Meet the Expert: Trust Your Physiatrist, We Don’t Make Mistakes in Sport

Injury

Tirza Z. Tamin1
1
Department of Physical Medicine and Rehabilitation, Cipto Mangunkusumo
Hospital; Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
Email: tirzaediva.tamin@gmail.com

Keywords: Physiatrist, return to sports, sports injury.

Abstract: The main focus of physiatrist is to evaluate and treat injuries, physical
illness, and disability through comprehensive, patient centered
treatment plans, utilizing cutting-edge as well as time-tested
methodologies to maximize function, reduce pain, and enhance the
quality of life. Injury specific rehabilitation protocols are being
practiced worldwide but need to be introduced according to the nature
of the sport.

1. Introduction
Sports injury is the process in which tissues or organs are damaged when playing a
game, causing loss of bodily function or structure Timpka.bin After a sports injury, the first
question asked is: ‘When will I (the athlete) be able to compete again?’ ardern Sports
injuries are a problem that almost every athlete will face, and even bring a lifetime of
pain. Many excellent athletes have left their careers because of sports injuries. The
players continue to increase their intensity, difficulty, and in the process of constantly
beyond, it also bring more sports injuries to athletes.bin
Approximately, there were 2.9 million sport related injuries a year. The most
number of injury is due to sprains and strains (41.4 per 1000). Following it are
fractures, 20 per 1,000, then contusions (19), open cuts (10), traumatic brain injury
(4.5), and dislocations (2.9)American Physical Therapy Association
Sports injuries have received more widespread attention in recent years due in part
to interest in injury monitoring and prevention and rising rates of traumatic brain
injury (TBI)-related emergency department (ED) visits. CDC2019 Concussions related to
sport have contributed to more than 200,000 hospital visits a year Marshall. Sports
injuries are a common type of injury presenting to hospital EDs and are most
common among older children and young adults.ruipinyau
Athletic injury recovery can be a long, challenging process Kraemer. The high risk of
injury reoccurrence caused by an insufficient rehabilitation program nor an ill timed
return to competition, showing important role of physiatrist and rehabilitation in sport
injury recoveryErickson.
We need an understanding of the sport and what biomechanical and physiological
demands this has on the athlete. Therefore, reviewing the literature on sports will help
in providing doctors with an understanding of the types of general injuries, the
mechanism behind them, and the management protocols currently used globally.himmat

2. Injury
As with any injury to biologic tissue, acute inflammation lasts 48 to 72 hours after
the injury and then gradually resolves as repair progresses. Some of the events that
occur during inflammation, including the release of cytokines or growth factors, may
help to stimulate tissue repair. These mediators promote vascular dilation and
increase vascular permeability, leading to exudation of fluid from vessels in the
injured region, which causes tissue edema. Blood escaping from the damaged vessels
forms a hematoma that temporarily fills the injured site. Fibrin accumulates within
the hematoma, and platelets bind to fibrillar collagen, thereby achieving hemostasis
and forming a clot consisting of fibrin, platelets, red cells, and cell and matrix debris.
The clot provides a framework for vascular and fibroblast cell invasion. As they
participate in clot formation, platelets release vasoactive mediators and various
cytokines or growth factors (e.g., transforming growth factor-β [TGF-β] and platelet-
derived growth factor). Polymorphonuclear leukocytes appear in the damaged tissue
and the clot. Shortly thereafter, monocytes arrive and increase in number until they
become the predominant cell type. Enzymes released from the inflammatory cells
help to digest necrotic tissue, and monocytes phagocytose small particles of necrotic
tissue and cell debris. Endothelial cells near the injury site begin to proliferate,
creating new capillaries that grow toward the region of tissue damage. Release of
chemotactic factors and cytokines from endothelial cells, monocytes, and other
inflammatory cells helps to stimulate migration and proliferation of the fibroblasts
that begin the repair process.sportinjury vol2

3. Repair
Tendons and ligaments may possess both intrinsic and extrinsic capabilities for
healing, and the contribution of each of these two mechanisms probably depends on
the location, extent, and mechanism of injury and the rehabilitation program used
after the injury. As in other areas in the body, tendon healing proceeds in three
phases: (1) an inflammatory stage, (2) a reparative or
collagen-producing stage, and (3) a remodeling phase.
3.1 Inflammatory Phase
Tendon and ligament healing begins with hematoma formation and an
inflammatory reaction that includes an accumulation of fibrin and inflammatory cells.
A clot forms between the two ends and is invaded by cells resembling fibroblasts and
migratory capillary buds. Within 2 to 3 days of the injury, fibroblasts within the
wound begin to proliferate rapidly and synthesize new matrix. They replace the clot
and the necrotic tissue with a soft, loose fibrous matrix containing high
concentrations of water, glycosaminoglycans, and type III collagen. Inflammatory
cells and fibroblasts fill this initial repair tissue. Within 3 to 4 days, vascular buds
from the surrounding tissue grow into the repair tissue and then canalize to allow
blood flow to the injured tissue and across small tissue defects. This vascular
granulation tissue fills the tissue defect and extends for a short distance into the
surrounding tissue but has little tensile strength. The inflammatory phase is evident
until the 8th to 10th day after injury.sport medicine vol2

