Essential Considerations in
Designing a Rehabilitation
Program for the Injured Patient
Chapter 1
Introduction
• Rehabilitation of athletic injuries through programs
utilizing progressive therapeutic exercises is a
responsibility of the sports medicine team,
emphasizing the skills and knowledge of the
therapist..
Philosophy of Sports Medicine
Rehabilitation
• Key words
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Aggressive
Quick return to play (RTP)
Safety
“Balancing Act”
• Finding the balance between to much exercise and not
enough exercise
Philosophy of Sports Medicine
Rehabilitation
• What sports medicine professional need to understand
– Types of injuries
– Healing process
– Pathomechanics of injuries and illnesses
• Etiology – Cause of disease/injury
• Pathology – Study of nature/causes of a disease which involves
changes in structure and function
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Psychological aspect of rehabilitation
Available tools and resources
Therapeutic exercise vs. conditioning exercises
Protocols
Types of Injuries
• Macro vs. microtrauma
– Macro
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Sprains (ligaments)
Strains (muscles)
Fractures (bones)
Contusion (soft-tissue and bone)
– Micro
• Stress fractures
• Tendonitis
Healing Process
• Altering a therapeutic exercise or conditioning
program is primarily dependent upon understanding
the different phases the body goes through while
healing
• Therefore, sports medicine professionals must try to
create an environment conducive to the healing
process
Healing Response
• Bodies mechanism to rid the body of damaged
tissue
• Immediate response to acute injuries
• Non-specific to site or stimulus
• Essential for tissue repair
• Divided into three process
– Acute inflammation, proliferation (fibroblasticrepair) & maturation (maturation-repair)
Healing Response
Inflammation
• Initial injury to body
– Microtrauma or
macrotrauma
• Used to protect, localize, and rid
the body of injurious agents
• Includes a number of vascular,
cellular and cellular changes
–  cell membrane
permeability and edema
formation
– Phagocytosis
• Concerned w/ 2nd death of
tissue – Secondary hypoxic
injury
• Cardinal Signs of Inflammation
– Heat and redness
•  BF and cell metabolism
to traumatized tissue
– Swelling
• Loss of continuity of
vascular structures
• Chemical mediators
– Pain
• Chemical mediators
• Swelling
– Loss of function
• Combination of the above
Healing Response
Proliferation
• Marked by the removal of the cellular debris and the creation
of a vascular network to support new tissue growth
• Rate of proliferation phase in influenced by several factors
include cell type, health, age, nutrition
• Looking for the regeneration and restoration of the
destroyed/lost tissue, however most tissue will never be
identical to the traumatized tissue
• May last 48-72 hrs up to 6 weeks after inflammatory phase
• May begin after 2nd tissue death and cell debris has been
cleaned
Healing Response
Maturation
• “Cleaning-up” period
• May last up to a year or more
• Fibroblasts, myofibroblasts, macrophages are
reduced to pre-injury state
• Scar begins to fade as the extra capillaries and water
are moved from the area
• Need to keep encouraging re-organization & tensile
stress to the tissue
Healing Process
• SAID Principle
– Specific Adaptation to Imposed Demands
• “When an injured structure is subjected to stress and
overloads of varying intensities, it will gradually adapt
over time to whatever demands were placed upon it”`
– In some situation failure to do this leads to injury
– Therefore, exercise intensity must be equal to the
healing phase
Pathomechanics
• Injuries result in changes to the normal joint
arthokinematics and osteokinematics
• Therefore, sports medicine professionals need to
have adequate knowledge in structural mechanics
and how the structures will react to these changes
Psychological
• This stage is often the most neglected
• Injuries/illnesses produce a wide range of emotions
and how an individual and/or athlete reacts will
affect his/her interpretation and reaction to pain,
cooperation, compliance, denial, etc
Tools
• Sports medicine professional should try to have knowledge
of things such as:
– Basic first aid principles, understanding of the differences
between different types of exercises based on the phase of
tissue healing, how and when to progress an athlete,
modalities, ortho evaluation skills
• Athletes differ in their response to rehabilitation therefore
avoid “cookbook” or “recipe” approach
• Do what is right and not what is seen. Strict application of
knowledge and using all knowledge separates a great
therapist from everyone else
Therapeutic Exercise vs.
