Chapter 11: Understanding
the Basics of Injury
Rehabilitation
McGraw-Hill/Irwin
© 2013 McGraw-Hill Companies. All Rights Reserved.
• Therapeutic Exercise
– Exercise used as part of a rehabilitation
program
• Conditioning Exercise
– Activities that are used to minimize injury
and maximize performance
11-2
Philosophy of Athletic Injury
Rehabilitation
• Majority of injuries do not involve long-term
rehabilitation programs
• Long term rehab requires supervision of
highly trained professionals
– Coach should rely on athletic trainer to design,
implement, and supervise rehabilitation
11-3
• Swelling and pain control should be
provided immediately
– Coach can be involved initially in
application of first aid
• Goal of athlete
– Return to activity as quickly and as safely
as possible
• Must be prudent in decisions regarding
aggressiveness of treatment and
rehabilitation
– A mistake in judgment could hinder the
athlete’s return
11-4
Basic Components and Goals of
a Rehabilitation Program
• Must address several basic components
• Short term goals
– Provide correct and immediate first aid to control
swelling
– Control pain
– Restore full ROM
– Restore core stability
– Restore and increase strength, endurance and
power
– Re-establish neuromuscular control and balance
– Maintain levels of cardiorespiratory fitness
11-5
Providing Correct First Aid
and Controlling Swelling
• Initial first aid is critical
• Should be directed towards swelling
control
• Utilize the PRICE principle
– Each factor is critical in limiting swelling
11-6
Controlling Pain
• Pain dependent on the severity
of the injury, athlete’s
response, perception of pain
and the circumstances
• PRICE and additional
modalities can be used to help
modulate pain
• Pain can interfere w/ rehab and
therefore must be addressed
throughout the rehab process
11-7
Restoring Range of Motion
• Injury to a joint will always be
associated w/ some loss of motion
– Due to contracture of connective tissue or
resistance to stretch of musculotendinous
unit
• Athlete will need to engage in dynamic,
static or PNF stretching activities to
improve flexibility
11-8
11-9
Restore Core Stability
• Involves strengthening the lumbopelvic
region and is critical for dynamic
functional strength and movement
• Without proximal core stability, distal
extremity function becomes compromised
– Core strength & power must be emphasized
early in the strength training program
11-10
11-11
Restoring Muscular Strength,
Endurance, and Power
• Essential factor necessary when
restoring function of a body part to preinjury status
• Variety of techniques can be utilized
– Isometrics
– Progressive resistance
– Isokinetics
– Plyometrics
• Emphasize work through a full ROM
11-12
• Isometrics
– Performed in early part of rehab following period
of immobilization
– Used when resistance through full range could
make injury worse
– Increase static strength, work to decrease/limit
atrophy, create a muscle pump to decrease
swelling
• Progressive Resistance Exercise (PRE)
– Can be performed using a variety of equipment
– Utilizes isotonic contractions to generate force
while muscle changes length
– Concentric and eccentric strengthening
exercises should be utilized
11-13
Progressive Resistance Exercises
11-14
• Isokinetic Exercise
– Incorporated in later
stage of rehabilitation
process
– Uses fixed speeds w/
accommodating
resistance to provide
maximal resistance
throughout ROM
– Speed of movement can
be altered
– Commonly used as part
of the criteria for return
to functional activity
11-15
• Plyometric Exercise
– Incorporated into later
stages of program
– Use quick stretch of
muscle to facilitate
subsequent concentric
contraction
– Useful in production of
dynamic movements
• Associated with
muscular power
• Generation of force
rapidly – key to
successful performance
in many activities
11-16
Re-establishing Neuromuscular
Control
• Neuromuscular control is mind’s attempt to teach
the body conscious control of a specific movement
• Relies on CNS to interpret and integrate sensory
and movement information and then control
muscles and joints to produce coordinated
movement
• Re-establishing neuromuscular control requires
repetition of same movement until it becomes
automatic
– Progression from simple to difficult task
• Functional exercises are critical for re-establishing
control
11-17
Regaining Balance
• Ability to balance and maintain postural
stability is essential to reacquiring athletic
skills
• Program should incorporate functional
exercises that involve balance training
• Failure to include balance training may
predispose the athlete to re-injury
11-18
• When balance is challenged the response is
reflexive and automatic
• The primary mechanism for controlling balance
occurs in the joints of the lower extremity
• Lack of balance or postural stability  lack
proprioceptive and kinesthetic information or
muscular strength  limits ability to generate
response to disequilibrium
• A rehabilitation plan must incorporate functional
activities that incorporate balance and
