Return to Play

*RTP

*Classification of Injury

*Primary Injury- acute or chronic resulting from macro-traumatic or micro-traumatic forces

*Macro-traumatic- result from acute trauma= immediate pain and disability

*Micro-traumatic- result from overloading or incorrect mechanics associated with repeated motion, also known as overuse injuries

*Secondary Injury- the inflammatory or hypoxia response that occurs with the primary injury

* Goals of Rehab1. ↓ swelling, pain, inflammation2. ↑ ROM3. ↑ muscular strength, endurance, power4. Maintain cardiovascular fitness5. Re-establish neuromuscular control6. Improve stability and balance7. Address psychological reaction to injury/pain8. Posture & core stability9. Protect/prevent further injury10.Kinetic Chain/ Jt above/below11.Functional Progressions- sport specific12.Return to Activity Criteria13.Home Program

*Phases of Healing *Overlap with each other

*Inflammatory Phase: 2-4 days, SHARP/D, Goals; 1-3,9

*Fibroblastic-Repair Phase: first few hours post injury to 4-6 weeks, Goals; (1-3), 4-9, (10-11)

*Maturation- Remodeling Phase: 3 weeks to several years, Goals; (1-9), 10-13

*Inflammatory Phase

***Critical- if this response does not accomplish what it is supposed to, or if it does not subside, normal healing cannot take place

*Leukocytes and phagocytic cells go to injured tissue

*2-4 days

*SHARP/D- Swelling, Heat , Redness, Altered Function, Pain, Deformity

*Goals; 1-3,9

*Fibroblastic-Repair Phase

*Scar formation and repair of the injured tissue

*Collagen- strong fibrous protein found in connective tissue

*First few hours post injury to 4-6 weeks

*Some tenderness and pain if touched or stressed with particular movements

*Goals; (1-3), 4-9, (10-11)

*Maturation- Remodeling

Phase

*Long term process, 3 weeks to several years

*Increase stress and strain to realign fibers in a position of max efficiency, parallel to lines of tension

*Goals; (1-9), (10-13)

*Factors That Impede Healing

*Extent of Injury

*Edema

*Hemorrhage

*Poor Vascular Supply

*Separation of Tissue

*Muscle Spasm

*Atrophy

*Corticosteroids

*Keloids and Hypertrophic Scars

*Infection

*Humidity, Climate, Oxygen Tension

*Health, Age, Nutrition

* Swelling, Pain and Inflammation

*PRICE –Protect, Rest, Ice, Compression, Elevation for the first 72 hours

*Rest- Active Rest or AAROM (active-assisted ROM)

*Ice- Decreases pain, vasoconstriction of vessels to control hemorrhage(bleeding) and edema (swelling)

*Compression-decreases hemorrhage and hematoma formation

*Elevation- reduces internal bleeding

* ROM

*Restoring normal ROM following injury is a primary goal in rehab

*Must include exercise designed to restore normal ROM to regain normal function

*Several factors can limit flexibility and ROM: shape of jt, capsule, ligaments, mm, scars, neural tissue

*Flexibility involves the ability of the neuromuscular sys to allow for efficient movement of a joint through ROM

* ROM

*Factors affecting flexibility:

*Muscle- most often responsible for limiting ROM

*Connective Tissue- lose elasticity and shorten

*Bony structure- restrict end point in the range

*Fat- limits full ROM

*Skin- inelastic scar tissue incapable of stretching with jt movement

*Neural Tissue- tightness can create morphological changes in neural tissues

* ROM

*Active ROM= dynamic flexibility- degree a joint can can be moved by a muscle contraction

*Passive ROM= static flexibility- degree to which a joint can be passively moved to the end points of ROM

* ROM

*Reflex Autogenic Inhibition: Golgi Tendon Organs = relaxation in antagonist mm

*Contraction of agonist causes a reflex relaxation in the antagonist muscle

*Flexibility can be lost quickly

*Can be maintained with 1 session/week

*Need 3-5 sessions a week to improve!

* ROM

*Elasticity- ability to recover normal length after elongation

*Viscoelasticity- slow return to normal length and shape after deformation

*Plasticity- allows for permanent change or deformation

* ROM

*Joint hypo-mobility most frequently treated causes of pain

*Leads to compensations in the kinetic chain – abnormal joint stress, soft tissue dysfunction, neural compromise

*Can be traced to faulty posture, muscular imbalances, and abnormal neuromuscular control.