Conditioning Exercise
• Therapeutic exercise
– Any kind of movement of any of the body parts to rehabilitate to
optimal function and to reduce symptoms
– Problem orientated
• Conditioning exercise
– Used to maintain cardiovascular and physical fitness to avoid injury
• Need to consider the affects of each of these on the types of exercise
– Effects on muscles
– Effects on joints
– Effects on cardiorespiratory system
Goals of Rehabilitation
• Provide correct/immediate
medical intervention to
limit or minimize swelling
and injury
• Decrease or minimize pain
• Restore full ROM
• Restore or increase
strength, endurance, and
power
• Re-establish neuromuscular
control
• Increase balance and
proprioception awareness
• Maintain cardiovascular
endurance
• Functional progression
Therapeutic Exercise Template
Every Assignment/Test
*You now have the keys to modalities & Ther X
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Modalities
–  Pain/Edema
–  Neurological functioning
Scar tissue formation
Joint Mobs, distraction, myofascial
release
ROM
Flexibility /restore
Balance/Gait training
Establish core stability
Postural stability/balance
Restore/increase strength
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 atrophy,  hypertrophy
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Restore or increase endurance
Restore or increase power
Reestablish neuromuscular control
Restore/ balance & proprioception
Maintain/ cardiovascular
endurance
Functional exercise/progression
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Multiple planes
Modalities
– As needed
Functional testing
Return to activity testing
Keys – Daily SOAP Note
Every Assignment/Test
• Subjective
– How does the patient feel,
NSAIDs/drugs, Pain
level, residual pain
• Objective
– Short term/long term
goals
– List entire treatment in
detail. Ortho special tests,
modality settings/time,
exercise,
sets/reps/weight,
duration
• Assessment
– How did the patient react
to the treatment. Specific
problems, effort,
adherence, special
tests/documentation as
needed
• Plan
– Add, delete, or continue
rehab plan. Special test or
measurements to be done
in the future.
Why Document Using SOAP
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Legal ramifications
Communication
Organization
Professionalism
Patient motivation
– Review goals
– Review objective data progress
Goals of Rehabilitation
Inflammation
• Prevent new tissue disruption using PRICE
– Protection
• Splints, pads, immobilization if necessary
– Restricted Activity (Rest)
• Research has shown that complete mobility can be bad, rather
controlled mobility may aid in reducing scar formation,
revascularization of tissue, muscle regeneration and reorientation of
muscle fibers and tensile strength
– Ice
• Decreases pain & promotes vasoconstriction, thereby controlling
hemorrhage & edema
– Decreases 2nd tissue death
– Decreases muscle spasms and provides an analgesic effect
– Used in the treatment of bursitis, tenosynovitis, and tendonitis
Goals of Rehabilitation
Inflammation
– Compression
• Most important factor in controlling swelling
– Purpose is to mechanically reduce the amount of space
available for swelling by applying pressure around the
injured area
– Wrap distal to proximal
– Elevation
• Eliminates the affects of gravity on blood and other fluid pooling
in an extremity
– Assists in venous and lymphatic drainage
– Greater the degree of elevation the more effective it is in
reducing swelling
Goals of Rehabilitation
Proliferation
• Goals is to prevent muscle atrophy and joint
deterioration while preventing destruction of new
tissues
• Begin to apply low-load stress to prevent a loss of
joint motion, however need to because about the
amount of load and point of application
• Continue to maintain cardiovascular and
cardiorespiratory function
Goals of Rehabilitation
Maturation
• Optimizing tissue function is the primary goal
during the final phase of healing
• Include the addition of functional and sportsspecific activities, however, still need to maintain the
balance between too much and not enough
Exercise Strategies
Proliferation
• Major goal is to work through “full pain-free ROM”
• Accomplished through the use of:
– Isometric exercise
• Submaximal
• However, they are joint angle specific
– Isotonic
• Movement with a constant external resistance
– Gravity
– Resistance bands
– Dumbbells
– Weight machines
– Proprioception
• Refers to conscious and unconscious appreciation of joint
position
Exercise Strategies
Maturation
• Focus is placed on:
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Functional activities
Sport-specific exercises
Closed and open chain exercises
Exercises to improve proprioception
Closed vs. Open Chain
• Panaereillo defines CKC as
– “activity of the extremities as an activity in which the
foot or hand is in contact with the ground or a
surface.”
