1. Rehabilitation and Reconditioning

2. Overview
The Sports Medicine Team
Types of Injuries
Tissue Response to Injury
Exercise Strategies During Recovery
Case Study
Take Home Points

3. Principles of Rehabilitation and Reconditioning
Healing tissues must not be overstressed
The individual must fulfill specific criteria to progress from one phase to another during the rehabilitative process
The rehabilitation program must be based on current clinical and scientific research

4. Principles of Rehabilitation and Reconditioning
The program must be adaptable to each individual and his or her specific requirements and goals
Rehabilitation is a team-oriented process requiring all the members of the sports medicine team to work together

5. The Sports Medicine Team
Physician
Athletic Trainer
Strength and Conditioning Coach/Personal Trainer
Physical Therapist
Nutritionist
Psychologist

6. Duties of Sports Medicine Team
Physician
Calls the shots
Game and practice medical coverage
Injury evaluation and diagnosis
Referrals if necessary
Determine return to play
Certified Athletic Trainer
Day to day physical health of the athletes
Injury prevention, management and rehabilitation
Evaluate, not diagnosis, injuries

7. Duties of Sports Medicine Team
Conditioning Coach/Personal Trainer
Injury prevention and rehabilitation
Invaluable resource for ATC and PT
Key in returning a player to the field
Certified through NSCA
Physical Therapists
Primarily clinically based
Longer term rehabilitation

8. Duties of Sports Medicine Team
Nutritionist
Registered Dietician
Member of ADA
SCAN (Sports, Cardiovascular and Wellness Nutritionists)
Nutrition professionals with expertise and skills in promoting the role of nutrition in physical performance, cardiovascular health and wellness
Psychologist
Improve performance
Return from injury

9. Types of Injuries
Macrotrauma
Microtrauma

10. Macrotrauma
Injury suffered as result of a specific, sudden episode of overload to a given tissue
Types
Bone
Joint
Soft Tissue
Compound Fracture dislocation of left ankle after falling 1m from ladder
Source: ED, Royal North Shore Hospital

11. Bone Macrotrauma Types Fracture A break in the bone or cartilage
Stress or Hairline
Compound or Open
Simple or Closed
Avulsion
Compression

12. Types of Bone Fractures
Stress Fracture or Hairline Fracture
A very fine crack in the bone
Compound Fracture or Open Fracture
A fracture in which the bone is sticking through the skin
Simple Fracture or Closed Fracture
The bone hasn't pierced the skin
Avulsion Fracture
Tendon or ligament pulls off a piece of the bone
Compression Fracture
Occurs when vertebrae in the spine are broken

13. Types of Fractures Video

15. Joint Macrotrauma Joint Dislocation Joint Subluxation
Complete displacement (joint surfaces are not in anatomical alignment) of the joint surfaces
Joint Subluxation
Partial displacement of the joint surfaces and may result in laxity or instability
Shoulder Dislocation

16. Dwayne Wade Shoulder Dislocation

18. Ligament Macrotrauma
Sprain: injury to the structures that connect the bones and help maintain joint stability
First Degree: partial tear of the ligament without increased joint stability
Second Degree: partial tear with minor instability
Third Degree: complete tear with full joint instability

19. Muscle Macrotrauma Muscle Strain: tear to the fibers of the muscle
First Degree : partial tear of individual fibers characterized by painful muscle activity
Second Degree: partial tear of muscle characterized by weak muscle activity
Third Degree: complete tear of the muscle fibers with painless muscle activity
A muscle contusion is an area of excess accumulation of blood and fluid in the tissues surrounding the injured muscle

20. Microtrauma
The result of repeated, abnormal stress applied to a tissue without sufficient recovery time
Joint and soft tissue
Tendonitis
Bursitis
Muscle soreness

21. Tendon Microtrauma Tendonitis Most common tendons affected Symptoms
Inflammation of the tendon
Most often due to excessive repetitive movement
Most common tendons affected
Rotator cuff, biceps, elbow, wrist, hip, knee (patellar tendon), and ankle (achilles tendon)
Symptoms
Swelling, pain and stiffness

22. Bursa Microtrauma Bursa
Fluid filled sac located between tendon and bone
Prevents friction
160 in the body
Majority located in the shoulder, elbow, hip and knee

23. Bursa Microtrauma Bursitis
Inflammation of bursa due to continuous rubbing of tendon over bone
Most often due to excessive repetitive movement
Most common bursa affected are elbow, shoulder, hip, knee and ankle (calcaneus)
Symptoms
Swelling, tenderness and pain