*ROM

*Intramuscular temperature should be increased prior to stretching

*Positive effects on collagen and elastin components within the musculotendinous unit to deform

*Capability of GTO to reflexively relax is enhanced when heated

*Low intensity warm up

*ROM

*Stretching Techniques:

*Dynamic and Static Stretching

*Proprioceptive Neuromuscular Facilitation

*Pilates

*Yoga

*Manual Therapy: Myofascial Release, Strain-Counterstrain, Soft Tissue, Massage, Graston

* Muscular Strength,

Endurance and Power

*First weeks of program is focused on training to be efficient ex. Technique, target fiber and contraction

*Strength directly related to efficiency of neuromuscular sys; increase motor unit recruitment, firing rate, enhancing synchronization of motor unit firing

*Muscular Strength,

Endurance and Power

*Resistance training plays a critical role in Rehab

*Muscle weakness/imbalance can result in abnormal movement/gait and can impair normal functional movement

*Muscular Strength- ability of a muscle to generate a force against some resistance

*Muscular Endurance- the ability to perform repetitive muscular contractions against some resistance for extended period of time

*Muscular Power- ability to generate great amounts of force against a certain resistance in a short period

*Types of Contractions

*ISOMETRIC- mm contracts, no change in mm length (static strength, decrease atrophy)

*CONCENTRIC- mm contracts, mm shortens to move resistance

*ECCENTRIC- mm contracts, mm lengthens to move resistance

*ISOKINETIC- mm contraction in which the length of the m is changing while the contraction is performed at a constant velocity

*MUST use ALL 3 (ISOM,CONC,ECCEN) for program, watch out for Rehabilitative Overload

*Factors that determine levels of strength,

power, and endurance

*Size of the muscle

*# of mm fibers

*Neuromuscular Efficiency

*Biomechanics

*Age

*Overtraining

*Types of Fibers

*Type 1- Slow Twitch, resistant to fatigue, time required to generate force is greater

*Type 2- Fast Twitch, fatigue rapidly, produce quick, forceful contractions

*Both types of fibers in muscle, varies between each individual

*Muscles whose function is to maintain posture have a higher percentage in slow twitch, and muscles whose function is to produce powerful, rapid movements tend to have more fast twitch

*Ratios are genetically determined

*Strength Development and

Adaptations

*Hypertrophy: increase in size of the muscle

*Reversibility: if resistance training is discontinued or interrupted, the muscle will atrophy, decreasing in bone strength and mass.

*Adaptations can reverse in as little as 48 hours

*Physical Adaptations to Resistance Training:

*Strength of non-contractile tissue is increased

*Mineral content of bone is increased

*Overload Principle

*For a muscle to improve in strength, it must be forced to work at a higher level than it is accustomed to

*Without overload, the muscle will maintain strength as long as long as training is continued against a resistance to which the muscle is accustomed, but no additional gains

*To most effectively build muscular strength resistance training requires a consistent increasing effort against progressively increasing resistance

*Techniques

*ISOMETRICS

*Progressive Resistive Exercise

*Surgical Tubing/ Theraband

*Repetitions- # of times movement is repeated

*Rep Max- max # of reps at a given weight

*Sets- # of reps

*Intensity- amount of weight lifted

*Recovery- rest interval between sets

*Frequency- # of times an exercise is done in week’s period

*Techniques

*Single Set

*Tri-sets

*Multiple Sets

*Supersets

*Pyramids

*Split Routine

*Circuit Training

*Plyometric

*Core Stabilization

*Open vs Closed Kinetic Chain

*Maintain Cardiorespiratory

Fitness

*Critical and often most neglected, improvements may be lost in as little as 12 days

*Regardless of training schedule/techniques; Main goal is to increase ability of Cardioresp sys. to supply a sufficient amt of oxygen to the mm.

