1. Rehabilitation and Reconditioning David H. Potach, PT; MS; CSCS,*D; NSCA-CPT,*D Terry L. Grindstaff, DPT; ATC; SCS; CSCS,*D chapter 20 Rehabilitation and Reconditioning

2. Chapter Objectives Identify members of the sports medicine team and their responsibilities during injury rehabilitation and reconditioning. Recognize types of injuries athletes sustain. Comprehend timing and events of tissue healing. Understand goals of each tissue healing phase. Describe the strength and conditioning profes- sional’s role during injury rehabilitation and reconditioning.

3. Rehabilitation and Reconditioning Principles of Rehabilitation and Reconditioning –Healing tissues must not be overstressed. –The athlete 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. –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.

4. Section Outline Sports Medicine Team –Sports Medicine Team Members –Communication

5. Sports Medicine Team Sports Medicine Team Members –All members of the sports medicine team are responsible for educating coaches and athletes regarding injury risks, precautions, and treatments. –The sports medicine team also works to prevent injuries and rehabilitate injured athletes. –Several different professionals play important roles in assisting an injured athlete’s return, so effective communication is necessary.

6. Sports Medicine Team team physician: A person that provides med- ical care to an organization, school, or team. –Prescriptions (not always sport related) –Referrals to specialists –Anyone with MD at the end of their name can be team physician

7. Sports Medicine Team athletic trainer: A person typically responsible for the day-to-day physical health of the athlete; certified by the National Athletic Trainers’ Association Board of Certification as a Certified Athletic Trainer (ATC). –Acute injury management –Injury rehab –Preventive care (wraps, tape, braces) –Therapeutic treatment (ice, heat, ultrasound)

8. Sports Medicine Team Physical Therapist: rehabilitation expert who may be consulted about or provide supervision for injury rehabilitation –Typically work in rehab clinics –Forms specific treatment plans –Supervises long-term rehab of athletes –Possess a Physical Therapist license; may have a Sports Certified Specialist (SCS) credential

9. Key Terms Strength and conditioning professional: person should certified by the National Strength and Conditioning Association (NSCA) Certification Commission as a Certified Strength and Conditioning Specialist (CSCS) –Consults with athletic trainer and physical therapist –Forms post-rehab, pre-return program

10. Key Terms exercise physiologist: A person who has a formal background in the study of the exercise sciences and uses his or her expertise to assist with the design of a conditioning program that carefully considers the body’s metabolic response to exercise and the ways in which that reaction aids the healing process.

11. Key Terms nutritionist: A person who has a background in sport nutrition may provide guidelines regard- ing proper food choices to optimize tissue recovery. Ideally, the nutritionist has been formally trained in food and nutrition sciences and is a Registered Dietitian (RD) recognized by the American Dietetic Association.

12. Key Terms psychologist or psychiatrist: A licensed professional with a background in sport may provide strategies that help the injured athlete better cope with the mental stress accom- panying an injury.

13. Sports Medicine Team Communication –Strength and conditioning professionals must understand the following: The diagnosis of the injury Indications—forms of treatment required Contraindications—activity or practice prohibited due to the injury –They must also inform the rest of the sports medicine team about the exercises performed by the athlete and the athlete’s response to the exercise.

14. Key Point The sports medicine team includes a large number of professionals working together to provide an optimal rehabilitation and reconditioning environment. The relation- ship among members requires thoughtful communication to ensure a safe, harmoni- ous climate for the injured athlete.

15. Section Outline Types of Injury –Macrotrauma –Microtrauma

16. Macrotrauma Macrotrauma is a specific, sudden episode of overload injury to a tissue, resulting in disrupted tissue integrity. –Dislocation/subluxation: the complete/partial separation of surfaces within a joint –Sprain: trauma to a ligament –Strain: indirect musculotendinous trauma resulting in tearing of fibers –Contusion: direct trauma to soft tissue resulting in an excess blood and fluid accumulation

17. Microtrauma Microtrauma results from repeated, abnormal stresses applied to a tissue by continuous training or training with too little recovery time; overuse injury –Stress fracture: small bone breaks usually resulting from excessive training on hard surfaces –Tendonitis: inflammation of a tendon –Tendonosis: degeneration of the tendon caused by chronic inflammation

18. Section Outline Tissue Healing –Inflammation Phase –Repair Phase –Remodeling Phase –The length of the phases depends on the nature of the injury and which tissue is involved

19. Table 20.1

20. Tissue Healing Inflammation Phase –Inflammation is the body’s initial reaction to injury and is necessary for normal healing to occur. Pain, swelling, redness Decreased collagen synthesis Increased number of inflammatory cells Increased blood flow removes tissue debris Lasts approximately 2-3 days, longer if injury is severe or blood flow is poor

21. Tissue Healing Repair Phase –Once the inflammatory phase has ended, tissue repair begins; this phase allows the replacement of tissues that are no longer viable following injury. Reduction in inflammatory cells New tissue and scar tissue formed New capillaries form Collagen fibers laid out randomly as structure for repairs –Not optimal for strength Begins as early as two days after injury and may last up to two months.

