Sports Rehabilitation of the Injured Athlete

Andrea Stracciolini, MD,*y William P. Meehan III, MD,* Pierre A. dHemecourt, MD, FACEPy
Correct and timely rehabilitation is a vital component of the treatment of sports injuries. The goals of rehabilitation include restoring function, restoring pain-free full range of motion, and achieving full muscle strength and sports endurance. Generally, sports rehabilitation entails a phased approach including progressive exercises and therapeutic modalities to achieve full recovery. This review discusses the rehabilitation of upper extremity, lower extremity, and back injuries. Clin Ped Emerg Med 8:43-53 2007 Elsevier Inc. All rights reserved. KEYWORDS sports injuries, rehabilitation, therapeutic modalities, alternative exercises, range of motion, physical therapy, strengthening exercises, stretching exercises, isometric exercises, plyometrics, shoulder instability, repetitions

ehabilitation of sports injuries should incorporate a few basic principles to maximize success of treatment, minimize rehabilitation failure, and prevent further injury. In general, the goals of rehabilitation include restoring function, restoring pain-free full range of motion (ROM), and achieving full muscle strength and sports endurance. Every attempt should be made to achieve preinjury function, strength, endurance, and ROM [1-5]. Because recommended follow-up is not guaranteed after acute care in the emergency department, discharge teaching by the emergency physician may be the only instructions on proper rehabilitation some patients receive.

General Principles
A sequential and progressive multiphased approach is essential for rehabilitation after injury or surgery. These phases usually include an acute management phase that entails treating the acute inflammation and pain and reversing the decreased ROM and strength caused by
*Department of Medicine, Division of Emergency Medicine, Harvard Medical School, Childrens Hospital Boston, Boston, MA. yDepartment of Orthopaedics, Division of Sports Medicine, Harvard Medical School, Childrens Hospital Boston, Boston, MA. Reprint requests and correspondence: Andrea Stracciolini, MD, Department of Medicine and Orthopaedics, Childrens Hospital Boston, 300 Longwood Ave, Boston, MA 02115. (E-mails: andrea.stracciolini@childrens.harvard.edu, william.meehan@childrens.harvard.edu, pierre.dhemecourt@childrens.harvard.edu) 1522-8401/$ - see front matter 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.cpem.2007.02.004

immobilization (Table 1). The first phase is followed by an intermediate phase, which focuses on restoring strength and ROM to preinjury level. The final phases concentrate on functional/sports-specific exercises and strive to return the athlete to sport so that she can play effectively, painlessly, and safely. Of note, there is significant overlap in each of these phases. Maintaining strength and ROM is a crucial component of each phase. Providing the patient with general guidelines regarding the length of time required for healing of specific tissue types/specific injuries is useful in terms of setting realistic goals and avoiding disappointment (Table 2). Obtaining a complete and accurate history is a necessary first step in the commencement of each rehabilitation program. Important information to obtain includes a history of acute macrotrauma versus an insidious onset/microtraumatic type injury. Is there pain with a specific activity or movement? Is there swelling? Is the patient experiencing mechanical symptoms (clicking, locking, or catching)? Is this a first time injury or chronic repetitive injury [2]? Mechanism of injury is an important component of the history in helping the practitioner correctly assess the injury. Examples include an athlete with a knee injury who may have had a twisting type injury, hyperextension injury, or valgus/varus stress to the knee. Each mechanism helps guide the treating professional down the correct diagnosis and treatment path. The mechanism of an ankle injury is commonly an inversion type injury versus the less common eversion/dorsiflexion type injury, the latter often resulting in different pathology and 43

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Table 1 Rest versus motion.

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water. Pool running is an excellent way to maintain aerobic fitness and may promote healing. The perfect candidate is the distance runner with a femoral neck stress fracture. Cycling, elliptical machine, and light weight training are examples of commonly used crosstraining activities.

Rest is appropriate in the first 48-72 h after trauma, especially if initial assessment and diagnosis are delayed. Once diagnosis is made, then motion is safe and encouraged under direct supervision by a physical therapist and/or certified athletic trainer. Initially passive motion progressing to active motion is instructed.

