Is in­
tense upon arising in the morning. Forcible dorsiflexion
of the toes and forefoot increases this heel pain. A local
physician has diagnosed plantar fascitis. X rays were un­ Figure 24-76 Prone position for cuboid manipulation.
remarkable. What treatment options migh t lhe athletic
trainer consider for this athlete?

place. Once tbe cuboid is manipulated. an orthotic often

Cuboid Subluxation
Pathomechanics. 1\ condition that often mimics
plantar fasciitis is cuboid subluxation. Pronation and
trauma have been reported to be prominent C<lllSeS of this
sy ndrome. 94 This displacement of the cuboid causes pain
along the fourth and nflh metatarsals. as well as over the
CUboid. The primary reason for pain is the stress placed on
the long peronealmusc!e wben the foot is in pronation. In
this position , the long peroneal muscle allows the cuboid
bone to move downward medially. This problem often
refers pain to the heel area as well. Many times this pain is
increased upon arising after a prolonged non-weight-bear­
ing period.
Rehabilitation Considerations. Dramatic treat­
ment results may be obtained by manipulating to restore
the cuboid to its natural pOSition. The manipulation is
donc with the athlete prone (Figure 24-76). The plantar
aspect of the forefoot is grasped by the thumbs with the fin­
gers supporting the dorsum of th e foot. The thumbs
should be over the cuboid. The manipulation should be a
thrust downward to move the cuboid into its more dorsal
pOSition. Often a pop is felt as the cuboid moves back into
helps to support it in its proper position.
Criteria for Full Return. If m an ipula tion is suc­
ccssful. quite oflen thc athlete can return to play im medi­
ately with little or no pain. It should be recommended that
the athlete wear an <lpp[oprialely constructed orthotic
when pmcticing or competing to reduce lhe chanccs of re­
currence.
with this
Hallux Valgus Deformity (Bunions)
Pathomechanics and Injury Mechanism. A
bunion is a deformity of the head of the first metatarsal in
which the la rge toe assumes a \ralgus position l (Fig u[e
24-77). Commonly it is associated witb a structural fore­ Morton's
foot varus in which the first ray lends to splay outwClrd,
pulling pressure on thc first metatarsa,l head. The bu[sCl
over the first metatarsophalangeal joint becomes inflamed
and eventual1y thickens. The joint becomes enlarged and
the great toe becomes mal aligned, moving laterally toward
thc second toe, sometimes to such elll extent that H even­
tually overlaps the second toe. This type of bunion may
also be associated wiU1 a depressed or flattened transverse
<lrch. Often the bunion occurs from wearing shoes that are
pointed, too narrow, too short, or have high heels.
 CHAPTER 24
Figure 24-77 Hallux valgus deformity with a bunion.
A bunion is one of the most frequent painful deformi­
ties of the great toe. As the bunion is developing there is
tenderness, swelling, and enlargement wiLh calcification
of the head of the first metatarsal. Poorly filling shoes in­
crease the irritation and pain.
Rehabilitation Concerns. If the condition pro­
gresses, a special orthotic device may help normalize foot
mill ipulation. mechanics. Often an orthotic designed to correct a struc­
tural foreioot varus thal can help increase stability of the
first ray significantly reduces the symptoms and progres­
ort hotic often sion of a bunion. Shoe selection may also play a n impor­
tant role in the lreatment of bunions. Shoes of the proper
JlaUon is suc­ width cause less irrilation to the bunion. Local therapy. in­
pla y immedi­ cluding moist heat. soaks, and ultrasound. may alleviate
rnmended that some of the acute symptoms of a bunion. Prolective de­
Jcted orthotic vices such as wedges , pads, and tape can also be used.
cha nces of re­ Surgery to correct the hallux valgus deformity is very com­
mon during the later stages of this condi tion.
Criteria for Full Return. It is likely that an athlete
with this condition can continue to compete while wear­
·ons)
ing an appropriately constructed orthotic. shoes wiLh a
chanism. A wide toe box, and some type of donut pad over the bunion
metatarsal in to disperse pressure.
>ition 1 (Figure
ructural fore­ Morton's Neuroma
lay outward.
d. The bursa Pathomechanics. A neuroma is a mass occurring
about the nerve sheath of the common plantar nerve
enla rged and where it divides inlo the two digilal branches to adjacenl
,terally toward toes. It occurs most commonly between lhe metatarsal
II that it even- heads and is the most common nerve problem of lhe lower
bunion may extremity. A Morton's neuroma is located between the
ed tran sverse third and fourth metatarsal heads where the nerve is the
hoes that arc thickest, receiving boUl branches from the medial and lat­
hee ls. eral plantar nerves. The athlete complains of se vere inter­
RehabiliLation of Ankle and Foot Injuries 643
millenl pain radiating from the distal metatarsal heads to
the Ups of the loes and is often relieved wh en non-weight­
bearing. Irritation increases with the collapse of the
transverse arch of the fool, putting the transverse
metalarsalligaments under stretch and thus compressing
the common digital nerve and vessels. Excessive foot
pronation can also be a predisposing factor. with more
metatarsal shearing forces occurring with th e prolonged
forefoot abduction.
The athlete complains of a burning paresthesia in the
forefoot that is allen localized to the third web space and
radjating to Lhe toes .S2 Hyperextension of the toes on
weight bearing. as in squat Ling. stair climbing, or running,
can increase the symptoms. Wearing shoes with a narrow
toe box or high heels can increase the symptoms. If there
is prolonged nerve irr,i talion. the pain can become con­
stant. t\ bone scan is often necessary to rule out a
metatarsal stress fracture.
Rehabilitation Concerns. OrthotiC therapy is es­
sential to reduce the shearing movements of the
metatarsal heads. To increase this effect, often either a
mGtatarsal bar is placed just pfClximal to the metatarsal
heads or a leardrop shaped pad is placed between the
heads of the third and fourth metatarsals in an attempt to
have these splay apart with weight bearing (Figure
24- 7K) .lt may decrease pressure on the affecled area.
Therapeutic modalities can be used to help reduce in­
nammation. The author has lIsed phonophoresis with hy­
drocortisone with some success in sy mptom reduction.
Shoe selection also plays an important role in treat­
ment of neuromas. Narrow shoes. particularly wome n's
sboes that are pOinted in lhe toe area and certain men 's
boots. may squeeze the metatarsal heads together and ex­
acerbate the problem. 1\ shoe that is wide in lbe toe box
area should be selected. 1\ straight-laced shoe often pro­
vides increased space in the toe box. 79 On a rare occasion
surgical excision may be required.
Criteria for Full Return. Appropriate soft orlhotic
padding orten will markedly reduce pain and allow the
atblete Lo continue Lo play despite this condition.
Turf Toe
Pathomechanics and Injury Mechanism. Turf
toe is a hyperextension injury resulting in a sprain of the
metatarsophalangeal joint of the great toe, from either
repetitive overuse or trauma. 9 0Typical'iy these injuries oc­
cur on unyielding synthetic turf. although it can occur on
grass also. Many of these injuries occur because many ar­
tificial turf shoes are more flexible and allow more dorsi­
flexion of lhe great toe.
644 PART TH REE The Tools of Rehabilitati on
A B
Figure 24-78 ~detalarsal suppor t pads. A, i'vletata rsa l bar. B, Tea rdrop pad .
Figure 24-79 Turf toe taping.
Rehabilitation Concerns. Some shoe companies
have addressed this problem by (ldding steel or other mate­
ria ls to the forefoot of their turf shoes to sUffen them. Flat
insoles that have thin sheets of steel under the forefoot arc
also available. When commercially made products arc not
availab le. a thin. flat piece of Orthoplast may be placed un­
der the shoe insole or may be mold ed to the foot. 9o Taping
as tendini t~
lems in thea
Summary
1. 'l'he m O\L
are Ct nkk
and e\'cr'
2. The posit
the m idt
bile. D} ~I
the toe to prevent dorsillexion may be done separately or
witb one of th e s hoe-sLiITening suggestions (Figure 24- 79 ).
Modalities of choice include icc and ultrasound. One of
the major ingredients in any trea lment for turf toe is rest.
The athlete should be discouraged from returning to acti\'­
ity unLiltbe toe is pain-free.
Criteria for Full Return. The athlete with turf toe
can rdurn to (lctivi!'y when the swelling in th e melalar­
sopha lange(l l joint has resolved and full pain-free Rm..l
from 0 to 90 degrees has been regained . In less severe cases
the athlete can continue to play with the addition of a rigid
insole. With more severe sprains, 3 to 4 weeks may be re­
quired for pain to reduce to the pOint where the athlete can
push off on the great toe.
CLINICAL DECISION MAKING Exercise 24-6
A 25-year-old professional foot hall player has sustained a
hyperextension injury to the metararsoph alangea l joint
of the right great toe in the previous week's game. X rays
were negative. and a diagnosis of acute turf toe was given
by the team physician . Follow ing treatments with ultra­
sound and ice. the ath lete has regained full RO~I with
only sligh t residual soreness. What shoe modiJkalions
might the athletic trainer suggest to lessen the chance of
reinjury in the following week's ga me;
.. ..... .....,,_..................................... ..................... ..... ................. ........... ..... ..
- - - - eli mi n ate
 CHAPTER 24
Tarsal Tunnel Syndrome
Pathomel~hanics and Injury Mechanism. The
tursa'i tunnel is a loosely de!lned area about the medial
malleolus that: is bordered by the retinaculum , which
binds the tibial nerve. lO Pronation. overuse problems such
as tendinitis. and trauma may cause neurovascular prob­
lems in the ankle and foot. Symptoms may vary. with pain.
I Summary
1. The movements that take place at the talocrural joint
arc ankle plantarflexion and dorsiflexion. Inversion
and eversion occur at the subtalar joint.
2. The position of the subtalar joint determines whether
the midtarsal joints will be hypermobile or hypomo­
bile. Dysfunction at either joint can profoundly affect
the foot and lower extremity.
3. Anlde sprains arc very common. Inversion sprains
usually involve the lateral ligaments of the ankle. and
eversion sprains frequently involve the medial liga­
ments of the ankle. Rotational injuries often involve
e separately or the tibiol1bular and syndesmodie ligaments and can be
Figure 24-79). very severe.
'.ro und.Oneof 4. The eanly phase of treatment uses ice. compression. el­
turf toe is rest. evation, rest, and protection. all 01 which are critical
llrning to aeliv- components in preventing swelling .
5. Early weight bearing follOWing ankle sprain is benefi­
Ie \\'ith turf toe cial to the healing process. Rehabilitation may become
in the metatar­ more aggressive following the acute inflammatory re­
pain-free ROM sponse phase of healing.
_ severe cases 6. Undisplaced ankle fractures should be managed with
dilion of a rigid rest and protection until the fracture has healed. Dis­
~ks may be re­ placed fractures arc treated with open reduction and
the athlete can internal fixation.
7. Neutral casting is essential for the production of an or­
thotic. whether it is to be produced in-house or by
someone clse.
8. Subluxation of peroneal tendons can occur from any
mechanism causing sudden and forceful contraction
of the peroneal muscles that involves dorsiflexion and
eversion of the foot. In the case of an avulsion injury
or when this becomes a chronic problem, conservative
treatment is unlikely to be successful and surgery is
needed to prevent the problem from recurring.
9. Tendinitis in the posterior tibialis, anterior tibialis, and
the peroneal tendons can result from one speCific
cause or from a collection of mechanisms. Rehabilita­
tion should incorporate techniques that reduce or
eliminate inOammation. including rest. therapeutic
Rehabilitation of Ankle and Poot rnjur.ies 645
numbness. and paresthesia reported along the medial an­
kle and into the sole of the foot.(' Tenderness may be pres­
ent over the tibial nerve area behind the medial malleolus.
Rehabilitation Concerns. Neutral foot control
may alleviate symptoms in less involved cases. Surgery is
often performed if symptoms do not respond to conserva­
tive treatment or if weakness occurs in the flexors of the
toes. 6
modalities (ice. ultrasound. diathermy), and anti­
inflammatory medications.
10. Excessive or prolonged supination or pronation at the
subtalar joint is likely to resullt from some structural or
functional deformity. including forefoot varus. a fore­
foot valgus. or a rearfoot varus. which forces the sub­
talar joint to compensate in a manner that will allow
the weight-bearing surfaces of the foot to make stable
contact with the ground and get into a weight-bearing
pOSition.
11. Orthotics are used to control abnormal compensatory
movements of the foot by "bringing the floor to the
fooL." By providing support so that the foot docs not
have to move abnormally. an orthotic should help pre­
vent compensatory problems.
12. Shoe selection is an important parameter in the treat­
ment of foot problems. The type of foot will dictate spe­
cific shoe features.
13. The most common stress fractures in the foot involve
the navicular. the second metatarsal (March fracture).
and the diaphysis of the fifth metatarsal Oones frac­
ture). Navicular and second metatarsal stress frac­
tures are likely to occur with excessive foot pronation.
Fifth metatarsal stress fractures tend to occur in a
more rigid pes cavus foot.
14. A number of anaLomical and biomechanical condi­
tions have been studied as possible causes of plantar
fasciitis. There is pain in the anterior medial heel. usu­
ally at the attachment of the plantar fascia to the cal­
caneus. Orthotics in combination with stretching
exercises can significantly reduce pain.
15 . Subluxation of the cuboid will create symptoms simi­
lar to those of plantar fasciitis and can be corrected
with manipulation.
16. A bunion is a deformity of the head of the first
metatarsal in which the large toe assumes a valgus po­
sition that is commonly associated with a structural
forefoot varus in which the !lrst ray tends to splay out­
ward, putting pressure on the first metatarsal head.
646 PART THREE The Tools of Rehabilitation
17. In treating a Morton's neuroma, a metatarsal bar is
placed just proximal to the metatarsal heads or a
teardrop shaped pad is placed between the heads of the
third and fourth metatarsals in an attempt to have
these splay apart with weight bearing.
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29. Giallonardo. L. M. 1988. Clinical evaluation of foot and an­
kle dysfunction. Physical Therapy 68:1850-56. 49.
30. Gill. E.1985. Orthotics. RlInners World. February. pp. 55-57.
31. Glascoe. W.. M. Allen. and B. Autrey. 1999. Weight bearing.
immobilization. and early exercise treatment following a
gmde II ankle sprain. Jourllal oj OrtilOpedic and Sporls Physical
Therapy 2':J(7): 395-99.
32. Glencross. D.• and E. Thornton. 1981. Position sense follow­
ing joint injury. JOIII'/wi of Sports Medicine alld Physical Fitness
21:23-27.
33. Glick. J.. and T. Sampson. 1996. Ankle and foot fractures in
athletics. In The IOlVer extremity awl spine in sports medicine. ed­ 52.
ited by J. Nicholas and E. Hersh man. SI. Louis: jvIosby.
34. Gross.:vI.. A. Lapp. and M. Davis. 1991. Comparison of Swed­
O-Universal ankle support and Aircast Sport Stirrup orthoses
and ankle tape in restricting eversion-inversion before and aJ­
 CHAPTER 24 Rehabilitation of i\nkle and Foot Injuries 647

res ulting in a ter exercise. joumal of Orthopaedic and Sports Physical Therapy 54. McPoiI. T G.. M. Adrian. and P. Pidcoe. 1989. Effects uf foot
rt of the great l3(1): 11-19.
35. Hirata. l. 1974. Proper playing conditions. journal of Sports
orthoses on center of pressure pattems in women. PJrysical
Th erapy 69:149-54.
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36. Hoppenfield. S. 1976. Physical exalllination o( the spine and cx­ Biomechanical evaluation and treatment. [n Ort/ropedic and
tremities. New York: Appleton-Century-Crorts. sports physical therapy. edited by J. Gould and G. Davies. St.
37. Hunt. G.1985. Examination 01' lowerextremitydysrunction. Louis: Mosby.
In Orthopedic and sports physical tllerapy. vol. 2, edited by j. 56. McPoiL T G.. H. G. Knecht, and D. Schmit. 1988. A survey of
Gould and G. Davies. St Louis: Mosby. root types in normal females belween the ages or 18 and 30
38. Hunter, S.. M. Dolan. and M. Davis. 1996. Foot orthotics in years. journal of Orthopaedic al1d Sports Physical Therapy
or the ankle. therapy and sport. Champaign, lL: Human Kinetics. 9:406-9.
ed ited by W. C. 39. Isakov, E., J. Mizrahi. P. Solzi. et al. 1986. Response or the per­ 57. McPoiL T G. 1988. Footwear. PII!Jsical Therapy 68:1857- 65.
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Physical Ther­ 40. Itay, S. 1982. Clinical and runctional status rollowing lateral 59. Morton. D.j.] 937. Foot disorders in general practice. journal
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44. Kelikian. H .. and A. S. Kelikian. 1985. Disorders of the ankle. and alterations induced by immobilization: A correlative bio­
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parison of Swed­ 53. McCluskey, G. M.. T A. Blackburn. and T Lewis. 1976. Pre­ 74. Rogers. M. M.. and B. r. LcVcall. 1982. Errectiveness of root
rirrup orthoses vention or ankle sprains. American journal of Sports Medicine orthotic devices used to modify pronation in runners. journal
o berure and af­ 4:151-57. of OrtllOpacdic and Sports PhYSical Therapy 4:86-90.
648 PART THREE The Tools of Rehabilitation
75. Root, M. L., W. P. Orien. andJ. H. Weed. 1977. Normal and ab­
normal functions of the foot. Los Angeles: Clinical Biome­
chanics.
76 . Sammarco, J. G. 1975. Biomechanics of foot and ankle in­
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77. Sammarco. J. :I 995. Rehabilitation of the Joot alld ankle. St.
Louis: Mosby.
78. Sims, D. 1986. Effects of positioning on ankle edema. Journal
oj Orthopaedic and Sports Physical Therapy 8:30-33 .
79. Sims. D. S.. P. R. Cavanaugh, and). S. Ulbrecht. 1988 . Risk
factors in the diabetic foot. Physical Therapy 68: 188 7- 1.901.
80. Sloan, J. P. , P. Guddings. and R. Hain. 1988. Effects of cold
and compression on edema. Pllysician mId Sport s Medicine
16:116-20.
81. Stover. C. N.. and J. M. York . 1980. Air stirrup management
of ankle injuries in the athlete. American Journal oj Sports
Met/icine 8:360-65.
82. Subotnick, S. I.. and S. G. Newell. 1975. Podiatric sports medi­
cine. Mt. Kisko. NY: tutura.
83. Subotnick. S.l. 1981. The flat foot. PhysiCian and Sports Med­
icine 9:85-91.
84. Subotnick. S. 1. 1977. The rfllming Joot t/octor. Mt. Vias. CA:
World.
85. Taunton, J., c. Smith . and D. Magee. 1996. Leg, foot. and an­
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Zachazewski. D. Magee, and W. Quillen. Philadelphia: W. B.
Saunders.
86. TiberiO. D. 1988. Pathomechanics of structural foot deformi­
ties . PhYSical Therapy 68:1840-49.
SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES
24-1 Regaining strength and ROM are certainly impor­
tant components of a rehabilitation follOWing ankle
injury. Key elements that are frequently omitted in
rehabilitation of the ankle are balance. propriocep­
tion. and neuromuscular control. These are very
important components of ankle rehabilitation for
recurrent ankle sprains.
24-2 Sprains of the syndesmosis and interosseus are
very hard to treat and often take months to heal. It
is not likely that this athlete will be ready in 2 weeks
following symptoms of this severity.
24-3 Peroneal tendon subluxation is a frequent cause of
"popping" and "giving way" in ankle injuries. Per­
oneal subluxation will cause tenderness and ecchy­
mosis in the retromalleolar space behind the lateral
malleolus.
24-4 This athlete's foot exam suggests moderate prona­
tion. This condition often creates hypermobility of
the fITst ray, increaSing pressure on the other
87. Tippett. S. R. 1982. A case st udy : The need for evaluatloo and Ct
reevaluation of acute ankle sprains. JourlJal oj Orthopaedic
and Sports Physical Therapy 4:44.
88. Tropp. H., C. Askling. and J. Gillquist. 1985. Prevention of
ankle sprains. Ameriran Journal oj Sports Medicine
13:259-66.
89. \laes. P.. H. DeBoeck. F. Handlebcfg. eta!' 1985. Comparative
R
radiologic study of the influence of ankle joint bandages on
te
ankle stabili ty. American Journal oj Sports ,\lltdicine 13:46- 49.
90. Visnich. A. 1. 1987. A playing orthoses for "turf toe." Athletic
Training 22 :21 5. Dan
91. Vogelbach. W. D.. and L. C. Combs. 1987. i\ biomechanical \\
approach to the management of chronic lower extremity
pathologies as they relate to excessive pronation . AIIIlcUr
Training 22:6-16.
92 . Wilk o K.. K. fisher. and W. Gutierrez. 2000. Defective run­
ning shoes as a contributing factor in plantar fasciitis in a
'-........
trialhlete. Journal oj Orthopedic and Sports Physical Therapy
30(1): 21-31.
93. Williams. J. G. P. 1.980. The foot and chondromalacia: A case
of biomechanic.al uncertainty. Journal oj OrllJOpaedic and
Sports Physical Therapy 2: 50-51,
To ber o
94. Woods. A.. and W. Smith. 1983. Cuboid syndrome and the
techniques used for treatment. AthleUc Trail/iny 18:64- 65.
New York: Churchill Livingston e.
96. Zylks. D. R. 1987. Alternative taping for plantar fasciitis. Ath­
letic Training 22:3 17.
metatarsals. The most desirable shoe characteristic
for a pronated foot is a shoe that is firm and give~
good support. Straight. board-lasted shoes with
dual-density midsoles will provide the best prona­
tion control.
24-5 Orthotic fabrication is very useful for this condition.
Use of these orthotics is critical during the first fell'
steps in the morning. Vigorous heel cord stretching
should be performed several times daily. The use of
a dorsinexion night splint has also been recom­
mended.
24-6 Some type of material should be added to the fore­
foot of the shoe to stiffen the shoe. Some shoe com­
panies address this problem by placing steel in the
forefoot of their shoes. Taping of the toe to prevent
hyperextension is one alternative method or pre­
venting reinjury.
 aJuatio[l and
OrlilOpaedic
CHAPTER 25
Medi cine
Rehabilitation of Injuries

to the Spine

Daniel N. Hooker
. mechanical William E. Prentice
~er ex tremity

[ion. Ilth/eLie

Defective run­
fasc iit is in a
ysica/ Thcrapu

ala cia: A case

~opacdic and
Study Resources • Conduct a thorough evaluation of the
iirome a nd the
To become more familiar with t.he know ledge and ski ll s back before developing a rehabilitation
necessary to design. imp lement. and document therapeu­
1 :64- 65. plan.
~n k/e illjuries. tic rehabilitalion programs as identified in the Nl1TA Ath­
letic Training Rducatiollal Competencies alld Clillical • Compare and contrast the importance
!f fasciilis. Ath­ Pro(kiencies'Therapeutic E.xercise content area. visit
www.mhhe.c.om/ prentkc 11 e. Also refer to the lab exer­
of using either joint mobilization or
cises in the new Labo ratory Manual and to eS ims, which core stabilization exercises for treating
simulates the a thletic training certification exam, at spine patients.
wIVw.mhh c.cQ m/esims. For more online study reso urces,
visit o ur Hea lth an d Human Performance website at • Differentiate between the acute vs.
\vIVW. mhhe.com/h h P. reinjury vs. chronic stage models for
~h a ra c teris tic
treating low back pain.
rm an d gives After Completion of This

hoes with • Explain the eclectic approach for reha­

Chapter, the Student Should

~ best prona­
Be Able to Do the Following:
bilitation of back pain in the athletic
~ . condition. population.
• Discuss the functional anatomy and
g the first few
rd stretching
biomechanics of the spine. • Describe basic- and advanced-level
tly. The use of
• Describe the difference between spinal training in the reinjury stage of
been reCOffi ­ treatment.
segmental stabilization and core
La the fore­ stabilization. • Incorporate the rehabilitation ap­
De shoe COffi­ proach to specific conditions affecting
g steel in the • Explain the rationale for using the dif­
to prevent ferent positioning exercises for treating the low back.
rthod of pre- pain in the spine. • Discuss the rehabilitation approach to
conditions of the cervical spine.