22. Tissue Healing Remodeling Phase –The weakened tissue produced during the repair phase is strengthened during the remodeling phase of healing. Improved collagen alignment Usually never as strong as before injury –Tissue remodeling can last up to two to four months after injury.

23. Key Point Following injury, all damaged tissues go through the same general phases of heal- ing: inflammation, repair, and remodeling. Characteristic events define each phase and separate one phase from another.

24. Section Outline Rehabilitation and Reconditioning Strategies –Goals of Rehabilitation and Reconditioning Inflammation Phase –Treatment Goal –Exercise Strategies Repair Phase –Treatment Goal –Exercise Strategies Remodeling Phase –Treatment Goal –Exercise Strategies (continued)

25. Section Outline (continued) Rehabilitation and Reconditioning Strategies –Program Design Resistance Training Aerobic and Anaerobic Training

26. Rehabilitation and Reconditioning Strategies Goals of Rehabilitation and Reconditioning –Choose a level of loading that neither overloads nor underloads healing tissue. Healing tissue must never be overstressed. But, controlled therapeutic stress is needed to optimize collagen matrix formation. –The athlete must meet specific objectives (established by the physician, athletic trainer, physical therapist, or a combination of these) to progress from one phase of healing to the next.

27. Loading During Rehabilitation Figure 20.3 (next slide) –Loading during rehabilitation should neither overload nor underload the athlete’s healing tissue.

28. Figure 20.3

29. Soft Tissue Injury Response Figure 20.4 (next slide) –Pain is often used as a guide for tissue health. –Pain levels often decrease well before tissue healing is complete, which may lead athletes to believe they can return to competition before the body is actually ready.

30. Figure 20.4 Reprinted, by permission, from Leadbetter, 1992.

31. Rehabilitation and Reconditioning Strategies Goals of Rehabilitation and Reconditioning –Inflammation Phase Treatment Goal –Preventing disruption of new tissue Exercise Strategies –General aerobic and anaerobic training and resistance training of uninjured extremities, with priority given to maximal protection of the injured area –RICE: rest, ice, compression, elevation »Cooling to re-warming ratio of 1:2 »Also ultrasound and electrical stimulation –Some passive movement of injured area if tolerable

32. Rehabilitation and Reconditioning Strategies Goals of Rehabilitation and Reconditioning –Repair Phase Treatment Goals –Preventing excessive muscle atrophy and joint deterioration in the injured area; maintaining muscular and cardiovascular function in uninjured areas –Avoid disruption of collagen mesh –Non-movement can cause adhesions in the collagen mesh Exercise Strategies (after consultation with team physician, athletic trainer, or physical therapist) –Submaximal isometric exercise –Isokinetic exercise –Specific exercises to improve neuromuscular control

33. Rehabilitation and Reconditioning Strategies Goals of Rehabilitation and Reconditioning –Remodeling Phase Treatment Goal –Optimizing tissue function by continuing and progressing the activities performed during the repair phase and adding more advanced, sport-specific exercises –Apply progressive amounts of stress to injured area –Helps collagen align and grow Exercise Strategies: progress from ones used in repair phase –Transition from general exercises to sport-specific exercises –Specificity of movement speed an important variable –Velocity-specific strengthening exercises (velocities must progress to those used in the athlete’s sport)

34. Return-to-Activity Phase Return to normal activity should be based on therapist recommendations as well as testing –ROM- equal to contralateral limb desirable –Strength- at least 20% of contralateral limb –Functional capacity tests- assess functional limitations in injured limb as a whole Several injury/sport specific rehab/return plans exists

35. Post-injury Programming Examine the goals of rehab to determine if athlete has satisfied all of them –Ex. Back to a certain % of original strength or ROM Determine program based on athlete’s needs for sport –Ex. Pulled hamstring in marathon runner vs. pulled hamstring in Olympic lifter Keep open communication w/therapists

36. Rotator Cuff Rehabilitation Figure 20.5 (next two slides) –Exercises generally transition from (a, b) isolation exercises to (c, d) multijoint, sport-specific exercises.

37. Figure 20.5a and b

38. Figure 20.5c and d

39. Key Term closed kinetic chain: An exercise in which the terminal joint meets with considerable resistance that prohibits or restrains its free motion; that is, the distal joint segment is stationary.

40. Closed Kinetic Chain Exercises Figure 20.6 (next slide) –Closed kinetic chain exercises: (a) squat exercise (b) push-up exercise

41. Figure 20.6

42. Key Term open kinetic chain: An exercise that uses a combination of successively arranged joints in which the terminal joint is free to move; open kinetic chain exercises allow for greater concentration on an isolated joint or muscle.

43. Open Kinetic Chain Exercise Figure 20.7 (next slide) –Example of an open kinetic chain exercise—leg (knee) extension exercise

44. Figure 20.7

45. Kinetic Chain: Sprinting Figure 20.8 (next slide) –Sprinting offers an example of open and closed kinetic chain movements occurring together.

46. Figure 20.8

47. Key Point Designing strength and conditioning programs for injured athletes requires the strength and conditioning professional to examine the rehabilitation and recondi- tioning goals to determine what type of program will allow the quickest return to competition.