Therapeutic Modalities
The use of therapeutic modalities during the rehabilitative process is an important component in the effort to return the athlete to full function. Modalities can be used to reduce pain and edema, increase mobility, and effectively deliver medications across the skin. Cryotherapy and thermotherapy are 2 commonly used modalities. Cryotherapy is the application of ice or other cold stimulus. Indications for this modality are the initial phases (24-48 hours) of acute traumatic injuries. Thermotherapy is the application of heat as a therapeutic modality (Table 3). Chronic injuries and conditions, muscle spasms, joint stiffness or restriction, and scar tissue are indications for thermotherapy. Ultrasound is excellent for increasing joint mobility and reducing scar tissue and adhesions. Iontophoresis is a painless, sterile, and noninvasive means of delivering ionized drugs by using the force of electrical currents. The anti-inflammatory medication most commonly used is dexamethasone. It is dispensed systematically and slowly through the skin, delivering a high concentration of the drug directly to the injured tissue. Indications for iontophoresis include inflammatory conditions such as bursitis, tendonitis, enthesopathy, and muscle soreness. Electrical agents are often used to manage pain during rehabilitation. Specialized current waveforms have physiologic responses that can be attributed to the characteristics of their waveforms. The physiologic response to
Table 3 Ice Vasoconstriction Reduce inflammation and edema Decrease tissue metabolism Decrease nerve conduction velocity Direct analgesia and continued analgesia when removed Heat Vasodilation Direct analgesia Increase metabolic activity Reduction of spasm Facilitation of tissue healing Tissue sensitivity somewhat increased when removed As a general rule, for acute trauma, use ice for the first 14 days; and for chronic/overuse injuries, use heat in the morning and ice in the afternoon/evening. Cryotherapy and thermotherapy.

treatment than the former. Sports that tend to be extension-based are often associated with posterior column pathology of the spine, that is, spondylolysis. Acute traumatic dislocations of the shoulder are treated very differently than the athlete with chronic shoulder subluxation/instability. The type of pain experienced by the athlete can help guide the practitioner during rehabilitation. The pain may be described as sharp, crampy, burning, or aching. Does the pain radiate or stay focal? Provocative physical examination maneuvers are often very useful. Pain at rest or at night may be due to an osteoid osteoma or other bony oncological process. Finally, always be on the lookout for signs of a systemic process including fever, multiple joints, chronic rash, abdominal pain, and weight loss. Deciphering whether or not the injury and pain pattern match the mechanism of injury is also important in guiding the practitioner [2]. A good example is extension-based lower lumbar spine pain in the ice skater, dancer, and gymnast. Performing a thorough assessment of the athlete before postulating a treatment plan is important. Assessing constitutional ligamentous laxity is often performed using the Marshall test. The Marshall test entails having the patient flex their wrist while the examiner attempts to touch the thumb to the forearm. A patient with significant laxity can touch the forearm easily with his or her thumb. A postural assessment entails inspection for scapular height, spinal curvature, pelvic obliquity, genu valgum, genu varum, and foot pronation or supination. Laterally, a postural assessment can detect thoracic kyphosis, lumbar lordosis, genu recurvatum, and genu flexion [2].

Alternative Exercise
It is essential for both physical and mental well-being that the athlete remains active during the rehabilitative period. Alternative forms of exercise should be encouraged. Athletes with injuries that prohibit weight bearing or impact (stress fractures, severe ankle sprains, plantar fasciitis) should be encouraged to cycle or train in the
Table 2 Tissue healing.

Muscle 2-6 wk Tendon 2-6 wk acute, 8-12 mo chronic Ligament 3-12 mo Bone 6-18 wk

Sports rehabilitation of the injured athlete

these waveforms allows them to be used therapeutically. The effects of electrical agents include modulation of pain, promotion of strengthening, reduction of edema, increase of ROM, and promotion of fracture healing.