649
650 PART THREE The Tools of Rehabilitation
FUNCTIONAL ANATOMY
AND BIOMECHANICS
From a biomechanical perspective, the spine is one of the
most complex regions of the body. with numerous bones,
joints, ligaments, and muscles, all of which are collectively
involved in spinal movement. The proximity to and rela­
tionship of the spinal cord, the nerve roots, and the pe­
ripheral nerves to the vertebral column adds to the
complexity of this region. Injury to the cervical spine has
potentially life-threatening implications, and low back
pain is one of the most common ailments known to man .
The 33 vertebrae of the spine are divided into flve re­
gions: cervical, thoracic, lumbar, sacral , and coccygeal.
Between each of the cervical, thoracic, and lumbar verte­
brae lie fibrocartilaginous intervertebral disks that act as
important shock absorbers for the spine.
The design of the spine allows a high degree of nexibU­
ity forward and laterally and limited mobility backward.
The movements of the vertebrall column are Ilexion and
extension, right and left lateraillexion, and rotation to the
left and right. The degree of movement cliffers in the vari­
ous regions of the vertebral column. The cervical and lum­
bar regions allow extension, /lexion , and rotation around
a central axis. Although the thoracic vertebrae have mini­
I}lal movement, theIr combined movement bet ween the
first and twelfth thoracic vertebrae can account for 20 to
30 degrees of nexion and extension.
As the spinal vertebrae progress downward from the
cenrical region, they grov" increasingly larger to accom­
modate the upright posture of the body. as well as to con­
tribute to weight bearing. The shape of the vertebrae is
irregular, but the vertebrae possess certain characteristics
that are common to all. Each vertebra consists of a neural
arch through which the spinal cord passes and several pro­
jecting processes that sen'e as attachments for muscles
and ligaments. Each neural arch has two pedicles and two
laminae. The pedicles are bony processes that project back­
ward from the body of the vertebrae and connect with the
laminae. The laminae are nat bony processes occurring on
either side of the neural arch that project backward and
inward from the pedicles. With the exception of the flrst
and second cervical vertebrae, each vertebra has a spinous
and transverse process for muscular and ligamentous at­
tachment, and all vertebrae have an articular process.
Intervcrtebral articulations are between vertebral bodies
and vertebral arches. Articulation between the bodies is of the
symphysial type. Besides motion at articulations between the
bodies of the vertebrae, movement takes place at four articu­
lar processes that derive [rom the pedicles and laminae. The di­
rection of movementof each vertebra is somewhat dependent
on the direction in which the articular facets face. The sacrwn
articulates with the iJiwn to form the sacroiliac joint, which the abdomin
has a synovium and is lubricated by synovial fluid. oblique. extern
iopsoas, tensor :
Ligaments 10-3). Se\7ent~ ­
bosacral j u 0
The major ligaments t.hat join the various vertebral parts between L4
are the anterior longitudinal. the posterior longitudinal. cute 5 to 10
and the supraspinous. The anterior longitudinal ligament ening of tbe
is a wide, strong band that extends the full length of the erector spinae a
anterior surface of the vertebral bodies. The posterior lon­ hip. Trunk rOOl
gitudinalligament is contained within the vertebral canal and the in teli"-O:
and extends the full length of the posterior aspect of the marily by t he a_
bodies of the vertebrae. Ligaments connect one lamina to obliques,latis..
another. 'Fhe interspinous, supraspinous, and intertrans­ nus on the side
verse ligaments stabilize the transverse and spinous Spinal seg
processes, extending between adjacent vertebrae. The of the spine
sacroiliac joint is maintained by the extremely strong dor­ costalis lu mbar
sal sacral ligaments. The sacrotuberous and the ing in concert ~
sacrospinous ligaments attach the sacrum to the ischium. abdominal 0:
the center or
Muscle Actions muscle leo=
ment. The trac:
The muscles that extend the spine and rotate the vertebral thoracolumbar
column can be classified as either superflcial or deep (see
Figure 10-1). The superficial muscles extend from the ver­
tebrae to ribs. The erector spinae is a group of superficial
paired muscles that is made up of three columns or bands, creased intra
the longissimus group, the iliocostalis group, and the a rigid cylin
spinalis group. Each of these groups is further divided into provides si¢
regions. the cervicis region in the neck. the thoracis region and pelvis.
in the middle back, and the lumborum region in the low
back. Generally the erector spinae muscles extend the
spine. The deep muscles attach one vertebra e to another
and function to extend and rotate the spine. The deep mus­
cles include the interspinales, multifldus. rotatores, tho­
racis, and the semispinalis cervicis (see Figure 10-1).
Flexion of the cervical region is produced primarily by
the sternocleidomastoid muscles and the scalene muscle
group on the anterior aspect of the neck. The scalenes /lex
the head and st.abilize the cerVical spine as the sternoclei­
domastoids flex the neck. The upper trapezius, semispinalis
capitis. splenius capitus, and splenius cervicis muscles ex­
tend the neck. Lateral flexion of the neck is accomplished
by all of the muscles on one side of the vertebral column
contracting unilaterally. Rotation is produced when the
sternocleidomastoid, the scalenes, the semispinalis cervi­ Quadratus
lumborum
cis, and the upper trapezius on the side opposite to the di­
rection of rotation contract in addition to a contraction of
the splenius capitus. splenius cerviCis, and longissimus ca­
pitus on the same side of the direction of rotation. Multifidus ~
Flexion of the trunk primarily involves lengthening of
Figure 25- 1
the deep and superncial back muscles and contraction of
and the qua
 CHAPTER 25 RehabiliLalion of Injuries Lo the Spine 6S 1

joint. which the abdominal muscles (rectus abdominns, internal Spinal Cord
oblique, external oblique) and hip flexors (rectus femoris, il­
iopsoas, tensor faciae lata . sartorius) (see Figures 10-2 and The spinal cord is thaL portion of the central nervous sys­
10-3). Seventy-fi ve percent of flexion occurs at the lum­ tem thaL is conta ined within Lhe verLebral canal of the
bosacral junction (L5-S1 ), whereas 15 to 70 percenL occurs spinal column. Thirty-one pairs of spinal nerves extend
rtebral parts between L4 and L5. The resL of the lumbar verLebrae exe­ from Lhe sides of Lhe spinal cord. coursing downward and
longitudinal. cute 5 to 10 percent of f1exion.h ExLension involves length­ outward through the intervertebral foramen passing near
inalligament ening of the abdominal muscles and contraction of the the articular facets of the vertebrae. Any abnormal move­
length of the erector spinae and the gluteus ma"imus, which extends the menL of these faceLs. SLich as in a dislocation or a fracture.
po terior lon­ hip. Trunk rotation is produced by the external obliques may expose the spinill nerves to injury. fnjuries that occur
rtebral canal and the internal obliques. Lateral flexion is produced pri­ below (he Lhird lumbar vertebra usually result in nerve
• a pect of the marlly by the quadralUs lumborum muscle, along wiLh the root damage but do not cause spinal cord damage.
De lamina to obliques, latissimus dorsi, iliopsoas, and Lhe rectus abdomi­ The spinal nerve roots combine to form a network of
od intertrans­ nus on the side of the direction of movement. nerves, or a plexus. There arc five nerve plexuses: cervic.al ,
and spinous Spinal segment stability is produced by the deep muscles brachial. lumbar, sacral, and coccygeal.
ertebrae. The of the spine (multifidi, medial quadratus lumborum, ilio­
~ly strong dor­
s and the
costalis lumborum, interspinales, intertransversarii) work­ THE IMPORTANCE OF
ing in concert wiLh the transversus abdontinis and internal
o t he ischium. abdominal oblique (Figure 25-1). Their location is close to
EVALUATION IN TREATI NG
the center of rotation of the spinal segment and their short BACK PAIN
muscle lengths are ideal for controlling each spinal seg­
In many instances after referral for medical evaluation. the
ment. The transversus abdominis, because of its pull on the
ethe vertebral thoracolumbar fascia, and its ability to create increased in­
athlete returns to th e aLh letic tmlner with a diagnosis of low
.1 o r deep (see traabdomlnal pressure, is a major partner in spinal segment
back pain. Even though Lhis is a correct diagnosis,
I [rom the ver­ stability (Figure 25-2). The transversus abdominis contrac­
it does not offer the specifiCity needed to help dircct the treut­
I of superfi cial tion also narrows the abdomina l caviLy which creates in­
menL planning. The athletic tminer planning the treMment
m ns or bands,
creased intraabdominal pressure. This combination creates
oup. and the
a rigid cyLinder and in concerL with the deep spinal muscles
r divided into
provides significanL segmenLal stability to the lumbar spine
boracis region and pelvis. 8.19.20.21.3 3.34.15.16.38.39.40
o n in the low
extend the
e to anoLher
he deep mus­
talOres, tho­ External
10-1). Transverse ­ --,1,1....-... obliques
d primari ly by abdominis
calene muscle
e calenes flex
Ihe sternoclei­
. emispinalis
muscles ex­
accomplished
t bral column
ced when the
spinalis cervi­ Quadratus - - - -""'"
)site to the di­ lumborum
on traction of
In gissimus ca­
Ilion. Multifidus ----....::....-----j
ngthening of
:onLraction of
Figure 25-1 Muscles of the low back. The multifidus Figure 25-2 The transverse abdominis and exLernal
and the quadratus lumborum muscles. oblique muscles.
652 PART THREE The Tools of Reha_bi/italion

wou ld be better served with a more specific diagnosis such as 3, To provide some provocative guidance to h elp the ath­ i. Piri
spondylolysis, disk herniation, quadratus lumborum strain, lete probe the limits 01 their condition, help them bet­ d)
piriformis syndrome. or sacroiliac ligament sprain. ter understand their problem, present limitations, and ii lim
Regardless of the diagnosis or the specificity of the di­ understand the management of their injury c. Silt inc
agnosis, the importance of a thorough evaluation of the problem,23.28,41 d. Slump
athlete's back pain is critical to good care. The athletic 4. To establish confidence in the athletic trainer. This 3. Supine
trainer should beoome an expert on this individual athlete's increases the placebo effect of the athletic trainer­ a. ,H i p
back. Taking the lime to perform a comprehensive evalua­ athlete interaction. 53,," b. Palpa'
tion will pay great rewards in the success of treatment and 5. To decrease the anxiety of the athlete. This increases SCgJ
rehabilitation. The evaluation has six major purposes: the athlete 's comfort, which will increase their com­ c. Palpa:
pliance with the rehabilitation plan; a more positive Some '
1. To clearly locate areas and tissues that might be part
environment is created, and the athletic trainer and n ot:;
of the problem. The athletic trainer should use this in­
patient avoid the "no one knows what is wrong with d. S llCIi~
formation to direct treatments and exercises.21.28Al
me" trap. 9 i. In
2. To establish the baseline measurements used to as­
6. To provide information for making judgments on a.
sess progress and guide the treatment progression
pads, braces, and corsets, b.
and help the athletic trainer make specific judg­
c_
ments on the progression of or changes in specific Table 25-1 provides a detailed scheme for evaluation of
exercises. The improvement in these measurements back pain,
d.
also guides the return to practice and play and pro­ e.
vides one measure of the success of the rehabilita­
tion plan.23.28,41 e. Saer
sacn
r.

• TABLE 25-1 Lumbar and Sacroiliac Joint Objective Examination

1. Standing Position i.
a. Posture- alignment
b. Gait 4.
i. Patient's trunk frequently bent laterally or hips shifted to one side a.
ii. Walks with difficulty or limps
c. Alignment and symmetry b,
i. Level of rna lIeoli c.
ii. Level of popliteal crease d.
iii. Trochanteric levels Pi
iv. PSIS and ASLS levels ar
v. Levels of iliac crests 5.
Recent studies have raised the concern that th ese clinical assessments of alignment are not valid because of the a.
small movements available at the sacroiliac joints. These tests should be lIsed as a small part of the overall evalua­
tion and not as stand-alone tests. In sacroiliac dysfunction, the ASIS, PSIS, and iliac crests may not appear to be in
the same horizontal plane.
d. Lumbar spine active movements
i. With sacroiliac dysfunction, the athlete will experience exacerbation of pain with side bending toward the
painful side b.
ii. Often a lumbar lesion is present along with a sacroiliac dysfunction c.
e. Single-leg standing backward-bending is a provocation test and can provoke pain h1 cases of spondylolysis or
spondylol isthesis d.
2. Silting Position
a. Lumbar spine rotation e.
b. Passive hip internal rotation and external rotation
 CHAPTER 25 Rehabilitation of lnj uries to the Spine 653

Ip weath­ i. Piriformis muscle irritation would be provoked by internal rotation and could be present from sacroiliac joint
Lh m bel­ dysfunctions or myofascial pain from overuse of this muscle
ii. Limited range of molion of the hip can be a red nag for hip problems
c. Sitting knee extension produces some stretch to the long neural slructures
d. Slump sit is used to evaluate lumber nexibility and neural tension
3. Supine Position
a. Hip externa'l rotation in a resting position may indicate piriformis muscle tightness
b. Pa1lpation of the transversus abdominis, as the athlete is directed to contract, can help in the assessment of spinal
segment control. Can the athlete isolate this contraction from the other abdominal muscles?
c. Palpation of the symphysis pubis for tenderness. Some sacroiliac problems create pain and tenderness in this area.
Sometimes the presenting subjective symptoms mimic adductor or groin strain but the objective evaluation does
not show pain or weakness on muscle contraction or muscle tenderness that would support this assessment
d. Straight leg raise (SLR)
i. Interpretation of SLR: Pain provoked before
a. 30 degrees-hip problem or very inOamed nerve
b. 30 to 60 degrees-sciatic nerve involvement
c. 70 to 90 degrees-sacroiliac joint involvement
c\-aiuation of
d. Neck fiexion--exacerbates symptoms--disk or root irritation
e. Ankle dorsmexion or Lasegue's sign--exacerbated symptoms usually indicates sciatic nerve or root irrita­
tion
e. Sacroiliac loading test (compression, distraction, posterior shear)-pain provoked by physical stress through the
sacroiliac joints can be helpful in assessing for sacroiliac joint dysfunction
f. FABER (flexion, abduction, external rotation), alIso known as Patrick's test-at end range assesses ,[rrUability of
the sacroiliac joint; hip muscle tightness can also be assessed using this test
g. FADIR (flexion, adduction, internal rotation) produces some stretch on the iliolumbar ligament
h. Bilateral knees to chest-will usually exacerbate 'l umbar spine symptoms as the sacroLliac joints move with the
sacrum in this maneuver
i. Single knee to chest can provoke pain from a variety of sources from sacroiliac joillt to lumbar spine muscles and
ligaments; make the athlete be specillc about their pain location and qua1ity
4. Side-Lying Position
a. Anterior and posterior iliac rotation-pain on movement indicates irritation of the sacroiliac joints; may also be
used as a joint mobilization to ease pain
b. Iliotibial band length-long-standing sacroiliac jOillt problems sometimes create tightness of the iliotibial band
c. Quadratus lumborum stretch and palpation
d. Hip abduction and piriformis muscle test

Pain provocation with any of this test indicates primary myofascial pain problems or secondary tightness, weakness,

and pain from muscle guarding associated with different pathologies.

5. Prone Position
u e oflhe a. Palpation
ra il evalua­ i. Well-localized tenderness medial to or around the PSlS indicates sacroiliac dysfunction
~pe a r to be in ii. Tenderness lateral and superior to the Ps:rs illdicates gluteus medius irritation or myofascial trigger point
iii. Gluteus maximus area-sacrotuberous and sacrospinous ligaments are in this area, as well as piriformis mus­
cle and sciatic nerve. Changes in tension and tenderness can help make the evaluation more specillc
iv. Tenderness or alignment from S-l to T-lO implicates some lumbar problems
b. Anterior-posterior or rotational prevocational stresses can be applied to the spinous processes
c. Sacral provocation stress test-pain from anterior-posterior pressure at the center of the sacral base and/or on
lysis or each side of the sacrum just medial to the PSIS may be indicative of sacroiliac joint dysfunction
d. Hip extension-knee nexion stretch will provoke the L-3 nerve root and create a nerve quality pain down the an­
terolateral thigh
e. Anterior rotation stress to the sacroiliac joint can be delivered by using passive hip extension and PSIS pressure;
pain would be indicative of sacroiliac dysfunction
654 PARTTHREE The Tools of Rehabilitalion
6. Manual :MuscleTest
II' the lumbar spine or posterior hip musculature is strained, active movement against gravity and /or resistance
should provoke a pain complaint similar to the athlete's subjective description or their problem
a. Hip extension
b. Hip internal rotation
c. Hip external rotation
d. Hip flexion
e. Hip adduction
r. Trunk extension-arm and shoulder extension
g. Trunk extension-arm, shoulder, and neck extension
h. Trunk extension-resisted
i. MulLifidus activation and control
j. Spinal segment coactivation or transversus abdominis and multifidi 13.23. 28.40.41
REHABILITATION TECHNIQUES
FOR THE LOW BACK
Positioning and Pain-Relieving
Exercises
Most athletes with back pain have some fluctuation or
their symptoms in response to certain postures and activi­
ties. The athletic trainer logically treats this athlete by re­
inforcing pain-reducing postures and motions and by
starting specific exercises aimed at specific muscle groups
or specific ranges of motion . A general rule to follow in
making these decisions is as follows: Any movement that
causes the back pain to radiate or spread over a
larger area should not be included during this early
phase of treatment. Movements that centralize or di­
minl.sh the pain are correct movements to include at this
time. u 1 Including some exercise during inilial pain man­
agement generally has a positive effect on the athlete. The
exercise encourages them to be active in the rehabilitation
plan and helps them to regain lumbar movement. I 5.54
When an athlete relieves pain through exercise and at­
tention to proper postural control. he or she is much more
likely to adopt these procedures into a daily routine. An
athlete whose pain is relieved via some other passive pro­
cedure, and then is taught exercises. wiU not be able to
readily see the connection between relief and exer­
cise.4.0.11.11.40
The types of exercises that may be included in initial
pain management include the following:
Spinal segment control, transverse abdorninis, and
multifidus coactivation
Lateral shift corrections
Extension exercises
letes with I
ing and fIrin
loses spinal
and return w
these muse
and testi ng:
scious cono-.
vation pal;
coactivatioc. ~
tivities. The
muscul ar 0
tral mO\'e'
control.
A mu
maxim u m
fidus and [.
sary to cr,
Flexion exercises levels grea
Postural traction positions flow of ac[
Spinal Segment Control Exercise. In devising ex­ the exerci
ercise plans to address the different clinical problems of the sus abdom .
lumbo-pelvic-hip complex , the use of core-stabilizing
exercises is a must for every problem for recovery,
maintenance, and prevention of reinjury. Clinically,
the core stabilization rehabilitation exercise sequence be­
gim with relearning the muscle activation patterns neces­
sary for segmental spinal stabilization. This beginning
exercise plan is based on the work of Richardson. Jull,
Hodges, and Hides.1 9.2o.21.21. .l5 .39.40
Th e first step in segmenta I spinal stabilization is to l.
reestablish separate control of the transversus abdo­
minis and the lumbar multifidii (Figure 25-1 and 25-2).
The control and activation of these deep muscles should
be separated from the control and activation of the
global or superficial muscles of the core. Once the ath­
lete has mastered the behavior of co activation of the
transversus abdominis and multifidii to create and
maintain a corsetlike control and stabilization of the
spinal segments, they may then progress to using the
global muscles in the core stabilization sequence and
more functional activities . Segmental spinal stabiliza­
tion is the basic building block of core stabilization exer­
cises and should be an automatic behavior to be used in
every subsequent exercise and activity.19.20.22.33.34
The basic exercise that the athlete must master is coac­
tivation of the transversus abdominis and multifidii, iso­
lating them from the global trunk muscles . This
contraction should be of sufficient magnitude to create a
small increase in the intra-abdominal pre.ssure. This is a
simple concept, but these muscle contractions are nor­
maIly under subconscious automatic control: and in ath­

letes with low back pain. the subconscious control of tim­
ta nce ing and flfing patterns becomes disturbed and the athlete
loses spinal segmental control. 1U To regain this vital skill
and return the subconscious liming and firing patterns of
these muscles. the athlete will need individuall instruction
and testing to prove that he or she has mastered the con­
sciolls control of each muscle individually and in a coacti­
vation pattern. The next step is to incorporate this
coactivation pattern into functional exercise and other ac­
tivilies. The success of this exercise is dependent upon this
muscular coactivation becoming a habitual postural con­
trol movement under both conscious and subconscious
control.
A muscle contraction of 10 to 15 percent of the
maximum voluntary contraction (MVC) of the multi­
fidus and the transversus abdominis is all that is neces­
sary to create segmen tal spinal stability. Contraction
levels greater than 20 percent of MVC will cause over­
now of activity to the more global muscles and negate
pdevising ex­ the exercise's intent of isolating control of the transver­
ioblems of the sus abdominis and multifidii. 22 Precision of contraction
e-stabilizing and control are the intent of these exercises; the ulti­
'or recovery, mate goal is a change in the athlete's behavior. As this
try. Clinically. behavior is incorporated into more daily activities and
~quence be­ exercise, the strength and endurance of these muscle
allerns neces­ groups will also improve and the core system will work
:tis beginning more effectively and efficiently.22.l9.40.l3.34
hardson. Jull. Transversus abdominis bellavior exercise plan.
ilization is to 1. Test the athlete's ability to consciously contract and
,\. rsus abdo­ control the transversus abdominis in isolation from
-1 and 25-2). the other abdominal muscles. The athletic trainer can
scles should assess the contraction through observation and pal­
:at ion of the pation. The athlete is positioned in a comfortable re­
:Jnce the ath­ laxed posture: stomach-lying. back-lYing, side-lying,
\'a ti on of the or hand-knee position. The best palpation location is
) create and medial to the AS IS about 1. 5 inches (Figure 25-3).
za tion of the The internal abdominal obl·i que has more vertical
to using the fibers and is closest to the ASIS, whereas the transver­
;cq uence and sus fibers run horizontal from ilia to ilia. The athletic
in al stabiliza­ trainer monitors the muscle with light palpation and
ilization exer­ instructs the athlete to contract the muscle, feeling
i to be used in for the transversus drawing together across the ab­
1 1.33. H
domen. As the contraction increases, the internal
n aster is coac­ oblique fibers and external oblique fibers will start to
multifidii, iso­ flfe. If the athlete cannot separate the firing of the
n uscLes. This transversus from the other groups and/ or can't main­
Ide to create a tain the separate contraction for 5 to 10 seconds, they
ure. This is a will need individual instruction with various forms of
dons are nor­ feedback to regain control of this muscle behavior. In
01 : and in ath­ athletes with low back pain, transversus contraction
CHAPTER 25 Rehabilitation of Injuries to the Spine 655
Figure 25-3 Palpation location to feel for isolated
transversus abdominis contraction.
usually becomes more phasic and fires only in combi­
nation with lhe obliques or reclus.l1.~j()
2. ' he alhlele is posilioned in a comfortable pain-free po­
sition and inslrucled to breat he in and out gently, stop
the breathing, and slowly, gently conlract and hold the
contraction of their transversus-and then resume
normal light breathing while try,ing 10 maintain the
contraction. Changes in body position (positions of
choice are prone, side-lYing, supine, or quadriped),
verbal cues, and visual and tactile feedback will speed
and enhance the learning process (Figure 2 5-4A, B).
The use of imaging ultrasound to visualize the con­
tractions of these muscles is a unique new idea for
biofeedback in isolating and bringing these muscle
contractions under cognitive conlrol. 1HO
3. The lumbar multifidii contractions are laughl with
tactile pressure over the muscle bellies next to the
spinous processes (Figure 25-5). The athlete is asked
to contract the muscle so the muscle swells up directly
under the finger pressure. The feeling should be a
deep tension . A rapid superficial contraction or a con­
traction that brings in the global muscles is not ac­
ceptable, and continued lrial and error wilh feedback
is used until the desired contraction and control are
achieved. 22 .40
4. As soon as cognitive control of the lransversus and
llluitifidii is achieved, more functional posilions and
exercises aimed at coaclivation of bOlh muscles are
begun. The ath letic trainer should allempt to have the
athlete use the transversus and multifidii coaclivalion
in a comfortable neutrallumbo-pelvic posilion with
restoration of a normal lordotic curve so thatlhe
656 PART THREE The Tools of Rehabilitation
A
B give the athlete feedback on their ability to perform a
figure 25-4 The guadriped position can be used to
demonstrate and practice the isolated transversus abdo­
minis contraction. Tne athlete is instructed to A, let their
belly sag, and then B, slowly and gently contract their
pelvic floor muscles and practice holding this position for tivities is the next step and is accomplished by gradu­
10 seconds. ating the exercises to include increases in stress and
Figure 25-5 Palpation location to feel for isolated lum­
bar mullifidii contractions.
A
Figure 25-6 Palpation location to feel contractions, to
coactivation segmental spinal stabili:wtion contraction.
muscle coactivation strategies can start to be incorpo­
rated into the athleLe's daily lire (Figure 25-6 ). Repeti­
tion improves the effectiveness of this contraction,
and as it is used more, the cognitive control becomes
less and the subconscious pattern of scgmental spinal
stabilization returns to normal. 22.40
5. Incorporating the coactivation back into athletic ac­
control. Supine lying with simple leg and arm move­
ments is a good starting point. Using a pressure A
biofeedback unit for this phase will help the athlete
measure their ability to usc the coactivation contrac­
tion effectively during increased exercise. The pres­
sure bladder or blood pressure cuff is inflated to a
pressure about 40 mm Hg. As the athlete coacUvates
the transversus abdominis and multil1di, the pressure
reading should stay the same or decrease slightly and
remain at that level throughout the increased mOve­
ment exercises (Figu re 25-7 A.B). This is an indirect
measure of the spinal segment stabilization, but gives
the athlete an outside feedba ck source to keep them
more focused on the cxcrcise. 22.411
6. This can be followed with trunk inclination exercises
in which the athlete maintains a neulrallumbo­
pelvic position and inclines their trunk in different po­
sitions away [rom the vertici:ll alignment and holds in
pOSitions of forward-lean Lo side-lean for speCific time
periods (Figures 2 5-HA.B, 2:;-9A, B). This is first done 7.
in the sitting position . As control. strength. and en-
 CHAPTER 25 Rehabilitation of Injuries to the Spine 6S 7

A
B

trac tions. to Figure 2 5-7 Pressure gauge biofeedback can be used as em indlrecL method of measuring correct activalion of the
·rform a spinal segment stabili.zation coactivatioll contraction. The pressure bladder or blood pressure cuff is inflated to 40 mm
Jlllraction. Hg pressure and plelced under the athlete's A. abdomen. or B. back. The elthlete is instructed to contract the transversus
in a way that does not make the pressure in the cuff start to rise or fall

to 'incorpo­
_ - -6). Repeli­ ration of the segmental spinal stabilization coactiva­
tion contraction as the precursor to each exercise is
the goal atth.is point in returning the athlete back to
Lheir sport.
enwl spinal
8. The elthletie trainer should teach this technique both
as an exercise and as a behavior. The exercises should
at hletic ac­
be taught and monitored in an individual session with
d by gradu­
opportullity for feedback and correction. The athlete
n stress and
must also use this skill in the functional things they do
d arm move­
B every day. The athlete is asked to trigger this spinal seg­
re ure
ment control skill in response to daily tasks. postures.
the athlete
'on contrac­ pains. und certain movements (Figure 25-lOA,B). As
The pres­ their pain is controlled and they return to their sport
lated to a practice. the coactivation contraction should be incor­
porated into the drills and scrimmage situations.
activates
• the press ure Segmental spinal stabilization is complementary for all
lig htly and forms of treatment and different pathologies. 'fhis exercise
, ed move­ program can be incorporated and started at the same time
an indirect as other therapies. The different forms of therapy sum­
on. but gives mate. and the athlete improves more quickly and main­
keep them Figure 25-8 Trunk incliniltion exercise. The athlete tains the gains in range and strength achieved with other
finds a comfortable neutral spine position and coactivates
therapies. Spinal segment control may also decrease pain
their tnmsversus abdoll1inis and lumbur multifidii to pro­
Ion exercises and give the athlete a measure or control to use in mini­
vide the segmentClI spinell st<lbilization.
Ilu mbo­ mizing painful stress through their injured tissues.
nd i ffcren t po­ Lateral Shift Corrections. Lateral shirt correc­
a nd holds in durance increase. the positions can become more ex­ tions und extensioll exercises probCibly should be discussed
. peci!'ic time aggerated and the holding times longer. together because the indications for usc arc similar. and
i first done 7. Return the athlete to a structured progressive resistive extension exercises will immediately follow the luteral shirt
h . and en- core exercise program (see Ch<lpter 10). The incorpo­ corrections.
658 PART THREE The Tools of Rchnbilii<llion

a mirror to prl
the athletic
The specific 1
A B eral shift cor

Figure 25·9 The athlete cllallengcs his or her spinal segment control by leaning
£!way from the vertica l posilion while holding the neutral spine position for J 0 seconds.

e.

