Rehabilitation of Multi-Sport Athletes Following Sports-Related Injury
Rehab and retraining of movement patterns can help revamp athletic efficiency postinjury
Multiple factors can contribute to the incidence of sports-related injuries, including improper training, inappropriate gear, lack of a proper warm-up or cool-down, poor biomechanics, overtraining, or an acute accident or trauma during the actual activity. The most prevalent sports-related injuries occur in the lower extremity, primarily the knee and ankle. These injuries can vary from a sprain or a strain to a stress fracture or acute fracture of the lower leg or foot. An acute injury relates to a sudden onset of pain, often associated with some type of trauma or physical contact, such as an ankle sprain or torn ACL in the knee joint. Chronic injuries are more often associated with an overuse syndrome and are characterized by the presence of pain during the activity and often a dull ache at rest. An example of a chronic injury may include Achilles tendonitis or a stress fracture. Higher training volumes have consistently been linked to an increased risk of overuse injuries in many sports.1 For degenerative knee conditions, the Elite Seat from AKT Medical, Noblesville, Ind, allows for full knee hyperextension and pain reduction in bent knees.
Incorporating ellipticals, rowing machines, or upright bikes, such as those available through Exertools, Petaluma, Calif, into athletic practice allows for continued aerobic activity with reduced load through the joints and lower-impact alternatives. This helps keep athletes engaged and active while also minimizing risk of injury or overuse by varying the activity, reducing stressful impact, and allowing for active recovery. Other manufacturers that offer these types of equipment include Spirit Medical Systems Group, Jonesboro, Ark.
Seeking a Speedy Recovery
Many athletes are involved in more than one sport and desire to be ready for the upcoming season in a timely manner—ready to play at their highest level. These multi-sport athletes are at high risk for future injury and need a well-designed rehab and prevention program for successful re-entry into the sports arena. To return an athlete safely to sports, physical therapists play an integral role in the evaluation of the individual and the proper management of return-to-play activities.
A thorough evaluation includes an assessment of the injury and associated risk factors that may have contributed to its origins. Part of this evaluation includes a strength assessment of the areas of weakness that may contribute to a higher potential for injury. For example, weak knee extension has been correlated with patellofemoral pain syndrome.2 Decreased hip strength, poor ankle control, and poor landing mechanics may also contribute to knee injuries. Poor scapular stability or strength places the throwing athlete or swimmer at higher risk of injury, while decreased core strength has been correlated to many overuse injuries and is the focus of most athletic rehabilitation programs from spinal injuries to upper-extremity injuries.1 Sports require a combination of movements, and all rely heavily on adequate control through the core musculature, especially for sports that include a rotary component to movement, such as throwing, swimming, swinging a bat, or planting a foot to kick.
A valgus lower limb alignment is commonly documented among noncontact ACL injuries, and athletes presenting with lower-extremity pain may be evaluated using the drop-jump test. The clinician videotapes a jump down from a box and examines the angles in the lower extremities at landing using a program such as Sportsmetrics Digitizer, software available through Sportsmetrics, an ACL injury-prevention program designed to decrease serious knee ligament injuries in female athletes. The interventions include a neuromuscular retraining program featuring a dynamic warm-up, jump training, speed and agility drills, and strength training.3 A variety of exercises and different equipment can be utilized to attain the goals of this retraining. The BTE PrimusRS, from Hanover, MD-based BTE, can also be used for neuromuscular re-education, orthopedic rehab, multi-joint testing, and advanced musculoskeletal athletic training.
An area of primary concern is hip control and stability with dynamic movement. West Warwick, RI-based Perform Better‘s resistance bands are extremely useful to initiate hip-strengthening
activities such as side steps for the hip abductors, external rotation exercises for deep hip musculature, and hip abduction activation during squatting activities for improved muscle-activation patterns. Resistance bands and tubing can also be found through Stretchwell Inc, Warminster, Pa.
The UltraSlide slide board is also a useful piece of equipment for higher-level athletic movement. A slippery surface allows athletes to progress with lateral movements consistent with sports such as basketball, soccer, or tennis, which require quick lateral movements. Available through Varisport Inc, Northbrook, Ill, it provides an effective, low-impact, aerobic exercise for athletes, strengthening the gluteals and lower-extremity musculature through a variety of challenging movements. One of the most common exercises is a lateral skating movement, pushing off the barriers at each end of the board. The slide board can be used to force focused control of the stance leg during a reverse lunge because it decreases the ability to push off the back leg when returning to the starting position. It may also be used for upper-extremity work, particularly with development of scapular control.
For ankle control and stability, an Airex foam pad works well to challenge the proprioception of the ankle joint during dynamic activities such as playing catch. A BOSU ball, produced by BOSU, Ashland, Ohio, or a FitBall Balance disc, from Longmont, Colo-based Ball Dynamics International LLC, also work well, challenging the athlete to maintain balance on an uneven surface while performing movements of the upper body. For runners, single-leg stance on one of these varying surfaces while moving through running form with the other lower extremity is highly challenging and effective when rehabilitating from lower-extremity injuries or in order to engage the core musculature.