proprioceptive training
11-19
11-20
Maintaining Cardiorespiratory
Fitness
• Single most neglected component of
rehabilitation
• When injury occurs athlete is forced to miss
training time resulting in decreased
cardiorespiratory endurance
• Alternative activities must be substituted that
allow athlete to maintain fitness
– Put into rehabilitation program as early as possible
in rehabilitation program
11-21
Functional Progressions
• Progressive activities designed to prepare the
individual for return to sport/activity
• Sport-specific skills are broken into components
– Athlete works to reacquire skills over time
• Incorporate into treatment as early as possible
– Athlete’s physical tolerance must be monitored
• If pain and swelling do not arise, the activity can
be advanced
• Assists injured athlete in achieving normal, painfree ROM, strength and neuromuscular control
11-22
Functional Testing
– Uses functional progression drills for the
purpose of assessing the athlete’s ability to
perform a specific activity
– Entails a single maximal effort to gauge
how close the athlete is to full return
– Pre-season baseline testing for
comparison post injury
– Variety of tests
•
•
•
•
Shuttle runs
Agility runs
Figure 8’s
Cariocca tests
-Vertical jumps
-Balance
-Hopping for distance
-Co-contraction test
11-23
11-24
Using Therapeutic Modalities
• Incorporated into rehabilitation program
as adjuncts to exercise
– Cryotherapy and thermotherapy
– Ultrasound and electrical stimulation
– Massage and traction
• Require special instruction and
supervised clinical experience
11-25
Ice Packs (Bags)
• Used for minimizing swelling and
providing analgesia following injury
• Ice may be flaked or crushed and will be
encapsulated in wet towel or plastic bag
– Both are easily moldable to body
• Elastic wrap generally utilized to secure
pack in place for 20 minutes
• Compression and elevation are also
used in conjunction with ice
11-26
Hot Packs
• Used post-acutely (after swelling stops)
– Increase blood flow
– Facilitate reabsorption of injury by-products
• Useful as analgesic and for relaxation
effects
• Be careful not to use too soon in healing
process
– Cold should be used for first 72 hours postinjury
11-27
• Moist heat packs (hydrocollator packs)
– Silicate gel in cotton pads
– Maintained in thermostatically controlled
hot water (160oF)
– Retain water and relatively constant heat
for 20-30 minutes
– Requires the use of 6 layers of toweling to
avoid burning patient
– Athlete should not lie on top of pack
11-28
Criteria for Full Return to Activity
• Rehab plan must determine what is meant
by complete recovery
– Athlete is fully reconditioned
– Regained full ROM, strength, neuromuscular
control, cardiovascular fitness and sports
specific functional skills
– Athlete is mentally prepared
• The decision to return to play should be a
group decision (sports medicine team)
– Team physician is ultimately responsible
11-29
ACLR Checklist for Phase Progression and Return to Sport
*Timelines are estimated and dependent upon passing criteria for
progression
0-6 weeks
Phase 1 Goals
 Full active and passive ROM
 Weight bearing
 Restoration of normal gait
 Pain control
Criteria for Progression to Phase 2
 Normal, pain-free ROM
 Normal gait
 Symmetrical upper and lower extremity rolling patterns
 Good core control
 Optimal loaded hip hinge in symmetrical stance
 Minimum load dead lift
 Optimal loaded body squat in symmetrical stance
 Optimal anterior lunge technique
 Comfortable and correct static half kneeling lunge bilaterally
 FMS: no asymmetries with shoulder mobility or active SLR
11-30
6-22/24 weeks
Phase 2 Goals
 Achieve minimum 14/21 FMS, ≤ 15% asymmetry in SL press, lumbopelvic neutral to advance to
below
activities
 Linear deceleration progression to complete before running (by ~Week 10)
 Maintain 14/21 FMS or higher
 Complete linear deceleration progression w/ no asymmetries
 Vertical deceleration progression to complete before jumping/plyos (by ~ Week 14)
 Maintain 14/21 FMS or higher
 Complete vertical deceleration progression w/ no asymmetries
 Lateral deceleration progression to complete before crossover/lateral speed and agility (By ~
Week 16)
 Maintain 14/21 or higher FMS
 Complete lateral deceleration progression w/ no asymmetries
Criteria for Progression to Phase 3
 15/21 or higher FMS
 Completed linear running progression w/ no asymmetries
22-24+ weeks
Phase 3 Goals
Average return to
 Linear non-contact, sport-specific movements
sport is 6-12 months,  Vertical non-contact, sport-specific movements
but is dependent on
 Lateral non-contact, sport-specific movements
passing functional
progression
Return to Sport Criteria
 FMS: 16/21 w/ no asymmetries, no 1’s/0’s
 Y-balance test: total anterior difference <4cm, total right and left composites >94%
 Vertical jump power assessment on jump pad: Power score within 10% bilaterally
Hop and stop test: Score of 5 or lower when compared bilaterally, mean distance must be at least 105%
11-31
of mean hop score