A B

letic trainer
aligned slig
3. Pauding sh
on the side
Figure 25·10 The athlete is instructed to become pusture savvy by fl'cquently using comfortable
the coactivation contraction throughout their day. The coactivalion thereby becomes a
subconscious movement pattern the athlete incorporates into a ll they do.

The indications for the usc of lateral shift corrections i\ tesl correct ion of the hip shift either reduces the pain

arc as foll'ow s: or causes the pain to centralize.

tween the jJj
Subjectively, the ath lete compl ains of unilateral pain The ncurologi ccil examination mayor may not elicit
ure 25-1 ll.
reference in the lumbar or hip area. the following positive findings:
5. Tile athletic l;'
The typi cal post ure is scoliotic with a hip ~hift and re­ 1. Struightlcg raising may be limited and pClinful. or i£ Jete's hips tOIl
duced lumbar lordosis. could be unaffected. thc athletic Ira
Walking and movemenls arc very guarded aDd robotic. 2. Sensation may be duJ I. ill1esthetic. or unarfected.
Forward bending is ext remely limited Dnd increases 3. Manual muscle test may indicate unilateral weak­
the pain. ness of specific movements, or the movements may again. tbe at hl,
Backward bending is limit ed . be slrong and painless. and allow com
Side bending toward the painful side is minimal to im­ 4 . Reflexes Illay be diminished or unClrrected. 4 . 11 tively extend ge
possible. matching th e [,
Side bending away [rom the painful side is usually rea­ The athlete will be assisted by the athletic trainer with trainer. The goa
sonable to normal. the initial lateral shift correction . The alhlete is then in- lion of the scoli
 CHAPTER 25 Rehabilitation of Injuries to the Spine 659

structed in the techniques of self-correction. The lateral shift

correction is designed to guide the athlete bClck to a more
symmetrical posture. The athletic trainer's pressure should
be llnn and steady amI more guiding than forcing. The use of
a mirror to proVide visual feedback is reconunended for both
the athletic trCliner-assisted and self-corrected maneuvers.
The specific technique guide for athletic trainer-assisted lClt­
eral shift correction is as follows (Figure 25- J I):

] . Preselthe athlete by explaining the correction ma­

neuver and the roles of the athlete and the athletic

trainer.

a. The athlete is to keep the shoulders level and avoid

the urge to side bend.
b. The athlete should allow the hips to move under
the trunk and shouldllot resist the pressure from
the athletic trainer but allow the hips to shift with
the pressure.
c. The athlete should keep the athletic trainer in­
formed about the behavior of their back pain.
d. The athlete should keep their feet stationary and not
move after the hip shift correction unlilthe standing
extension part of the correction is completed. Figure 25-11 Lateral shift correction exercise. Empha­
e. They should practice the standing extension
sis is on pulling the hips, not on pushing the ribs.
exercise as part of this initial explanation.

2. The athletic trainer should stand on the athlete's side

that is opposite their hip shift. The athlete's feet
should be a comfortable distance apart, and the ath­
letic trainer should have a comfortable stride stance
aligned slightly behind the athlete.
3. Padding should be placed around the athlete's elbow.
on the side next to the athletic trainer, to provide
comfortable contact between the athlete and the
sports athletic trainer.
4. The athletic trainer should contact the uthlcle's elbow
with their shoulder and chest with their head aligned
along the athlete's back. Their arms should reach
le duces the pain around the athlete's waist and apply pressure be­
tween the iliac crest and the greater trochanter (Fig­
- may not elicit ure 25-11).
5. The athletic trainer should gradually gUide the ath­
d painful, or it lete's hips toward him or her. If the pain increases,
the athletic trainer should ease the pressure and
If unaffected . maintain a more comfortable posture for 10 to 20
n ilateral weak­ seconds, then again pull gently. If the pain increases
vements may again, the athletic trainer should again lessen the pull
and allow comfort. then instruct the athlete to ac­
tively extend gently, pushing their back into and
matching the resistance supplied by the athletic
6. Once the corrected or overcorrected posture is
achieved . the athletic trainer should mainta,in this
posture for 1 to 2 minutes. This procedure may take 2
to 3 minutes to complete. and the llrst attempt may be
less than a lOtal success. Repeated efforts 3 to 4 min­
utes apart should be attempted during the I1rst treat­
ment effort before the athletic trainer stops the
treatment for that episode.
7. The athletic trainer gradually releases pressure on the
hip while the athlete does a standing extension move­
ment (see rigufe 25-16). The athlete should complete
approximately six repetitions of the standing exten­
sion movement. holding each 15 to 20 seconds.
8. Once the athlete moves their feet and walks even a
short distance. the latera'l hip shift usu811y will recur,
but to a lesser degree. The athlete then should be
taught the self-correction maneuver (Figure 25-12).
The athlete should stand in front of a mirror and
place one hund on the hip where the athletic trainer's
hands were and the other hand 0.11 the lower ribs
where the athletic trainer's shoulder was.
9. The athlete then guides their hip under their trunk,

lic trainer with trainer. The goal for this man euver is an overcorrec­ watching the mirror to keep their shoulders level

lete is then i.n­ tion 0[' the scoliosis, reversing its direction. and trying to achieve a corrected or overcorrected

660 PART THREE The Tools of Rehabilitation
Figure 25-12 Hip shift self-correction. The athlete can
use a mirror for visual feedb ack as they apply the gentle
guiding force to correct their hip shift posture. The athlete
uses one hand to stabilize themselves at the rib level' and
uses the other hand to guide the hips across to correct
their alignment. This position is held for 30 to 45 sec­
onds, and then the athlete is instructed to go into the
standing extension position for 5 to 6 repetitrions, holding
the position for 20 to 30 seconds.
posture, They should hold this posture for 30 to 45
seconds and then follow with several standing exten­
sion movements as described in step 7 4 . 31 (Figure
25-12).
Extension Exercises, The indications for the use of
extension exercise are as follows:
Subjectively, back pain is diminished with lying down
and increased with siltin g. The location of the pain
may be unilateral, bilateral, or central, and there may
or may not be radiating pain into either or both legs.
Forward bending is extremely limited and increases
the pain, or the pain reference location enlarges as the
athlete bends forward.
Backward bending can be limited, but the movement
centralizes or diminishes the pain.
The neurological examination is the same as outlined
for la teral shift correction.1.3I.32
The efficacy of extension exercise is theorized to be
from one or a combination of the following effects:
Figure 25-13 Prone extension on elbows.
Figure 25- 1~
A reduction in the neural tension
A reduction of the load on the disk, which in turn de­
creases disk pressure
Increases in the strength and endurance of the exten­
sor muscles
Proprioceptive interference with pain perception as
the exercises aLlow self-mobilization of the spinal joints
Hip shift posture has previously been theoretically cor­
related to the anatomical location of the disk bulge or
nucleus pulposus herniation . Creating a centralizing Figure 25- 1
movement of the nucleus pulpos us has been the theoreti­
cal emphasis of hip shift correction and extension exercise.
This theory has good logie, but research on this phenome­
non h as not been supportivc. l 7 However, in explaining th e
exercises to the athlete, the use of thls theory may help in­
crease the athlete's motivation and compliance with the
exercise plan.
End-range hyperextension exercise should be used
cautiously when the athlete has facet joint degeneration or
impingement of the vert.ebral foramen borders on neural
structures. Also, spondylolysis and spondylolisthesis prob­
lems should be approached ca utiously with aoy end-range
movement exercise using either llexion or hyperextension.
Figures 25-13 through 25-20 are examples of exten­
sion exercises . These examples are not exha ustive but are
representative of most of the exercises used clinically.
The order in which exercises are presented is not sig­
nificant. fnstead , each athletic trainer should basc thc
starting exercises on the evaluative findings. Jackson, in a
review of back exercise, stated, "no support was found for
the use of a preprogrammed t1exion regimcn that includes
exercises of little value or potcntial harm ancl is not specific
to the current needs of the patien t, as determincd by a
thorough back eva luation." The review also included a re­
port of Kendall and Jenkins's study, which stated that onc­
third of the patients for whol11 hyperextension exercises
had been prescribed worsened. 24
 CHAPTER 2S Rehabilitation of Injuries to the Spine 661

Figure 25-14 Prone extension on hands.

h in lurn de-

f the exten­

rceplion as Figure 25-16 Staoding exteosion.

e.-pi na l joints
reLicaliy COf­
. k bulge or
Figure 25-15 Alternate arm and leg extension.

sion exercise.
is phenome­
~I< ining the
may help in­
mee with the

Duld be used
'generation or
lers on neural
isthesis prob­
Iny end-range
rperextension.
!pIes of exten­
uslivc but are
tlin icaHy.
led is not sig­
u ld base the
Jackson, in a
\\ as fou nd for
I tha t includes
I i not specif1c
n nined by a
included a re­
aled that one­
io n exercises Hgure 25-17 Supine hip extension-butt lift or bridge.
A, Double-leg support. B, Single-leg support.
662 PART THREE The Tools or RehabUitation

flexion I

~
Figure 25-18 Prone single-leg hip extension. A, Knee flexed. B, Knee extended.

Figure 25-19 Prone double-leg hip extension A, Kn ees tlexed. B, Knees ex tended.

A IB

Figure 25-20 Trunk extension-prone. A, Hands near head. B, Arms extended-superman position .
 CHAPTER 25 RehabUitution of Injuries to the Spine 663

Flexion Exercises. The indications for the usc of

nexion exercises are as follows :
Subjectively. back pain is diminished with sitting and
increased with lying down or standing. Pa in is a lso in­
creased with walking.
Repeated or sustained forward bending eases the
pain.
The athlete's lordotic curve does not reverse as th ey
forward bend.
The end range of sustained backward bending is
pa inful or increases the pain.
Abdominal tone and strength are poor.
In his approach , Saal elaborates on the thought that "No Figure 25-21 Single knee to chest. A, Stretch holding
one sho uld continue with one particular type of exercise 15 to 20 seconds. B, Same as step 2.
regimen during the en tire treatment program." 41 We con­
cur with this an d believe that starting with one type of ex­
ercise should not preclude rapidly adding other exercises
as the athlete's pain resolves and other movements be­
come more comfortable.
The efficacy of nexion exercise is theorized to derive
from one or a combination of the following effects:
A reduc tion in the articular stresses on the facet
joints
Stretching to the thoracolumbar rascia and musculature
Opening of the intervertebral foramen
Relief of the stenosis of the spinal canal
Improvement of the stabilizing effect of the abdominal
musculature
Increasing the intraabdominal pressure because of in­
creased abdominal muscle strength and tone
Proprioceptive interference with pain perception as Figure 25-22 Double knee to chest. A, Stretching­
the exercises allow self-mobilization of the spinal holding posture 15 to 20 seconds. B, Mobilizing-using
joints 14 a rhythmic rocking motion within a pain-free range of
Flexion exercises should be used cautiously or motion.
avoided in most cases of acute disk prolapse and when a
laterally shifted posture is present. In patients recovering
from disk-rela ted back pain. Oexion exercise should not
be commenced immediately after a Oat-lying rest inter­
val longer than 30 minutes. The disk can become more
hydrated in this amount of time. and the athlete would
be more susceptible to pain with postures that increase
disk pressures. Other. less stressful exercises should be
initiated first a nd nexion exercise done later in the exer­
cise program. 4 . 32
Pigures 25-21 through 25-31 show examples of nex­
ion exercises. Again these examples are not exhaustive but
are representative of the exercises used clinically. Figure 25-23 Posterior pelvic tilt.
664 PARTTHREE The Tools of Rehabilitation

Figure 25-24 Partial sit-up.

Figure 25-27 Flat-footed squat stretch.

Figure 2 5-~

Joint Mo

Figure 25-25 Rota tion partial sit-up.

Figure 25-28 Hamstring stretch.

li on ~
firing
ccpt iol'

Figure 25-26 Slump sit stretch position. Figure 25-29 Hip flexor stretch.

Figure 25-30 Knee rocking side to side.
Joint 'M obilizations
The indications for the usc of joint mobilizations are as fol­
lows:
Subjectively, the athlete's pain is centered around a
speciflc joint area and increases with activity and de­
creases with rest.
The accessory motion available at individual spinal
segments is diminished.
Passive range of motion is diminished.
Active range of motion is diminished.
There may be muscular lightness or increased fascial
tension in the area of the pain.
Back movements are asymmetrical when comparing
right and left rotation or sidebending.
Forward and backward bending may steer away from
the midline.
The efficacy of mobilization is theorized to be from one
or a combin ation of the fol'lowing effects:
Tight structures can be stretched to increase the range
of motion.
The joint involved is stimulated by the movemen t to
more normal mech anics, and irritation is redu ced be­
cause of better nutrient waste exchange.
Proprioceptive interference occurs with pain percep­
tion as the joint movement stimulates normal neural
[iring whose perception supersedes nocioceptive per­
ception.
CHAPTER 25 Rehabilitation of Injuries to the Spine 665
Figure 25-31 Knees toward chcst rock.
Figure 25-32 Supine hip lif't-bridge-rock.
Mo bilization techniques arc multidimensional and are
easily adapted to any back pain problem. The mobilizations
can be active or passive or assisted by the athletic trainer.
All ranges (flexion. cxtension, sidebending, rotation. and
accessory) can be incorporated within the exerc ise plan.
The mobilizations can be carried out according to Mait­
land's grades of oscillation as discussed in Chapter 14. The
magnitude of the forces applied can range [rom grade 1 to
grade 4 depending on levels of pain. The theory, technique,
and application of the athletic trainer-assisted mobiliza­
tions are best gained through guided study with an expert
practitioner. 2.1
figures 25-30 through 25-39 show the various self­
mobilization exercises.
Figures ] 4-35 through 14-45 show joint mobiliza­
tions that can be used by the athletic trainer.
666 PART THREE ThcTools of Rehahilitation

Figure 25-33 Pelvic lill or pelvic rock. A. Swayback horse. B, Scared cal.

Figure 25-3 6

Figure 25-34 Kneeling- dog-tail wags.

Figure 25-35 Silling or standing rolation.

 CHAPTER 25 Rehubililulion or lnjuries lo the Spine 667

Figure 25·36 Sitting or standing side bending. Figure 25·3 7 Standing hip shift side to side.

I :1.

Figure 25·38 Standing pelvic rock. A, Butt out. B, Tail tuck.

668 PARTTI-IREE The Tools of Rehabilitation
Figure 25-39 Various side-lying and back-lying posi­
tiOQS can be used to both stretch and mobilize specific
joint in the lumbar area.
REHABILITATION TECHNIIQUES
FOR LOW BACK PAIN
Low Back Pain
Pathomechanics. In most cases. low back pajn in
athletes does not have serious or long-lasting pathology. II
is generally accepted that the soft tissu es (ligament. fascia.
and muscle) can be the initial pain sorlrce. The athJ ele's re­
sponse to the injury and to the provoc<:ttive stresses of eval­
uation is usuaHy proportional to the time since tbe injury
and the magnitude of the physical trauma of the injury.
The sort ti ssues of the lumbar region should react accord­
ing to the biological process of healing. and the time lines
for healing should be like those for other body parts. There
is no subsLanliation that athletic inj-ury to the low back
should cause a pain syndrome that lasts longer than 6to 8
weeks. 9 .42
Injury Mechanism. Back pain can result frolll one
or a combination of the following problems: muscle strain,
piriformis muscle or quadratus lumfuorum myofascial pain
or strain, myofa scial trigger points. lumbar facet joint
sprains, hy permobi'lity syndromes. disk-related back prob­
lems. or sacroilliac joint dysfunction.
Re habilitation Concerns.
Acu te versus chronic low back pain. The low back
pai n that athletes most often experience is an acute.
painful experience rarely lasting longer than 3 weeks. The
athlcLe rarely misses a practice and even more rarely
misses a game because of this type of back pain. As with
many athletic injuries, athletic trainers orten go through
exercise or treatment fads in trying to rehabilitate the ath­
lete with low back pain. The latest fad might involve flex­
ion exercise, extension exercise. joint mobiUzaUon. dy­
namic muscular stabilization . <lbdominal bracing, myofas­
cial release, electrical stimulation protocols, and so on. To
keep perspective. as athletic trainers select exercises and
modalities. they should keep in mind that 90 percent or
people with back pain get resolution of the symptoms in 6
weeks, regardless of the care administered .42 . i4
There are athletes who have pain persisting beyond 6
weeks. This group of athletes will generally have a history
of reinjury or exacerbation of previous injury. They de­
scribe a low back pain that is similar to their previous back
pain experience.
These athletes are experiencing an exacerbation or
reinjury of previously injured tissues by continuing to ap­
ply stresses that may have created their original injury.
This group of athletes needs <l more specific and formal
treatment and reh abilitaiion program 9 42
There are also people who have chronic low back pain.
This is a very small percentage of the populalion suffering
from low back pain and an even sm<:tller percentage of the
athletic low back pain subgroup. The difference between
the athlete with an acute injury or reinjury and a person
with chronic pain has been defined by \I\laddcll. He states,
"Chronic pain becomes a completely difl'erent clinical syn­
drome from acute pain.',i4 Acute and chronic pain not
only are different in time scale but are fundamentaIly dif­
ferent in kind. l\cute and experimental p<lins bear a rela­
tively straightforward relationship to peripheral stimulus,
nociception. and tissue damage.
There may be some understandable anxiety about the
me<lning and conseq uences of the pain, but acute pain.
disability, and illness behavior are generally proportionate
to the physical finding s. PharmacologicaL physical. and
even surgical treatments directed to the underlying physi­
cal disorder are generally highly erfective in relieving acute
pain. Chronic pain. disability. and illness behavior, in con­
trast, become increasingly dissocia ted from their original
physical basis. <lnd there Dlay be little objective evidence of
any remaining nociceptive stimulus. Instead. chronic pain
and disability become increasingly associated with emo­
tional distress, depression. failed treatment, and adoption
of a sick rol e. Chronic pain progressively becomes a self­
sustaining condition t.hat is resistant to traditional medical
management. Physical treatment directed to a supposed
but unidentified and possibly nonexistent nociceptive using one , .
source is not only understandably unsuccessful but may Stagt' nI
cause additional physical damage. Failed treatment may jury or chr
both reinforce and aggravate pain. distress, disability. and the trealmc:-'
illness behavior. 54 thorou gh e
Rehabilitation Progression. A discussion of the of the ath le:
rehabilitation progression for the athlete with low bock
pain can be much more speCific and meaningful if treat-
 CHAP'fER 25 Rehabilitation of Injuries to the Spine 669

lizalion . dy­ ment plans arc lumped into two stages. Stage 1 (acute make the athlete responsible for the management of their
ng . my fa ­ stage) treatment consists mainly of the modality treat­ back problem. The athllcUc trainer shou'ld identify specific
dsoon.To ment and pain-relieving exercises. Stage II treatment in­ problems and corrections tha t will help the aLhlete better
ercises and volves treating athletes with a reinjury or exacerbation of understand the mechanisms a nd management of their
percent of a previous problem. The treatment, plan in stage II goes be­ problemY
pLOrn - in 6 yond pain relief. strengthening. stretching. and mobiliza­ Specinc goals and exercises should be identified about
tion to include trunk stabilization and movement training the following:
Illg beyond 6 sequences and to provide a specific, guided program to re­ Which structures to stretch
e a hi sto r~> turn the athlete to the chosen sportY Which structures to strengthen
'}. The de ­ Stage I (acute stage) trelltment. ~v!odulaling pain Incorporating segmental spinal stabilization and ab­
\ io us back should be the initial focus of the athJclic trainer. Progress­ dominal bracing into the athlete's daily life and c.'(er~
ing rapidly frol11 pain management to specific rehabilita­ cise rout ine
. rba lion or tion should be a primary goal of the acute stage of th e Progression of core stabilization exercises
uing to ap­ rehabilitation plan. The most common treatment for pain Which movements need a motor learning approach to
~ina l injury. relief in the acute stage is to use ice for analgesia. Rest, but control faulty m(;chanics· 2
a nd formal not total bed rest. is used to allow the injured tissues to be­ Stretching. The athletic tra iner and th e athlete need
gin the healing process without the stresses thilt created to plan specific exercises to stretch restricted groups, main­
\ back pain . the injury. JII tain f1exibility in normal muscle groups, and identify
n uffe ri ng Along with rest, during the initial treatment stage, the hypermobility that may be a part of the problem. In plan­
<"mag of th e athlete should be taught to increase comfort by using the ning, instructing, and monitoring each exercise, adequate
· c~ bel\\' en appropriate body positioning techniques, described previ­ thought and good instruction must be used to ensure that
and a per on ously, which may involve (1) lateral shift corrections (Fig­ the intended strllctures get stretched and areas of hyper­
I. He stat . ure 25-11), (2) extension exercises (figures 25-13 mobility are protected from overstretching. IS Inadequate
1 clinical syn­ through 25-20), (3) flexion exercises (Figures 25-21 stabili;(ation will lead to exercise movements that are so
nic pain not through 2S-3J), or (4) self-mobilization exercises (see Fig­ general that the exercise will encourage hyperflexibility at
un~ll taJ ly dlf­ ures 14-46 and 14-47), Segmental spinal stabilization ex­ already hypermobile are<lS. Lack of proper stabilizatio n
· bea r a rela­ ercise should be initiated concurrently with these other during stretching may help perpetuate a structural prob­
~raJ timulu s. exercises. Outsiclc support, in the form of corsets and the lem that will continue to add to the athlete's back pain.
use of props or pillows to enhance comfortable positions, In the athletic trainer's evaluation of the athlete with
ely about the also needs to be included in the initial pain management back pain, the following muscle groups should be assessed
acu te pain. phase of treatment. 42 . 54 The athlete shouJd also be taught for flexibility: 23
lfopor tiona tc to avoid positions and movements that increase any sharp, Hip flexors
~bys i c al. an d painful episodes. The limits of these movements and posi­ Hamstrings
~Iyi ng phys i­ tions that provide comfort should be the initial focus of any Low back extensors
ie\~in g ac ute exercises. Lumbar rotators
'ior. in con­ The athlete should be encouraged to move through Lumbar lateral f1exors
eir original this stage quickly and return to practice and playas soon Hip adductors
evi dence of as range, strength, and comfort will allow. The addition of Hip abductors
[chron ic pain a supportive corset for practice and play during this stage Hip rotators
· with emo­ should be based mostly on athlete comfort. We suggest us­ Strengthenillg. There are numerous techniques for
nd adoption ing an eclectic approach to the selection of the exercises, strengthening the musc.les of the trunk and hip. Muscles
. mes a self­ mixing the various protocols described according to the are perhaps best strengthened by using techniques of pro­
na l medical findings of the athlete's evaluation. Rarely will an athlete gressive overload to achieve specific adaptation to imposed
present with classic signs and symptoms that will dictate demands (SAlD principle). The overload ca ll take the form
I nociceptive using one variety of exercise. of increased weight load, increased holding time, in­
fl1 l but may Stane II (reinjllry stage) treatment. In the rein­ creased repetition load , or increased stretch load to ac­
~atme n t m ay jury or chronic stage of back rehabilitation, the goals of complish phYSiological changes in muscle strength,
lisa bility. a nd the treatment a nd training should again be based on a muscle endurance, or f1exibility of a body part. J I
thorough evaluation of the athlete. Identifying the causes Th e treatment plan should call for an exercise that
lSSion of the of the athlete's back problem and recurrences is very im­ the athlete can easily accomplish successfully. Rapidly
Ith loll' back portant in the manage ment of their rehabilitation and but gradua'lIy, the overload should push the athlete to
Igful if tre a[­ prevention of reinjury. A goal for this stage of care is to challenge the muscle group needing strengthening. The
670 PART THREE The Tools of Rehabilitation
athletic trainer and the athlete should monitor continu­
ously ror increases in the athlete' s pain or recurrences of
previous symptoms, If those changes occur, the exercises
should be modified, delayed, or elimin a ted from the reha­
bilitation plan 2 4A2
Core stabilization_ Core stabilization training, dy­
namic abdominal bracing, and finding neutral position all
describe a technique used to increase the stability of the
trunk (see Chapter 10), This increased stability will enable
the athlete to maintain the spine and pelviS in the most
comfortable and acceptable mechanical position that will
control the rorces of repetitive microtrauma and protect
the structures or the back from furth er damage. Core mus­
cular control is one key to giving the athlete the ability to
stabilize their trunk and control their posture. Abdominal
strengthening routines are rigorous , and the athlete must
complete them with vigor. However, in their functional ac­
tivities, the athlete needs to take advantage of their ab­
dominal strength to stabilize the trunk and protect the
back,18.29.j,j
Richardson et a!. focus a ttention on motor control of
the transversus abdominis and lumbar multifidii in vari­
ous positions. 22.4 0 Once this control is established, different
positions and movements are added. As the vigor of the ex­
ercise is progressively increased, the athlete will incorpo­
rate the more global muscles in stabiliZing his or her core
(see Chapter 10). Then the athlete moves into the func­
tional exercise progression with the spinal segment sta bi­
Lization as the base movement in core stabilization , which is
needed to perform functionallyY The concept of increasing
trunk stability with muscle contractions that support and
limit the extremes of spinal movement is important.
Basicjullctiollal training. The athlete must be constantly
commilled to improving body mechanics and trunk con­
trol in all postures in both sport-related activities and in
their activities of daily living. The athletic trainer needs to
evaluate the athlete's daily patterns and give them in­
struction, practice, and monitoring on the best and least
stressful body mechanics for them in as many activities as
possible.
The basic program follows the developmental se­
quence of posture control, starting with supine and prone
extremity movement while actively stabilizing the trunk ,
The athlete is then progressed to all fours, kneeling, and
standing (Figure 25-40) , Emphasis on trunk control and
stabUily is maintained as the athlete works through this
exercise sequence. l~.30.42
The most critical aspect for developing motor control is
repetition of exercise, However, variability in positioning,
speed! or movement, and changes in movement' patterns
must also be incorporated. The variability of the exercise
will allow the athlete to generalize their newly learned
trunk control to the constant changes necessary in their
sport, The basic exercise, transversus abdominis and lum­
bar multifidii coactivation, is the key, Incorporating this
stabilization contraction into various activities helps rein­
force trunk stabilization and returns trunk control a sub­
conscious automatic response.
The use of augmented feedback (EMG, palpation, ul­
trasound imagery, pressure gauges) of the transversus
abdominus and lumbar l11ultil1dii contractions may be
needed early in the exercise plan to help maximize the re­
sults each exercise session supervised by the athletic
trainer. The athletic trainer should have the athlete inter­
nalize this feedback as quickly as possible to make the
athlete apparatus-free and more functional. With aug­
mented feedback, it is recommended that the patient be
rapidly and progressively weaned from dependency on
external feedback,
AdvancedjuncnonaI training, Each activity that the ath­ A
lete is involved in becomes part of the advanced exercise
rehabilitation plan, The usual place to start is with the ath­
lete's strength and conditioning program, Each step of the
program is monitored and emphasis ,is placed on spinal
segmental stabilization for even the simple task of putting
the weights on a bar or getting on and off of exercise equip­
ment. Each exercise in their strength and conditioning
program should be retaught, and the athlete is made
aware of their best mechanical position and the proper sta­
bilizing muscular contraction. The strength program is
sport and athlete speCific, attempting to strengthen weak
areas and improve strength in muscle groups needed for
better sports performance,12
Aerobic activities are also included in advanced pro­
grams, The same emphasis on technique and stabilization
is used as the athlete begins aerobic conditioning activi­
ties, A functional progression should be used so thal
changes in symptoms can be controlled by working with Figure 25­
lower-level exercises and then progressing to more diffi­
cult and stressful exercises,42 Modification of normal aer­
obic conditioning for a particular sport may be an
important part of eliminating some of the unnecessary
stress from the athlete's overall program, Substituting an letic trai ner
aquatic conditioning program for sprinting and runnhlg ing, but the:
may keep the athlete participating effectively without in­ alignment
creasing their back pain. each drill. -­
Using exercises designed to incorporate core stabiliza­ The a1h
tion into speCific skills is the next step in the exercise pro­
gression. Sport-specific skills should be tailored to the
individual athlete. The athletic trainer should work in
concert with the coach and athlete to incorporate stabi­
lization training with sport drills and postures, The ath-
 CHAPTER 25 RehabiUtation of fnjuries to the Spine 671