While these activities are fun aspects of rehabilitation and mimic sports activities, athletes in the early stages of acute injury will not be able to tolerate this level of exercise. Immediately following injury, the focus of rehab is to reduce pain, decrease swelling, and restore range of motion around the injured joint or to eliminate soft-tissue restrictions. In these early stages, the Game Ready from Game Ready Accelerated Recovery, Berkeley, Calif, is a great device to apply compression and ice around an injured joint.
Other modalities may include low-level laser therapy (LLLT) and electrical stimulation (e-stim). LLLT technologies include the MR4 Super Pulsed Lasers from Multi Radiance Medical, Solon, Ohio, and the LightForce EX from LightForce Therapy Lasers by LiteCure Medical, Newark, Del. Manufacturers of e-stim technologies include Empi, Inc, a DJO Global company, Vista, Calif, and Zimmer MedizinSystems, headquartered in Irvine, Calif, which offers products such as single-use electrodes and EMS 5 Therapy System.
In addition, a topical analgesic such as Ari-Med Pharmaceuticals’ Flexall and Maximum Strength Flexall topical pain-relieving gel formulas can also play a role in acute injury treatment, zeroing in on pain resulting from conditions that include muscle strains and sprains, as well as arthritis and backaches. Sombra, Albuquerque, NM, also offers pain-relieving gel for warm and cool therapy that is formulated to help relieve minor aches and pains of muscles and joints linked to these conditions. Sore No More, Moab, Utah, also markets natural pain-relieving gel that blends six natural plant extracts with menthol, capsaicin, and witch hazel to address sports injuries, muscle soreness, and more.
Early mobilization is key in returning an athlete to sport and maintaining fitness levels throughout the rehabilitation process. This may be initiated by adding medical exercise therapy, a high-repetition, low-load approach to movement to reduce pain, restore mobility, and allow for neuromuscular re-education.
A Cardon pulley system, from Cardon Rehabilitation & Medical Equipment Ltd, Burlington, Ontario, Canada, is extremely effective for proper gradation of exercise prescription and allows for consistent resistance throughout the prescribed movement. The weight stacks allow for appropriate rehabilitation resistances and slow progression versus the standard pulley systems found in most gyms. Pinellas Park, Fla-based Endorphin Corp also offers a variety of pulley systems to build strength and increase range of motion. These include the 390 Series Pulleys, which feature wall-mounted, freestanding, or mobile pulleys and combos of double, tri, or quad systems.
Consistency with a stabilization and core-strengthening program are critical components to the prevention of future injury in athletes. Other self care techniques include a flexibility routine, use of Austin, Texas-based Trigger Point Performance’s GRID foam roller to maintain proper soft-tissue extensibility by breaking up fascial restrictions, and consistent icing to reduce inflammation and swelling following workouts or competition. The GRID foam roller is also among the lines of foam rollers available through OPTP, Minneapolis, which include the PRO-ROLLER.
Sports-related injuries can be frustrating, yet they also quickly expose areas of weakness and dysfunction in athletes. This leads to the ability to retrain proper movement patterns, increase strength and neuromuscular control around the joints, and offer education to balance strength throughout the extremities and core musculature. The result may often lead to a more efficient athlete, equipped with the tools necessary to prevent future injury. PTP
Lindsay A. Holmes, PT, DPT, MTC, OCS, is a physical therapist and site supervisor at Gaylord Physical Therapy Orthopedics and Sports Medicine in North Haven, Conn. A graduate from Quinnipiac University, she has been a licensed physical therapist for more than 10 years and also works as online faculty for the University of St Augustine in the flexible DPT, MOT, and MOA programs. For more information, contact PTPEditor@nullallied360.com
1. DiFiori JP, Benjamin HJ, Brenner JS, et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med. 2014;48(4):287-288.
2. Pappas E, Wong-Tom WM. Prospective predictors of patellofemoral pain syndrome: A systematic review with meta-analysis. Sports Health. 2012;4(2):115-120.
3. Barber-Westin SD, Noyes FR, Smith ST, Campbell TM. Reducing the risk of noncontact anterior cruciate ligament injuries in the female athlete. Phys Sportsmed. 2009;37(3):49-61.
The following companies also offer products for rehab and fitness:
Ball Dynamics International LLC
Cardon Rehabilitation & Medical Equipment, Ltd
Empi, Inc, a DJO Company
Flexall (Ari-Med Pharmaceuticals)
Game Ready Accelerated Recovery
General Physiotherapy Inc
Kinesio Holding Company
LightForce Therapy Lasers by LiteCure
Mad Dogg Athletics
Multi Radiance Medical
NK Therapy Products Inc
NZ Manufacturing Inc
Power Systems Inc
Rejuvenation Prevent + Perform + Recover
Sombra Professional Therapy Products
Sore No More
Southwest Technologies Inc
Straight Arrow Products
Spirit Medical Systems
Trigger Point Performce Inc