45 decrease pain and inflammation, and to retard muscular atrophy. The elbow becomes stiff and is predisposed to flexion contractures very rapidly after a brief period of immobilization. This is due to the intimate congruency of the joint articulations, the tightness of the joint capsule, and the tendency of the anterior capsule to develop adhesions after injury [7]. Injury to the elbow may cause excessive scar tissue formation of the brachialis muscle and functional splinting of the elbow [7]. Every effort should be made to keep immobilization of the elbow joint to a minimum; and when necessary, the elbow should be splinted in extension. Range of motion exercises are performed for the humeroulnar joint to restore flexion/ extension and supination/pronation for the humeroradial and radial ulnar joints. Reestablishing full elbow extension to preinjury motion is of utmost importance during this phase to prevent flexion contractures [4]. The aggressiveness of stretching is dependent upon the healing constraints of the injured tissue as well as the amount of motion and end feel. If the patient presents with a decrease in motion and hard end feel without pain, aggressive stretching and mobilization techniques can safely be used [4]. An important part of phase I rehabilitation is reducing inflammation and pain control. Treatment with a short course of systemic anti-inflammatories may help with this phase of therapy. Cryotherapy and high-voltage stimulation may be performed as required to assist in reducing pain and inflammation. Once the acute inflammatory response has subsided, moist heat, warm whirlpool, and ultrasound may be used at the onset of treatment to prepare the tissue for stretching and to improve the extensibility of the capsule and musculotendinous structures. The first phase of rehabilitation should also focus on light strengthening to inhibit muscle atrophy. Subpainful and submaximal isometrics are performed initially for the elbow flexor and extensor and the wrist flexor, extensor, supinator, and pronator muscle groups. Phase II: Intermediate Phase This phase is initiated when the patient exhibits full ROM, minimal pain and tenderness, and good strength. The goals of this phase of therapy include enhancing mobility, improving strength and endurance, and reestablishing neuromuscular control of the elbow complex [4]. Elbow extension and forearm pronation flexibility are of particular importance for effective performance in throwing athletes. Shoulder flexibility is also maintained in athletes, with emphasis on external and internal rotation at 908 of abduction, flexion, and horizontal adduction. Loss of external rotation may result in increased strain on the medial elbow structures during the overhead throwing motion [4]. Strengthening exercises progress during this phase to include isotonic contractions, beginning with concentric

Return to Activity
The decision to allow the athlete to return to sports is often difficult. A few basic rules should be followed. Returning to full activity/sport is considered once the patient has regained full functional ROM and once pain and swelling are minimal. It is helpful when assessing strength to compare the affected side with the unaffected side. Patients must have at least 70% strength of the affected limb, when compared with the unaffected limb, to run. The patient must be able to walk first. Patients must have 90% strength of the affected part compared to the unaffected part to return to agilities/sport. The patient must be able to return to full walking and running first [1-5].

When Is Activity Too Much?

Frequently, the practitioner is asked about activity limitations and risk for injury. As a general rule, more than 15 to 20 hours per week in a specific activity/sport can lead to microtrauma/overuse injuries. Sports with no defined season (ie, figure skaters, dancers, swimmers) predispose the athlete to overuse injury [2].

Upper Extremity Rehabilitation

The Elbow
Injuries to the elbow are common to athletes playing overhead sports, specifically throwers. Multiple forces act on the elbow during the act of throwing including valgus stress with tension across the medial aspect of the elbow. These forces are maximal during the acceleration phase of throwing. The skeletally immature athlete is prone to injury of the medial epicondyle physis [4,6]. Compression forces are also applied to the lateral aspect of the elbow during the throwing motion. The posterior compartment is subject to tensile, compressive, and torsional forces during acceleration and deceleration, resulting in possible osteophyte formation, stress fractures of the olecranon, or olecranon physeal injuries. Tennis players are prone to stress on the lateral aspect of the elbow secondary to repetitive swinging motions [4]. The rehabilitation of an elbow injury, as is the case with most injuries, follows a phased approach. Wilk et al [4] present a nice review of elbow rehabilitation. A summary of the 4 phases of elbow rehabilitation is included below, as well as specific rehabilitation guidelines for nonoperative injuries [4]. Phase I: Immediate Motion Phase The goals of this phase are to minimize the effects of immobilization, to reestablish nonpainful ROM, to