newly learned
ary in their
is and lum­
rporating this
helps rein­
control a sub-

e transversus
'ons may be
imize the re­
- the athletic

A B

ced exercise
\\'ith the ath­
ch step of the
ed on spinal
k of putting
exercise equip-
conditioning
Wete is made
the proper sta­
h program is
'engthen weak
p needed for

ad vanced pro­
.d stabilization
lioning activi­
used so that C
working with Figure 25-40 Weight shifting and stabilization exercises should progress from A, quadriped, to B, triped, to C, biped.
to more diffi­
~r normal aer­
~ may be an
~ unnecessary

ubstituting an letic trainer may not know the intricacies of pass block­ They might revert to old postures and habits, so feed­
: a nd running ing. but they can help the coach and athlete identify good back is important. The next step is to incorporate a flfmer
y wiJhout in- alignment and core stabilization a s the athle te performs stabili7.Cllion contmclion during the power phase of the
each drillY drill. The athlete is instructed to contract more firmly dur­
C re stabiliza­ The athlete should be ta ught to start their stabilizing ing iniliCllion 01" a jump or push during change in direction.
_ xercise pro­ contractions before starting any movement. This presets The drills should be constructed to have several chClnges in
! ilored to the the athlete's posture and stabilization awareness before contraction strength planned as the athlete moves through
o uld work in their movement takes place. As the movement occurs. they the drill. Expect that the athlete may experience paralysis
po rate stabi­ will become less aware of the stabilization contractlon as by analysis as they try to think through stabilizing contrac­
u es. The ath- they attempt to accomplish the drill. tion plus drill execution. Adequate practice time will be
672 PARTTHREE The Tools of Rehabilitation
necessary before the athlete is ready to reenter a team prac­
tice. The athlete should find this stabilization control com­
fortable, efficient, and powerful.
Each athlete is different, not only with their individual
back problem but also with their abilities to gain motor
skill. Athletes differ in degree of control and i·n the speed at
which they acquire these new skills of core stabilization.
Reducing stress to the back by using braces, or­
thotics. shoes, or comfortable supportive furniture (beds,
desks, or chairs) is essential to help the athlete minimize
chronic or overload stresses to their back. The stabiliza­
tion exercise should also be incorporated into their activ­
ities of daily living and sport activities. 4 \ The use of a low
back corset or brace may also make the athlete more
comfortable (Figure 25-56).
Criteria for Return. For most low back problems
the stage I treatment a nd exercise programs will get the
athlete back into their activities qUickly. If the pain or
dysfunction is pronounced or the problem becomes re­
current, an in-depth evaluation and treatment using
stage I and stage II exercise protocols will be necessary.
The team approach with athlete, doctor. athletic trainer,
physical therapist. and coach working together will pro­
vide the comprehensive approach needed to manage the
athlete's back problem. Close attention to and emphasis
on the athlete's progress will provide both the athlete and
the athletic trainer with the encouragement to continue
this program.
Muscular Strains
Injury Mechanism. Evaluative findings include a
history of sudden or chronic stress that initiates pain in a
muscular area during the workout. There are three points
on the physical examination that must be positive to indi­
cate the muscle as the primary problem. There will be ten­
derness to palpation in the muscular area. The muscular
pain will be provoked with contraction and with stretch of
the involved muscle.
Rehabilitation Progression. The treatment
should include the standard protection, ice, and compres­
sion. Ice may be applied in the form of ice massage or ice
bags, depending on the area involved. An elastic wrap or
corset would protect an d compress the back musculature.
Additional modalities would include pulsed ultrasound for
a biostimulative effect and electrical stimulation for pain
relief and muscle reeducation. The exercises used in reha­
bilitation should make the involved muscle contract and
stretch, starting with very mild exercise and progressively
increasing the intensity aDd repetition loads. In general
this would include active e)!:tension exercises such as hip
lifts (Figures 25-17 to 25-19 ), alternate arm and leg, hip
extension (Figure 25- r 5), trunk extension (Figure 2 5-20).
and quadratus hip shift exercises (Figures 25-41 through
25-43). A good series of abdominal spinal segmental sta­
bilization and core stabilization exercises would also be
helpful (Figures 25-23 and 25-24). Stretching exercises
might include the following; knee to chest (Figures 25-21
and 25-22), side-lying leg hang to stretch the hip flexors
(Figure 25-29), slump sitting (Figure 25-26), and knee
rocking side to side (Figure 25-30).
Criteria for Return, When the athlete can ,perform
function a l activities on the same level as teammates, he or
she may return to practice and competition. Initially. the
athlete may wish to continue to use a brace or corset. but
they should be encouraged to do away with the corset as Figure 25 41
th eir back strengthens and their performance returns to
normal. 1 1. 2 .J
Piriformis Muscle Strain
Pathome,c hanics. Piriformis syndrome was dis­
cussed in detail in Chapter 21. The piriformis muscle
refers pain to the posterior sacroiliac region, to the but­
tocks, and sometimes down the posterior or posterolat­
eral thigh . The pain is usually described as a deep ache
that can get more intense with exercise and with silling
with the hips Ilexed, adducted, and medially rotated . The
pa in gets sharper and more intense with activities that
require decelerating medial hip and leg rotation during
weight bearing.
Tenderness to palpation bas a characteristic pattern.
with tenderness medial and proximal to the greater
trochan ter and just lateral to the posterior superior iliac
spine. Isometric abduction in the sitting position produces
pain in the posterior hip buttock area, and the movement
will be weak or hesitant. Passive hip internal rotation in
the sitting position will also bring on posterior hip and but­ Figure 25
tock pain .
Rehabilitation Progression. Rehabilitation exer­
cises should include both strengthening and stretching.
Strengthening exercises should include prone-lying hip in­
ternal rotation with elastic resistance (Figure 25-44), hip­
lift bridges (Figure 2 'lA5) , hand-knee pOSition fire hydrant
exercise (Figure 25-46). side-lying hip abduction straight
leg raises (Figure 2 5A 7), and prone hip ex tension exercise
(Figure 25-48) .
Stretching exercises for the piriformis include back­
lying legs-crossed hip adduction stretch (Figure 25-49),
bacl-i.-lyLng with the involved leg crossed over the unin­
volved leg, ankle to knee position . pulling the uninvolved
knee toward the chest to create the stretch (Figure 25-50),
contract-relax-stretch with elbow pressure to the muscle
 g exercises
,.. re r -2 ]
'lip nexors
• and knee

Figure 25-41 Back-Iying-hip-hike shifting.

ret urn to Figure 25-44 Prone-lying hip internal rotation with
elastic resistan ce.

e was di s-

r po terola t­
deep ac h e
il
\\'it b sitting
rota t d . The
Lh ut
Figure 25-45 Hip-lift bridges.

tlC pa tt ern.
'he greater
uperio r ili a
loon produ ce
Ile m \'emc nt
rota tio n in
r hip an d but- Figure 25-42 Standing hip hike.

Figure 25-46 Hand-knee position-nrc hydrant

exercise.

Figure 25-43 Back-Iying­ hip-hike resisted.

 insertion du
51A,B). :>'~- .

with the sam

waist and b

Quadratu$

Figure 25-47 Side-lying hip abduction straight-leg Figure 25-50 Sell' piriformis stretch.
raises.

Figure 15-48 Prone hip extension exercise.

Figure 25-49 Back-lying legs-crossed hip adduction

stretch.

Figure 25-51 Piriformis st retch using elbow pressure.

A, Start-contract. B, Relaxation-stretch. Figure 25-5~
 CHAPTER 25 RehabilitaLion of Injurie, to the Spine 675

insertion during the relaxation phase (Figure 25­

51A,B).21.47.50 This can also be done in the sitting position
with the same mechanics, but the athlete leans over at the
waist and brings their chest toward the knee.

Quadratus Lumborum Strain

Pathomechanics. Pain from the quadratus lumbo­
rum muscle is described as an aching, sharp pain located
in the flank , in the lateral back area, and near the posterior
sacroiliac region and upper buttocks. The athlete usually Figure 25-53 Supine self-stretch- legs crossed.
describes pain on moving from sitting to standing, stand­
ing for long periods, coughing, sneezing, and walking. Ac­
tivities requiring trunk rotation or side bending aggravate
the pain. The muscle is tender to palpation near the origin
along the lower ribs and along the insertion on the iliac
crest. Pain will be aggravated on side bending, and the pain
will usually be localized to one side. For example, with a
right quadratus problem, side bending right and left would
provoke only right-side pain. Supine hip-hiking move­
ments would also provoke the pain.
Rehabilitation Progression. Rehabilitation strength­
ening exercises should include back-lying hip-hike shilling
(Figure 25-54), standing with one leg on elevated surface
and the other free to move below that level, hip-hike on the
free side (Figure 25-55), and back-lying hip-hike resisted
by pulling on the involved leg (Figure 25-43).
Stretching exercises should include side-lying over a
pillow roll leg-hand stretch (Figure 25-52), supine self­
stretch with legs crossed (Figure 25-53). hip-hike exercise Figure 25-54 Hip-hike exercise with hand pressure.
with hand press ure to increase stretch (Figure 25 - 54). and
standing one leg on a small book stretch (Figure 25-55).55

Myofascial Pain and Trigger Points

Pathomechanics and Injury Mechanism. The
above examples of muscle-oriented back pain in both the
piriformis and quadratus lumborum co uld also have a my­
ofas cia I origin . The major component in successfully

lOW pressure.
Figure 25-52 Sidelying stretch over pillow roll. Figure 25-55 Standing one-leg-up stretch.
676 PART THREE The Tools of Rehabilitation
Figure 25-56 i\ lower-lumbar corset or brace.
changing myofascial pain is stretching the muscle back to
a normal resting length. The muscle irritation and conges­
tion that create the trigger points are relieved. and normal
blood now resumes, further reducing the irritants in the
area. Stretching through a painful trigger point is diff\cult.
/\ variety of comfort and counterirritant modalities can be
used preliminary to, during. cll1d after the stretching to en­
hance the effect of the exercise. Some of the methods used
successful:ly arc dry needling, local anesthetic injection,
icc massage, friclionmassage. acupressure massage, ultra­
sound electrical stimulation. extracorporal shock wave
therapy. and cold sprays.
The indications for treating low back pain with my­
ofasci a I stretching and treatment techniques are as
follows:
1. Subjectively, in athletes, early-season muscle soreness
aDd fatigue from repetitive motions are common an­
tecedent mechanisms. Athletes are also susceptible
later in their season as fatigue and stress overload spe­
cific muscle groups. There may be a history of sudden
onsct during or shSlrtly after an acute overload stress,
or there may be a gradual onset with repetitive or pos­
tural overload of the affected muscle.
The pain may be an incapacitating event in the
case of acute onset, but it may also be a nagging, ag­
gravating type of pain with an intensity that varies :;. Begin :',u
from an awareness of discomfort to a severe unrelent­ stretch
ing type of pain. The pain location is usually a ·r e­ ollds. P­
ferred pajn area remote from the actual myofascial is com~
trigger pOint. These trigger points can be presenl but should
quiescent until they are activated by overload, fatigue. and lhe
trauma, or chilling. These points are called latent trig. slig hl ])
gel' pOints. This deep, aching pain can be specifka:Ily 6. Hot pa
localized, but the athlete is not sensitive to palpation some a,
in these areas. This pain can often be reproduced by 7. Refer I
maintaining pressure on a hypersensitive myofascial
trigger point.
2. Passive or active stretching of the affected myofascial
structure increases pain.
3. The stretch range of muscle is restricted.
4. The pain is increased when the muscle is contracted In lh b
against a flxed resistance or the muscle is allowed to with lie
contract into a very shortened range. The pain in this
case is described as a muscle cramping pain.
5. The muscle may be slightly weak.
6. Trigger points may be located within a taut band of
tbe muscle. If taut bands are found during palpation,
explore them for local hypersensitive areas.
7. Pressure on the hypersensitive area wiil often cause a
"jump sign"; as the athletic trainer strums the sensi­
tive area, the athlete's muscle involuntarily jumps in
response.
8. The primary muscle groups that create low back pain
in athletes are the quadratus lumborum and the piri­
formis muscles.E47.iO., 1
'I'ravell and Simons have devoted two volumes to the
causes and treatment of various myofascial pains. iO.51
They have done a very thorough job of describing the
symptoms and signs of each area of the body, and they give
very specific guidance on exercises and pOSitioning in their
their \ iI
treatmen t protocols.
Rehabilitation Technique. Myofascial trigger
points may be trealed using the following steps:
1. Position the athlete comfortably butin a position that
will lend itself to stretching the involved muscle
group.
2. Caution the athlete to usc mild progressive stretches
ral.her than sudden, sharp, hard stretches.
3. Hot pack the area for 10 minutes, and follow with an
ultrasound and electrical stimulation treatment over
the affected muscle.
4. Use an ice cup, and use 2 to 3 slow strokes starling at
the trigger point and moving in one direction toward
their pain reference area and over the ful11length of
the mu,sc[e.

5. Begin stretc hin g well within the ath lete's com fo r t. A
stret ch shou ld be maintained a minimum of 15 sec­
onds. he stretch shou ld be released until the athlete
is comfortable again . The next st retc.h repetiLion
present but should then be progressively more intense if tolera ted,
I ad , fati g ue, an d the position of the stretch should a lso be varied
ed latent trig­ slighUy. Repea t the stretch 4 to 6 times.
pecifically 6. Hot pack the area. and have the a thlete go through
lO palpation some active stretches of the mu s Ie.
pr duced by 7. Refer to Travel! an d Simons's m a nual for speCific ref­
e myo l'asc ial eren ces on othe r m uscle grou pS.2;.iU. ; j
H. Active release and posilton re lease tec hniques
ed myofascial are used to treat and resolv tri gger points (see
Ch a pLer] '5 ). Therapeutic eccen tric active massage
l. (TEAivf tec hnique ) has sho wn some clinical success.
contra cted In this tec hniqu e. th e muscle or fascia associated
is a llowed to with the id entified trigger poin t is actively con­
~e pain in this tra cted to its sh ortes t possible length . . sing a small
a in. amoLlnl. of lubricant, th e active trigger pOint is com­
pressed with a firm steady pressure. The a thl eUc
ut band of trainer provide:.; resista nce to the shor tened O1ove­
n g pa lpation, menlo and the ath lete is instructed to con tinue to re­
as. sist but also allow the eccentric len gthening of the
orten ca lise a muscle to occ ur in a smoot h . controlled mctnne r. As
filS the sensi­ the muscle len gthens u nder the co mpressive mas­
ily jumps in sage, the trigger poin t is co mpressed a nd th e irri­
tants in the area are dispersed ovcr a greater area.
/Ow back pain This hdps th e pa in decease. ,mel the musc le begi ns
, a nd the piri­ to function more normaJIy.
The first repctiti on i ~ usually uncomfortabk for
the patient. Subsequent repetitions a rc m ore co m­
(umes to the
fortable and thc athlete can co ntrol the contra ction
_'al pains. 5o ,) l
better. Six to ig h t repetitions are used for each trig­
describing the
ger point trcated. This technique is empirically
. a nd they give
based , and research stu dies are needed to es tab lish
'on ing in their
their validity.
ial trigger
p : CLINICAL DECISION MAKING Exercise 25-1
position that
m uscle A basketball player has becn having tightness in the
lower buck and right hip region. ,'lIer a regular workout
without any known trauma, the athlete started to have
an intl'nse ache in his right buttock area. The next day
the pain is radiating laterally across the bullock and
down the posterior thigh. There arc two distinct tender
areas lateral to the sacrum. which reprodul'e the athlete's
pain. What stratcgies can the athletic trainer use to re­
duce the uth lete's discomforI ; Should the athlete COl)­
tlion toward
Ile nglh of tinue to train ?
CHAPTER 25 Hehab ilitat ion of 'Injuries to the Spine 677
Lumbar Facet Joint Sprains
Patbomechanics and Injury Mechanism, Sprains
may occur in any of the ligamcnts in the lumba r spine. How­
ever, the most co mmon sprain involves lumbar facet joints.
facet joint sprain typically occurs when bending fo rward
and twisting while lifting or moving some object. The athlete
will report a sudden acute episode that ca used th e problem,
or th ey will give a history of a chronic repetitive stress that
caused the gradual onset of a pain that got progressively
worse with continuing activity. The pain is loca l to the struc­
ture that has been injured, and the athlete ca n clearly local­
ize the area . The pain is described as a sore pain that gcts
sharper in respo nse to certain movements or pos tures. The
pain is located centrally or just lateral to the spinous process
areas and is deep.
Loca l symptoms will occur in response to move­
ments, and th e athlete will uSl\ally limit th e movement
in those raoges that are painful. Whe n the vertebra is
moved pass ively with a posteroanterior or rotational
pressure through the spinous process, th e pain mD Y be
provoked.
Rehabilitation Progres ion, The treatment should
include the standard protection. ice, and compression as
mentioned previously. Both pulsed ultrasound and electrical
stimulation could a lso be llsed Similarly to the treatment of
muscle stn'lins but localize(j to the specific joint area.
Joint mobilization usin g posterior-an terior glides (see
Figure J4-.16) and rotational glides (see Figures ]4-3 8 .
14-39) should help reduce paill a nd increase jOint nutri­
tion . The athlete sho uld be instructed in segmental spinal
stabilization exercises using transversus abdominis and
lumbar multifldii coactivation and good postural control
(Figures 2 5-3t hroLlgh 25-10) . Strengthening exercises for
abdomin a ls (rigurcs 25-23 to 25-25) and back extensors
(Figures 25-17 to 25-20) should initially be limited to a
pain-free range. Stretching in all ranges should start well
within a comfort range a nd gradually increase until trunk
movements reach norm a l ranges. Athletes sho uld be sup­
ported with a corse t or range limiting brace when th ey re­
turn to th eir competitive activity, whic h should be used
only temporarily until normal strength, muscle co ntrol.
and pain-free ra nge are achieved. ll.17 .1H.49 .51 It is impor­
tant to guard against the development of pos tural changes
that might occur in response to pain.
Hypermobility Syndromes
(Spondylolysis/Spondylolisthesis)
Pathomechanics. Hypermobility o/' th e low back
may be attributed to spondylolysis or spondylolisthesis .
678 PART THREE The'lbols of Rehabilitation
Spondylolysis involves a degeneration of the vertebrae
and, more commonly. a defect in the pars interarticularis
of the articular processes of the vertebrae. It is often at­
tributed to a congenital weakness, with the defect occur­
ring as a stress fracture. Spondyl'olysis might produce no
symptoms unl ess a disk herniation occurs or there is sud­
den trauma such as hyperextension. Commonly spondy­
lolysis begins unilaterally. However. if it extends bilaterally.
there may be some slipping of one vertebrae on the one be­
low it.
A spondylolisthesis is considered to be a complication
o[ spondylolysis often resulting in b)7permobility or a ver­
tebral scgment. l l Spondylolisthesis has the highest inci­
dence with L5 slipping on S I .
[njllr)' Mechanism. Sports movements that char­
acterisUcally hyperextcnd the spine. such as the back arch
in gymnastics. lifting wcights. blocking in [ootball . scrving
in tennis. spiking in volleyball. and the buttcrlly stroke in
swi mm ing. are most likely to cause t.his condition.
Rehabilitation Concerns. The athlete usually has
a relatively long history of feeling "something go" in their
back. They complain o[ a low back pain described as a per­
si stent ache across the back (belt type). This pain does not
usually interfcre with their workout performance but is
usually worse when [atigued or after sitting in a slumped
posture [or em extended time. The athlete may also com­
plain o[ a tired reeling in the low back. They describe the
need to move frequently and get temp0r<iry relief 0[' pain
through self-manipulation. They often describe self­
m anipul<Jt.ive behavior m orc than JO times a day. Their
pain is relieved by rest. and they do not usuaHy feel th e pain
during exercise. On physiced examination. the athlete usu­
ally w ill have full and painless trunk movements. but there
may be a wiggle or hesitation at the midrange or forward
bending. On backward bencling their movement may ap­
pear to hinge at one spinal segment. vVhen extremes of
range are maintai ned for I:; to 30 seconds. the athlete
I'eels a lumbosacral ache. On return from forward bending.
the athlete will use thigh climbing to regain the neutral
position. On palpation there may be tendern ess localized to
one spinal segment.
Reha bilitation Progression. Athletes with this
problem will fall into the reinjur.y stage of back pain and
may require extensive treatment to regain stability of the
trun k. The athlete's pain should be treated symptomati­
cally. Initially. braCing and occasionally bed rest ror I to
3 days will help reduce pain. The major focus in rehabil­
itation shou Id be on segmen tal spinal stabilization exer­
cises that control or stabilize the hype rmobi'lc segment
(Figures 2 ')-3 to 2 'i-I 0). Progressive trunk-strengthen­
ing exercises. es pecially through the midrange. should
be incorporated. Core stabilization exercises that con­
centrate on transversus abdominis behavior and endurance
should also be used (see Chapter 10).1 ~.20.1 1.1 2.3S .36. J 8 . 3 9.40The
athlete sllOuld avoid manipulation and self-manipulation
as well as stretching and flexibility exercises. Corsets and
braces are benefiCial if the athlete uses them only [or sup­ MI',j:1
port during higher-level activities and [or short (1 to
INJURY SfTUA
2 hour) periods to help with pain relief and fatigue J8 .41
squat tes!
(Figure 25- 56). Hypermobility of a lumbar vertebrae
the floor \\ .
may make the athlete more susceptible to lumbar muscle
strains and ligament sprains. Thus it may be necessary SIGNS AND Sl
for the athlete to avoid vigorous activity. The use of a low Fibular He,
back corset or brace might also make the athlete more Trochantt"r
comfortable (Figure 25-56). psrs
Iliac Cr,
AS IS
CLINICAL DECISION MAKING Exercise 25-2
Ra ng
back paw
A fema le gymnast arrives at your school with a previ­
into h is n",
ously diagnosed spondylolysis at LS-Sl. The athlete has
provoked
bad periodic problems with back palo and has not been
ment and
on a formal program to rehabiUtate her back. What
bendio g 0;'-
program should the athletic trainer recommend for this
Righl ,;
athlete?
siOexion a· .
a mild lef1 '
Disk-Related Back Pain
Pathomechanics. The lumbar disks arc subject to
constant abnormal stresses stemming from faulty body
mechanics. trauma. or both. which, over a period of time.
can cause degen eration. tears. and cracks in the annulus
fibroSllS. 7 The disk most often injured lies between the L4
and L5 vertebrae. The L5-S1 disk is the second most com­
monly affected.
[njury Mechanism. In sports. ,t he mechanism of
a disk injury is the same as for the lumbosacral sprain­
forward bending and twisting that places abnormal strain
on the lumbar region. The movement that produces herni­
ation or bulging of the nucleus pulposus may be minimal.
and associated pain may be significant. Besides injuring
soft tissues. such a stress may herniate an already degen­
erated disk by causing the nuc.leu s pulposus to protrude
into aT through the annulus fibrosis. As the disk progres­
Sively degenerates. a prolapsed disk may develop in which
the nucleus moves completely through the annulus. If the
nucleus moves into the spinal canal and comes in contact
with a nerve root. this is referred to as an extruded disk.
This protrusion of the nucleus pulposus may place pres­
sure on the spinal cord or spinal nerves. causing radiating
pains similar to those of sciatica. as occurs in piriJormis
syndrome. If the material of the nucleus separates rrom
the disk and begins to migrate. a sequestrated disk exists.
 CHAPTER 25 Rehabilitation of Injuries to the Spine 6 79

>, 16.3 . 3 ~ .40The

REHABILITATION PLAN
-m nipulation
. Corsets and
only for sup­
DISK-RELATED BACK PAI N
r bort (1 to

INJURY SITUATION A 19-year-old ath'lete with a 2-week history of back stiffness and tightness was attempting a Il1clximum
"d fatigue 1S .42
squat test with approximately 500 pounds. As he attempted the ftrst repetition, his right leg gave way and he collapsed to
bar vertebrae
the floor with back and right leg pain .
umbar muscle
SIGNS AND SYMPTOMS Body landmarks were evaluated:
Fibular Heads Level
Trochanter Level
PSIS Level standing and sitting
Iliac Crest Level standing and Sitting
ASIS Level standing an c! sitting
Range of Motion was assessed. Lumbar spine forward-bending provoked central L4-L5
back pain when his fingertips reached the top of his pa tella. The pain increased and radiated
into his right posterior thigh as his fingertips reached his inferior pole. Backward bending
provoked central L4-L5 pain when the movement reached 25 percent of his normal move­
ment and increased and was restricted when he reached 50 percent of his normal range. Side
bending right and left and rotation right and left were full-range a nd did not change his pain.
Right straight leg raising was restricted at 25 degrees and provoked central L4-L5 an d right posterior thi gh pain . 0 r­
sil1exion at the ankle and chin to chest movement increased this pain. Left leg straight leg raising to 70 degrees pr \foked
a mild left-side iliac crest pain, which increased with dorsiflexion and chin to chest movement. Sitting kn ee extension
movement with the right leg provoked central L4-L 5 pain and posterior thigh pain wh en the knee fle xion a ngle reached
60 degrees. Left knee extension provoked central L4-L5 pain when the knee flexion angle reached 3() degrees .
Posterior-anterior mobilizations to the sacrum and the L 5 spinous process increased his central bnck pain and caused
are subject to some shooting pain down his rigi1tleg.
m fa ulty body On manual muscle test, trunk extension was strong and painless. Left hip extension and left hip internal rotation and
period of time. external rotation were strong but provoked right posterior leg pain. All 1m Ct:. ankle, fool, and toe muscles were slJf(mg and
n the annulus painless. A sensory check demonstrated normal feeling over both lower extremities.

tween the L4
On palpation , he was nontender over all major structures .

nd most com-
Functionally, he was very guarded and stiff looking. On all forlVard bending behavior. he was very guarded 8ml used
compensating movement patterns to move from sit to stand or sta nding to lying down.
mechanism of
~c ral
sprain­ MANAGEMENT PLAN The goals a re to reduce pain, reduce the irritation of the nerve roots with positioning an d medica­
normal strain tions, optimize the nouri shment of the disk complex so the healing process is optimum. increase movcmt:nt a nd strt'l1gth.
and return to activities.