– Emphasizes that the body weight must be supported
for a closed-kinetic chain to exist
• Note: Few exercises can be absolutely classified as
open or closed chain kinetic exercises
• Most such as running and jumping fall somewhere
in between
Closed vs. Open Chain
Characteristics
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CKC
 Joint compression force
 Joint congruency
(stability)
 Shear force
 Acceleration force
Larger resistance force
Stimulation of
proprioceptors
OKC
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 Distraction and rotational
forces
 Deformation of joint and
muscle mechanoreceptors
 Acceleration forces
 Resistance force
Concentric acceleration and
eccentric deceleration forces
Promotion of functional
activity
Closed vs. Open Chain
CKC Advantages
• Safer and produces stress and force that are
potentially less of a threat to the healing tissue
• Muscular co-activation – required for joint
stabilization
• Decrease in shear force, caused by muscular coactivation
• Lower extremity activities tend to be more
functional in nature
• Requires synchronism of the agonist and antagonist
Closed vs. Open Chain
OKC Advantages
• Motion isolated to a single joint within a specific
plane
• Used to improve strength and ROM
• Applied to single joint manually as in PNF and joint
mobilizations or threw some type of machine
• Isokinetic exercises are an example of open chain
exercises
Guidelines for Progression of
CKC Exercises
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Static stabilization  dynamic stabilization
Stable surface  unstable surface
Single plane movements  multi-plane movements
Straight planes  diagonal planes
Wide base of support  small base of support
No resistance  resistance
Fundamental movements – dynamic movements
Bilateral support  unilateral support
Consistent movements  perturbation training
Functional
Progression/Functional Testing
• Functional Progression
– Gradually helps achieve normal pain-free ROM
– Helps to restore adequate strength levels
– Helps to regain neuromuscular control and balance
• Functional Testing
– Uses functional progression drills to assess the
athlete’s ability to perform a specific activity
Developing Relationships
• Developing and working with rehabilitating athletes
requires
– Communication between all involved parties
• Do not be afraid to consult others
– The Power of Consultation
– Understanding all individuals’ rehabilitation
philosophies (AT, MD, Athlete, etc)
– Continually working to improve and re-assess the
athletes functional status
– ABOVE ALL ELSE “DO NO HARM”
Specific Closed Chain Exercises
Lower Extremity Exercises
• Mini-squats / Wall slides / Lunges
– Involves simultaneous hip and knee extension and is
performed between 0-40°
• 60-90° increases tibial translation compared to OKC
exercises
– Concurrent shift helps minimize the flexion moment at the
knee
– Half squat produces less shear at the knee than OCK exercises
in full extension
– Slight flexion flexion of the trunk anteriorly helps to increase
hip flexion moment and decrease knee moment
Lower Extremity Exercises
• Leg Press
– Utilize the CKC, while providing stability and
decreasing strain on low back
– Allows for lower resistance and unilateral exercises
– Recommend from 0-60°, utilizing full hip extension
• Lateral Step-Ups
– Adjusted to the needs of the athlete and progress up
to 8 in.