3.2 Reparative Phase

As the repair progresses during the next several weeks, proliferating fibroblasts
continue to produce fibrous tissue containing a high proportion of type III collagen.
Collagen synthesis reaches its maximal level after approximately 4 weeks, and at 3
months, collagen synthesis continues at a rate 3 to 4 times that of normal tissue. Over
time, water, glycosaminoglycan, and type III collagen
concentrations decline, the inflammatory cells disappear, and the concentration of
type I collagen increases. Newly synthesized collagen fibrils increase in size and
begin to form tightly packed bundles, and the density of fibroblasts decreases. Matrix
organization increases as the fibrils begin to align along the lines of stress, the
number of blood vessels decreases, and small amounts of elastin may appear within
the site of injury. The tensile strength of the repair tissue increases as the collagen
concentration increases.miller

3.3. Remodelling Phase

Repair of many tendon and ligament injuries results in an excessive volume of
highly cellular tissue with limited mechanical properties and a poorly organized
matrix. Remodelling reshapes and strengthens this tissue by removing, reorganizing,
and replacing cells and matrix. In most tendon and ligament injuries, evidence of
remodelling appears within several weeks of injury as fibroblasts and macrophages
decrease, fibroblast synthetic activity decreases, and fibroblasts and collagen fibrils
assume a more organized appearance. As these changes occur in the repair tissue,
collagen fibrils grow in diameter, the concentration of collagen and the ratio of type I
to type III collagen increase, and the water and proteoglycan concentrations decline.
During the months after the injury occurs, the matrix continues to align, presumably
in response to loads applied to the repair tissue. The most apparent signs of
remodelling disappear within 4 to 6 months of injury. However, removal,
replacement, and reorganization of repair tissue continue to some extent for years.
The mechanical strength of the healing tendon and ligament increases as the collagen
becomes stabilized by cross-links and the fibrils assemble into fibers.miller

4. Sport Injury Definition

Sports injury is the process in which tissues or organs are damaged as a direct
result of participating in sport and exercise, limiting the activity of athletes 1 or more
days following injury day.timpka The occurrence of sports injuries is not caused by a
single factor but is related to sports training, physical education, sports competitions,
sports events and corresponding technical movements.bin

4.1 Classify Sports Injuries Satish Bhardwaj

Sports or performance injuries can be classified according to cause, the three
categories are direct injury, indirect injury and overuse injury. Satish Bhardwaj
a. Direct injury
A direct injury can be caused by a collision with another person being struck with
an object (for example, a cricket ball or hockey stick).Examples of injuries that
result from external forces include hematomas (‘corks’) and bruises, joint and
ligament damage, dislocations and bone fractures. Satish Bhardwaj
b. Indirect injury
An indirect injury can occur in two ways Satish Bhardwaj:
 a) The actual injury can occur some distance from the impact site.
b) The injury does not result from physical contact with an object or person, but
from internal forces built up by the actions of the performer, such as may be
caused by poor technique, over-stretching, fatigue and lack of fitness. The
examples are ligament sprains and muscle strains and tears.
c. Overuse injuries
Overuse injuries occur when repetitive and excessive force is placed on the
bones and other connective tissues of the body. The symptoms of overuse injury
often occur when increasing training frequency or intensity, and the body is unable
to deal with the new stresses that are placed upon it. A large number of overuse
injuries results from athlete is not given appropriate time to recover between
intense sessions. Poor use of equipment and poor techniques are another cause of
excessive injury and put extra pressure on their bodies.Satish Bhardwaj
Injuries may also be categorized by particular location of injury (e.g. bone,
cartilage, joint, ligament, muscle, tendon, bursa, nerve, skin) and nature of injury
(e.g. fracture, dislocation, sprain, or strain)Brukner.