*Upper vs Lower body injury

*Cardiorespiratory Fitness

*Cardiorespiratory Endurance- ability to perform whole-body activities for extended periods of time without undue fatigue

*Training Effects:

*Heart, blood vessels, blood, lungs

*Training for Cardio

*Continuous- technique that uses exercises performed at the same level of intensity for long periods of time

*Interval- alternating periods of relativity intense work followed by active recovery

*Detraining- Changes of the effects from training can reverse, improvements may be lost in as little as 12 days – several months

*Re-establish Neuromuscular

Control

*After injury, the CNS “forgets” how to put together information from mm and jt receptors

*Stimulus from cutaneous (skin), visual, and vestibular input as well

*Neuromuscular control is the mind’s attempt to teach the body conscious control of a specific movement

*NMC

*How it works:Successful repetition of a patterned movement makes its performance progressively less difficult and thus requires less concentration- eventually becoming automatic *Requires many repetitions, from simple to complex

movements

*Strengthening exercises- specifically those that are more functional= essential for NMC

*MOST critical during the early stages of rehab to avoid reinjury

*NMC

*Regaining NMC means regaining the ability to follow a previously established sensory pattern

*CNS will compare the intent and production of a specific movement with stored information and adjust until any discrepancy in movement is corrected

*Relearning normal functional movement and timing after injury to a joint may require several months

*NMC

*4 components:

*Proprioception (position of jt in space) & Kinesthesia (ability to detect movement)

*Dynamic Stability

*Preparatory and reactive mm characteristics

*Conscious and unconscious functional motor patterns

*Relies on the CNS to interpret and integrate proprioceptive and kinesthetic info and then control the mm and jts to produce coordinated movements

*NMC

*Multiplanar Lunges

*Single Leg Squat

*Proprioceptive Neuromuscular Facilitation Techniques

*An unstable platform promotes reactive muscle activity- attempting to balance on a platform- manually perturb

*Improve stability and Balance

*Process of maintaining the COG within the body’s base of support

*Involves integration of muscular forces, neurological sensory information, and biomechanical information

*The ability to maintain postural stability and balance is essential in acquiring or reacquiring complex motor skills

*Decreased sense of balance or a lack of postural stability following injury might lack sufficient proprioceptive and kinesthetic information and/or might have muscular weakness

*Improve Stability and Balance

*Single most important element dictating movement strategies within the close kinetic chain

*Highly integrative dynamic process involving multiple neurological pathways

*Postural Equilibrium- Alignment of joint segments in an effort to maintain COG within an optimal range of the max limits of stability

*Re-establishing neuromuscular control is one part of balance

*Improve Stability and Balance

*Somatosensory inputs provide information concerning the orientation of body parts to one another and to the support surface

*Injury can cause a disruption at some point between the body’s COG and base of support

*This can cause compensatory weight shifts and gait changes along the kinetic chain that have resulted in balance deficits

*BESS- Balance Error Scoring system

*Improve Stability and Balance

*Static: COG is maintained over a fixed base of support- on a stable surface- double, single leg, or tandem stance

*Semidynamic- maintain COG on a moving surface, or unstable surface- foam, trampoline, mini squats

*Dynamic (functional)- base of support is changing, forcing COG to adjust- balance beam, bounding

*BAPS board, BOSU, Dynadisc

*2-3 sets of 15 reps progress to 30 reps

*10 sets of 15 second period, progress to 30 seconds

*Psychological Reaction to Pain/

Injury

*Psychological and sociological consequences of injury are just as debilitating as the injury itself

*Can have an adverse impact on RTP

*Barriers to rehabilitation

*Focus on prevention: Listen, Educate on injury and rehab, Goal setting, Meditation/Progressive Relaxation, Imagery, REFERRAL

*Maintain confidentiality!

*Sociological Response

*Athletes may have problems adjusting socially and may feel alienated from the rest of the team

*Common feelings:

*Coaches cease to care

*Teammates have no time to spend with them

*Friends are no longer around

*Little support from coaches and teammates

*Predictors of Injury

*Stress: positive and negative forces that can disrupt the body’s equilibrium

*Negative stress tends to decrease the athlete’s attentional focus and create mm tension- can lead to a reduction in in flexibility, problems in coordination, and an overall decrease in movement efficiency, can cause athlete to miss important cues

*Physical Response to Stress: hormonal increases- cortisol, produce fear/anxiety = fight or flight response, epinephrine and norepinephrine, blood corticoids

*Emotional Response- personality change, if athlete enters a contest angry, frustrated or discouraged they are more prone to injury

*Predictors of Injury

*Overtraining: imbalance between a physical load placed on an athlete and their coping capacity. Can lead to staleness and burnout.