46 and progressing to eccentric contractions. Neuromuscular control exercises are initiated in this phase to enhance the muscles ability to control the elbow joint during athletic activities. Phase III: Advanced Strengthening Phase The third phase of rehabilitation of the elbow involves a progression of activities to prepare the athlete for sportsspecific participation. The goals of this phase include increasing strength, power, endurance, and neuromuscular control. The athlete must have full nonpainful ROM, no tenderness, and strength that is 70% of the contralateral extremity. Advanced strengthening activities during this phase include aggressive strengthening exercises, emphasizing high speed and eccentric contraction and plyometric activities. Plyometric drills are performed using weighted medicine balls during the latter stages of this phase to train the elbow to develop and withstand high levels of stress. Neuromuscular control exercises progress to include side-lying external rotation with manual resistance. Phase IV: Return to Activity Phase The final phase of elbow rehabilitation, the return to activity phase allows the athlete to progressively return to full competition using an interval return to throwing program. Before progressing to this phase, the athlete must have full ROM, be pain-free, have no tenderness on examination, and have a satisfactory isokinetic test. Isokinetic testing is commonly used to determine the readiness of the athlete to begin an interval sport program. Upon achieving these goals, a formal interval sport program can begin. Examples include, for an overhead thrower, a long-toss interval throwing program, beginning at 45 ft and gradually progressing to 120 or 180 ft. Wilk et al [7] feel it is important to perform stretching and an abbreviated strengthening program before and after performing the interval sport program. After the long-toss program, a pitcher will progress to throwing off the mound. Generally, the pitcher begins at 50% intensity and gradually progresses to 75%, 90%, and 100% over a 4- to 6-week period.

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about 2% of cases, it displaces posteriorly. The major cause of shoulder dislocation is traumatic injury; 96% of shoulder dislocations result from a forceful collision, a fall on an outstretched arm, or a sudden wrenching motion. The incidence of redislocation has been studied extensively [8-11]. Deitch et al [12] reported that 72% of patients sustained a redislocation and 75% reported at minimum a subluxation. Chronic instability and recurrent dislocation may cause articular damage leading to glenohumeral arthropathy in the long term; in the short term, they may produce silent symptoms that interfere with work or sport [12]. Treatment options for this injury include shoulder immobilization, rehabilitation, and shoulder stabilization surgery. The aim of rehabilitation is to enhance the dynamic muscular and proprioceptive restraints to shoulder instability. Buss et al [9] recently reviewed 30 athletes with acute or recurrent shoulder instability to determine if in-season athletes treated with physical therapy and either with or without a brace could return to their sport quickly and effectively. They found that most were able to return to their sports for the complete season at an average time missed of 10.2 days, although 37% experienced at least one additional episode of instability during the season [9].

Atraumatic/Traumatic Instability and Impingement

A small group of patients dislocates or subluxates their shoulder after minimal force or by putting their arm into a certain position. Neer and Foster [13] believed the pathologic entity was a loose, redundant inferior capsule and introduced the term multidirectional instability . The condition may be associated with generalized ligamentous laxity. Adolescent athletes are often seen with shoulder pain that is attributed to instability. These athletes usually perform activities that place the arm in the overhead position, such as softball, volleyball, swimming, and tennis. Repetitive microtrauma in high-level overhead sports can lead to tendonitis, secondary muscle weakness, mechanical imbalance, and secondary instability [6]. In the pediatric athlete with joint laxity, impingement is secondary to muscle imbalance and instability. It is hypothesized that repetitive glenohumeral capsular overload at an extreme ROM (especially abduction external rotation) leads to gradual stretching of the anterior capsule and tightening of the posterior capsule, with a subsequent increase in humeral head translation. With the athletes shoulder at an extreme ROM or during periods of rotator cuff or periscapular fatigue, this increase in humeral head translation may produce shoulder pain due to rotator cuff impingement and subsequent tendonosis [8]. An accurate assessment of the tightness of the posterior capsule, with subsequent loss of internal

The Shoulder
Acute Traumatic Instability
The shoulder is a joint evolved for mobility. To some extent, the structural stability of the shoulder has been sacrificed to achieve a wide ROM. Instability is usually defined as a clinical syndrome that occurs when shoulder laxity produces symptoms [8]. Traumatic anterior dislocation is not an uncommon problem in athletically active children. In young people, most dislocations are intracapsular, with capsular and labral detachments. In 98% of cases, the shoulder displaces anteriorly; and in

Sports rehabilitation of the injured athlete

rotation, as well as increase in external rotation from stretching of the anterior capsule, is important.