5. Epidemiology
Total number of sport injuries incidents aged 5 years and older was 8.6 million, or
34,1 episodes per 1,000 people. Most of them were people aged 5–24 years with 61%
of men. Half of the injury incidents associated with sport and exercise (or 4.3 million
annually) resulted in therapy in a doctor's office without going into ED, and 36.6%
(or 3.2 million) resulted in a non-hospitalized ED stay.CDC.
For 2010–2016, the top five most frequent activities that caused ED visits for
sports injuries by patients aged 5–24 years were football (14.1%), basketball (12.5%),
pedal cycling (9.9%), soccer (7.1%), and ice or roller skating or skateboarding
(6.9%). Variation was observed by age and sex in the types of activities causing ED
visits for sports injuries (Table 1).ruipinyau
ruipinyau
The top five most frequent activities causing ED visits for sports injuries among
male patients aged 5–24 were football (20.2%), basketball (14.3%), pedal cycling
(10.3%), soccer (6.8%), and ice or roller skating or skateboarding (6.7%). Among
female patients, the top five most frequent activities causing ED visits for sports
injuries were gymnastics or cheerleading (11.8%), playground (9.2%), pedal cycling
(9.1%), basketball (8.9%), and other or unspecified activities (8.8%). ruipinyau
Sprains and strains or dislocations (28.1%) accounted for the largest percentage of
ED visits by patients aged 5–24 years for sports injuries, followed by other or
unspecified injuries (22.6%), fractures (18.0%), contusions and superficial injuries
(16.1%), open wounds (10.5%), and internal injuries (4.7%) (Table 2).rupinyau
Two body regions (upper and lower extremities) accounted for a majority of all
ED visits for sports injuries by patients aged 5–24 years (62.6%), followed by injuries
affecting the head and neck (23.0%) (Table 2).rupinyau
ruipinyau

6. Extrinsic factors causes of sports injury Satish Bhardwaj

6.1 Training-related factors
Sudden increases in intensity, frequency, and duration, or changing training
method can increased risk of injury. Exercise techniques poorly can place excessive
strain on tissues. Satish Bhardwaj
6.2 Equipment selection factors
Incorrect footwear, training or competing with equipment that is not the correct
size or weight can make movements biomechanically inefficient and place greater
strain on joints, connective tissues, and muscles. Not obey to the personal protective
Satish Bhardwaj
equipment rules places individuals under increased risk of injury.
6.3 Environmental factors
Training on surfaces that are too soft or too hard can lead to a greater risk of
sprains because feet/legs can become stuck in wet turf. Uneven surfaces, such as
cambered paths or roads, can lead to increased force being placed through one side of
the body. Satish Bhardwaj
6.4 Psychological factors
Psychological factors relate to the psychological demands of training or competition
and how individuals deal with the situation. Satish Bhardwaj
6.5 Nutritional factors
These factors mainly encompass ensuring the athlete has adequate intake. Having
adequate glycogen stores increases the time taken to become fatigued. Correct
hydration reduces the effect of dehydration, prevents hypernatremia, and overheating
of the body. Without correct protein intake, an individual’s soft tissue may not
recover or adapt properly, and can lead to Delayed Onset Muscle Soreness (DOMS)
and overtraining syndrome. Satish Bhardwaj

7. Most common injuries in the sports Satish Bhardwaj

7.1 Skin injuries
a. Blister: These types of injuries are observed mostly in early stages of athletics
training. Blister mostly occurs on the palms of the hands and sole of the foot.
The treatment to blister is to relieve soreness and prevent infection. This can be
accomplished by opening the blister from one side with the help of sterilized
injection needle and fluid is evacuated. Swabbing the inside of the blister with
some antiseptic and applying compression dressing will hoop to recover the
blister. Care must be taken that blister does not develop any infection. Satish Bhardwaj
b. Abrasion: Often protective surface of the skin broken as a fall on a rough
surface sometime foreign substances are rubbed in. All the abrasions should be
cleaned with soap and water. Foreign substances should be picked out and then
should be coated with the tincture or benzoin. Deeper abrasion should be
bandaged. Satish Bhardwaj
c. Contusion: The contusion is caused by the hammering of some solid object
against bones. Sometime turner like formation is observed, care contusion may
be treated with message of ice to limit its size. Bleeding tendency of an athlete
may be obtained. The larger superficial contusion require pressure bandage for
24 hours following the initial application of ice. Satish Bhardwaj
d. Puncture Wounds: Puncture wounds are caused by pricking of needle or sharp
nail etc. Puncture wounds must be seriously handled. Tetanus protection is
must. The wound should be soaked with Epson salt solution four timed daily.
All These wounds manifest a considerable inflammation and one should not
wait to start treatment until). Frank infection is present. If mouth is closed, it
should be opened and sterilized with antiseptic location. For deep puncture in
the sole, a complete rest at least for four weeks is necessary. Satish Bhardwaj
 e. Laceration: Laceration is caused by sharp-edged object. These types of
wounds should be cleaned with antiseptic Lotion and sutured at the earliest
possible. Application of ice after suture will relieve swelling and pain,
Extensive and deep, laceration should be given compression dressing.
Laceration would must be explored to its bottoms All players with lacerations
should receive tetanus prophylaxis. Doctors may suggest oral administration
of antibiotics. Satish Bhardwaj