*Staleness: often attributed to emotional problems stemming from daily worries, fears, and anxieties.

*Anxiety: feeling of uncertainty or apprehension. The most common mental and emotional stress producer. Athlete can feel inadequate, have heart palpitations, shortness of breath, sweaty palms, etc.

*Symptoms of Staleness: chronic fatigue, deterioration in performance, apathy, loss of appetite, indigestion, weight loss, inability to sleep

*Predictors of Injury

*Burnout: syndrome related to physical and emotional exhaustion that leads to a negative self-concept, negative job or sport attitudes, and loss of concern for the feelings of others.

*Stems from overwork- affects both athlete and trainer, Detrimental to health

*Symptoms: headaches, gastrointestinal disturbances, sleeplessness, chronic fatigue

*Athletes can feel depersonalization, increased emotional exhaustion, a reduced sense of accomplishment, cynicism, and a depressed mood

*Psych and Rehab

*Must include:

*Rapport: relationship or a mutual trust and understanding

*Education: need to explain and educate on the rehab process, explaining the exercises to be performed correctly at home

*Cooperation: need cooperation between athlete, trainer, doctor

*RTP

*Many return to full participation physically ready but are psychologically ill prepared

*Progress in small increments: complete necessary skills away from team, engage in a small practice group, then attempt participation in full team non-contact

*Complete rehab exercises on the sideline- bike, core, functional, progressive exercises

*Use relaxation methods

*Goal Set

*Goal Setting

*Establishing progressive, attainable goals is essential in rehab

*Injured athlete has to take responsibility for the progress of the injury and be responsible for doing the necessary rehab

*9 Factors for goal setting: specific and measurable, positive language, challenging but realistic, reasonable timeline, short/ medium/ long goals, link outcome to process, internalize goals, monitor and evaluate goals, link sport goals to life goals.

*Mental Training

*Reducing tensions/ anxiety: Meditation and Progressive Relaxation

*Cognitive Restructuring: Refuting Irrational thoughts and Thought stopping

*Imagery

*Coping with Pain: Reducing Muscle Tension, Diverting Attention, Altering the Pain Sensation

*Mental Disorders

*Must be able to recognize and make a referral to the appropriate medical team

*Keys to referral:

*Recognize the need

*Know your limits

*Discuss referral with other members of the sports medicine team

*Maintain Confidentiality

*Mood Disorders

*Depression: disease in which an individual experiences helplessness and misery, loss of energy, excessive guilt, diminished ability to think, changes in eating and sleeping habits.

*1/5 suffer from depression

*SAD: Seasonal Affective Disorder characterized by mental depression related to a certain season of the year

*Most likely to occur due to a decrease in sunlight

*Symptoms: fatigue, diminished concentration, day-time drowsiness

*Anxiety Disorders

*Contribute to 20% of all medical conditions

*Physiological responses: sweating, increased heart rate and blood pressure, irritability, sleep disturbances

*Panic Attacks: unexpected and unprovoked emotionally intense experience of terror and fear. Occur in 30% of young adults and at night

*Phobias: persistent and irrational fear of a specific situation, activity, or object (heights, flying, closed spaces)

*Personality Disorders

*A pathological disturbance in cognition, affect interpersonal functioning, or impulse control

*Paranoia: having unrealistic and unfounded suspicions about specific people or things.

*OCD: Obsessive Compulsive Disorder combination of emotional and behavioral symptoms. Engages in unreasonable acts (washing hands, counting)

*PTSD: Posttraumatic Stress Disorder affects individuals who have suffered a psychologically traumatic event. Numbing of general responsiveness, insomnia, increased aggression

*Posture and Core Stability

*Core= Lumbo-pelvic-hip complex, location of COG and where all movements begin

*Posture- involves positioning the body’s center of gravity within the base of support

*Weak core= fundamental problem of many inefficient movements that lead to injury

*If one sys is out of alignment= patterns of dysfunction= Mechanical imbalance= bad posture (kyphosis, lordosis, sway back)

*MUST emphasize stable positions to maintain the structural integrity of the entire kinetic chain

*Core

*29 muscles have an attachment to the lumbo-pelvic-hip complex

*Referred to as “Butt and Gut”

