Rehabilitation in Sport. There is no ‘One size fits all’

I was recently asked to give a 1-hour online talk on Rehabilitation in Sport. At first I wondered what to do with this topic. It’s so broad & ill-defined. There are so many different sports, so many different levels of competency and competition. From social participation to competing at the highest international level. Individual and team sports, one player to two players to 15 players on the field at one time, all with different muscle energy requirements. Different tactics and skill-sets and even personalities needed for each different position within a team. There are endurance athletes and sprinters, sports that require brute strength and others that demand balance and co-ordination or an ability to hold one’s breath for an inordinate amount of time. Some sports are stock standard at school level, others are extreme. Some require upper body strength, others flexibility and dexterity. Not all athletes are fiercely competitive, some are ‘weekend warriors’ and many must confront their deepest fears and consistently push through pain barriers. Doubts and anxieties, denial, fear of failure, poor coping strategies and catastrophisation are just a few of the emotional battles that athletes must face.  Many risk severe injury, crashing at high speeds. Some injuries are because of overtraining, undertraining, extreme weather conditions or poor training environment or equipment. Each individual athlete can respond profoundly differently both to a specific injury as well as the prescribed rehabilitation. Some injuries occur in-season and others pre or post-season.

So how do we tailor our prescriptive rehabilitation to meet such variations and demands.

The answer is that we can’t. There is no ‘One size fits all’ approach. But there are some key points to structure the best management and prescriptive rehabilitation program for each specific athlete.

Based on all these considerations here are my top 11 tips

1. Know the Sport. Read about it, watch it, and better yet, get involved. Build up a rapport by understanding the rules of the game, key players and the types of injuries typical for that sport. Athletes feel a bond and therefore gravitate towards health professionals they believe understand the sport and its challenges. For example, a hockey player will tend to seek out a physio who has played hockey at some competitive level or who has covered on-field hockey injuries.
2. Get to understand the athlete in front of you. What level of competition and if relevant, what position do they play? What part of the season are they in: competition, off-season, or in-training (pre-season)? What aspirations or what level do they want to attain? This varies from simply wanting to participate socially to being selected for the 1^st school team and upwards to Provincial, National, or International selection. Do they have emotional (and financial) support from their family and/or friends? What Psychological factors such as denial, fears and anxieties and other mood disturbances may be relevant? Injuries do threaten athletes’ careers and have impacts on their quality of life. Who’s paying for the treatment? This may be relevant to the athlete’s compliancy or ‘buy-in’ to doing, as well as completing the prescribed rehab program.
3. Conduct a thorough and detailed subjective assessment (interview). Is the onset of injury from a traumatic incident or was there a slow build up or history of overload? What is the site of pain or instability etc and what areas of referral? Do you think there’s an inflammatory component? Are there any Red flags that might suggest a more sinister pathology? There are a multitude of important questions to ask. By the end of the assessment, you need to be able to visualise the problem as well as its significance to the athlete as related to, for example, maintaining their position in the team, or the stressful implications of an injury that threatens to limit their career or success.
4. Keep objective tests to a minimum. ‘Less is More’. Understand the value of each test, including the significance of a composite of positive tests. The most important test is the functional restriction the athlete demonstrates to you.
5. Use specific biomechanical loading tests especially if the injury is persistent or has developed over time. This guides specific rehabilitation that focuses on movement dysfunctions. It assists in finding the ‘Source’ of the problem and not focusing on the ‘Site’ of pain. These will also be relevant as rehabilitation becomes functional or sports specific. Remember that a lot of biomechanical information can first be derived by assessing loading in static postural positions. ‘If it ain’t right at rest, it ain’t going to be right in motion’. For example, if a hypermobile athlete, presenting with anterior knee pain during knee extension whilst running between the wickets is standing in knee hyperextension, the source of the problem might be exactly that.
6. Clinically reason your findings and develop a working hypothesis. This includes a provisional diagnosis and a management plan for short to long term outcome goals. This may include the need for further referral or for investigations such as an MRI or CT scan. Ideally the aim is to return the athlete back to ‘pre-injury condition’. This may only take 10 days, if a soft issue injury, or months if management requires surgery, and sometimes full return to top competition is not always achievable.
7. Prescribe a rehabilitation program that is specific to the time in the season (pre-season, competition, post-season). Rehabilitating an injury, especially during the in-season period is often challenging as the athlete often must fulfil playing and training commitments. Certain exercises, such as isometrics have been shown to produce an immediate analgesia effect and so may be more effective to use for in-season athletes to control pain (Rio et al, 2017).
8. Prescribe a rehabilitation program that is relevant to that specific athlete as well as to that stage and severity of the injury. From pain management and protection, the therapist must be cognitive of flexibility and restoring optimal joint range of motion. The entry point to rehabilitation is individual specific and needs to consider motor control, strength, endurance, proprioception and functional rehabilitation back to pre-injury condition. Utilise various visual and auditory feedbacks to enhance neuroplastic training. Monitor and gradually progress loading utilising isometric, isotonics, eccentrics, isokinetics and plyometrics. Watch for a 24-hour pain response. An increase in pain over 24 hours implies that the injury was overloaded. The exercise may be correct, but simply prescribed too soon or with too many repetitions or load.
9. Advice, reassurance, and education are paramount. Rehabilitation requires complete buy-in, commitment and compliancy from the athlete. Educating and including the athlete in decision making as well as goal-setting all increase the athlete’s motivation and focus (Norsworthy et al, 2017). Improving commitment from the athlete often involves including his trainer, his manager or coach and if relevant, his parents in the information stream. For example, in the early stages of rehab its often those small stability movements that are important to get segmental control but motivating the athlete to persist with the program when they don’t see rapid results is sometimes the greatest challenge.
10. Utilise the help of experts in their fields. Perhaps you need the assistance of a Nutritionist, Sports Psychologist or Sports Physician to best manage this athlete. Where possible, utilise the combined skills of a multi-disciplinary team. As the Physiotherapist, read and continually learn to be as well-informed as you can be. This is particularly important if you work in regions or certain sporting codes where there are budgetary restraints or limited facilities. Although not ideal, the reality is that for many of us, these limitations demand that we wear many hats and have a workable knowledge of many roles.
11. Be flexible and adaptive. Modify your program and management based on changes on injury behaviour as well as the athlete’s response. Be cognitive of the stresses, fears, anxieties and other psychosocial factors that can influence your patient’s response to treatment as well as speed of recovery. Rehabilitation back to full competition is not only physical, but often also psychological.

If you’d like to watch the webinar related to this article, click here. In this presentation I expand on these ‘tips’, as well as suggesting various entry points into different stages of rehabilitation, all with specific exercises and loading principles.