47 with progressive resistance exercises for strengthening of the muscles surrounding the joints above and below the shoulder. Phase III: Selective Strengthening Phase Exercise performance in the scapular plane is indicated in the treatment of many shoulder pathologies, including impingement. The scapular plane is 308 to 458 anterior to the coronal plane. The scientific rationale for exercise performance in this plane is that it is believed to be a position of optimal length to tension relationships for the deltoid and rotator cuff musculature [1]. It provides a more direct line of pull for the deltoid and the supraspinatus muscles, thereby avoiding subacromial impingement as the arm is abducted. Normalizing shoulder arthrokinematics is achieved by aggressive joint mobilization and performance of capsule self-stretching and active-assisted ROM exercises. Exercise prescription should include core rotator cuff exercises: prone horizontal abduction, extension, scapular retraction and external rotation at 908 of abduction, and supine scapular protraction. Core scapular strengthening exercises include rowing, elevation of the arm in the scapular plane with the humerus externally rotated, and push-ups followed by scapular protraction when elbows are extended (push-ups with a plus). Phase IV: Return to Function This phase is characterized by a gradual return to normal function including overhead activities of daily living, occupational activities, and athletic activities. Correcting technique in overhead sports is crucial for success during this phase. Activity and job modification may be appropriate to minimize chance for reoccurrence of injury. A maintenance home exercise program should be initiated including flexibility exercises, rotator cuff and scapular muscle strengthening exercises, and total arm strengthening exercises.

Rotator Cuff Tendonitis

One or many factors can be involved in rotator cuff tendonitis including poor technique; muscular fatigue; muscular imbalance; shoulder ROM limitations; lack of flexibility in the hip flexors, gastrocnemius, soleus, or lower back; improper practice regimens; cervical and scapular tightness; decreased proprioceptive ability; glenohumeral instability; and general fatigue [1].

Rehabilitation of the Shoulder

Each pathology requires different application and timing of the exercises for strength and ROM. Healing soft tissue must be respected. As with the elbow rehabilitation program, aggressive treatment of athletic injuries is determined by an athletes ability to perform certain activities based on what activities were done before as a foundation. The rehabilitation program is fashioned on a step-by-step progression based on ROM, strength, endurance, neuromuscular coordination, and the tissues ability to handle the stresses caused by these activities. All shoulder soft tissue rehabilitation can be divided into 4 healing phases. In postoperative situations, the acute phase (1-2 weeks) is the time that careful attention should be given to making certain that the sutured tissues are not overstressed. In the subacute or fibroblastic stage (1-3 weeks), more stress can be added to the tissues in the form of gravity-eliminated exercises and submaximal isometrics. In the selective strengthening phase, when tissue maturation and remodeling occurs (3-8 weeks), the patient will progress toward exercise against gravity. Final soft tissue maturation may take up to a year. After 8 to 12 weeks, the sutured material will withstand gradual passive stretching. Generally, soft tissue will be remodeled by 14 or 15 weeks and will be able to withstand normal stresses. Phase I: Acute Inflammatory Phase The primary goal is to ease the patients discomfort while maintaining or restoring ROM. Maintaining joint mobility by addressing posterior capsule tightness is tantamount. Phase II: Subacute Phase The subacute phase of rehabilitation generally coincides with tissue repair and remodeling. Inflammation has been retarded, and the period of scar tissue maturation has begun. The dissimilarity of phase I and II lies in the progression and advancement of the activities. Joint mobility is maintained by the addition of the following: active-assisted abduction with the rope and pulley; self-stretching for the posterior, inferior, and anterior capsule (as needed); and progressive joint mobilization. Muscular atrophy prevention is advanced

Lower Extremity Rehabilitation

The Knee
The knee is the most commonly injured joint, with both acute injuries and overuse injuries seen [14]. Being the largest joint in the body, the knee is subjected to an enormous workload. Such large forces can readily result in acute injury. The joint is stabilized by a relatively large number of muscles, tendons, and ligaments, each perfectly balanced to support it. Imbalances due to asymmetry in conditioning, commonly resulting from activities preferentially requiring one planar motion over others, can result in overuse injuries. In addition, anatomical anomalies (bowlegs, knock-knees, flat feet, etc), which affect the function of the knee, are relatively common and can result in overuse injuries.

