Rehabilitation and
Reconditioning
Overview
• The Sports Medicine Team
• Types of Injuries
• Tissue Response to Injury
• Exercise Strategies During
Recovery
• Case Study
• Take Home Points
Principles of Rehabilitation and
Reconditioning
• Healing tissues must not be
overstressed
• The individual must fulfill specific criteria
to progress from one phase to another
during the rehabilitative process
• The rehabilitation program must be
based on current clinical and scientific
research
Principles of Rehabilitation and
Reconditioning
• The program must be adaptable to
each individual and his or her specific
requirements and goals
• Rehabilitation is a team-oriented
process requiring all the members of
the sports medicine team to work
together
The Sports Medicine Team
• Physician
• Athletic Trainer
• Strength and
Conditioning
Coach/Personal
Trainer
• Physical Therapist
• Nutritionist
• Psychologist
Duties of Sports Medicine Team
• Physician
– Calls the shots
– Game and practice medical
coverage
– Injury evaluation and diagnosis
– Referrals if necessary
– Determine return to play
• Certified Athletic Trainer
– Day to day physical health of
the athletes
– Injury prevention, management
and rehabilitation
– Evaluate, not diagnosis, injuries
Duties of Sports Medicine Team
• Conditioning Coach/Personal Trainer
–Injury prevention and rehabilitation
–Invaluable resource for ATC and PT
–Key in returning a player to the field
–Certified through NSCA
• Physical Therapists
–Primarily clinically based
–Longer term rehabilitation
Duties of Sports Medicine Team
• Nutritionist
– Registered Dietician
– Member of ADA
• SCAN (Sports, Cardiovascular and
Wellness Nutritionists)
– Nutrition professionals with expertise and skills in
promoting the role of nutrition in physical performance,
cardiovascular health and wellness
• Psychologist
– Improve performance
– Return from injury
Types of Injuries
• Macrotrauma
• Microtrauma
Macrotrauma
• Injury
suffered as
result of a
specific,
sudden
episode of
overload to a
given tissue
• Types
– Bone
– Joint
– Soft Tissue
Compound Fracture dislocation of left
ankle after falling 1m from ladder
Source: ED, Royal North Shore Hospital
Bone Macrotrauma
• Fracture
–A break in the
bone or cartilage
• Types
–Stress or Hairline
–Compound or
Open
–Simple or Closed
–Avulsion
–Compression
Types of Bone Fractures
• Stress Fracture or Hairline Fracture
– A very fine crack in the bone
• Compound Fracture or Open Fracture
– A fracture in which the bone is sticking through
the skin
• Simple Fracture or Closed Fracture
– The bone hasn't pierced the skin
• Avulsion Fracture
– Tendon or ligament pulls off a piece of the
bone
• Compression Fracture
– Occurs when vertebrae in the spine are broken
Types of Fractures Video
• http://www.youtube.com/watch?v=7jp7eDYkVq
8&feature=related
Joint Macrotrauma
• Joint Dislocation
– Complete displacement (joint surfaces are not in
anatomical alignment) of the joint surfaces
• Joint Subluxation
– Partial displacement of the joint surfaces and may
result in laxity or instability
Shoulder
Dislocation
Dwayne Wade Shoulder Dislocation
• http://www.youtube.com/watch?v=09ZZbJzeKU
A
Ligament Macrotrauma
• Sprain: injury to the
structures that connect
the bones and help
maintain joint stability
• First Degree: partial
tear of the ligament
without increased joint
stability
• Second Degree: partial
tear with minor
instability
• Third Degree: complete
tear with full joint
instability
Muscle Macrotrauma
• Muscle Strain: tear to the fibers of the muscle
– First Degree : partial tear of individual
fibers characterized by painful muscle
activity
– Second Degree: partial tear of muscle
characterized by weak muscle activity
– Third Degree: complete tear of the muscle
fibers with painless muscle activity
• A muscle contusion is an area of excess
accumulation of blood and fluid in the tissues
surrounding the injured muscle
Microtrauma
• The result of repeated, abnormal
stress applied to a tissue without
sufficient recovery time
• Joint and soft tissue
– Tendonitis
– Bursitis
– Muscle soreness
Tendon Microtrauma
• Tendonitis
– Inflammation of the tendon
– Most often due to excessive repetitive
movement
• Most common tendons affected
– Rotator cuff, biceps, elbow, wrist, hip, knee
(patellar tendon), and ankle (achilles tendon)
• Symptoms
– Swelling, pain and stiffness
Bursa Microtrauma
• Bursa
– Fluid filled sac
located between
tendon and
bone
– Prevents friction
– 160 in the body
– Majority located
in the shoulder,
elbow, hip and
knee
Bursa Microtrauma
• Bursitis
– Inflammation of bursa due to
continuous rubbing of tendon
over bone
– Most often due to excessive
repetitive movement
– Most common bursa affected
are elbow, shoulder, hip,
knee and ankle (calcaneus)
• Symptoms
– Swelling, tenderness and
pain
Muscle Microtrauma
• Muscle Soreness
– Acute
• Build up of lactic acid, potassium and
other fluids within the muscle causes
pain by impeding circulation and
stimulating pain receptors
– Delayed Onset Muscle Soreness
(DOMS)
• Damaged muscle fibers stimulate
pain receptors
• Caused by eccentric muscle
contraction
Tissue Healing
• Three phases of tissue
healing:
–Inflammation Phase
–Repair Phase
–Remodeling Phase
Tissue Response to Injury
Phase One: Inflammation
• Normal reaction that is necessary to the healing
process of the body, but excessive
inflammation will delay recovery
• 24-72 hrs after injury
• Vasodilation
• Pain, swelling, and redness
• Decreased collagen synthesis
• Bradykinin is released which dilates blood
vessels, contracts non-vascular smooth muscle,
and causes pain.
