Lecture 5 Treatment and rehabilitation

Question 1

Ice

Answer 1

• Overlapping phases of healing:
• Hemostasis (0–several hours after injury),
• Inflammation (1–3 days),
• Proliferation (4–21 days) and,
• Re-modelling (21 days–2 years)
• It has been suggested that ice could disrupt the inflammation as well as the proliferation phases.
• Therefore, potentially, impairing tissue repair.
• BUT ice can effectively relieve pain.

Question 2

Wound healing

Answer 2

• Tissue never achieve the same level of tissue strength then before injury!
• It can reach up to 80% of it’s original strength.
• Form and function of the scar tissue depend on loading the
  tissue during this stage – injured area needs proper loading!
• Don’t confuse the tissue strength of the injured area and function!, load the tissue in order to restore function

Question 3

Re-injury

Answer 3

• Re-injury most often in the same location (Wangensteen et al, 2016)
• If the injury has gained enough strength, then the biomechanical
  weak-point becomes the interface between the scar tissue, and
  regenerating skeletal muscle fibre (Pieters et al, 2021)

Question 4

Elements of diagnosis- History

Answer 4

• age; sex
• details of injury
• training program and training history: spikes in load, were they prepared for the task ahead of them
• diet
• history of previous injury
• general health
• work/ and leisure activities
• other predisposing factors

Question 5

Elements of diagnosis- physical examination

Answer 5

• Inspection
• palpation
• ROM testing: active means athlete does it, passive means clinician does it
• strength testing
• ligament testing
• neural testing
• spinal examination
• bio-mechanical examination: balance and stability exercises

Question 6

Elements of diagnosis- imaging

Answer 6

• X-ray (radiography)
• CT (computed tomography)
• US (ultrasound)
• MRI ( magnetic resonance imaging)

Question 7

Stages of rehabilitation

Answer 7

1. acute stage
2. rehabilitation stage
3. training stage
   - often don’t know if they’ve moved from one stage to another

Question 8

Acute stage

Answer 8

Acute injury: PEACE/PRICE/POLICE
Repetitive injury: partial unloading of the injured structure, the loading pattern must be altered

Question 9

Rehabilitation stage

Answer 9

Monitor pain and swelling-> ensure normal ROM-> ensure strength-> ensure normal neuromuscular function-> ensure normal aerobic capacity
- restore their functions

Question 10

Rehabilitation stage: monitor pain and swelling

Answer 10

• It is necessary to tolerate some pain
• gradually increasing pain and/or swelling need to be reduced

Question 11

rehabilitation stage: re-establish ROM

Answer 11

• Normal ROM is a prerequisite for returning the athlete to normal technique
• reduced ROM limits ability to do strength and other training

Question 12

Ensure normal strength

Answer 12

• Often Manual Muscle Test – The Oxford Scale
  (0-5) (Navi, 2019)
• Consider, what is normal?
• Sport, Limb Dominance etc. (Kalata et al, 2020)
• Strength v Endurance
• Equipment v No Equipment
• 10-15% often used as marker, of symmetry, left vs right, for RTS

Question 13

Rehabilitation stage: neuromuscular training to regain normal neuromuscular function is vital

Answer 13

• Painful conditions may result in reflex inhibitions → changes in movement
  patterns → unfavourable loading pattern → INCREASED RISK OF RE- INJURY
• Acute ligament injuries may also result in reduced joint position sense and
  coordination → INCREASED RISK OF RE-INJURY
• Proprioceptive training
• Progressive strength training (injured structures)

Question 14

Normal aerobic capacity

Answer 14

• sport specific aerobic fitness
• modifiable intrinsic risk factor for injury

Question 15

Rehabilitation stage: alternative training

Answer 15

• training the other muscles and not on the injured areas
• maintaining general strength and endurance
• well performed alternative training will allow the athlete to return to sport sooner

Question 16

Rehabilitation stage: specific training

Answer 16

• Training that affects the injured structures
• The amount, intensity, frequency, duration and exercises depend on the injury
• Highly repetitive training
• Weekly consultation with a physiotherapist

Question 17

Rehabilitation stage: Other therapies

Answer 17

• Manual treatments: e.g., massage,
  manipulation, dry needling, vacuum
  cupping
• Taping, bracing
• Electrophysical agents: e.g.,
  therapeutic ultrasound, laser, shockwave therapy
• Medication: e.g., NSAIDs, corticosteroids
• Dietary supplements: e.g., vitamin D, glucosamine
• And many many more…