7.2 Injuries to the muscles, fibers tendons. Ligaments and joints

a. Deep Contusion: This type of contusion often affects muscles. Immediate
treatment is cold compress and rest. The site of injury may be given sponge &
rubber bandage. Large hematoma may be evacuated by surgery and
arrangements may be made for continued drainage, and light compression is
maintained until the wound is healed. There after proper rehabilitation methods
may be followed once healing has taken place. Satish Bhardwaj
b. Strains: Sometimes those may be known as pulls as a result of sometimes
sudden excessive uncoordinated or unopposed muscle contraction. Strains are
caused by a muscle that is overstretched or that over-contracts. Symptoms of a
strain include: muscle spasm, a loss of strength in the muscle, and pain. To help
prevent sprains and strains, proper warm up before exercising and suitable
footwear are required. Conditioning and strengthening exercises can also help.
elmagd

c. Sprain: A sprain is where one or more of your ligaments is stretched, twisted or

torn. Sprain causes damage to a greater degree to ligaments, joints capsule
synovial membrane and cartilage. The symptoms of a sprain include: pain,
inflammation (swelling), bruising, and restricted movement in the affected area.
Sprains can be treated with rest and anti-inflammatory medication. Immediate
treatment is cold compression and rest. The latest trend is surgical exploration.
Stitching of ligaments makes recovery faster. Cold compress may be repeated
after every four hours for 36 hours. Area may be elevated to reduce pain. elmagd
d. Dislocation: A dislocation is an injury in which the ends of your bones are
forced from their normal positions. The cause is usually trauma resulting from a
fall, an auto accident, or high-speed sports. Dislocation usually involves the
body's larger joints. The most common site of the injury in adult is the shoulder.
In children, it's the elbow. This injury can be diagnosed very easily with the
help of X-Ray or comparing the area with healthy area. There is loss of
movements and joint becomes stiff. There may be tenderness also on the joint.
 Movement to the area should be stopped and physiologist may be consulted.
elmagd

7.3 Injuries to the bones

Diagnosing a fracture depends on location and how the fragments are aligned. A
fracture for a child could take only a few weeks to heal because their bodies are still
growing, whereas an older adult could take months.
a. Green stick fracture: There is crankiness and or bend in the bone.
b. Simple fracture: Only Bone is fractured but there is no damage to the skin.
c. Compound fracture: There is damage to the bone and skin as well.
d. Comminuted and compacted fracture: It is splinting of bones or splinting at the
sight of fracture.
e. Impacted fracture: The telescopic ends of the bones have taken place and
pierced through the skin.
f. Multiple fractures: Bone is broken more than one place.
g. Oblique fracture: The ends extended diagonally across the bone. Bone is
broken in L, shape.
8. Diagnosis of Sport Injury
Basic principles of obtaining a thorough history and performing a physical
examination will allow you to hone in on an accurate diagnosis. For acute injuries,
excluding a head injury, the following five simple questions should be asked: (1) pain
location; (2) Mechanism of injury; (3) Pop, crack, snap sound; (4) Pain and
instability; (5) Ability to bear weight on the leg (if a lower body injury)Gotlin.
For chronic injuries, information includes duration of symptoms, alleviating
and aggravating factors, description of the pain, prior treatments, functional deficits,
numbness or tingling, weakness, swelling, instability, or mechanical symptoms such
as locking or catching. Certain “red flag” signs should prompt emergency medical
evaluation, including disorientation following a head injury, inability to walk or move
extremities following a collision or fall, inability to bear weight, numbness or tingling
following back or extremity injury, and an obviously dislocated body part. Gotlin
When examining an athlete, it is important to fully expose the injured body
part. Inspect and palpate the injured area, assess strength and range of motion, and
perform a basic neurovascular exam. Inspect the area for swelling, deformity,
bruising, abrasions or lacerations, and asymmetry. Gotlin
Red flags include inability to move the extremity (this may be limited by pain,
so the athlete should be asked to perform simpler tasks like wiggling toes), numbness
or tingling, and a pale or cold extremity. Gotlin
Diagnostic Tools for Injury Assessment Among the most helpful instruments
for assessment and diagnosis, particularly for fractures and other injuries to the
skeletal system, are X- rays. Computed Tomography (CT) Scan is able to take
“slices” of the involved areas. It can provide physicians with an accurate read on
concussions and can help to rule out head bleeds. Magnetic resonance imaging (MRI)
has ability to identify injuries in soft tissues such as ligaments (ACL tears), tendons,
cartilage, and muscles. One drawback is that, compared to X-rays and CT scans, MRI
is fairly expensive. Magnetic resonance imaging is more often utilized in diagnosing
stress fractures because it is also able to identify soft tissue pathology without any
radiation exposureGotlin.