48 The rehabilitation of the knee, as with most injuries, follows a phased approach [1]. Whereas the initial phases are general and useful in treating most types of injuries, the latter phases are tailored to achieve maximal rehabilitation of a specific injury and to achieve the skills necessary for competition in a specific sport. The following guidelines for rehabilitation are useful in treating injuries that often do not require surgery such as medial collateral ligament sprain, iliotibial band syndrome, Osgood-Schlatter syndrome, patellofemoral pain syndrome, patellar tendonitis, quadriceps tendonitis, and partial anterior cruciate ligament injuries [15]. Surgical treatment of many knee injuries uses similar phases of rehabilitation tailored by the treating surgeon. Phase 1: Acute Phase The goals of this phase are to reduce pain and swelling, restore and maintain full ROM of the injured knee, and prevent the muscular atrophy associated with immobilization and decreased activity. Acutely, an injured knee should be treated as soon as possible using the rest, ice, compression, and elevation (RICE) principles. This may only be required for 24 hours for mild ligamentous injuries or up to 72 hours for more significant injuries. As soon as pain abates, rehabilitation designed to restore and maintain ROM and prevent muscular atrophy should be started. Both active-assisted and passive ROM exercises are used during phase I. In addition, isometric exercises, muscle contractions that do not result in a change in muscle length, should be performed during this phase. To reduce pain and improve flexibility, allowing for maximal benefit of the exercises, cryotherapy, thermotherapy, transcutaneous electrical nerve stimulation, or ultrasound may be used. As soon as patients are able to perform unassisted ROM exercises and isometric strength training without pain, they should be advanced to phase II. Please note that for mild injuries that do not require surgical intervention, many patients may be ready to start phase II immediately after the initial period of RICE. Phase II: Rehabilitation Phase The goals of this phase are to restore and maintain active ROM in the injured knee and regain strength and flexibility of the previously immobilized or rested muscles. Phase II should begin as soon as patients are able to move the injured knee on their own. Stretching exercises to maintain flexibility of the hamstrings, quadriceps, groin, and iliotibial band should be performed a minimum of 3 times per day. Initial exercises should consist of extension and flexion of the knee without resistance, holding the knee in full extension and full flexion for a period of 10 to 20 seconds, followed by 5 seconds of rest. This should be repeated as many times as possible without eliciting pain. The number of repetitions may be advanced every few days as tolerated. If pain is elicited, the patient should hold at

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that number of repeats or reduce the number of repeats until they can be performed without pain. When the patient is able to do 30 of these exercises per session without pain, resistance may be added by having the patient support the weight of the body or by the use of weight cuffs. When resistance is first added, the number of repeats should be decreased to 10 and then gradually increased as tolerated without eliciting pain. If pain is elicited with 10 repeats, the patient should return to exercises without resistance for a few more days before again attempting to add resistance. If at any point during phase II pain is elicited, the number of repeats should be held or decreased until they can be performed without pain before advancing again. When the injured knee and supporting muscles are 90% of their original strength (if known) or 90% of the uninjured extremity, the patient should be advanced to phase III. Phase III: Functional Activity Phase The goal of phase III is to prepare the athlete for return to athletic participation. This involves improving flexibility and further strengthening the major muscle groups surrounding the knee as well as regaining muscle endurance, proprioception, and sport-specific skills. Flexibility is improved and maintained by continuing stretching exercises as mentioned above. To further strengthen the surrounding muscles and further stabilize the knee, lunges, squats with resistance, and heel raises with resistance are often used. Endurance is achieved by continuation of phase II and III exercises, but the goal is to perform a higher number of repetitions at decreased resistance. Proprioception is an essential but often overlooked part of rehabilitation. Proprioception at the knee joint can be regained by balancing exercises. Initially, balancing on each leg in isolation with the eyes closed until steady balance is achieved is attempted. After this task can be performed readily, balancing on one leg in sand or on a spring mattress will add further proprioceptive skills. This may also be accomplished by standing on one leg while rotating or moving the weight-bearing leg [1]. Sport-specific skills are regained by performing required tasks at a slower pace, with less resistance, and for shorter periods of time, and advancing as tolerated. For runners, this may first consist of walking short distances, followed by walking longer distances with intermittent, short lengths of easy jogging. This is eventually advanced to longer lengths of easy jogging, followed by short lengths of faster-paced running and so forth, until full-length runs are accomplished. For sports that require cutting and dodging, first walking in a bfigure 8Q pattern or a bZQ pattern is useful. This is gradually increased to light jogging in these patterns. Eventually, these exercises are combined with mild accelerations and decelerations and so forth, until preinjury capabilities are achieved. Once preinjury capabilities are achieved, the athlete may return to competition.