P HASE ONE ,\ClITE PAIN STACE

ides injuring
ready degen­ GOALS: Decrease pain, encourage motion , maintain spinal segment stability, and crea,te safc, pain-fi.-ee movement be­
to protrude
haviors that minimize the stress on the disk complex. Encourage rest positions that enha nce centraHzation of the disk nu­
disk progres­
cleus and provide optimum nourishment for the disk complex.

elop in whicl:! Fstimated Length of Time (ELT): Weeks 1 to 4

n ulus . If th e The athlete was treated with 3 days of relative bed rest. He was encouraged to work on spinal segment stability exercises,
e in contact knees toward chest, and knee rocking mobilizations while in a ITat lying position (supine, side-lying , or prone). Multiple
extruded disk. bouts of the 90-90 position and prone-on-elbows position were used for th eir posltionaltractlon benefit. Activities of daily
living were kept to a necessary level-remain at home. avoid Sitting posture. Standing and walking for brief peri ods (less
than 10 minutes) were allowed. The physician prescribed ana,lgesic and anti-inflammatory medications.
After 3 days, the athlete was encouraged to come to the ath letic training roo m for treatment once a day. The above ac­
tivities were preceded with the comfort modalities of hot packs and electrical stimulation. Spinal segment stabili.zation was
680 PART THREE The Tools of Rehabilitation

trica I slin1l.
R E H A B I L I T A T ION P LAN (CONT'D) use the lat,
a gentle c\
reassessed. and the athlete started on the beginning-level core stability exercises. The athlete was instructed to be nat ly­ then sent h
ing for 20 to 30 minutes 4 times daily and to continue to minimize time spent in siUing postures. program:
At 1 week, the athlete was encouraged to walk for condiLioning and movement purposes. starling with 10 minutes and Thealo
working up Lo 30 minutes. The walking was followed by nat-lying and positional traction periods of 20 to 30 minutes. The silion 3 to -+
core stability exercises were gradually progressed to continue to challenge strength and endurance as the pain became that tim e I
more manageable. sion exert
At 3 weeks. more functional exercises were included. Squats. balance activities. and light wcightliftLng (no axial load­ 20 second
ing) were begun. Flat-lying postures 4 times daily wcre encouraged.
At 4 weeks. the athlcte was instructed to gradually increase silting times. guided by comfort.
PHASE TWO MAl'll Ri\TI()~ A:\ I) 1,'1 ~CTI()I'\AL STREI'\( ;'1'11 Ei'i I ~C STACE cises pro\
GOALS: ~ilaximizc core stability strength and endurance, retrain functional and sport-specific movement patterns to which enh
include spinal segment and core stability, rcturn normal l1exibility and strength to lower extremities. and cncourage feet of the
good mechanics in activities of daily living. leads to de~
Estimated Length of Time (ELT): Week 5 to 6 Months tal spin al
The athlete had a complete back evaluation, and speeil1c l1exibility and strengthening problems were identified. Tight into the r
muscle groups were stretched 3 or 4 times a day, weak muscle groups were isolated and progressively strengthened. with olher
Spinal segment stability and core stability were stressed with more challenging exercises. Normal strength and condi­ The g
tioning exercises were encouraged, but technique was monitored closely and the athlete was encouraged to use spinal
segment stability coactivation patterns in every exercise. Sport-speCific drills were begun, with the athtete being encour­
aged to incorporate spinal segment coactivation patterns ,i nto their motor planning for each drill.
CRITERIA FOR RETURN TO PRACTICE AND PLAY
1. The athlete demonstrates good spinal segment control in the athlelic training room.
2. The athlete has normal flexibility and strength in their lower extremities.
3. Funclional performance test scores are at least 90 percent of previous baseline scores.
4. The athlete tolerates 1 to 1.5 hours of exercise with no symptoms.
5. The athlete demonstrates in practice drills that he can perform the activities of his sport ,"'ith no noticeable compen­

satory movement patterns.

coactiva I iI'~
DISCUSSION QlJESTIONS gentle nC\
1. Theoretically, what are the beneficial effects of positional traction? may makt:
2. Do disk-related problems ever heal?
3. Once the athlete has recovered from this injury, what preventive strategies can be used to avoid reinjury?
4. Are braces. corsets. or back belts effective in supporling the disk?

Rehabilitation Concerns. The athlete will report a
centrally located pain that radiates unilaterally or spreads
across the back. They may describe a sudden or gradual
onset after a workout that becomes particularly severe af­
ter they have rested and then tried to resume their activi­
ties. They Iuay complain of tingling or numb feelings in a
dennatomal pattern or sciatic radiation. Forward bending
and sitting post ures increase their pain . The athlete's
symptoms are usuaLly worse in the morning on flrst aris­
ing and get better through the day. Coughing and sneezing
may rncrease their pain.
On physical examination . the athlete will have a hip
shifted, forward bent posture. On active movemenls. side
bending toward the hip shirt is painful and limited. Side A en.'"
bending away from the shm. is more mobile and does not
provoke the pain. Forward bending is very limited and
painful, and guarding is very apparent. On palpation there
may be tenderness around the painful area. Posteroante­
rior pressure over the ,involved segment increases the pain .
Passive straight-leg raising will increase the back or leg
pain during the IIrst 30 degrees 01' hip flexion. Bilateral
knee-to-chest movement will increase the back pain. Neu­ cen U-d
rological testing (strength. sensory reflex) may be positive
for difl'erences between right and left. Should
Rehabilitation Progression. The athlete should der of'
be treated initially with pain-reducing modalities (ice, elec-
 CI f/\PTER 2') Rehabililation of Injuries to tJ1e Spine 681

trical stimulation. rest). The athletic trainer shoulcl then

LIse the lateral shift correction (Figure 25-1l) fo llowed by
a gentle extension exercise (Figure 2 :;-1 6). T he athlete is
j La be l1at Iy­ then sent home with the following rest ancl home exercise
program:
min utes and The athlete mLlst commit to resting in a nat-lying po­
minu tes. The sition '3 to 4 times a day for 20 to 10 minutes. During
'.lain became that time the athlete can use so me prone press-up exten­
sion cxercises . holding the stretched positioll for 15 to
1 a xial load- 20 seconds each repetition (Figures 25-13 and 25-14) .
Another recommended pain-rdicving position is the
90-90 position-90 deg rees of hip flexion and 90 de­
grees of knee flexion (P igure 25- .) 7). Both of th ese exer­
MIttI­ cises provide very mild traction to the lumbar spine.
tteros to which enhances the centralization and n o urishment ef­
courage fect of th e flat-lying position on the disk . which in turn Figure 25-57 The 90-90 position. The athlete is posi­
leads to decreased pain and increased function. Segmen­ tioned back-lYing with hips flexed to 90 degrees and
tal spinal stabilization exercises can also be incorporated knees supported at 90 degrees by stool or pillows.
. Tight into the rest positions and may be used concurrently
tbened. with other modalities (Figures 2:;- > to 2 'i-10) .
If the disk is extruded or sequestrated. about the only
nd condi­ The goal i.s to reduce th e disk. protrusion and restore
thing that can be done is to modulate pain with electrical
pinal normal posture. Wh en posture. pain. and segmental stimulation. Flexion exercises aI1l11S'ing supine in a flexed
ing encour- spinal control return to normal. the core ~tabiJization ex­
position may help with comfort. The use of a low back
ercises should be emphasized al1d progressed. The athlete corset or brace may also make the athlete more comfort­
may recover easily from the first episode. but if repeated able (Figure 25-56). Sometimes the symptoms will resolve
episodes occur. then the athlete should also start on the
with Lime. But if there are signs of nerve damage. surgery
reinjury stage of back rehabilitation.
may be necessary.
When the athlete changes positioos-sit to stand or ly­
ing to stand- they should do a lateral shift seJkorrection
Ie compen­ (Figures 2:;-12. 2'i-16). follolVed by a segmental; spina ! CLINICAL DECISION MAKING Exercise 25-4
coactivation contraction (Figures 25 -X to 2 5-1 OJ. Some
gentle f'lexion exercises. 101V back corsets. and heat wraps A wrestler has reccntly recovered from disk-related back
may make the athlete more comfortable. pain and Is entering thc strength and fllnclional recovery
part of the rehabilitation process. What arc the impor­
tant factors to consider. to prevent a recurrencc of his
problem?

CLINICAL DECISION MAKING Exercise 25-3

ited . Side J\ crew rowel' has been having centraliaI\' back pain
d doe n ot since the third week of the season. There arc 2 weeks of
limited and n~glliar season and 2 week, of championships left l'or this
season. Recently she has experienced some paresthesia in
Lhe L5 and Sl dermatome areas of her right leg. Neuro­
logical tests (reflex. strength. sensory) arc all equal to her
other leg. An ,\oIRI shows a disk herniation at L'5 that is
not compromising the nerve root:. Her major findings are
centralillmbar spine discomfort. some stiffness on for­
ward bending. and tingling sensations in the right leg.
Should the athlete continuc to partidpatc for the remain­
der of thc season:
Sacroiliac Joint Dysfunction
Pathomechanics and Injury Mechanism. A
sprain of the sacroiliac joint may result from twisting with
both feet on the ground. stumbling forward. filJling back­
ward, stepping too far down and landing heavily on one
leg. or forward bending with the knees locked during Iift­
ingY Athletic activities involVing unilateral forceful
movements. such as punting. h urdling. throwing. jump­
ing. or trunk rotations with both feet I1xed (swinging a
club or a bat). are th e usual activities associated with the
onset of pain. Any of these mechanisms can produce
stretching and irritation of the sacroiliac. sacrotuberous .
or sacrospinous IigamenLs.
682 PART THREE The Too[s of Rehabilitation
Rehabilitation Concerns. The athlete will report Cl
dull. achy back pain ncar or medial to the posterior supe­
rior iliac spine (PSIS) with somc associated muscle guard­
ling. The pain may radiate into thc buttocks or
posterolateral thigh. '1'hc athlete may dcscribe a heaviness.
dullness, or deadness in the leg or referred pain to the
groin, adductor. or hamstring on the same side. The pain
may be more noliccab'le during the sl<mcc phase of walk­
ing and on stair climbing.
Side-bending toward the painful side will increase the
pain. Straight leg raising will increasc pain in the sacroil­
iac joint area after 45 degrees of motion. On palpation,
there may be tende.rness over the PSIS. mcdialto the PSIS.
in the muscles of the buttocks. and anteriorly (wcr the pu­
bic symphysis. 'l'he back musculature will have increased
tone on one side.13. 23.11
If a sacroiliac joint is stressed and: reaches an end­
range position in rotation. the joint can become dysfunc­
tional as pain, mechanical form closure locking. and /or
muscle gu a rding create hypomobility at the joint. T his hy­
pomobility is usually tcmporary, and often spontaneoLls
reposilioning will occur. This allows the pain to go away
and muscJc gUClrding to disappear. With the Joint back to
normal alignment. function returns to normal. 23.41
vVhen normal alignment docs not spontaneously re­
turn, treatment efforts should initially mobilize thc joints
and then work on spinal segment stabilization to maintain
and improve sacroiliac joint stability. Tbese exercises.
along with core stability training, arc the key to preventing
recurrences. The athletic trainer should consider sacroil­
iac dysfunction as a problem with pelviC stability rather
than mobility.2119
Rehabilitation Progression. Recent studies of
sacroiliac joint testing cast severe do u bt on our ability to
recognize the postura l asymmetries that h ave been asso­
ciated with directionally spccific techniqucs.I.l·23.4 1 Thc
treatment of sacroiliac dysfunction has been grounded in
the empiricism of doing techniques that reduce pain.
Postural asymmetries have given the athletic trainer a
starting point for directional spccific techniques, but the
instruction in deciding on appropriate technique is to try
one and , if the outcome isn't satisfactory, move on to the
next technique, which may be biomechanically opposite
to the first technique. JI Empirically, these mobilizations
bave been used for many years and have demonstrated a
good effect on sacroiliac dysfunctions with an asymme­
try of the pelvis and pain. Ea.ch technique wlll have about
the same effect on the pelvis and sacroiliac joints because
the joints arc part of an arch and for ces at any point in
the arch can be translated throughout thc structure to
affect each joint. These stretches should be uscd only at
the beginning stage of treatment to free the joint from the
initial hypomobility.
i\ posterior innominrIte rotation may be used to treat
sacrQiliac dysfunction (Figure 25-58). The athlete is posi­
tioned \\-1tl1 legs and trunk moved toward the side of the low
ASIS. This locks the lumbar spine so the mobilization will af­
fect the sacroiliac joint. The athletic trainer stands on the side
away from the loll' I\srs and rotates the athlete's trunk to­
ward the athletic trainer. The athlete is instructed to breathe
a nd relax as thc athletic traincr overpressures the rotation to
take up the slack. The lower hand contacts the low ASIS and
mobilizes the ,i nnominate into posterior rotation.
The athletic trainer should also mobilize the sacroiliac
jOint using stretching positions 1 and 2 or the anterior-pos­
terior sacroiliac joint rotation stretch to correct the postural
asymmetry (figu.fes 25- 59 and 25-(0). 5.6.7.17.55 The stretch
exercise shou ld be done in 2 or 3 bouts a day,
3 or 4 repetitions each time. holding the stretch posit,ion for A
20 to 30 seconds. Spinal segment stability excrcises are uti­
lized after each stretching bout lq (Figures 25-4 to
25-J 0). The stretches shou:ld not be continued longer than
2 or 3 days. The spina I segmen tal stabilization exercises are
continued to try to create the behaviors that stabilize the
sacroiliac jOints and strengthen the muscles that support
the join t. The excrcises should be progressed to include more
core stabilization aod functional training. leading to return
A Figure 2"- ­
position.
to sports. C
during hig
problems \\
B
a Ulil~[,;1
f'igure 25-58 Posterior innomioate rotation. A, Start­
ing position. B, Mobilization position.
 C'll ;\I'TII{ 15 Rehabilitation of Injuries tu the Spine 683

the rotation to
_low ASIS and
n.
the sacroiliac
_anterior-pos­
lhe postural
. ~ ;T he stretch
Pouts a day.
h po iUon for A
B
mises are uti­ I
IreS 25-4 to
-d longcr than
p exercises are
t stabilize the
. lhat support
,include more
ding to return

c
Figure 25-59 Sacroiliac stretch. position J. A. Starting position. B. Position for isometric resistan ce. C, Stretch
position.

to sports. Corsets and pclvic stabilizing belts (Ire also h ·lph.II
during higher-level <lclivilies and/or il' the athll'te is having
problems with recurrences (Figure 25-5h).
CLINICAL DECISION MAKING Exercise 25-5
The physician sends an athlete to the training roOIll wilh
a diagnosis of low back strain. The athlete has pain
around the PSIS urca and some restriction of range.
What rehabilitation exercise plan should the athletic
ation. A, Start- trainer use to help this ath lete?
Sacroilic stretch positions I and 2 that will help re­
aligll an athlete's pelvi. when they arc having sacroil­
iac dysfunction. Position 1 (Figure 22-59 ) and position
2 (Figure 22-60) stretches can be done in both right
side-lying and left side-l)' ing positiom . The st<lrling po­
siti on of the pOSition 1 stretch is side-lying with the up­
pe r hip flexC'd 70 to RO degrees and the knee flexed
aboLlt90 degrees (Figure 25-59). The athlete's Lrunk is
then rotated toward the upper side as rar as is comfort­
able. The athlete is inslructed to lift Lhe top leg in 10
hip abdu<.:l ion and inLernal rotation and resist the
athletic tt lin er for 5 seconds . The athlete is instructed
to breathe and exhale as the athletic trainer gently
684 PART THREE The Tools of' Rehabilitation

overpressures the trunk rolillion. The athlete is then

instr ucted to relax the hip and leg and allow the leg to
drop toward th e floor. As the athl ete relaxes, the ath­
letic trainer app lies a gentle overpressure to the foot
and takes up the slack as the athlete allows the hip and
leg to drop further to the floor.
In the position 2 streich (Figure 22-60), the athlete
A
is positioned 011 either the right or left side. The athlete
is side-lying with their t runk rotated so the lower arm is
behind th eir hip and their upper arm is ab le to reach off
the table toward the floor. Both knees and hips are
flexed to approxi mately 90 degrees. The athlelL"s knees
arc supported on the 'lthlelic trainer's thigh. The ath­
letic trainer a lso s upports the feet in this stage of the
stretch.
l3efore beginning the stretc h com ponent or the posi­
sition 2 stretches. the athletic trainer provides iso metric
resistanc e to lifting both legs towmd the ceiling holding
t he contraction for.5 seconds. The ath lete is instructed to
ex hale while relaXing the legs and allowing them to drop
tow ard the floor. The ath letic trainer adds a light pres­
sure to the feet and shoulder blade area to guide the B
stretch and take up slack. The ath letic trainer holds
the athlete in a comfortilble maximum stretch for 2{) to
30 seconds.

REHABILITATION TECHNIQUES
FOR THE CERVICAL SPINE
Acute Facet Joint Lock
Patbomechanics. Acute ce rvical joint lock is a
very co mmon condition. more frequently ca lled wry­ c
neck or stiffneck. The athlete llsually complains of pain
on one side of the neck following a sudden backward
hending. side bending. and / or rotation of th e neck. Puin
can also occ ur after holding the head in an unusual po­
sition over a period of Lime. as when awakening from
s leep. This prohlem can also occasionally follow expo­
sure to a cold draft of a ir. There is no report of other Figure 25-60 Sacroiliac stretch position 2 . A, Startin g
acute traum a that could h ave produced the pain. This position. D, Posi tion for isometric resistance. C, Stretch
usually occurs when a small piece of synovial Illem­ position.
brane lining the joint capsule or a meniscoid body is im­
pinged or trapped within a facet joint in the cervical
vertebrae. During inspection. there is palpable poin t ten­ the sidc on which there is locki ng. Otiler movements are
derness und ma rkcd muscle gua rding. The athlete will relatively painless. "h
report that the neck is "locked." Side bending and rota­ Rehabilitation Progression. Various therapeutic
tion arc painful when mov ing in the direction opposite to modaliti es may be used to Illodulate p<)in in an attempt to
 CHAPTER 25 Rehabilitation of Injuries to the Spine 685

REHABILITATION PLAN
SACROILIAC JOINT DYSFUNCTION

INJURY SITUATION A 21-year-old male wide receiver demonstrated a subtle limp returning to the huddle between plays
and on the sideline when not in the game. He cont·i nued to play for the entire game and performed very well. He stated that
the 'i njury had occurred as he was planting his left loot and taming his body to the right to avoid a defender. His previous
medical history was unremarkable for hip. sacroiliac. or muscle problems. and he was in excellent phySical condition with
no other injuries at this time.

SIGNS AND SYMPTOMS i\fler the game the athlete complained of mild pain and a stiff-light
feeling in his left groin area. with hip flexion and adduction. increasing his discomfort.

Body landmarks were evaluated:

Fibular heads Level
Trochanter Level
PSIS High on the left- Standing and sitting
AS IS High on the left-Standing and sitting
Iliac Crest High on the left-Stauding and silting
Range of Motion was assessed. Lumbar spine range was full in all ranges. but side­
bending left and backward-bending created pain in the left sacroiliac region. Holding the
backward bent position created some left groin pain similar in nature to the pain that oc­
curred during the game. Passive hip range of motion was full in all ranges. with mild groin pain provoked on the end range
of l1exion. abduction, and internal rotation.
On manual muscle test. hip flexion and abduction were strong but produced pain in the left groin similar in nature to
the presenting pain.
Right and left straight ileg raise tests were positive for left groin pa.in. Right and left FABER and FADIR and knee-to­
armpit tests were also pOSitive for left groin pain. Bilateral knees-to-chesttest was full-range and painless. as were the stress
test of iliac approximation. iliac rotation. and posterior-anterior spring test.
On palpation, there was mild tenderness along the left sacroiliac joint and over the ldt gluteus medius just ,l ateral to
the psrs. The hip abductors, hip flexors. and hamstring muscles were llontender but had increased tone.
Functional'!y, the athlele walked with a reduced stride length on the left. which produced a mild limp. Walking pro­
duced some mild left groin pain . and stair climbing increased this pain in his left groin.

MANAGEMENT PLAN The goals are to reduce pain, return and stabilize the sacroiliac joints in a symmetrical position. in­
crease strength and function. and retnrn the athlete to elite-l.evel sport.

PH AS EON E /\Cl IT E E\Jl\l ST,\CE

GOALS: Modulate the pain, stretch, and strengthen the sacroiliac joint to return them to a more symmetric position.
Estimated Length of Time (ELl'): Days 1 to 3
The athlete was treated with stretch A to bring his sacroiliac joints into symmetric positions. Spinal segment stabilization
was initiated along with beginning core stabilization exercises (hip lift bridges. isometric h·ip adduction baH squeezes). The
left groin and sacroiliac area were treated with ice. The athlete was instructed to repeat stretch A and the strengthening
exercises 3 times a day when not involved ,in the athletic training room treatment sessions. He was also given ana lgesic
medicine to make him more comfortable.
On day 2, position 1 was continued and the stretching exercise load was increased by adding repetitions. A stretching
program was begun for the hip abductors. hip interna;l rotators, hip l1exors, and hamstrings. His usual weight-lirting ses­
sion was modified to a non-weight-bearing program. His conditioning workout was done on the exercise bike and in the
pool. Hot packs were applied to the adductor area preliminary to the exercise and stretching programs. The sacroiliac area
was treated with ice and electrical stimulation. high volt, 120 pps, at a moderate sensory intensity.
686 PAKrTHREE The Tools of Rehabilitation

R E H A B I LIT A T ION P LAN (CONT'D~

On day 3. position 1 was discontinued. Strengtbening was increased with the addition of clastic resistance to hip ab­
duction and adduction. Functional exercises were initiated. including line walking. mioisquats. side shufl1e with tubing
resistance. ModaUtics remained the same.

PHASE TWO RETlJRI\ TO PLAY

GOALS: Increase spinal segment awareness. core stabilization strength. return to functional exercises, anclreturn to

practice and pLay status.

Estimated !Length of Time (ELT): Days 4 to 7

Pain modalities were continued. Stretching exercises to the left hip abductors, ilexors and internal rotators were contin­

ued. Strengthening exercises continued with increased repetitions, resistance, and diHiculty. On day 4, the athlete was

tested on a cluster of functional performance tests. His scores indicated that he was capable of practicing, and he did par­

Figure 2 5-6
ticipate fuHy with reduced repetitions. Hot packs and electrical stimulation were continued, as were the spinal segment
and core stabilization exercises.
CRITERIA FOR RETURN TO PRACTICE AND PLAY
1. Functional performance test scores are at least 90 percent of previous base.line scores.
2. The athlete demonstrates in practice drills that he can perform the acLivilies of his sport with no noticeable compen­

satory movements.

3. Satisfactory completion of all phases of practice without exacerbation of the symptoms.

~- -

PHASE THREE !'vl0NITORING. MArNTEN/\NCE. AND MATIII\ATIOI\

GOALS: I'vlaintain spinal segment strength, increase core strength, and return to normal exercise routines for strength

and conditioning.

Estimated Length of Time (ELT): Day 8 to 6 Weeks Post Injury

Pain modali ties should be used if needed. Tight muscle groups should continue to be stretched 2 or 3 times a day.

~trengtbening routines should become more challenging but not more time-consuming.