8. Aim of Sports Injury Rehabilitation

Rehabilitation goal setting is needed in rehabilitation programs as it will help
energize athletes to become more competitive and successful to recover, and the key
purpose should be to define specific goals for the recovery process to allow athletes
to return to full health, both mentally and physically. The plan should promote
complete physical, psychological and performanceErickson.
The aim of sport injury rehabilitation:
a. Restore function and performance to a preinjury level
b. Safe return to the sport
c. Minimize risks of reinjury

9. International Classification Functioning (ICF) Role in Rehabilitation

The International Classification of Functioning, Disability and Health (ICF)
has been developed by the World Health Organization (WHO) contributes to provide
a comprehensive rehabilitative program. WHO
 The conceptualization provided in the ICF makes a point of comprehensive
rehabilitation to an injured athletes, based on two main components: (1) Functioning
and Disability; and (2) Contextual factors. WHO
Components of Functioning and Disability are divided in: (1) Body
component including Body functions and Anatomical structures, noted as an
impairments; (2) ‘Activity’ and ‘Participation’ components A difficulty at the person
level would be noted as an activity limitation, and at the societal level as a
participation restriction. WHO
Component of Contextual factors is an independent and integral component of
the classification and is divided into (1) ‘environmental factors’ and (2) ‘personal
factors.’WHO
9. Stages of Sport Injury Rehabilitation
The clinicans must Understanding the physiology of healing is important to
successful treatment of acute sports injuries.
9.1 Acute phase: Promote tissue healing and avoid deconditioning
 Traditionally, clinicians have been employing a protocol inclusive of protection,
rest, ice, compression, and elevation (P.R.I.C.E) with the aim of avoiding further
tissue damage, reducing associated pain, edema, and attempt to promote the healing
process. Moreover, elite athletes are expected to return to competition at the earliest
possible time and therefore require a different, more aggressive approach to
rehabilitation, which needs to be initiated in the acute phase itself. Keeping the end
goal of risk-free injury performance, it is proposed that clinicians follow a protocol
inclusive of protection, optimal loading, ice, compression, and elevation
(P.O.L.I.C.E) in the acute care setting for athletes.hemme At this point, physical
exercises may be restricted to aquatic training or stationary cycles to sustain
cardiovascular health and muscular endurance. Brukner.
9.2 Reconditioning phase
Rehabilitation involving strength and conditioning in athletes could be highly
variable as compared to the general population. Rupture ACL is one of the most
common lower limb injuries seen in sports. Reinjury and graft rupture as a result of
returning to play too early resulting in excessive load on a poorly rehabilitated knee.
Therefore, it is highly important to ensure optimum loading of injured and recovering
tissues through an individualized approach according to the sport and its physical
demand. Due to the physical demands of high-level sports, graded load progression
plays a significant role in a successful sports injury rehabilitation program as it is
corresponding to the healing tissue entering the remodeling/maturation phase. This
Brukner
phase also aims to restore the athlete's confidence. . Cardiorespiratory loading to
maintain and improve aerobic capacity, in conjunction with neuromuscular training to
maintain overall muscle strength, flexibility, and proprioception, has been well
defined in literature. In addition, various sports-specific speed, strength, agility, and
flexibility drills, when incorporated early in the rehabilitation, have proven to be
effective in the initial stages in avoiding overall deconditioning and positively
affecting return to participation. While progressive loading plays a key role in an
efficient RTP, the clinicians need to monitor for undue overloading.hammet
10. Exercise Program for Rehabilitation
Components of exercise programs for rehabilitation include: (1) Muscle
conditioning; (2) Cardiovascular fitness; (3) Flexibility; (4) Joint range of motivation;
(5) Proprioception; (6) Functional exercise; (7) Sport skills; (8) Hydrotherapy; (9)
Deep water running; (10) Correction of biomechanical abnormalitiesBrukner
A. Muscle conditioning
There are four main components of muscle conditioning: (1) muscle
activation and motor control; (2) muscle strength; (3) muscle power; (4) muscle
enduranceBrukner.
Muscle activation and motor control incorporates muscle activation with neural input
to gain the desired movement and/or skill. Techniques included are visualization of
the correct muscle action, use of instructions that cue the correct action, focus on
precision, and show the patient how to feel the muscle contractingBrukner.
Muscle strength is the muscle's ability to exert force. Strength training is often
used in rehabilitation when weaknesses compromises function and sport performance.
This is particularly true following periods of immobilization. or injury and in pain
presentations. The initial strength gain in response to exercise is thought to be related
to increased neuromuscular facilitationBrukner.
Muscle power is the muscle's rate of doing work. It is equivalent to explosive
strength such as measured in a single leg hop lest or a vertical jump test.
Improvements in power can be at attributed to improved muscle coordination
between agonist and antagonist muscles. Commonly, power-focused exercises are
incorporated into the later stage of rehabilitation due to the potential of re-injury.
Power exercises may include: fast-speed isotonic or isokinetic exercises (concentric
and/or eccentric), increased speed of functional exercises (faster reverse calf raise,
drop squat), plyometric exercises (e.g. hopping, bounding) Brukner.
Muscle endurance is the muscle's ability to sustain contraction or perform