• Phagocytosis: macrophages remove cellular
debris
Tissue Response to Injury
Phase Two: Repair
• Highlighted by the repair and regeneration of new tissue
– Two to three days after injury up to eight weeks
• Tissue repair is accomplished by either:
– Regeneration (Replacement of tissue by the same
tissue)
• Dead and unviable tissue is removed
• New capillaries are formed and collagen fibers are
laid down
– Collagen fibers are placed haphazardly, which
can result in sub-optimal strength and athletic
performance if not corrected
– The formation of granulated tissue (scars)
• Scars are made up of dense, inelastic, non-vascular
fibrous tissue
Tissue Response to Injury
Phase Three: Remodeling
• Overlaps with Repair phase
• Strengthening of the new, weak tissue
– Production of new collagen fibers
slows
– Collagen tissue begins to
hypertrophy and align with the lines
of force
– Strength of new collagen tissue
continue for up to two years postinjury
• Ligamentous tissue can take up
to one year to completely remodel
Exercise Strategies/Approaches
• Inflammation Stage
– Exercise is not recommended
– Tissue needs time to heal
– P.R.I.C.E. Principle should be used for the first 4872 hours immediately following the injury. The goal
is to reduce swelling, prevent further injury, and
reduce pain
• Protection
• Rest
• Ice
• Compression
• Elevation
• Ultrasound
• Electrical Stimulation
Exercise Strategies/Approaches
• Repair Stage
– If possible, implement exercises to
maintain cardiovascular conditioning
(stationary bike, upper body ergometer)
and muscular strength (isometric
contractions)
• Remodeling Stage
– Game on
– Sports specific exercises
– Proprioception work (balance exercises)
– Isotonic strength training (closed vs. open
chained), agility training, etc
Case Study
• Shannon Sharpe,
Denver Broncos
• Posterior Elbow
Dislocation
• Injury occurred 11-11
• Non-surgical rehab
• Back to practice 11-27
(16 days)
• Back to game 12-8 (27
days)
MRI Results
• Disruption of the anterior
capsule with 2-3cm defect of
distal brachialis with extensive
hemorrhage and fluid
• Tearing/stripping of the
anterior bundle of the medial
collateral ligament complex,
distally greater than proximal
• High grade partial tearing of
the common flexor tendon at
medial epicondyle and
hemorrhage within the flexor
pronator musle mass
• Large joint effusion with
multiple internal bodies
Rehabilitation Protocol
Phase 1: Inflammation
• Goals
– Minimize inflammatory
response
– Protect injury
• Program Components
– Hinged
Brace/Compression
– NSAIDS
– Ice and Elevation
– Electrical Stimulation
Rehabilitation Protocol
Phase Two: Repair
• Goals
– Speed up tissue repair
– Limit loss of range of
motion (ROM)
• Program Components
– Passive ROM (Day 2)
– Soft tissue massage (Day
4)
– Active ROM (Day 5)
– Stretching (Day 5)
– Myofascial release (Day 5)
– Hydro therapy (Day 6)
Rehabilitation Protocol
Phase Three: Remodeling
• Goals
–Return to play
• Program Components
(Strength)
–Manual resistance
wrist, biceps/triceps
(Day 7)
–Manual resistance
shoulder (Day 9)
–Sport cord
biceps/triceps wrist
(Day 10)
Rehabilitation Protocol
Phase Three: Remodeling
• Sport cord shoulder
(Day 12)
• Weight room
biceps/triceps (Day
12)
• Weight room upper
body modified (19
Days)
– (Ball stabilization
for core/lower
extremity-Day 5)
Rehabilitation Protocol
• Program
Components
(Strength and
Proprioception)
– Closed chain
seated/standing
(Day 8-10)
– Closed chain
quad/tripod
(Days 11-15)
– Closed chain
uneven surface
(Day 14)
Rehabilitation Protocol
• Program
Components
(Sports Specific)
– Catching (Day
10)
– Stance (Day 12)
– Running (Day
12)
– Blocking (Day
12)
Take Home Points
• The point person for the sports medicine
team is generally a physician
• Injuries occur as the result of either macro
or microtrauma
• The three phases of tissue healing are
– Inflammation
– Repair
– Remodeling
• Closed chain exercises (push-up, squat,
split squat…) tend to be more sportsspecific than open chain