DISCUSSION QUESTIONS

.1 . What other mobilizatIons or stretches could be used to make the sacroiliac joints symmetrical?
2. What were the mechanics that created this problem?
3. What exercises have the best chance of stabilizing the sacroiliac joints and why ?
4. VVhy was stretch I\. discontinued after 2 days?
5. Are there assistive devices to help stabilize the sacroiliac joints? Describe their mode of action.
6. What are the risk of returning to practice and play too early?

break a pain-spasm-pain cycle. Joint mobilizations involv­ Cervical Sprain

ing gentle tradion (rigure 25-61). rotation (see figure
.14- 32 ), and lateral bending (see Figure 14-33), l1rst in the
pain-free direction and then in the direction of pain, can
help reduce the guarding. Occasionally pain will be re­
lieved almost immediately following mobilization. If not.
it may be helpful to wear a soft cervical collar to provide
for cOJ11fort (Figure 25-(2). This muscle guarding will
generally last for 2 or 3 days as the athlete progressively
regains motion.
Pathomechanics and Injury Mechanism. A cer­
vical sprain usually results from a moderate to severe
trauma. More commonly the head snaps suddenly, such as
when the athlete is tackled or blocked whi,le unprepared.
Frequently muscle strains occur with ligament sprains. A
sprain of the neck can produce tears in the major support­
ing tissue of the anterior or posterior longitudinal liga­
ments, the interspinous ligament. and the supraspinous
 CHAPTER 25 Rehabilitation of lnjuries to the ' pint: 687

(COHT'D)

• were contin­
_ Ite ath le te was
"" and he did par­
Figure 25 -61 Cervical traction.
_pinal segment
Figure 25-63 Manually assisted flexion tr
ercise.

'cea ble compen-

HI() \
u nes for strength

3 mes a day.

Figure 25 -6 2 The use of a soft or hard collar can in­

Figure 2 5-64 Manually assisted ex tension lT~
crease comfort.
exercise.

~lechani sm. A cer­
a moderate to severe
ap suddenly, such as
'e while unprepared.
th ligament sprains. A
'in the major support­
~io r longitudinal Iiga­
an d the supraspinous
ligament. There may be palpable te nderness over the
transverse and spinous processes that. serve as sites of at­
tachment for the ligaments.
The sprain displays all the sign s of the facet joint lock.
but the movement restriction is much greater and can po­
tentially involve more than one vertebral segment. The
main difference between the two is that acute joint lock
can usually be dealt with in a very short period of time but
a sprain will require a signif'icantly longer period for reha­
bilitation. Pain may not be significant initially bLlt always
appears the day after the trauma. Pain st ems from the in­
flammation of injured tissue and a protective muscle
guarding that restricts motion.
Rehabilitatiou Progression. A oon c.
the at11lete should have a physician e alualiol l
the possibility at' fracture, dislocation , disk inJu~
to the spinal cord or nerve root. /\ soft cerdca
be applied to reduce muscle guarding (Fi Uft; _ ; - _
and electrical stimulation arc used for 4 to, ~
the injury isin the acute stage or healin a.lna na
a severe injury. the physiCian may pre. cribe _ t
bed rest, along with analgesics and anti­
medication . Range-of-motion excrci 'es th rou =­
range should begin as soon as possible. illl
(figure 25 -63). extension (Figure 25-6·:1:1. r<
25-65 ). and Side-bending (Figure 25 -6"'1.
688 PARTTHREE ThcTools of Rehabilita tion

Figure 25 -65 Man ually assisted rotation stretching Figure 25-66 Ma nually assisted Side-bendi ng stretch­
exercise. ing exercise.

1.

Figure 25-67 Manually resisted nexion strengthening Figure 25-68

Manually resisted extension strengthen-
exercise. in g exercise. 2.

3.

4.

5.

Figure 25-69 Manually resisted rotation strengthen­ Figure 25-70 Man ually resisted side-bending 6.
ing exercise. strengthening exercise. appr
 CHAPTER 25 Rehabilitation of Injuries to the SpillL' G8S

Figure 25-71 Gravity-resisted cervical stabilization ex­ Figure 25-72 Cervical stabilization exerci e done
ercise done on a treatment table with the head maintain­ Swiss ball.
ing a static position. May be done side-Iying(right and
left). prone. and supine.

demonstrated that using early ROM exercises. as opposed to mobility. Thus strengthening exercises (Figu r
long periods of immobility. tends to reduce the likelihood of through 23-70) along with stabili:wtion exerc' .
neck hypomobility when the healing process is complete: l !, 25-71 to 25-72) should also be incorporated inw
It is important to regain motion as soon as possible. How­ bilitation program.
ever. it is critical to understand that a sprain. particuIarly Mechanical traction may also be prescribed I
one that involves a complete ligament tear, causes hyper- pain and muscle guarding (Figures 25-71.2 - - / ~ .

Summary
.............................................................................................................................................................................................................. --­
1. The low back pain that athletes most often experience ious protocols described according to the

is an acute. painful experience of relatively short dura­ the athlete's evaluation.

tion that seldom causes significant time loss from prac­ 7. Specific goals and exercises included in la!!dl
_ te nsion slrengthen­ tice or competition. address which structures to stretch . which n"~n",,",
2. Regardless of the diagnosis or the specificity of the di­ to strengthen. incorporating segmentill p'
agnosis. a thorough evaluation o[ the athlete's back lizalion into the athlete's daily life and
pain is critical to good care. tine. and which movements need a m t
3. Back rehabilitation may be classified as a two-stage ap­ approach to control faulty mecha nic.
proach. Stage I (acute stage) treatment consists 8. The rehabilitation program should inclu

-
mainly of the modality treatment and pain-relieving training. which may be divid ed into
exercises. Stage II treatment involves tre<Jting athletes vanced phases.
with a reinjury or exacerbation of a previous problem. 9. Back pain can result from ooe or a canwinalioo
4. Segmental spinal stabilization and core exercise following problems: muscle strain. nor,r.....-m...
should be included in the exercise plun of every athlete or quadratus lumborum myora iill
with back pain. ofascialtrigger points. lum bar rae'
5. The lypes o[ exercises that may be included in the ini­ permobility syndromes. di k- relal~
tial pain management phase include the [ollowing: lat­ sacroiliac jOint dysfunction.
eral shill corrections. extension exercises. flexion 10. Cervical pain can resulL [r om m
exercises. mobilization exercises. and myo[ascial cervical joinl lock. ligamcl1l
stretching exercises. problems.
,id -bending 6. It is suggested that the athletic trainer use an eclectic
approach to the selection of exercises. mixing the var­
690 PART THREE The Tools of Reh abili tation
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 CHAPTER 25 Rehabilitation of Injuries to the Spine 691

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42. Saal. J. 1988.!. Rehabilitation of football players with lumbar
spine injury. Physicia.n and Sports Medici/Ie 16(9): 61-68.
43. Saal. J. 1988. Rehabilitation of football players with
lumbar spine injury. Physician and Sports Medicine 16(10):
117-25.
44. Saal. J. 1990. Dynamic muscular stabilization in the nonop­
IIlJd sacroiliac erative treatment of lumbar pain syndromes. Orthopedic Re­
.:\.T . :\a­ views 19(8): 691-700.
45. Saal. J.. and J. Saal. 1989. Nonoperative treatment of herni­
:urreat ap­ ated lumbar intervertebral disk with radiculopathy: An out­
relSe. li/l­ come study. Spine 14(4): 431-37.
46. Saunders, D. 1985. Evaluatioll, treatment, and prevention oj
!!lief by post­ musculoskeletal disorders. Bloomington, MN: Educational Op­
:nJ Relrabili­ portunities.
47. Steiner. C.. C. Staubs. M. Ganon. et al. 1987. Piriformis syn­
drome: Pathogenesis. diagnosis. and treatment. Journal
Americnn Orthopedic Academy 87(4): 318-23.
48. Tenhula. I.. S. Rose. and A. Delilto. 1990. Association be­
tween direction of lateral lumbar shift. movement tests, and
side of symptoms in patients with low back pain syndrome.
Physical Therapy 70(8): 480-86.
49. Threlkeld. A. 1992. The effects of manual therapy on con­
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50. Travell. J.. and D. Simon. 1992. lvlyoJascial pain and dysJimc­
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51. Travell. I.. and D. Simons. 1992. ,vlyoJascial pain and dys)imc­
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52. Twomey, L. 1992. A rationale for treatment of back pain and
joint pain by manual therapy. Physical Therapy 720 2): 885-92.
53. Waddell. G. 1987. Clinical assessment of lumbar impair­
ment. Clinical Orthopedics and Related Research 221:110-20.
54. Waddell. G. 1987. A new clinical model for the treatment of
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55. Walker. J. 1992. The sacroiliac joint: A critical review. Physi­
cal Therapy 72(12): 903-16.

_ The effect of SOLUTIONS TO CLINICAL DECISION MAKING EXERCISES

oack pain: A
opcrant-condi­
- ~ el l; 27<)-90.
25-1 The athlete most Hkely has myofascial trigger points
umbar origin.
in his pirtformis, The muscle's hyper-irritability
i 9,: 391- 95.
could be helped with exercise and stretch. ischemic
. I.JJndon: But­
pressure and stretch. and modalities to decrease
.management or
pain and increase cLrculation in conjunction with
-! 1. exercise. The sciatic nerve should also be consid­
of the hlllll(ln ered as a possible source of the discomfort. The play
and practice decision is complex. The trigger pomt
Oliosis. Sew does not inherently compromise function. The ath­
lete's reaction to the pain and use of compensatory
behaviors wiH dictate the activity modifications
necessary to balance the athlete's recovery against
his need to perform in his sport.
25-2 The athlete needs to be fully evaluated. and prob­
lems with llexibility and weakness should be specif­
ically identified. SpondylolYSiS is considered a
ent or chronic hypermobility problem and could be a reason the
ndylolysis or athlete might experience some pain with increased
activity. With good spinal segment stabilization and
fIOPCrative treat­ core strength and endurance. this athlete should be
!x>ndylolisthesis. capable of participation in all athletic activities
without provoking this pain. If the athlete does de­
trunk list. Spine
velop back pain. she should be monitored for con­
tinued problems from this spondylolysis. such as a
Idus muscle five
d" c herniation.
slip of L5 on Sl creating a spondylolisthesis.
25-3 Each athlete's situation should be evaluated on an
'p between the individual basis. The athlete. athletic trainer.
int mechanics. physician. parents. and coach should confer on
the risks associated with continued participation
in crew. Potential treatments and possible surgical
interventions should be discussed. focusing on
how continued partiCipation might affect the
eventual recovery and long-term health of the
athlete. If the risks are negligible. and the primary
problem is the athlete's pain. the athlete herself
should be able to decide whether to continue for
the rest of the season.
25-4 The athlete should be continuing forever on a pro­
gram of spinal segmental stabilization and core sta­
bilization. Strength-training exercises should be
structured so that axial loads are minimized until
the disk has healed. Doing knee extension and flex­
ion. and leg-press exercises instead of squats and
lunges with weight on the shoulders. would provide
a strengthening load for the legs while keeping the
axial load reduced. To promote the centralization of
the disk nucleus in the disk space. the athlete
should routinely lie flat or inverted after workouts.
25- 5 The diagnosis from the physician is nonspeCific. The
athletic trainer should first evaluate the athlete to
identify the specific muscle groups that are weak
and painful. Appropriate exercise plans can then be
established. Muscle strain diagnoses are overused
in cases of low back pain. To confirm a diagnosis of
muscle strain. the evaluation should demonstrate
pain and tenderness over a muscle area. The pain
should be reproduced by stretching the muscle and
contracting the muscle.
 Gllossary
A placemen
abduction The movement of a body part away from the
ruptioD.
midline of the body.
closed' .
accessory motion The movement of one articulating
fo ot or
joint surface relative to another. involving spin . roll. glide.
collagen
active range of motion That portion of the total range
sue.
of motion through which a joint can be moved by an ac­
tive muscle contraction.
acute injury An injury with a sudden onset and short
duration
adduction The movement of a body part toward the mid­
line of the body.
adherence A term used in a behavior modification set­
concen1ric c
ting/ program for what is usually a long-term commit­
de short
ment to a rehabilitation program.
continuoas I
aerobic activity An activity in which the intensity of the
formed 14 ·-1
activity is low enough that a sufficient amount of oxygen
time.
can be delivered to continue activity [or an indefinite pe­
contractie t
riod of time.
muscles ..
agonist muscle The muscle that contracts to produce a
coping rebel
movement.
sually rebe
anaerobic activity An activity in which the intensity is
so great that the demand for oxygen is greater than the
body's ability to deliver oxygen.
analgesia A loss of sensitivity to pain.
anemia An iron deficiency.
antagonist muscle The muscle being stretched in re­
sponse to contraction of the agonist muscle.
anteversion. Tipping forward of a part as a whole. with­
out bending.
antiemetlcs Drugs used to treat nausea an.d vomiting
arising from any of a variety of causes.
antipyretic An agent that relieves or reduces fever.
antitusslves Drugs that suppress coughing.
aponeurosis A thin. sheetlike tendon made of dense
connective tissue.
apophysis Bony outgrowth to which muscles attach.
arthokinematics The physiology of joint movement. The
manner in which two articulated joint surfaces move rel­
ative to one another.
arthroscopic Technique. using an arthroscope. which
uses a smaill camera lens. to view the inside of a body
part. such as a joint.
cavitation
pand and ...
pressure
chronic: ~.
tion.
circu it traiaI
consistin",
flexibilil~
closed fr-=t
arthrosis A degenerative process involving destruction
of cartilage. remodeling of bone. and possible secondary
inl1ammation.
atrophy A decrease in muscle size due to inactivity.
attenuation A decrease in energy intensity as the ultra­
sound wave is transmitted through various tissues;
caused by scattering and dispersion .
avulsion Forcible tearing away of a part or a structure of
a tissue from its normal attachment.
thoritam
B usuallrha..
Bad Ragaz technique An aquatic therapy technique
where buoyancy is used for 110tation purposes only.
ballistic stretching A stretching technique in which
repetitive contraction s of the agonist muscle are
used to produce quick stretches of the antagonist
muscle.
basal metabolic rate The rate at which calories are used
for carrying on the body's vital function s and mainte­
nance activities when the body is at rest.
biomechanics The mechanics of biological movement.
regarding forces that arise either from within or outside
of the body.
buffers Techniques that allay the symptoms of stress but
do not address the problem that initially caused the stres­
sor.
buoyant force A force that assists motion toward the
water's surface and resists submersive motion .
bursitis fnl1ammation of a bursa. espeCially of a bursa
located around a joint.
C
calisthenic exercises Exercises that use body weight as
resistance.
capacitor electrodes Air space plates or pad electrodes
that create a stronger electrical field than a magnetic D
field .
cardiac output The volume of blood the heart is capable
of pumping in exactly 1 minute.
cardiorespiratory endurance The ability to persist in a
physical activity requiring oxygen for physical exertion
without experiencing undue fatigue.
 Glossary 693

cavitation The formation of gas-filled bubbles that ex­ sunny day at the beach or the game-winn ing shot at the

pand and compress because of ultrasonically induced buzzer.

pressure changes in tissue fluids. distal Farthest from center, from the midline. or from the

chronic injury A injury with long onset and long dura­ trunk.

tion. dorsiflexion Bending toward the dorsum or rear of the

circuit training A series of exercise stations; typically foot; opposite of plantarflexion.

consisting of various combinations of weight training,

flexibility, calisthenics, and brief aerobic exercises. E
closed fracture A fracture that involves little or no dis­ eccentric contraction A contraction in which the mus­

placement of bones and thus little or no soft-tissue dis­ cle lengthens while contracting.

:lesrruction ruption. edema Swelling as a result of a collection of fluid in con­

esecondary closed kinetic chain A position in which at least one nective tissue.

foot or one hand are in a weight-bearing position. energy Biologically, the ability to do work that is pro­

Icrivity. collagen The main organic constituent of connective tis­ duced as body cells break down the chemical units of glu­

the ultra­
iI.S sue. cose, fats, or amino acids,

is ues: compliance A term used in the rehabilitation setting to epiphysis A cartilaginous growth region of a bone.

describe a patient's attitude toward the caregiver's in­ etiology The science of dealing ""ith causes of disease or

I structure of structions. The patient is obedient to the physician or trauma; or the chain of conditions that give rise to a dis­

health caregiver's directions, the care giver is in an au­ ease or trauma.

thoritative position, and the treatment is short-term and eversion Turning the foot outward.

usually has been prescribed. exudate An accumulation of fluid in an area.

tec hnique concentric contraction A contraction in which the mus­

:!Sonly. cle shortens. F
e in which continuous training A technique that uses exercises per­ fartlek A type of workout that involves jogging at vary­
Ie are formed at the same level of intensity for long periods of ing speeds over varying terrain.
19onist time. fascia A fibrous membrane that covers, supports. and
contractile tissue Tissue capable on contraction (i .e .. separates muscles.
aries are used muscles). fasciotomy An incision into the fascia to release pres­
d ma.inte­ coping rehearsal A tcchnique in which an individual \'i­ sure within the compartment.
sually rehearses a problem they feel may be an obstacle to fast-twitch muscle fibers A type of muscle fiber respon­
movement, reaching a goal, such as a return to competition, a.nd en­ sible for speed or power activities such as sprinting or
11 or outside visions being successful. weight lifting.
core stability The ability to transfer the vertical projec­ fibrinogen A blood plasma protein that is converted into
. of stress but t,ion of the center of gravity around a stationary support­ a fibrin clot.
d the stres­ ing base. fibroblast Any cell component from which fibers are de­
crepitation A crackling sound heard and felt during the veloped.
oward th e movement of broken bones or in a case of soft tissue in­ fibrocartilage A type of cartilage (e.g" intervertebral
m, flammation. disks) in which the matrix contains thick bundles of col­
" of a bursa cryotherapy Cold therapy. laginous fibers.
cubital tunnel syndrome Entrapment of the ulnar nerve fibroplasia The period of scar formation that occurs dur­
in the cubita l tunnel. ing the fibroblastic-repair phase.
cyanosis Slightly bluish, grayish, slatelike, or dark pur­ flexibility The ability to move the arms, legs and trunk
Mi. weight as ple discoloration of the skin caused by a lack of suftlc ient freely throughout a full, nonrestricted, pain-free range of
oxygen. motion.
Id electrodes foot pronation Combined foot movement of eversion
magnetic o and abduction.
degeneration Deterioration of tissue.
foot supination Combined foot movement of inversion
act is capable diapedesis A passage of blood cells via ameboid action
and abduction.
through the intact capillary wall.
force A push or a pull produced by the action of one ob­
[) per ' ist in a disassociation A technique that can be used in rchabili­
ject or another: measured in pounds or newtons.
:al exertion tation for temporary pain modulation. The individual
force couple Action of two forces in opposing direction
thinks about something other than the pain, such as a
about some axis of rotation.
694 Glossary

force-velocity relationship The faster a muscle is loaded

ischemia Local anemia.
neuroma
or lengthened eccentrically. the greater the resultant
isokinetic exercise An exercise in which the speed of
nerve fi hers.
force output.
movement is constant regardless of the strength of a con­
neuromusa
frequency With therapeutic modalities. the number of
traction .
nervous an
cycles per seconds that a specific exercise is performed
isometric exercise An exercise in which the muscle con­
move ment.
during a training cycle.
tracts against resistance but does not change in length.

functional progression A series of gradual progressive

isotonic exercise An exercise in which the muscle con­
o
activities designed to prepare an individual for return to a
tracts against resistance and changes in length.
open fractur
specific sport.
ment of th

G
joint capsule A saclike structure that encloses the ends
open ki
genu recurvatum Hyperextension at the knee joint.
of bones in a diarthrodial joint.
with th
genu valgum Knock-knee.
orthosis
genu varum Bowleg.
K suppOrt.
Golgi tendon organ (GTO) A mechanoreceptor sensi­
kinesthesia, kinesthesis Sensation or feeling of move­ prove fun
tive to changes in tension of the musculotendinous unit.
ment; the awareness one has of the spatial orientation of orthotics
his or her body and the relationships among its parts. tory roo
H osteoc'-'dr
hemorrhage A discharge or loss of blood.
M of cartila;
herniation A bulging or enlargement of soft tissue.
macrotears Tears usually caused by acute trauma, in­
articular •
hip pointer A subcutaneus contusion that can cause. in
volVing significant destruction of soft tissue and resulting
osteokinenu
most cases, a separation or tearing of the origins or inser­
in clinical symptoms and function alteration.
results fr,
tions of the muscles. The injury is usually caused by a di­
margination An accumulation of leukocytes on blood

rect blow to the iliac crest or anterosuperior iliac spine.

vessel walls at the site of an injury during early stages of

hyperextension Extreme stretching of a body part.

inflammation.

hypermobile Extreme mobility of a joint.

maximal aerobic capacity The maximal amount of oxy­

hypertonic Having a higher osmotic pressure than a

gen an individual can use during exercise.

compared solution.
microstreaming The unidirectional movement of fluids

hypertrophy An increase in muscle size in response to

along the boundaries of cell membranes, resulting from

training.
the mechanical pressure wave in an ultrasonic field.

hyperventilation Abnormally deep breathing that is pro­

microtears Soft-tissue tears that involve only minor

longed . resulting in too much oxygen intake and too little

damage and most often are associated with overuse.

carbon dioxide outtake.

muscle guarding A protective response in muscle that

hypoxia Oxygen deficiency.

occurs because of pain or fear of movement.

muscle spindle l'vlechanoreceptors within skeletal mus­

cle sensitive to changes in length and rate of length

idiopathic Cause of a condition is unknown.

changes in muscle.

imagery A technique in which the athlete Vividly imag­

muscular endurance The ability to perform repetitive

ines a sensory experience in order to practice or prepare

muscular contractions against some resistance for an ex­

for a situation.
tended period of time.

infrared The portion of the electromagnetic spectrum

muscular strength The ability of a muscle to generate

associated with thermal changes. Infrared wavelengths.

force against some resistance.

located adjacent to the red portion of the visible light

myofilaments Small protein structures that are the con­

spectrum.
tractile elements in a muscle fiber.

interosseous membrane Connective tissue membrane

myositis Inflammation or soreness of muscle tissue.

between bones.

interval training Alternating periods of relatively intense

N
work followed by active recovery.
negative reinforcement A punishment (verbal or a
inversion Turning the foot inward.
stimulus) to elicit a certain behavior or inhibit a specific
iontophoresis A therapeutic technique that involves in­
behavior.
troducing ions into the body tissue by means of a contin­
nerve entrapment Compression of a nerve between
uous direct electrical current.
bone or soft tissue.
 Glossary 695

neuroma A tumor consisting mostly of nerve cells and plyometric exercise A technique of exercise that in­

speed of
Ie nerve fibers. volves a rapid eccentric (lengthening) stretch of a

~ of a con- neuromuscular control The interaction of the muscle. followed immediately by a rapid concentric

nervous and muscular systems to create coordinated contraction of that muscle [or the purpose of producing

r m uscle con­ movement. a forceful explosive movement.

in length. positive reinforcement A reward (verbal or a stimulus)

muscle con­ o that elicits a desired behavior.

~. open fracture A fracture that involves enough displace­

posterior interosseus nerve compression Compres­

ment of the fracture ends that the bone actually disrupts

sion of the posterior interosseus nerve within the radial

the cutaneous layers and breaks through the skin.

tunnel. prodUCing motor weakness with no pain.

the ends open kinetic chain The foot and hand are not in contact
power The ability to generate great amounts of force

with the f100r or any other surfaces.

against a certain resistance in a short period of time.

orthosis An appliance or apparatus used in sports to

progression Gradually increases in the level and inten­

support, a.lign, prevent. or correct deformities or to im­

sity of exercise.

n of move­ prove function of a movable body part.

progressive resistance exercise A technique that

rientation of orthotics Devices used to control abnormal compensa­

progressively strengthens muscles through a muscle

i parts. tory movement of the foot.

contraction that overcomes some fixed resistance.

osteochondritis dissecans Trauma in which fragments

prone To be positioned , lying down. on one's ventral

of cartilage and underlying bone are detached from the

surface.

Iau ma. in­ articular surface.

proprioception The ability to determine the position of a

and resulting osteokinematic motion A physiological movement that

joint in space.

J. results from either concentric or eccentric active muscle

proprioceptive neuromuscular facilitation (PNF) A
on blood contraction that moves a bone or joint.
group of manually resisted strengthening and stretching

trly stages of osteoporosis A decrease in bone density.

techniques.

overload Exercising at a higher level than normal.

prothrombin A substance that interacts with calcium to

nou nt of oxy­ produce thrombin.

P
proximal Nearest to the pOint of reference.

lent of f1uids pain threshold The amo unt of noxious stimulus re­

lting from quired before pain is perceived.

rUe field. painful arc Pain that occurs at some point in the

radial tunnel syndrome Entrapment of the radial nerve

ly mlnor midrange but disappears as the limb passes this point in

within the radial tunnel. which produces pain with no

O'\"eruse. either direction.

motor weakness.

Duscle that par cours A technique for improving cardiorespiratory

rating of perceived exertion (RPE) A technique used

endurance that basically combines continuous training

to subjectively rate exercise intensity on a numerical

and circuit training.

scale.

passive range of motion That portion of the total range

regeneration The repair, regrowth, or restoration of a

of motion through which a joint may be moved passively

part of a tissue.

~repetitive with no muscle con traction.

retroversion Tilting or turning backward of a part.

pee for an ex- pathology Science of the structural and functional man­

ifestation of disease; the manifestations of disease.

to generate pathomechanics Mechanical forces applied to a living

S

organism that adversely change the body's structure and

SAID principle When the body is subjected to stresses

are the con­ function.

and overloads of varying intensities. it will gradually

periosteum A highly vascularized and innervated mem­

adapt, over time, to overcome whatever demands are

:le tissue. brane lining the surface of bone.

placed on it.

phagocytosis Destruction of injurious cells or particles

scapulohumeral rhythm The movement of the scapula

by phagocytes (white blood cells).

relative to the movement of the humerus throughout a

~b al or a phalanges Bones of the fingers and toes.

full range of abduction.

oit a speciftc phalanx Anyone of the bones of the fingers or toes.

scoliosis Lateral rotary curve of the spine.

phonophoresis A technique in which ultrasound is used

slow-twitch muscle fibers Muscle fibers that are resist­

between to drive a topical application of a selected medication into

ant to fatigue and more useful in long-term. endurance

the tissue.
activities.