*Inner (pelvic floor mm, TA, multifidus, diaphragm) and Outer unit (posterior oblique, deep longitudinal, anterior oblique, lateral)

*Lumbopelvic like a cylinder- inferior- pelvic floor, superior- diaphragm, posterior- multifidus, anterior/ lateral- transverse abdominus

*Core Units

*NEED ALL 5 ( including scapular stability)

*POST OB: glute max, contralateral lat

*Deep longitudinal- ES, biceps femoris, ligaments – Glute hamstring ES

*Anterior Oblique- internal and external obliques and contralateral adductors

*Lateral- glute med and min and contralateral adductors

*Simple exercises first then complex, need proper activation with any activity

*Imbalances

*Can create predictable patterns of dysfunction throughout the entire kinetic chain

*Crossed Pelvis Syndrome

*Upper Crossed Syndrome

*Posture

*Postural faults that persist can give rise to discomfort, pain, or disability

*Lack of mobility closely associated with faulty alignment

*Main goal- strengthen weak, stretch tight

*Pain in relation to Faulty posture- cumulative effects of constant or repeated small stresses over a period of time (muscle shortness, muscle weakness, stretch weakness)

*Posture

*Kyphotic- lordotic- Csp hyperextended, Tsp Increased flexion, Lsp hyperextended, pelvis anterior tilt

*Lordotic- Lsp hyperextended, pelvis anterior tilt

*Flat-back- Csp- extended, Tsp- upper flexion, lower flat, Lsp- flexed (straight), pelvis- posterior tilt

*Sway-back- Csp- extended, Tsp- flexion with posterior displacement of upper trunk, Lsp- flattening, pelvis- posterior tilt, anterior displacement of hips

*Scoliosis

*Handedness Patterns

*Knees/ feet, Scapular movement

*Protect and Prevent

*Equipment= Helmets!, facial protection (face, throat, mouth, ears, and eyes), neck protecting, trunk and thorax, hips/ buttock, groin/ genetalia, upper leg, lower leg, footwear

*Protect with injury= crutches, splints, tensors, tape, slings, foam padding

*Rehab program must allow for Rest!

*Strapping &Taping

*Tensor: ankle, calf, hip (x3), shoulder (x2), wrist, elbow

*Sling-cervical sling, shoulder sling, sling and swathe

*Taping

*Kinetic Chain

*Kinetic Chain- integrated functional unit, includes mm, fascia, ligaments, tendons, articular sys, and neural sys

*Joint above and below

*All of these systems function simultaneously as an integrated unit to allow for structural and functional efficiency

*If any system within kinetic chain is not working efficiently, the other systems are forced to adapt and compensate

*Kinetic Chain

*Compensation- leads to tissue overload, decreased performance, and predictable patterns of injury

*During functional movements, some muscles contract concentrically to produce movement, others contract eccentrically to allow movement to occur, other muscles contract isometrically to create a stable base on which the functional movement occurs

*Kinetic Chain

*Open- Kinetic Chain Exercise- distal segment is mobile and not fixed (foot or hand not in contact with ground or surface)

*Open- non-weight bearing, not all upper body exercises are open some closed, bicep curls, triceps extensions, bench press, leg curl/extension- more isolating exercises to target certain muscles, usually one jt

*Kinetic Chain

*Closed-Kinetic Chain Exercise- when the distal segment of the lower extremity is stabilized or fixed

*More sport or activity specific, exercises incorporate strengthening the entire kinetic chain rather than an isolated body segment

*Closed- associated with weight bearing activities and the lower extremity , minisquats, push ups,lunges, wall slides, leg press, stair climbing/ step ups, stationary bike, trampoline, BAPS board, slide boards, usually multi jt

*Functional Progressions

*A series of gradually progressive activities designed to prepare the individual for RTP

*Progress from simple to complex sport specific skills

*Skills are broken down into component parts and the athlete gradually reacquires those skills within the limitations of progress

*May be broken down into 3 phases: stabilization, strengthening, power

*RTP Criteria

*Physicians Release

*Pain Free

*No swelling

*Normal ROM

*Normal Strength

*Mentally Prepared

*Pass Functional Tests!

*Home Program

*All exercises completed during rehab should be completed at home or at practice