repeated contractions. The aim of endurance training is to increase the capacity to
sustain repetitive. high-intensity, low-resistance exercise such as running, cycling,
and swimming. Adaptations to endurance training include an increase in maximal
oxygen uptake (VOmax) and an increased ability of skeletal muscle to generate
energy via oxidative metabolism. Endurance exercise into a rehabilitation program
include riding a stationary bike, swimming, and specific low-load, high- repetition
isotonic or isokinetic gym-based exercises or circuit trainingBrukner
The three main types of exercise used in muscle conditioning are isometric,
isotonic, isokinetic. An isometric exercise occurs when muscle length remains
constant while tension experiences varying changes. Isometric exercises are often the
first form of strengthening exercise used after injury, especially if the region is
excessively painful or if the area is immobilized. Isotonic exercises are performed
when the joint moves through a range of motion against a constant resistance or
weight. Isotonic exercises may be: concentric and eccentric. The site of injury should
be considered when prescribing eccentric exercises. Isokinetic exercises are
performed on devices at a fixed speed with a variable resistance that is
accommodative to the individual throughout the range of motion. Brukner
B. Cardiovascular fitness can be maintained by doing activities such as cycling
or water sports. This depends on the athlete's specific sport, this may include a
combination of endurance, intervals, anaerobes, and energy. Brukner
C. Flexibility often decreases as a result of spasm of surrounding muscles. This
may result in dysfunction of adjacent joints and soft tissues. Stretching muscles and
joints is one way of improving tissue and joint extensibility. Recommendations for
effective stretching are state of pain free, a gentle warm-up, cryotherapy to reduce
pain and muscle spasm, careful instruction regarding the correct stretching position,
appropriate durations of stretch, and able to feel stretch. Brukner
D. Proprioception
Proprioception relates to how the body perceives and maintains itself in space.
Proprioceptive rehabilitation can involve balance exercises such as single-leg stance,
plyometric exercises, agility exercises, and sport-specific exercises. Equipment that
may be used to challenge the athlete's proprioception and balance include rocker
boards, dura disks, Swiss balls, and mini trampolinesBrukner
E. Functional exercise
Functional activities that form the basis of sport. These activities can prepare the
athlete physically and mentally for the demands of the sport. Functional exercises are
often supplemented with progressive strength, power, endurance, flexibility, and
motor control exercises that become more sport-specific. Brukner
F. Sport skills
For tissues that have not been subjected to performance level stress for an extended
period of time, progression should be gradual-through sports-specific tasks of
increasing difficulty. The athlete can begin with basic sports skills (such as kicking a
football) and then progress to more sports-specific skills (such as kicking for a goal or
to a teammate on the run). An athlete can only progress to skills training if there is no
increase in the signs and symptoms of the injury following training. If there is any
exacerbation of symptoms, the task should be reassessed and modified. Brukner
G. Hydrotherapy
Hydrotherapy or pool therapy is a form of treatment widely used in the treatment of
sports injuries for increased muscular strength, power, and endurance, as well as
improvement of functional levels including coordination and balance. Brukner
H. Deep water running
Deep water running, or aqua running, consists of simulated running in the deep end of
a pool, aided by a flotation device (vest or belt) that maintains the head above water.
Differences in metabolic response, muscle use, and activation patterns to deep-water
running and land-based running effects on sufficient cardiovascular response despite
slightly lower heart rates. Brukner
I. Correction of biomechanical abnormalities
When biomechanical abnormality is detected, the clinician must determine whether
the abnormality is contributing to the injury, either directly or indirectly. This
requires the clinician to have a good understanding of the biomechanics and the
pathology of the injury within the specific sporting environment. Brukner
3.4. Psychology in Rehabilitation
Typical anxieties with which an athlete might have to cope include those
related to the pain they are experiencing lengthy rehabilitation anxieties, the loss of
their starting place and change in daily routines, performance outcome anxieties
(team doing well or poorly whilst injured), pre- and/or postoperative stress, anxieties
related to fitness demands and returning to peak performance and also anxieties
related to re-injury during rehabilitation or return to training and competition Ivarsson.
Evidence has shown that injuries may have a direct negative impact on the
athlete's career that cause substantial impact on his/ her well-being. Negative
psychological reactions may reduce the chances of a successful RTP, by interfering
with their attention and concentration during rehabilitation exercises and, hence,
increasing the risk of re-injury further. Also, in effect, negative reactions hinder the
inflammatory phase and increase the likelihood of infectionIvarsson.
It is important to provide stress management intervention, a positive atmosphere that
decreases negative affective reactions and maximizes recovery, as well as a high-
quality social support network and independent motivationIvarsson.
The use of breathing techniques and Progressive Muscular Relaxation (PMR)
are reported to be the most beneficial techniques for coping with stress and anxiety
associated with injuryIvarsson.
Breathing techniques including centering, diaphragm breathing, and ratio
breathing have the same principle, which is alternating focus negative thoughts into
breathing techniques. By doing it repeatedly, it may help increasing adherence of
rehabilitationIvarsson.