696 Glossary
somatosensation Specialized variation of the sensory
In
modality of touch that encompasses the sensation of
joint movement (kinesthesia) and joint position UOint po­
sition sense).
speed The ability to perform a particular movement
very rapidly. It is a function of distance and time.
spondylolysis Degeneration of the vertebrae: most com­
monly it is a defect in the pars interarticulaFis of the ar­
ticular processes of the vertebrae.
sprains Damage to a ligament that provides support to a
joint.
static balance The ability to maintain a center of grav­
ity over a rLXed base of support (unilateral or bilateral)
while standing on a stable surface.
static stretching Passively stretching a given antagonist
muscle by placing it in a maximal position of stretch and
holding it there for an extended time.
steadiness The ability to keep the body as motionless as
possible; this is a measurement of postural sway.
strain The extent of deformation of tissue under loading.
stress A positive or negative force that can disrupt the
body's equilibrium.
stressor Anything that affects the body's physiological
or psychological condition, upsetting the homeostatic
balance.
stroke volume The volume of blood being pumped out
of the heart with each beat.
subluxation A partial or incomplete dislocation of an ar­
ticulation.
supine To be positioned, lying down, on one's dorsal sur­
face.
symmetry The ability to distribute weight evenly be­
tween both feet in an upright stance.
T
target heart rate A specific heart rate to be achieved
and maintained during exercise.
tendinitis InOammation of a tendon.
tenosynovitis InOammation of a tendon synovial
sheath.
thermotherapy Heat therapy.
torque The moment of force applied during rotational
motion (measured in foot-pounds or Newton-meters).
traction A tension applied to a body segment which sep­
arates joint surfaces.
translation Equality of body parts on one side of the
body when compared to the opposite side.
traumatic Pertaining to an injury or wound.
trigger point Localized deep tenderness in a palpable
firm band of muscle, When stretched, palpating finger
can snap the band like a taut string, which produces local
pain , a local twitch of that portion of muscle, and a jump
by the patient. Sustained pressure on a trigger point re­
produces the pattern of referred pain for that site.
V
3 _'
{ ­
valgus Position of a body part that is bent outward.
varus Position of a body part that is bent inward.
vasoconstriction A decrease in the diameter of a blood
vessel.
vasodilation An increase in the diameter of a blood ves­
sel.
volar Referring to the palm or the sole.
volume Regarding exercise, the total amount of work
A ge
that is performed in a single workout session .
W
Wolff's law A law that states that bone remodels itself
and provides increased strength along the lines of the
mechanical forces placed on it.
 Index

1O\'ial

rotational
-illters).
t which sep-

Ie of the A
reestablishing neuromuscular control Atrophy. impact on healing process. 24

Abdominal breathing. 77
of. 619-620
Autogenic inhibition. principLes and use of.

Abductor poWeus longus (APL). 453. 472

strengthening exercises for. 614-616
305-306

palpable Accessory motion. 59-60.277

stretching techniques for. 612-613
Avulsion fractures. 31. 477-478.

lo g finger Acetabulum labraltear. 509

subtalar joint in. 609
510-513. 514-518

roduces local Acetaminophen. 42

as a talocrural jOint. 608-609

Ace wrap. 476

tarsometatarsal joint of. 611
B
and ajump
Achilles tendon. 36
Ankle rehabilitation techniques
Back pain
If point re- Achilles tendinitis. 598-601
for ank le fractures and dislocation.
evaluation 01'.651-652
t site. rupture of. 601-602
628-6 29
See also Spine; Spine rehabilitation
Acromioclavicular joint (AC joint). 369.
for ankle sprains. 622-628
techniques

372
for subluxation and dislocation of
Bad Ragaz aquatic therapy. 342-343

lllward. Active range of motion. evaluation of. 58.

peroneal tendons. 629
Balance

123-124
for tendinitis. 629-630
assessment of. 161-166

'BId.
Active release technique (ART). 321-322
Ankle strategy in balance. 160-16 1
classification of. 169-170

r of a blood Acute facel joint lock. 684. 686

Antagonist muscles. 125
closed-kinetic,;hain and. 160

Acute patellar sublu.xation or dislocation .

Anterior cruciate ligament (ACL)
dynamic stability and. 164

a blood ves- 568-569

anterior cruciate deficient knee. 548
functional tests of. 162. 363

Adhesive capsulitis. 409-410

effects of injury on balance. 166. 168
high-technology assessment systems

Adipose tissne. 26. 27

injuries and treatment 01'.548-555
for. 162. 164-166. 179-180

II of work Aerobic metabolism. 191

nonoperative and surgical rehabilitation
movement strategies for disruption of.

Age
of. 551-555
160-161

as factor in healing process. 24-25

risk factors for injury of. 549-550
muscles involven in. 161

as factor of muscular strength.

Anteroinferior iliac spine. 502
phases of exercises for. 169-179

endurance. and power. 140

Anterosuperior iLiac spine. 502
restoring postural control and stability.

Pdels itself Agility test. 357. 362

Anthropometric assessments. 63
12.156-185

nes of the Agonist muscles. 12 5

Aquatic therapy
somatosensation and. 159-1 60

All-or-none response of muscle. 35

buoyant force 01'.327-328 steadiness and. 162. 164

Anaerobic metabolism. 191

contraindications and precautions for. symmetry and. 164

Analgesia. 41-43
334
system of control of. 157-159

Anatomic snuffbox. 405. 467-468

disadvantages of. 333-334
training program for improving of.

Angle of anteversion. 486

facilities and equipment for. 334-335
168-179

Angle of declination . 486

indica tions and benefits of. 331-333
See also Postural stability and balance

Angle of inclination. 486

resistive forces of water in. 328-330
Balance Error Scoring System (.BESS).162.

Ankle
specific gravity of. 328
163.164

biomechanics of normal gait in. 611

techniques and methods of. 335-343
Balance Master. 162. 164.166. 169. 179.181

closen-kinetic-chain exercises for. 617

water healing techniques and goals of.
Balance Shoes. 177

effects of injuries on balance. 166-168

326-327
Ball. training and exercises with. 173.

exercises for cardiorespiratory

Archimedes' Principle. 330
210-211.214-220

endurance in. 62 1
Arthritis. 32
BaLlistic stretching technique. 125-126

isok1netic strengthening exercises for.

Arthro.lkinematic motions. 59-60.
Bass Test for Dynamic Balance. 162

617
277-278
Berger's adjustment technique. 148-149

midtarsal joint in. 609-6U

Artlcular mechanoreceptors. 102
Biceps. 35. 422

mobilization and traction of. 298-299

Aspirin. 41-42
Biodex System. 166. 169.171. 258. 264.

open- versus closed-kinetic,;hain

Assessment. See Evaluation process
269.541

activities for. 245

Athletes. relationships with the
Biofeedback. 109-11 O. 543

orthotics for problems in . 633-638

rehabilitation team. 3-4. 93-95
Biomecbanical Ankle Platform System

PNF strengthening exercises for.

Athletic pubalgia. 506-507
(BAPS board). 166. 169. 1 71. 172.
618-619
Athletic trainers. 3. 48-72. 93-95
251-252.542

697

698 Index

Blood. as connective tissue. 28

Carpal tunnel syndrome. 470--471 Concurrent shift in kinetic chain. 243

Blood and blood vessels. effects of

Cartilage
Conditioning exercise. 6

cardiorespiratory training. 187. 189

as connective tissue. 26. 27
Connective tissue

Blood pressure. 188-189

damage of. 32-33
dense connective tissue in. 27

Body Blade. 388. 391

fibrillation of. 32
fibrous connective tissue as. 25. 26. 27

Bone
healing capacity of. 33
pathophysiology of injuries to. 25. 26.
using
as a connective tissue. 26. 27-28
types of. 27
27-28
Drag for~ L
epiphysis in. 27
Center of gravity (COG). 156--157 types of. 25. 26. 27-28
Drugs. S«~
fractures of. 3(}-32
Cervical spine
Continuous passive motion (CPM). 553. 554
DynadJsc
growth plates in. 27
mobilization and traction of. 290
Continuous training. 192-193
Dynamic
healing of. 31-32
rehabilitation techniques for. 684--689
Contract-relax-agonistcontraction (CRAC)
Dynamk
See also specific site oj injury
See also Spine; Spine rehabilitation
technique. 127
Dyn amic
Bone marrow. 28
techniques Contract-relax (CR) stretching technique.
Dynamic
"Bone spurs." 3 2
Cervical sprain. 686--689 126

Borzov. Valery. 226

Chattecx Balance System. 162. 164. Contusions. 39--40
E
Bosu Balance Trainer. 170. 171. 173
165. 169
Convex-concave rule. 278
Eccentric
Boutonniere deformity. 480
Chondromalacia. 32
Coracoacromial arch. 369. 372
144 :5
Bow force. 328. 329
Chondromalacia patella. 567-568
Core. 201

Bowleg deformity. 633

Chronic compartment syndrome (CCS). 595
Core stabilization

Boxer's fracture. 472

Chronic inflammation versus acute
assessment of. 208-209

Brachialis. 422
inflammatory response. 19. 23
definition of. 201

Brachial plexus injuries. 411--412

Chronic pateUar subluxation. 569
description of. 12
Elastic

Brachioradialis. 422
Chronic tendinitis. 36
exercises for. 211-220
Elastin. 2 3

Break test. 60
Circuit training. 147
functional anatomy for. 202-206

Bruise. 39--40
Clavicle
for low back pain rehabilitation.

Bunions. 642-643
mobilization and traction of. 285
67(}-672

Burdenko Method. 343

rehabilitation of fractures of. 396-397
muscle imbalances and. 207

Burner syndrome. 411--412

Clicking. 51. 58
neuromuscular effiCiency and.

Bursae. 39
Clicking hip syndrome. 508-509
20(}-201. 207-208

Bursitis. 39. 503-505. 572. 602-603

Climate and humidity. impact on healing
postural considerations in. 206--207

process. 24--25 rationale and guidelines for training

C
Closed-kinetic-chain exercise
with. 209-211

Cancellous bone. 28
in balance rehabilitation. 160. 169
strengthening program for. 15(}-151

Capsular ligaments. 528

description of. 242-243
training in rehabilitation for. 200-224

Capsular/noncapsular patterns of motion.

for elbow injuries. 426
Corticosteroids. impact on healing
59
for groin. hip. and thigh injuries.
process. 24

Cardiac muscle. 33
497--499
Cousins. Norman. 91

Cardiac output. 188

importance of balance in. 156
Crepitus. 36.57.58

cardiorespiratory endurance. 186-187. 190

for knee rehabilitation. 536--539
Cruciate ligaments. 166. 168. 527. 528.

Cardiorespiratory fitness
for neuromuscular control of upper and
548-557

anaerobic versus aerobic metabolism in.

lower extremities. 109. 112
Cryotherapy. 41

191
in rehabilitation. 151. 242-262
Cubital tunnel syndrome. 439

cardiorespiratory endurance and.

for shoulder injuries. 384
Cuboid subluxation. 642

186-187.190
Close-packed position. 279.281
Cybex 6000. 264. 265. 266

continuous training for. 192-193

Coban. 470. 476
Cyriax. 57. 59.60

energy-generating systems for exercise

Co-contraction. 244

in. 19(}-191
Co-contraction semicircular test. 362. 363
D
fartlek training for. 194
Cohesive force. 328
Daily adjusted progressive resistive exercise
interval training for. 193-194
Cold applications to injuries. 8
(DAPRE) working weight program .. 148

maintaining during rehabilitation.

Collagen. 23. 25
Deep tendon reflexes. 64

12-13. 186-197
Comminuted fracture. 31
Delayed-onset muscle soreness (DOMS). 39

maximal aerobic capacity in. 189-190

Compartment syndrome. 594-595
DeLorme's program. 147

oxygen consumption rate and.

Compliance and adherence to
DeQuervain's tenosynovitis. 472--474

189-191
rehabilitation. 88-92
Dermatome testing. 63-64

par cours training for. 194

Compression to injuries. 8
Disk-related back pain. 678-681

techniques for maintaining. 191-194

Compressive force. 246
Dislocations

Carioca test . 361. 363

Concentric muscular contraction. 139. 144
injuries and treatment of. 38

Caroline Functional Performance Index

Concentric versus eccentric contractions.
See also specific site oj injury
(CFP!).364
144
Distal interphalangeal (DIP) joint. 453. 454

 Ind 6 99

Distal radioulnar joint (DRUj) . 453

DPrirl::a1 stimulating currents, 41
Fingers

Distal radius fractures . 462-464

I'l=ltiDo 01 injtl.r'ed area . 8-9
functional anatomy and bic:1CI)I!ct1.lC:D

Documentation
Elgin ankIe~. 616
of. 454

ue in. 27 of evaluation findings. 66

Endosteum. 1
reestablishing neuromuscular

. sue as. 25. 26. 27 of rehabilitation . 14-15

End-point feel assessxneOl. 5 -59
of. 461

using SOAP notes. 66. 1i8. p9

Endurance training. 151
strengthening exercises for. .J -+--! ­
Drag force. 328-330
Epithelial tissue. patbopIl) iology of injuries
Finkelsteln's test. 4:-3

Drugs. See Medications

to, 25. 26
Fitter. training with. 1 52 :! - 3. ­
Dynadisc system. 174. 179
EquiTest. 165. 169
538.617
Dynamic balance. 169
Evaluation process
Flexibility

contraction (CRAC) Dynamic nexibility. 123

documenting findings of. 66
anatomic factors that limiI. 1 2 .?- }:! 3

Dynamic stability. 164

injury evaluation checklist for. 50-51
importance of. 121-122. 124

Dynamic stretching. 125-126

injury prevention screening in. 65-66
restoring normal range of. 121- L!3

objective e a ion in . SO. 53-56

stretching techniques for. 124-1.? 5

E
palpation in . 50 . 56-57
133

Ecoentric muscular contraction. 139.

progress evaluations in, 69-70
Flexor carpi ulnaris (FCU). 453

144. 150
resistive strength testi ng in. S0, 60-62
Flexor digitorum profund us (FDP I. .J - 3

Econcentric muscular contraction. 139

setting rehabilitation goals with ,
477-478

Edema, impact on healing process. 24

68-69
Flexor digitorum superficialis (FDS ,

-209 Efneurage. 323

special tests in. 51. 62-65
453.454
Elastic cartilage, 27
subjective e\'aluation in. 49-53
Foot

Elastic connective tissue. 27

Excess postexercise oxygen consumption
biomechanics of normal gait in. 61

Elastin. 23
(oxygen dellei t). 191
excessive pronation and supination c:J..

Elbow. 254
Exercise, therapeutic versus conditioning
630-638

anatomy and biomechanics of, exercise. 6

exercises for cardiorespiratory

419-423
Exercise machines, in progressive resistive
endurance in, 621

dislocations of. 440-442

exercises. 144-145 . 146
isokinetic strengthening exerci5es

dynamic stabilizers for complex of. 422

Exercise sandals. 587-590, 591
for. 617

function al activity of the upper quarter.

Extensor carpi ulnaris, 453
metatarsal joints In. 611

422-423
Extensor poUicus brevis (EPR). 453. 472
mobilization and traction of. 29

humeroradial joint of. 419. 420. 421

Extensor poUicus longus (EPL) . 472-473
orthotics for problems in . 63 3-63

humeroulnar joint of, 419. 420. 421

Extra-articular lesions. 59
PNF strengthening exercise (ar.

joint capsule of, 420. 421

618-619

ligamentous support of. 421-422

F
reestablishing neuromuscular

medial coUateralligament (MCL) in, 422

Fartlek training. 194
of,619-620

proxima I radioulnar join t of. 419,

Fascia, 27 , 128
selecting shoes for. 638. 6 39

420 , 421
FASTEX, 543
strengthening exercises for. 614-01
Elbow injury rehabilitation techniques
Fast-twitch fibers
stretching techniques for. 6I:!.-bl
aquatic therapy for. 445-447
oxygen consumption rate of. 190
tarsometatarsal joint of. 611

bracing and taping for. 433

as type OalJIb fibers, 141
Foot rehabilitation techniques
closed-kinetic-chain exercises for, 426
Femoral fractures. traumatic, 518
closed-kine tic-chain exercises for
orne. 439 for elbow dislocations , 440-442
Femoral stress fractures. 513-514
for cuboid subluxation. 64 2
. 642 for elbow fractures , 434-435
Femoral trochanter. avulsion fracture of.
for hallux valgus deformity (
exercises for neuromuscular control. 432
514.518
642-643

functional exercises for, 434

Fibrillation of cartilage, 32
for Morton's neuroma. 643

isokinetic exercises for. 428

Fibrocartilage. 27
open- versus closed-kine

isometric and isotonic strengthening

Fibroplasia and granulation tissue. 23
activities for. 245

,ogressive resistive exercise

exercises for. 423-425
Fibroplastic-repair phase. 21. 23
for plantar fasciitis. 1i41-6·L

~g weight program; 148

for medial and lateral epicondylitis.
Fibula
for stress fractures in the fOOl.

~ .64 442-444
fractures of. 590-594
for tarsal tunnel syndrome. 6

Je soreness (DOMS), 39
for nerve entrapments. 439-440
mobilization and traction of. 297-298
for turf toe, 643-644

ram. 147
for osteochondritis dissecans/ Panner's
Finger rehabilitation techniques
Force-velocity curve, 271-2;- 2

ynovitis.472-474
Disease, 436-437
for boutonniere deformity, 480
Forefoot valgus, 631

g. 63-64
plyometric exercise for. 427
closed-kinetic-chain exercises for.
Forefoot varus. 631

. pain. 678-681
stretching exercises for, 429-431
458-461
Fractures

throwing program for return to sport.

for finger joint dislocations. 475-477
of the ankle, 628-629

Itreatment of, 38
447-449
for nexor digitorum profundus avulsion
avulsion fractures. 31. .J 7,-17

Inc site of injury for ulnar collateral ligament injuries.

Uersey finger), 477-478
510-513,514-5 1 8

iangeal (DW) joint, 453. 454

437-438
for mallet finger, 479
of clavicle, 396-397

700 Index

Fractures (continued) Goniometer. 124

Health. impact on bealing process. 25

closed and open. 30

Groin
Heart. effects of training on. 187-189

comminuted fracture. 31
closed-kinetic-chain strengthening
Heat application s. 41

complete and incomplete. 30

exercises for. 497-499
Hedgpeth/Gansneder Athletic

of distal radius. 462-4 64

differential diagnosis for injury of. 504
Rehabilitation Indicators. 89
Injuries

of the elbow. 434-435

functional anatomy and biomechanics
Hemorrhage. impact on healing process. 24

femoral stress fractures in. 513-514. of. 486

Hip

515-516
isokinetic exercise for. 499
as a ball-in-socket jOint. 486

greenstick. 30.31 plyometric exercise for. 500

closed-kinetic-chain strengthening

of the hamate. 469-470

strengthening exercises for. 492-496
exercises for. 497-499

impacted fracture. 31
stretching exercises for. 487-491
fun ctional anatomy and biomechanics

of inferior ramus. 508

Groin disruption . 506-507
of. 486

of ischlal tuberosity. 510--513 Groin strain. 505-506

isokinetic exercise for. 499

linear fracture. 30
mobilization and traction of. 294-295

oblique fracture. 30. 31

H plyometric exercise for. 500

of the scaphoid. 465. 46 7-468

Halliwick Method. 343
strengthening exercises for. 492-496

spiral fracture. 31
Hallux valgus deformity (bunions).
stretching exercises for. 487-491

stress fracture. 31. 513-514. 515-516. 642-643

Hip dislocatioll , 509- 510

592-594.638.640 Hamate fracture. 469-470

Hip pointer. 500-501

tibial and fibular fractures. 590-594

Hamstring. 486
Hip rehabilitation techniques

transverse fracture . 30. 31

strai.ns of. 510-513
for anteroinferior iliac spine injury, 502

traumatic femoral fractures. 518

tendon strains of. 513
for anterosuperior iliac spine injury. 502

See also specific site of injury Hand

for hip dislocation , 509-510

Free weights. in progressive resistive closed-kinetic-chain exercises for.

for hip pointer. 500-501

exercises. 144-145
458-461
for hip strain. 505-5 06

Frozen shoulder. 409-4 lO

functional anatomy and biomechanics
for iliopectineal bursitis. 504-505

Functio nal balance. 169

of. 453-454
for ischial bursitis. 504

Functional progressions
reestablishing neuromuscular control
for piriformiS syndrome (sciatica).

benefits of using. 348-349

of. 461
502-503

components of. 350-351

strengthening exercises for. 454-458
for posterosuperior iliac spine

description of. 13
Hand injury rehabilitation techniques
contusion. 502

design of. 351-352

for boxer's fracture. 472
for snapping or clicking hip syndrome.

functional testing in. 353-365

for ganglion cysts of the hand.
'5 08-509

psychological and social considerations 471-472

for trocha nteric bursitis. 503-504

in . 349-350
for scaphoid fractures. 465 . 467-468
Hip strain. 505-506

role in rehabilitation. 348

Head injury. effects on balance. 168
Hip strategy in balance. 1 h 1

See also specijlc site of injury Healing process

Hold. relax (HR) stretching technique.

Function al strength. 200

chemical mediators in. 19
126-127

Functional testlng
clot formation in. 19
Hops/hopping. 177- 178. 362. 363

description of. 13. 14. 352-353

cycle of sport-related injuries . 18
Humeroradial joint. 43.9. 42(), 421

in evaluation process. 65
effects of swelling after injury. 7-9
Hurneroulnar joint. 419. 420. 421

during remodeling phase. 41

fact.ors that impede. 24-25
Humerus

Functional training. 41
fibroplastic-repair phase. 21. 23
in elbow joint. 419. 420. 421

innammatory response phase of.

mobilization and traction of. 286- 288

G 19- 20. 23
in shoulder joint. 369. 372-373.

Gait. normal. 611

of ligaments. 29-30
397-401

Gamekeeper·sThumb.474
managing through rehabilitation.
Hyaline cartilage. 27

Ganglion cysts. 471-472

17-47
Hypermobility syndromes of the spin e.

Gender. differences in resistance training.

maturation-remodeling phase of. 22.
677-678

151-152
23-24

Clenohumeraljoint. 369. 372-373.

pathophysiology of injuries to various

397-401
tissues and. 25-40
Ibuprofen. 42-43

Gliding motion. 59. 277-278

pbases of rehabilitation based on.
Ice applications to injuries. 8

Goals of rehabilitation
40-41
Iliac crest. 486

importance of balance in. 157

progressive controlled mobility
fliopectineal bursitis. 504-50'5

as motivators for compliance. 91-92

du ring. 24
Iliotibial band friction syndrome. 572- 573

short- and long-term goals in a restricted activity and rest. 8

Imagery. 78

program. 6-14.68-69 sports medicine approach to. 43-44

Immobilization . effects of. 30

See also specific site of injury using medications to facilitate. 6

Impacted fra cture. 31

 Index 70]

Infection. impact on healing process. 24

Joinl play motion. 59-60, 27
open- reC'Sus closed-kinetic..:
Inferior ramus. fracture of. 508
JoinlS
activities for. 2-*5-H,

Innammatory response phase of healing.

bursae in. 39
patellar function in. 529

19-20.23 close-packed position of. 279. 28 1

range-of-motion exerci5es for.

Injuries
convex-conca\'e rule of. 278
529-533

career-ending. 79. 87-88

joint co mpr ion tests of. 62-63
reestablishing neuromuscular

chronic. 79. 85-87

join t play. 2 7
of. 542-5 44

effects on balance. 16h-1h8

joint stability tests of. 62
strengthening exercises for. )3~~J ­

long-term. 79.80-8:)
loose-packed position of. 279.281
vnstlls medialis oblique I\~fO llll :;

from macrotraumatic and

meniscus in. 28
562-563.567. 56

microtrau.Ilwtic forces. 18-19

positions of. 278-279
Knee injury rehabilitation L bnlques

mechanism of. 51-52

resting pOSition of. 278-279. 280
for acute patellar sublul<atlon or

pathophysiology of injuries in body

structures of. 28-29
dislocation. 568-569

tissues. 25-2 8
treatment plane of. 279.281
for an terior eruciate ligament fA

previous injuries and. 51-52

See also specific joint
sprain. 548-555

primary and secondary. 18-19

See also Synovial jolnts
for bursitis. 572

psychological considerations of. 73-98

Join t traction
for chondromalacia pateUa. - £, - - ~ •

risk screeni ng for. 6'; -66. 67. 68

grades of. 284-285
for iliotibial band friction syndr

short-term. 78-80
techniques of. 285-300
572-573

hniques See a/so specific site of injury

Jumper's knee, 569-571
for Larsen-Johansson disease, - - .,.

iliac spine injury. 502 Innominate. mobilization and traction of. Jumps
for lateral collateral (LeLl sprairu

292~293 in baIa nce training. 178-179

547-548

iliac spine injl1r}~ 502

- 9-510 Internal derangement. 59
in plyometric exercise, 225-241
for medial collateral UgameDL .\\

501 Interval training. 193-194

sprains, 545-5 47

Ischial bursitis. 504

K for meniseal injuries. 55 - -5':·

Ischial tuberosity. avulsion fracture.