24. Muscle Microtrauma Muscle Soreness Acute
Build up of lactic acid, potassium and other fluids within the muscle causes pain by impeding circulation and stimulating pain receptors
Delayed Onset Muscle Soreness (DOMS)
Damaged muscle fibers stimulate pain receptors
Caused by eccentric muscle contraction

25. Three phases of tissue healing: Inflammation Phase Repair Phase
Remodeling Phase

26. Tissue Response to Injury Phase One: Inflammation
Normal reaction that is necessary to the healing process of the body, but excessive inflammation will delay recovery
24-72 hrs after injury
Vasodilation
Pain, swelling, and redness
Decreased collagen synthesis
Bradykinin is released which dilates blood vessels, contracts non-vascular smooth muscle, and causes pain.
Phagocytosis: macrophages remove cellular debris

27. Tissue Response to Injury Phase Two: Repair
Highlighted by the repair and regeneration of new tissue
Two to three days after injury up to eight weeks
Tissue repair is accomplished by either:
Regeneration (Replacement of tissue by the same tissue)
Dead and unviable tissue is removed
New capillaries are formed and collagen fibers are laid down
Collagen fibers are placed haphazardly, which can result in sub-optimal strength and athletic performance if not corrected
The formation of granulated tissue (scars)
Scars are made up of dense, inelastic, non-vascular fibrous tissue

28. Tissue Response to Injury Phase Three: Remodeling
Overlaps with Repair phase
Strengthening of the new, weak tissue
Production of new collagen fibers slows
Collagen tissue begins to hypertrophy and align with the lines of force
Strength of new collagen tissue continue for up to two years post-injury
Ligamentous tissue can take up to one year to completely remodel

30. Exercise Strategies/Approaches
Inflammation Stage
Exercise is not recommended
Tissue needs time to heal
P.R.I.C.E. Principle should be used for the first hours immediately following the injury. The goal is to reduce swelling, prevent further injury, and reduce pain
Protection
Rest
Ice
Compression
Elevation
Ultrasound
Electrical Stimulation

31. Exercise Strategies/Approaches
Repair Stage
If possible, implement exercises to maintain cardiovascular conditioning (stationary bike, upper body ergometer) and muscular strength (isometric contractions)
Remodeling Stage
Game on
Sports specific exercises
Proprioception work (balance exercises)
Isotonic strength training (closed vs. open chained), agility training, etc

32. Case Study Shannon Sharpe, Denver Broncos Posterior Elbow Dislocation
Injury occurred 11-11
Non-surgical rehab
Back to practice (16 days)
Back to game 12-8 (27 days)

33. MRI Results
Disruption of the anterior capsule with 2-3cm defect of distal brachialis with extensive hemorrhage and fluid
Tearing/stripping of the anterior bundle of the medial collateral ligament complex, distally greater than proximal
High grade partial tearing of the common flexor tendon at medial epicondyle and hemorrhage within the flexor pronator musle mass
Large joint effusion with multiple internal bodies

34. Rehabilitation Protocol Phase 1: Inflammation
Goals
Minimize inflammatory response
Protect injury
Program Components
Hinged Brace/Compression
NSAIDS
Ice and Elevation
Electrical Stimulation

35. Rehabilitation Protocol Phase Two: Repair
Goals
Speed up tissue repair
Limit loss of range of motion (ROM)
Program Components
Passive ROM (Day 2)
Soft tissue massage (Day 4)
Active ROM (Day 5)
Stretching (Day 5)
Myofascial release (Day 5)
Hydro therapy (Day 6)

36. Rehabilitation Protocol Phase Three: Remodeling
Goals
Return to play
Program Components (Strength)
Manual resistance wrist, biceps/triceps (Day 7)
Manual resistance shoulder (Day 9)
Sport cord biceps/triceps wrist (Day 10)

37. Rehabilitation Protocol Phase Three: Remodeling
Sport cord shoulder (Day 12)
Weight room biceps/triceps (Day 12)
Weight room upper body modified (19 Days)
(Ball stabilization for core/lower extremity-Day 5)

38. Rehabilitation Protocol
Program Components (Strength and Proprioception)
Closed chain seated/standing (Day 8-10)
Closed chain quad/tripod (Days 11-15)
Closed chain uneven surface (Day 14)

39. Rehabilitation Protocol
Program Components (Sports Specific)
Catching (Day 10)
Stance (Day 12)
Running (Day 12)
Blocking (Day 12)

40. Take Home Points
The point person for the sports medicine team is generally a physician
Injuries occur as the result of either macro or microtrauma
The three phases of tissue healing are
Inflammation
Repair
Remodeling
Closed chain exercises (push-up, squat, split squat…) tend to be more sports-specific than open chain