3.5. Rehabilitation Modality

Modalities, physical agents, and manual therapies (MTs) are commonly
applied interventions for sports-related injuries and are designed to facilitate the
rehabilitation process. Clinicians must stay vigilant to address the patient’s
impairments and then design and implement treatments that meet specific treatment
goalsMiller.
Modalities such as cryotherapy (ice), electrical stimulation, heat, ultrasound,
and laser are commonly applied to the body to affect the inflammatory cascade and to
reduce pain. Ice is probably the most commonly applied treatment and is part of the
standard of careMiller.
Electrical modalities are applied as either transcutaneous electrical nerve
stimulation (TENS) or as neuromuscular electrical nerve stimulation (NMES) to
reduce pain or stimulate a muscle contraction. Newer forms of electrotherapy, such as
patterned electrical nerve stimulation (PENS), have additional application in muscle
activation and recruitmentMiller.
Ultrasound and laser are often termed biostimulators since they use
mechanical (acoustical energy) or light energy to stimulate cellular processes within
the tissues. Thus the types of energies and equipment available for clinical use are
continually expanding. Miller
Since modalities often apply thermal, electrical, acoustical, or light energy to
the body, precautions include cardiac pacemakers (or implanted electromagnetic
devices), sensory loss (especially to temperature changes), and peripheral artery
disease that affects normal physiology in the extremities Miller
Similar to modalities, Manual Therapy (MT) is a passive, nonsurgical type of
conservative management that involves skilled movements applied by clinicians to
the patient’s body that directly or indirectly targets a variety of anatomical structures
or systems. Precautions, and contraindications for MT include joint pain with the
technique, joint effusion, unknown pathology, auto-immune diseases, fracture, tumor,
infection and osteoporosis. MT should be avoided with nerve and vascular
pathologies where movement and pressure can exacerbate the condition. You may see
MT listed as trigger point release (TPR), proprioceptive neuromuscular facilitation
(PNF), muscle energy technique (MET), strain-counterstrain active release technique
(ART), cranio-sacral therapy, myofascial release, positional release therapy, and
others. Most of these MT techniques may be categorized into four major groups: (1)
manipulation (high velocity low amplitude—HVLA); (2) mobilization (nonthrust
manipulation); (3) stretching; and (4) muscle- modifying techniquesMiller

3.6. Orthosis and braces

An orthosis or a brace is an externally applied support with the aim to support
or align the joint. Orthoses and braces are increasingly used in sports. They are
mostly used for the ankle and knee, but increasingly are used for the shoulder, elbow,
hand and wristPeterson. In order to avoid patients to develop instability in the long term,
brace use and physiotherapy can be continued as long as 3 monthsDoral.

The braces has various differ in terms of rigidity, material texture, padding,
size, color, and brands. They can be classified in two main groups: rigid and
functional. Clinically, they are used to relieve pain, improve physical function, slow
down the progression of tendinopathies, and prevent recurrent injuries. Their main
mechanism of action was the prevention of the initiation of the extremes of range-of-
motion moments mostly inversion. Doral.
 Knee braces can be divided into three types: prophylactic, rehabilitative and
functional. Prophylactic knee braces are designed to distribute applied loads away
from the knee joint and, thereby, reduce the load on the medial collateral ligament
(MCL) and perhaps also on the anterior cruciate ligament (ACL). Rehabilitative knee
braces are more effective than a plaster cast in treatment of MCL injuries, since they
allow controlled early motion. Functional braces are valuable in supporting the knee
so that the joint can function without ‘giving way’ after an ACL injuryPeterson.

4. Pain management
Treat injury pain with ice, compression, elevation and rest. But stretching injury
site is forbidden during period of pain. When a tendon or muscle is pulsing with
injury pain, resist the temptation to stretch it outMurphy.