Karvonen Formula for water exercise. 333
for Osgood-Schlatterdlse •

510-513
Keloids and hypertrophic scars. impact on
for patellar plica. 5 i 3-- - 4

fsokinetic Assessment Protocol. 268-269

healing process. 24
for patellar tendinitis Uurnper

Isokinetlc exercise
Kin-Com. 265. 266
569-571

for ankle and foot rehabilitation. 617

Klnesthesia.102.106-107
for patellofemoral stress~,_.-ntII",,­
closed-kinetic-chain exercise In. 258
Kinetic chain
559-567

for conditioning and rehabilitation.

concept of. 243
for posterior cruciate Ii~

149-150
concurrent shift in. 243
sprains. 555-557

deSCription of. 11. 149,263-264

muscle actions in. 243
Knight's DAPRE program. 14

dynamometers for. 264-266

open- versus closed-kinetic-cbain

for elbow injuries. 428

exercise in rehabilitation. L
evaluation and testlng for. 266-271
242-262
Lactic acid theory. 39

force-veloCity curve in, 271-272

rehabilitation and. 5
Larsen-Johansson disease. -,-l

---118 .362.363 for groin. hip. and thigh injuries. 499

role in balance and core stability.
LateraI collateral ligament (LeLl 5.:' - ;_

4.1 9.420.421
for knee rehabilitation. 541
169.207 547-548

-n 9. 420.421
for shoulder injuries. 38 7
See also Closed-kinetic-chaln exercise Lateral epicondylitis, 442-4·;4

training program with. 271-272

See also Open-kInetic-chain exercise Lateral menisclls. 527.528--29

·H9. 420. 421

(solytic muscle contraction. 319
Knee
Legal considerations in rehabillt

and traction of. 286- 288

Isometric exercise, 10. 139. 143-144
articular cartilage lnjuries of. 33
Leg press, 248-249

t. 369. 3 72-37 3.
Isometric muscular contraction. 139
capsular ligaments of, 528
Life Events Survey for CoLLegiate ;\

(sotonic exercises. 534-536

coIJateralligaments in. 527-528
(LESCA),75

cruciate ligaments of. 527. 528

Ligamentous adhesions. 59

mdro mes of the spine. effects of injuries on balance, 168

LigarnenlS

Jersey finger. 477-478

functional anatomy and biomechanics
in the ankle. 609

Joint arthrokinematics, 59-60. 277-278

of. 527-529
anterior cruciate ligament (:\CL

Joint capsules. 27. 28-29

as a hinge jolnt, 527
168.548-555

3
Joint mobilizatio n
isokinetic exercises for. 541
capsular ligaments. 528

, injuries. 8
accessory motion in. 277
isotoniC open-kinetic-chain exercises
as connective tissue. 27

indications and contraindications for.

for. 534-536
cruciate ligaments, 527. - 2

·tis. 504-505
283-284
joint mobilization techniques for.
of the elbow joint. 421-422. H~ 43

cHon sy ndrome. 571-573

in knee rehabilitation. 544-545
544-545
functions of. 28

osteokinematic motions in. 277

medial and lateral menisci of. 527.
healing process of lnjuries to. 29-3

physiological movements in. 277

528-529
of knee jolnts, 527-528. 545- - ~­

effects of. 30

.",3 1
techniques of. 279 , 281-282, 285-300
muscle actions in. 529
sprains of. 28-30

702 Index

Ligaments (conUnued)
Lungs. effects of cardiorespiratory training
healing of, 36

ulnarcoUateralligaments.437-438,
on. 187, 189
imbalances in , 61-62

474-475
length-tension relationship in, 140

Limits of stability (LOS). 156

M motor units of. 3 ~

Linear fracture. 30
MacQueen 's technique. 147-148
mOl'ement group muscles in, 61-62, 63

Link system, 243

Macrotears and microtears, 24
pain and soreness of. 39

Locking, 51
Mac.rotraumatic injuries, 18-19
physiology of strength development of.

Loose connective tissue, 27

Mallet finger, 479
141-142

Loose-packed position. 279,281

Margination in healing process. 19
position of tendon attachment to. 140

Low back pain

Massage, 41. 322-323
resistance training techniques for.

evaluation of, 651-652

M~ximal aerobic capacity. 189-190
142-150

positioning and pain-relieving exercises

McMurray'sTest,63
reversibUity of trained muscles, 142

for. 654- ()64

Medial collateral ligament (MCL), 422.
skeletal muscle, 33-35,139

rehabilitation techniques for. 668-672

527-528,545-547
smooth muscle. 33

working ",1th myofascia] pain and

Medial epicondylitis, 442-444
stabilization group muscles in. 62, 63

trigger points in. 675-677

:'vlediai meniscns. 528-529
strains of. 35-36, 596.672

Lower extremity
Medial tibial stress syndrome (MTSS), 592,
training for muscular endurance. 151

aquatic therapy for, 340-342

597-598
types and parts of. 33- 35

biome.chanics of normal gait in. 611

Median nerve entrapmellt. 439
See also specific site of injury
cartilage in. 32
Median nerve glide, 459
Muscle spasm, impact on healing process. 24

closed-kinetic-chain exercises for.

Medicalions
Muscle strains. 35-36,596.672

247-253
facilitating healing with. 6, 23. 40-43
Muscle tendons, parts and functions of.

functional progressions and testing of.

See also specific site of injury 33,35

357-364
Meniscus
Musculoskeletal injuries. See SPp.cijlc site of

movernentpatterns of, 314-316

in joints, 29
injury

open- versus closed-kinetic-chain

in knee joints, 527- 529, 557-559
MyofasciaJ tissue, stretching techniques for

activities in, 245-247

Metacarpal phalangeal (MCP) joints.
release of. 125. 127-130. 131

orthotics for problems in. 633-638

453-454
Myositis ossillcans. 40. 522

reestablishing neuromuscular control

Metatarsal joints. 611
Myotome testing. 64

of. 109-112
Mtcrotroumatic injuries. 18-19

Ser also Lower leg

Midrange-of-molion muscle testing, 60
N
Lower leg
Midtarsal joint. 609-611
National Athletic Trainers Association

compartments of, 580

Minisquats, 248
Board of Certi ocation (NATABOC). 3

functional anatomy and biomechonics

Minilramp. 251-252. 542
Neck, movement patterns of. 318-319

of. 579-580
MobiJjzation and traction of joints. 279,
Nerve entrapments. 439-440

improving cardiorespiratory endurance

281-282,285-300
Nerve tissue

of,587-590
See also specific joill! healing after injury. 38

reestablishing neuromuscular control

Moment. 24()
injuries to. 37- 38

of. 585-586
Morton's neuroma, 643
Schwann cells in. 38

strengthening exercises for. 580-583

Movement group muscles, 61-62, 63
structures of. 37

stretching exercises for. 584

Muscle-bound strength training. 133
Neurological testing. 63

Lower-leg rehabilitation techniques

Muscle energy techniques. 319-320
Neuromuscular contro)

for Achilles tendinitis. 598-601

Muscle hypertrophy. 141-142
articular mechanoreceptors in. 102

for Achilles tendon rupture. 601-602

Muscles
critical role in rehabilitation process.

for compartment syndrome. 594-595

agonist versus antagonist muscles. 125
100-101

for mediollibial stress syndrome

all-or-none response of, 35
description of. 9. 102

(MTSS),597-598
biomechan ical factors or. 140
discriminative muscle activation in . 106

for retrocalcaneal bursitis. 602-603

cardioc muscle, 33
dynamic stabilization in. 107.108

for tibial and fibular tractures, 590-592

core and imbal8nces of. 207
elements of. 106-108

Lower trunk, movement patterns of.

delayed-onset muscle soreness (DOMS)
exercises for elbow injuries. 432

317-318
in. 39
feed-forward and feedback mechanisms

Lumbar disk-related back pain. 678-681

effects of stretching on, 132
in. 103-104

Lumbar facet joint sprain. (, 77

evaluation and testiug of. 60-61
functionol motor patterns in , 108

Lumbar vertebrae
factors affecting strength, endurance,
in knee rehabilitation, 542-544

mobilizalion nnd tracLion of. 291-292

and power or. 13 9- 1 ~ 5
in lower-extremity techniques,

See also Spine; Spine rehabilitotion

fast-twitch and slow-twitch fibers in.
109-112

techniques
141. 190
muscle stiffness and. 10';-106

Lunate dislocations, 468-469

functional anatomy for core stability of.
neural pathways of peripheral afferents

Lunges, 248
202-206
in. 103

 Index 703

neuromuscular characteristics in,

monitoring a nd controlling during
Postural stability a nd bala nce

105-106
rehabilitation, 9
center of gravity (COG) in, 156-185

objectives of rehabi.litation for, 105

See also specific site of illjury
control system of balance in , 157-1 S9

peripheral afferent receptors in, 105

Palpa tion in evaluation process, 50,
dynamic postural control system

proprioception and kinesthesia of, 102,

56-57
for, 157

106-10 7,1 08
Panner's Disease, 43 6-4 37
muscle coordination in , J 58-159

reactive neuromuscular control in,

Para tenonitis, 36
restoring in rehabilitation, 12

107-108
Par cours training, 194
sensory organization in, 158

reestablishing during rehabilitation , 9 ,

Passive range of motion, 58, 123-124
somatosensory inputs of, 159-160

104-116
Patell a, 296, 486, 529
vestibular apparatus role in, 159

rellex muscle acLiva tion in, 106

patellar plica, 573-574
visual input for, 159

role in core stabilization, 207-208

patell ar subluxation or dislocation ,
See also Baja nce

for shoulder injuries, 389- 391

568-569
Press-ups, 255, 257, 258

tenomuscular mechanoreceptors in,

patellar tendinitis, 569-571
PRICE prinCiple (protection, restricted

102-103
patellofemoral jOint. 247
activity, ice, compression, a nd elevation

usin g c1osed-kinetic-chain exercises for,

patellofemoral stress syndrome,
of injured area). 7- 9,40

244-245
559-567
Primary injuries, 18-19

See also specijlc site oj injury Pathological tissue, S1

Profil es of Mood States (POMS), 76

Neuromuscular effiCiency, 200-201,

Patterns of movement. 59, 309-319
Progress evalu ati ons

207-208
Pelvis, functional anatomy and
athletes returning to competition and,

Non-steroidal anti-inlla uunatory drugs

biomechanics of, 486
92-93

(NSAlDs)
Peroneal tendons, subluxation and
components of. 69-70

monitOring liver function s with, 42

dislocation of, 629
Progressive resistive exercise (PRE)

use during the hea ling phase, 23,

Piriformis muscle, 491
accommodating resistance or variable

40-43
piriformis sy ndrome, 502-503
resistance of, 146

Normal gait, 611

strain of. 672-6 75
conce.ntric versus eccen t.ric

Nutrition, as factor in healing process, 25

Plantar fasciitis, 64 1- 642
contractions, 144

Plyometric exercise
description of, 10-11

o biomechanical and physiologica l

free weights versus exercise machines,

Objective evaluation, 50, 53-56

principles of. 226-229
144-145,146

Oblique fracture, 30-31

description of, 11. 225-226
with surgical tubing orTherabands,

Open-kinetic-chain exercise, 151. 242-262

for elbow injuries, 427
145-146

Open- versus c1osed-kinetic-cha in exercises

for groin, hip, and thigh injuries, 500
tec hniques of, 146-147

advantages and disadvantages of, 244

integrating into rehabilitation,
variable resistance in , 146

description of. 12
235-238
Pronation in ankle and foot , 630- 638

kinetic chain , concept of. 242-243

for knee rehabilitation, 539-540
Pronator quadratus, 422

for knee rehabilitation,S 34

medial-lateral loading in, 236-237
Pronator teres, 422

in resista nce tra ining programs, 151

for neuromu scular control in upper and
Proprioception, 102, 106- 107

for upper extremity rehabilitation,

lower extremities, 1l0, 111 ,
Proprioceptive neuromuscu lar facilitation

253- 258
112, 114
(PNF)

Orthotics, 633-638
prerequisites and program design of,
for ankle and foot reh abi litation ,

Osgood-Schlatter disease, S 74
229- 235
618-619

Osteitis pubis, 507-508

as reactive neuromu scular training,
au togenic and reciprocal inhibition in ,

Osteoarthriti s, 32
150
305-306

Osteochondriti s dissecans, 436-437

during remodeling phase, 4 1
movement patterns of. 309- 319

Osteokinematic motio n, 277

rotatio nal loading and shock absorption
neurophysiological basis of, 304-307

Osteophytosis, 32
in,238
for shoulder injuries, 387-388

Otoform, 470
for shoulder injuries, 385-38 6
soft-ti ssue mobilization techn iques of,

Overload princi ple, 142-143

PNF. See Proprioceptive neuromu sc ular
303-320

Overtraining, effects on mu scle, 140-141

facilitation (PNF)
strengthening techniques of. 30 7-3 09

Oxford technique, 147, 148

POinttenderness, 57
stretchin g techniques for, 125,

Oxygen tension , impact on hea ling process,

Popping, 51. 511
307-309

24-25
Positional release therapy (PRT), 321
techniques of, 126- 127, 128

Posterior cruciate ligament (PCL), 555-557

Provocation, quality, region, severity

p Posterior interosseous nerve compression,

(PQRST) evaluation of symptoms,

Pain
439
52-5 3

control of. 41
Posterosuperior iliac spine contusion, 502
Provoked tissue, 51

as deterrent to compliance, 90-91

Postural alignment, evaluation of. 53-56
Proximal interphalangeal (PIP) joint.

dictating rate of progression, 24

Postural equilibrium, 1%-157
453,454

704 Index

Proximal radioulnar joint, 419, 420, 421

stretching techniques for improvement
Resistance training

Psychological factors in rehabilitation

of. 124-134
overload prinCiple in, 142-143

acculturation of athletes and,

See also specific site of illjury progressive resistive exercises in,

74-75,94
Rating of perceived exertion (RPE) .
144-149

adjustments and reactive phases to

192-193
techniques and routines of. 147-149

injuries, 78
Rearfoot valgus, 631
in young athletes , 152

benet1ts of using functional

Reciprocal inhibition, 305-30 6
Resistive strength testing, 50, 60--62

progressions, 349-350
Renexes
Resting position, 278-279. 280

career-ending injuries and, 79, 87-88

deep tendon renexes, 64
Reticular connective tissue, 27

chronic injuries and, 79. 85-87

pathological renexes, 64-65
Retrocalcaneal bursitis. 602- 603

compliance and adherence to program,

stretch renex, 130--132
Return to full activity

88-92
superficial reflexes, 64
criteria for, 13-14

depression and suicidal intentions, signs

testing for, 64-66
psychological fadors in, 92-93

of. 81
Rehabilitation
throwing program for. 447--449

injury-prone athletes and. 75

acute injury phase of. 40--41
using functional progressions, 352

interpersonal relationships of athletes

avoiding "cookbook" or "recipe"
Rolling motion, 59. 277- 278

and athletic trainers in , 93-95

protocols, 5-6
Romberg test , 161- 162 , 169, 170

irrational thinking toward injury and

exercise intensity in, 4-5
Rotator cuff tendinitis and tears, 406--408

rehabilitation, 81-83
kinelic chain and, 5. 243

long-term injuries and. 79, 80-85

members of the rehabilitation team.
S

predictors of injury in , 75-78

3--4
Sacroiliac joint dysfunction, 681-684.

reducing stress, 76-78

pathomechanics of injury and. 5
685-686

returning to competition , 92-93

phases based on healing process,
Sacrum, mobilization and traction of, 292

role of sport psychologists in, 94-95

40--41
SAID. See Speciftc adaptation to imposed

short-term injuries in. 78-80

philosophy of sports medicine
demand (SAID) principle

social support and. 83-84

rehabilitation, 4-6, 43--44
Sander's program, 148

stress and risk of injury in, 75-76, 94

physiologic~1 event s of the healing
Scaphoid fractures, 4(;5, 4fii- 468

Pubis and pubic bone. 486. 507-508

process, 4-5
Scapula. 287, 374

Push-ups, 255 , 257,458--459

presurgical exercise phase in. 40
ScapuJothoracic jOint. 3 fi9, 372

psychological aspects of. 5, 73- 98

Scars/scar formation, 23. 24

o remodeling phase of healing and. 41

Sciatica, 502-503

Quadratus lumborum strain, 675

repair phase of, 41
Secondary injuries, 19

Quadriceps muscle. 486

therapeutic modalities in , 6
Semidynamic balance, ]69

contusion of. 520-522

tools of. 5-6
Serial distortion patterns, 206-207

strain of. 518-520

using medications to facilitate healing, 6
Shear force, 245-24(;

RehabUitation programs
Sherrington 's law. 61

R components of a well-designed
Shoulder

Radial nerve entrapment. 439

program , 2-16
acromioclavicular joint (AC joint) in,

Radial tunnel syndrome. 439

controlling pain. 9
369,372

Radius
criteria for full recovery, 13-14
complex joint of. 253 - 254

in elbow joint, 419. 420.421

documentation in, 14-15
coracoacromial arch in. 3fi9. 372

Ii-actures of. 462--464

functional progressions in. 13
corona I and tra nsverse pia ne in. 3 i 3

mobiliZation and traction of, 288

functional testing during, 13, 14
glenohumeral joint. 369. 372- 373.

Range of motion
initial first aid management a fter injury.
397--401

accessory motion and joint play in,

7-9
scapular stability and mobility in . .374

59-60
legal considerations in supervising of. 15
scapulothoracic joint of. 369. 372

active range of motion in. 58

maintaining c~diorespiratory fitness
stability in joint of. 372-3 74

capsular/ noncapsular patterns of

during. 12-13, 186--187
static stabilizers in jOint of. 3i3-374

motion in, 59
reestablishing neuromuscular control
sternoclavicular joint (SC joint) of. 369

description of. 9-10

in,9
Shoulder impingemenl. 401 - 405

end-point feel assessment in, 58-59

restoring muscular strength,
Shoulder injury rehabilitation techniques

in evaluation process, 57-60

endurance, and power in, 10-12,
for acromioclavicular joint sprains.

exercises for knees, 529-533

138-155
393-396

improving nexibility and restoring of.

restoring postural control and
for adhesive capsulitis, 409-410

121-137
balance. 12
for brachial plexus injuries, 411--412

inert and contractile tissue pathology

restoring range of motion Ln , 9-1 0
closed-kinetic-chain exercises for, 384

in, 57-58
short-and long-term goals in. 4. 6-14 ,
exercises for neuromuscular control.

passive range of motion in. 58

68-69
389- 391

restoring in rehabilitation, 9-10

Relaxation techniques, 7 7
for frozen shoulder. 409--410

 for glenohumeral
for cen1cal sprain. 686-689
efTects on

dislocationslinstabilities, 397-399
for disk-related back paIn . 678-681
properues

exercises in, for multidirectional instabilities of the

for hyper mobility syndromes, 677-678
for elbow inj unes. _

glenohumeral joint, 399--401

for low back pain. 668-672
for flexibility. 12-t-L! 3 11

tin es of. 147- [49 for myofascial trigger points, 412--414

for lumbar facet jOint sprolns. 677
guidelines and precautiOns .J

plyometric exercise for, 385-386

for muscular strains. 6,2
neurophysiological basis of, 13(,1-132

PKF strengthening techniques for, 387

for myofascial pain and trigger points,
warm-up prior to, 133

rehabilitation plan for, 370-371

675-677
See also specific site of injury

ue,27
for rotator cuff tendinitis and tears,
for piriformis muscle slrain. 672-675
Stretch reflex, 130-132

. , 602-603
406--408
for quadratus lumborum strains. 675
Stretch-shortening exercises for

for shoulder impingement. 401--405

for sacroiliac joint dysfunction,
neuromuscular control of lower

for sternoclavicular jOint sprains,

681-684,6115-686
extremities, 110

392- 393
for spondylolYSis/spondylolisthesis,
Subjective, Objective, Assessment. Plan

strengthening techniques for. 379- 383

677-678
(SOAP) notes, 66, 68 , 69

stretching exercises for, 37 5-37

Spin motion, 59, 277
Subjective evaluation, 49- 53, 363-3M

for thoraCic outlet syndrome, 41()--t II

Spiral fracture, 31
Subluxations. injuries and treatment 0/'. 3

Sh uttle runs, 363

plit routine. 14 7
568-569,629,642

Skeletal muscle, 33- 35

Spof\dylol Sis/spondylolisthesis, 677-678
Subtalar joint, 609

Slide boards, 252, 257-258, 538, 617

ports hernia. 50 6-507
Superficial reflexes, 64

Slow reversal-hold-relax (SRHR) stretching

ports massage. 322-323
Supination in ankle and foot. 6 63

technique, 127
Sport-specific U'aining ( ). 343
Supinator, 422

Slow-t\<\1tch fibers
Sprain
Surgical tubing, training \ Itb . 145-1

oxygen co nsumption rate of. 190

grades or. 2 19
1 7 , 250-151.389

as type r or slow-oxidative (SO) fibers, 141

Su a1sc sptd,(ic SlIL c{ .
welling

Smooth muscle, 33
Sprint test. 35 i'
rontroIllng after Injury, i'­
Snapping hip syndrome, 508-509
Stabilization up mlJ.5C 3
PRIG: protection. restncted
SOAP notes, 66 , 68 , 69
Stabilization s em. 11 1 - I­

Social and Athletic Readjustment Rating

Stair-climbing. 249-_ 50

Scale (SARRS) , 76
Static balance, 169

Soft tissue
Static stretching. 126. 12 9

injury and tissue necrosis in , 41--42

Stationary bicycling. 251

sports-related injuries in, 25

Steadiness, 162, 164

Soft-tissue mobilization techniques, 128

Step-ups, 250, 255, 257

active release technique (ART) in ,

Sternoclavicular joint (SC joint), 369.

321-322
392-393

muscle energy techniques in,

Stinger syndrome, 4 i 1--412

319-320
Strain-counterstrain technique, 32(}-321

positional release therapy (PRT) in , 321

Strains

sports massage and, 322-323

injuries of, 35-36
T
strain-counterstrain technique of.
See also specific site of injury Talocrural JOinL

320-321
Strengthening exercises
ligaments In. 60CJ

using PNF, 304-319

descriptions of. 10-11
muscles or. 609

Soviet training programs, 226

during remodeling phase, 41
Tarsal tunnel syndrome. 6-1 -

Specific adaptation to imposed demand

See also specific site of injury
Tarsometatarsal jolnl, 611

(SAID) prinCiple, 4-5,348

Stress
Tendinitis, 472--474, 629- 630

Spine
abdominal breathing and, 77
Achilles tendinitis, 59 -601

aquatic t.herapy for. 338-340

im"gery for. 78
of the ankle, 629-630

flexion exercises for, 663-664

interventions for reduction of. 76-78
chronic tendinitis, 36

functional anatomy and biomechanics

rela,ation techn.iques and, 77
patellar tendinitis Uumper's Im et l.

of,650-651
risk of injury with , 75-76,94
569-571

lateral shift corrections and extension

using buffers for, 77
rotator cuff tendinitis and tears.

exercises for, 657-662

Stress fracture
406--408

pOSitioning and pain-relieving exercises

co=on sites or. 31
types and healing of. 36, 37

for, 654-664
of femur. 513-5 14. 515-516
Tendinosis , 36

segmental spi ne stabilization, 654-657

in the foot. 638, 64CJ
Tendon gliding, 460

using joint mobilizations for, 665-668

of tibia and flbula , 592-594
Tendons

Spine rehabihtation techniques

Stretching techniques
Achilles tendon. 36, 601- 602

J for acute facet joint lock, 684, 686

comparison of. 127
as connective tissue, 26, 27

jvulder, 409--410 for the cervical spine, 684-689

effects on kinetic chain, 131-)3 3
deep tendon reflexes of, 64

706 Index

parts and functions of muscle tendons. medial tibial stress syndrome (MTSS) of.
Upper-trunk. movement patterns of.

33.35
592.597-598
316-317

passive tendon stretch test of. 63

mobilization and traction of. 296. 297

peroneal tendon injuries. 629

Tibial varum. 633
V

position of attachment to muscles. 140

Tissue. healing process in. 24
Vascular reaction in healing phase. 19

Tenodesis strap. 5 7U-5 71

Topigel. 470
Vascular supply. impacl on healing process

Tenomuscular mechanoreceptors.
Torque. 246
of. 24

102-103
Traction injury. 411
Vaslus medialis oblique (VMO). 561 .

Tenosynovitis. "sticky" inflammatory

Transverse fracture. 30. 31
562-563 .567.568

process of. 37
Transversus abdominus. 654-656
Verhoshanski. Yuri. 226

Testing. See Evaluation process: See also

Trauma. assessing for. 56
Vertical jump. 362

specific site oj injury

Traumatic femoral fractures. 518
Vision. role in postural stability and

Therabands.145-146. 175. 177

Treatment plane. 279. 281
balance. 159. 170

Therapeutic exercise. 6
Triangular fibrocartilage complex (TFCC).

Thermal-assisted capsular shrinkage

453.464-465.466-467

W
(TACS). 370-371. 400
Triceps. 35

Triceps brachii. 422

Wall slides. 248

Thigh

Warm-up. prior to stretching . 133

closed-kinetic-chain strengthening
Trigger point (TP). 57.412-414

Weight shifting. 255. 256

exercises for. 497-499

Trochanteric bursitis. 503-504

Turf toe. 643-644

Wolff's law. 24. 32. 36

functional anatomy and biomechanics

Wrist

of. 486

closed-kinetic-chain exercises for.

isokinetic exercise for. 499

U 458-461

plyometric exercise for. 500

Ulna
functional anatomy and biomechanics

strengthening exercises for. 492-496

distal radioulnar joint (DRUIl of. 453
01'.452-453

stretching exercises for. 487-491

in elbow joint. 419. 420. 421
mobilization and traction of. 289-290

Thigh injury rehabilitation techniques

mobilization and traction 01'.289
reestablishing neuromu scular control

for myositis ossificans. 522

Ulnar collateral ligament (UCL) injury.
01'. 461

for quadriceps contusion. 520-522

437-438.474-475
strengthening exercises for. 454-458

for quadriceps muscle strain. 518-520

Ulnar nerve entrapment. 439
taping and bracing techniques for. 462

Thoracic outlet syndrome. 410-411

Upper extremity
Wrist injury rehabilitation techniques

Thoracic vertebrae
aquatic therapy for. 336-338
for carpal tunnel syndrome. 470-471

mobilization and traction of. 291

elbow. exercises for. 254
for distal radius fractures. 462-464

See also Spine: Spine rehabilitation

functional progressions and testing of.
for ganglion cysts of the hand .

techniques
353-357
471-472

Throwing program for return to sport.

movement patterns of. 311-313
for hamate fractures. 469-470

447-449
open- versus closed-kinetic chain
for lunate dislocations. 468-469

Thumb. 457-458. 474-475

activities for. 253-258
for triangular fibroca rtilage complex

Tibia
shoulder complex joint. exercises for.
(TFCC). 464-465. 466-467

fractures of. 590-594

253-254
Wrist sprain. 464

iliotibial band friction syndrome in.

teclmiques of reestablishing

572-573
neuromuscular control of. 112-115

ISB N 0-07-246210-8

90000