Question 18

Training stage: sport specific training

Answer 18

• Gradual transition from controlled rehabilitation exercises to sport specific training
• Functional and sport specific testing to determine whether an athlete can tolerate sport specific training loads
• Necessary that at least 85-90% of original strength is regained before being allowed to compete again

Question 19

Defining return to sport

Answer 19

• Restore physical strength from the injury.
• Nature of the sport or level
• Is it offseason or during the season
• Psychological readiness
• The definition of each RTS process should be according to the sport and the level of participation
• RTS success means different things to different people
• Contextual factors influence the expectations and risk tolerance
• Planning and documentation
• Three elements of the RTS continuum
• RTS= shared decision-making process

Question 20

RTS continuum

Answer 20

• return to participate
• return to sport
• return to perform

Question 21

What evidence do we have to inform the clinician’s contribution to the shared RTS
decision?

Answer 21

• Functional and sport-specific conditioning tests play an important role in RTS decision-making
• Assessing readiness to RTS
• Tests assessing the athlete’s readiness to RTS should consider both closed and
  open skills
• Psychological readiness is also an
  important element for optimal RTS
• RTS criteria: acute knee injuries, acute
  hamstring injuries, groin injury, Achilles
  tendon injuries, and shoulder injury

Question 22

Low back pain in youth athletes

Answer 22

• posterior overuse syndrome
  Continuum:
  1) Bone stress reaction (Posterior element overuse
  syndrome)
  2) Fracture (Spondylolysis)
  3) Slipping of vertebra (Spondylolisthesis)

Question 23

risk factors for spondylolysis and spondylolisthesis

Answer 23

• excessive extension and rotation loads
• improper technique
• hyperlordosis

Question 24

Posterior element overuse syndrome: diagnosis and treatment

Answer 24

• History, physical and neurological examination
• Imaging: e.g., X-ray, MRI, single-photon emission computed tomography (SPECT)
• Pain management*
• Pain free activities – avoiding extension
• Physiotherapy: core strength, anti lordotic exercises, hamstring and iliopsoas stretching
• Return to sport within 4-8 weeks

Question 25

Posterior element overuse syndrome: After surgery

Answer 25

• Week 1: short walks and stretching
• Weeks 2-9: static stabilization exercises
  (core)
• Weeks 6-12: dynamic strength exercises
• Weeks 9-12: low impact aerobic training
  RTS between 6 months and 1 year

Question 26

Prevention of low back pain in youth athletes

Answer 26

• Recognition of risk factors
• In youth athletes → reduced training
  during rapid growth
• Proper techniques!
• Core strength
• Hamstring and hip flexor flexibility
  Purcel 2009

Question 27

Groin pain

Answer 27

• Groin region = Where the abdomen meets the lower limbs via pelvis
• Adductor-related groin pain
• Iliopsoas-related groin pain
• Inguinal-related groin pain
• Pubic-related groin pain
• Hip-related groin pain

Question 28

Adductor-related groin pain

Answer 28

• Most common groin injury
• Pain during sprinting, direction changes, and kicking
• Pain in the insertion of the adductor longus

Question 29

Diagnosis and treatment

Answer 29

• History and physical examination (palpation and resisted adduction test)
• MRI is used to grade the injury extent from 0 to 3:
• 0 = no acute injury
• 1 = edema only
• 2 = structural disruption
• 3 = complete tear
• Exercise therapy programs
• Hölmich Exercise program (chronic groin pain)
• Progressive groin exercise program (acute groin injury)

Question 30

Treatment of chronic adductor-related groin pain

Answer 30

• The Hölmich Exercise program (8-12
  weeks)
• Isometric and dynamic exercises to reactivate the adductor muscles (2 weeks)
• Heavier resistance training, balance and coordination (6-10 weeks)
• Jogging is allowed after 6 weeks (if pain free)
• No stretching of the adductor muscles during this period!
  Sport specific training progressively after
  the program
  Chronic adductor-related groin pain = pain for at least 2 months

Question 31

Progressive groin exercise program

Answer 31

• nine groin exercise
• alternative days 3 times a week
• no groin pain allowed during the exercise

Question 32

RTS progression

Answer 32

• Three milestones:
  1. Clinically pain free
  2. Controlled sports training
  3. Full team training → RTS
• Athletes with an MRI grade 0-2
  adductor injury
• Usually return to full team training after 3 weeks
• Athletes with an MRI grade 3 adductor injury
• Usually return to full team training within 3 months