9.3 Return to sport (RTS)

Once the rehabilitation criteria for the reconditioning phase have been fulfilled, a
decision to RTS needs to be taken.himmat Success means different things to different
people and is context-dependent and outcome-dependent. Success to the athlete might
be defined by return to participation in sport in the shortest possible time (goal focus).
Success to the coach might be defined relative to the athlete’s performance on RTS.
Success to the clinician might be defined by the prevention of new or recurring
injuries. The decision-making team must collaboratively decide on how success will
be defined, as soon as possible after the injury.ardemm
In a RTS there are three elements (figure 1), emphasising a graded, criterion-based
progression, that is applicable for any sport and aligned with RTS goals.ardemm
 1. Return to participation. The athlete may be participating in rehabilitation,
training (modified or unrestricted), or in sport, but at a level lower than his or
her RTS goal. The athlete is physically active, but not yet ‘ready’ (medically,
physically and/or psychologically) to RTS.ardem
2. Return to sport (RTS). The athlete has returned to his or her defined sport, but
is not performing at his or her desired performance level. Some athletes may
be satisfied with
reaching this stage, and this can represent successful RTS for that individual.
3. Return to performance. The athlete has gradually returned to his or her
defined sport and is performing at or above his or her preinjury level. For
some athletes this stage may be characterised by personal best performance or
expected personal growth as it relates to performance.ardem

Type Of injury Return To Sport Criteria

1.Acute knee Injury Efficient symptom free direction changes

Reactive agality testing
Psychological readiness:ACL Return to Sport after Injury Scale
2.Hamstring Injury Athlete should be pain free
Minimal ROM and strength deficits compared to contralateral side
Symmetrical hopping performance
Succesfull completion of sports spesific field testing
Attain pre-injury sprint speed
No evidence of apprehension during sport spesific movements, during
full speed sprints.
3.Achiless Tendinophaty Pain not exceeding>5/10
Pain after physical activity should subside completely the following
morning
No increase in pain or stiffness over the following week
4.Shouder Injury A minimum of 10% increase in rotator cuff strength of dominant side as
 compared to pre-injury strength
External rotation Internal rotation ratio 65% isokinetic and 100%
Isometric

hammet

10. Prevention of reinjury

A previous injury is the highest predictor of a risk of reinjury, and therefore, it is
extremely important to monitor the athlete even when he has gone back to full
participation. Satish Bhardwaj
Any approach to preventing injury in an individual or team context should be
sequential and follow the guidelines as mentioned below. Satish Bhardwaj,Emery
a. Proper conditioning programs (general and specific)
b. Proper warming up.
c. Protective equipment may be used (shoulder cap, knee cape head gears,
abdominal guards, skin splints, gloves, leg guards, tapping and bandages etc )
d. Care & use of equipment.
e. Standard equipment.
f. Proper diet (nutrients to maintain energy balance within 1 hour of high-intensity
exercise. High carbohydrate / protein substitution within 15-30 minutes of
completion of high-intensity exercise leads to faster muscle and liver glycogen
regeneration and maintenance of muscle mass).
g. Proper supervision
h. Maintenance of playing areas.
i. Psychological fitness
j. Prevention of over training
k. Proper rest and sleep.
l. Prevention of in toxic drugs.
m. First aid equipment.
n. Proper technical and tactical training.
An athlete should continue independent rehabilitation after return to sport to aid
in minimizing re-injury riskErickson. Video analysis may help both in assessment and for
feedback purposes of correct techniques which should be used in order to avoid
injuryBrukner. Orchard et al. documented a majority of recurrence of muscle injury in
the first week of RTP. Nevertheless, the risk may keep rising for several weeks. In
addition to the risk of a recurrence of the same injury, the risk of a new injury to
another location or tissue may also be higher. All of these events have been identified
as a corresponding injuryStares.

11. Conclusion
Sports make a vital contribution to the development of healthy and active
communities. If the objective of increased and sustainable participation in sport is to
be achieved, injury prevention and management will need to be supported and
promoted as an indispensable component of sports participation programs and
strategies. The use of facility design and the role of standards to reduce injury risks
were noted carefully. Improvements in the design, quality and maintenance of
facilities, including playing surfaces, would benefit injury prevention. Future
opportunities to identify and cost-effectively improve facility safety, as part of the
government’s ongoing investment in all types of sports infrastructure, should be
considered. The practical limitations on improving facility safety highlight the
imperative of improving the use of injury risk management strategies and medical
emergency planning in sport. Satish Bhardwaj
The main focus of physiatrist is to evaluate and treat injuries, physical illness, and
disability through comprehensive, patient centered treatment plans, utilizing cutting-
edge as well as time-tested methodologies to maximize function, reduce pain, and
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