– Generate significantly more quad activity
Lower Extremity Exercises
• Stair-Climbing
– Steeping machines are true CKC exercises
– Body should be held erect with slight trunk flexion
– EMB studies have show that the gastrocnemius fires
considerably
• Terminal Extension with Tubing
– Anterior tibial translation occurs between 0-30° of flexion
– Application of resistance anteriorly at the femur produces
anterior shear of femur, eliminating anterior translation of the
tibia
– Tubing produces an eccentric contraction of the quad when
moving into knee flexion
Lower Extremity Exercises
• Bike
– Utilized for cardiovascular, strengthening, and ROM
– Toe clips facilitate HS contractions on the upstroke
• BAPS Board and Mini-tramp
– Provide unstable base
– Allows simultaneous work for strength and ROM
while regain NMC and balance
• Slide Board and Fitter
– Weight shifts and more functional activities
– Re-establishes dynamic control
Upper Extremity
• Glenohumeral joint force couples must be re-established
– Anterior deltoid along with the infraspinatus and teres
minor in the frontal plane
– Subscapularis counterbalanced by the infraspinatus and
teres minor in the transverse plane
• Scapulohumeral rhythm is also necessary to ensure
proper positioning of the scapula during motion
– Force couple between the inferior traps and upper trap
and levator scaupla
– Rhomboids and middle traps counterbalanced by the
serratus anterior
Upper Extremity
• CKC GH joint exercises are used during the early
phases of rehabilitation, especially with unstable
shoulders to
– Promote co-contraction and muscle recruitment and
preventing shut down of the RC 2nd to pain and
inflammation
• Also used in later stages to:
– Promote muscular endurance and stability (Dynamic
and ballistic motions)
OKC & CKC Exercises for the
GH Joint
Phase
CKC
OKC
Acute
Isometric press-up, push-up, and
strengthening; WB shifts; axial
compression against wall
Subacute
Resisted wall circles and wall
abduction/adduction; slide board; pushups; PNF
Isotonic and isokientic
strengthening
Chronic
Push-ups on balance board; lateral stetups; shuttle walking; Stairmaster;
plyometric push-ups
Isotonic and isokinetic
strengthening; plyometrics;
sport-specific training
OKC & CKC Exercises for the
Scapulothoracic Joint
Phase
CKC
OKC
Acute
Isometric punches, strengthening, and
press-ups
Isotonic strengthening
Subacute
Push-ups, military presses, press-up
Isotonic and isokinetic
strengthening, rowing, prone
horizontal abduction
Chronic
NMC drills, rhythmic stabilization, circles, Progression of isotonic
diagonal patterns
strengthening exercises
Upper Extremity
• Weight Shifts
– Used to facilitate GH and ST dynamic stability
– Done in standing, quadruped, tripod, or biped
moving from stable to unstable
– Movements are from side to side, front to back, and
diagonal
– Progress from a wide base to a small base
– Provide resistance to stimulate rhythmic stabilization
(Used also to regain NMC of scapular muscles with
the hand in a CKC and random pressure applied to
the scapula border)
Upper Extremity
• Push-ups, Push-Ups with a Plus, Press-Ups and
Step-Ups
– Push-ups and press-ups are done to regain NMC
– Push-ups with a plus are done to strengthen the
serratus anterior which is critical for dynamic stability
in overhead activities
– Press-ups (sitting on the table and lifting body weight
up) involves isometric contraction of the GH
stabilizers
Upper Extremity
• Slide Board
– Promote strength and stability and improves
muscular endurance
• Hands move forward, side to side, wax-on-wax off
Upper Extremity
Immediately after GH joint subluxation or dislocations
• Acute
– Isometric press-up & isomeric weight bearing & shifts, axial
compression against a table or wall
• These movements produce joint compression and approximation
which enhances muscular co-contraction about the joint, leading
to dynamic stabilization
• Sub-acute
– Resistance is applied to the distal segment
• Include resisted arm circles against a wall, resisted axial load side
to side either against a wall or on a slide board, and push-ups
• Resistance can be applied in different amounts to multiple
positions
Upper Extremity
Immediately after GH joint subluxation or dislocations
• Advanced
– Weight bearing exercises are usually high-demanding movements
that require a tremendous degree of dynamic stability
• Push-up with the hands on a ball, which produces axial load on
the joint but keeps the distal segment somewhat free to move
(additional unstable foot platform)
• Lateral step-ups using the hands and retrograde lateral walking
on the hands on a treadmill or stair steppers
• Requires a fair amount of dynamic stability and strength
Exceeding Healing Tissue Strength
• Pain
• Swelling
• Loss/plateau of
strength
• Loss/plateau of ROM
• Increase in joint laxity
• When do I increase
weights or difficulty of
therapeutic exercise
plan?
– Refer to left