Sports rehabilitation of the injured athlete

49 earlier return to activities than immobilization [22,23]. In the initial stages of rehabilitation of the ankle, the focus should be on plantarflexion and dorsiflexion without resistance, at high repetition (20-30 repeats). Inversion and eversion should be avoided initially, and gradually added to the regimen as pain and tenderness over the ligaments dissipates. Isometric exercises should be performed during this phase to prevent muscular atrophy associated with immobilization and decreased activity. Again, these should be performed initially in plantarflexion and dorsiflexion only, avoiding inversion and eversion, so as not to endanger the fragile ligaments [3]. As with the knee, modalities may be used to decrease inflammation and treat pain. Phase II: Rehabilitation Phase Phase II should begin as soon as patients are able to move the injured ankle on their own, without assistance. For the ankle especially, exercises to improve proprioception at the ankle joint should be started early in this phase and should be a major component of the rehabilitation program. Stretches to restore and maintain flexibility of the ankle should be performed a minimum of 3 times per day. Using the foot to trace letters of the alphabet or circles in the air, repetitive alternating of plantarflexion and dorsiflexion at the ankle while in the supine position and repetitive alternating of eversion and inversion while supine are common exercises. In addition, wall calf stretches and sitting toe touch stretches should be used to restore and maintain flexibility of the gastrocnemius and soleus. Once isometric exercises can be performed without pain or swelling, dynamic exercise should be started to improve strength. These will initially be dynamic movements about the ankle in all 4 of its principle motions: plantarflexion, dorsiflexion, inversion, and eversion. Once able to perform these movements 10 to 15 times without pain or swelling, resistance should be added using an elastic resistance band. Toe raises, using plantarflexion to elevate the heel of the foot off of the floor placing all weight on the anterior portion of the feet, are important in developing muscle strength and should be performed 3 times per day. They should initially be performed on both legs simultaneously. As the patient is able to do these without pain or swelling, weight can gradually be shifted to the injured ankle until the patient is able to achieve 3 sets of 10 to 15 repeats each without pain or swelling. Holding onto something for support and balance is recommended. If pain is elicited at any point during phase II, the number of repeats should be held or decreased until they can be performed without pain before advancing again. Proprioceptive training should be started early in the course of ankle rehabilitation. Often, this is initially achieved by using a Biomechanical Ankle Platform

The Ankle
Ankle sprains are the most common acute sports injuries, occurring at a rate of 1:10 000 people in the United States each day [5,16]. There are many reasons for this, not least of which is the frequency with which this joint is used. Many joints are stabilized to a large extent by their bony structure, with muscles, tendons, and ligaments adding additional support. Whereas this is true of the ankle in dorsiflexion, plantarflexion brings the more narrow, posterior aspect of the talus into the mortise [17]. The increased space between the talus and the walls of the mortise create a less stable joint, which relies more heavily on the ligamentous structures for stability. Thus, inversion of a plantarflexed foot readily leads to acute ligamentous injury, most commonly the anterior talofibular ligament, often with associated injury to the calcaneofibular and posterior talofibular ligaments. As with the knee, overuse injuries also occur at the ankle joint. These may be secondary to vigorous changes in training or to anatomical problems, particularly varus alignment, pes cavus (high arches), and excessive pronation of the foot during running. As with most injuries, the rehabilitation of the ankle follows a phased approach. Whereas the initial phases are general and useful in treating most types of injuries, the latter phases are tailored to achieve maximal rehabilitation of a specific ankle injury and to achieve skills necessary for competition in a specific sport. The goals of rehabilitation of the ankle are similar to that of most other joints: to treat initial pain and swelling; to restore and maintain ROM; to restore and maintain strength; and ultimately, to regain full strength, ROM, and proprioception and return sport-specific skills to their preinjury level. Perhaps the main difference between ankle rehabilitation and that of most other joints is the emphasis on proprioception. Although reestablishing proprioception is important in all rehabilitation programs, it is particularly important in rehabilitating ankle sprains, as poor proprioception has been shown to be a major cause of repeat sprains and functional instability [18-20]. The following guidelines for rehabilitation would be useful in treating the most common ankle injuries that do not require surgery, such as ankle sprains (grade I-II), anterior and posterior tibial tendonitis, and Achilles tendonitis. Often, these techniques will be used after surgical repairs as well. This decision is left to the surgeon performing the procedure. Phase I: Acute Phase Acutely, the ankle should be treated using the RICE principles previously described. At this stage, it is important to keep the ankle in dorsiflexion, as this has been shown to reapproximate the fibers of the anterior talofibular ligament, the weakest and most commonly injured of the ankle ligaments [16,21]. Early mobilization of the ankle has been shown to result in less pain and an

50 System (Figure 1) in a sitting position, performing 10 to 20 rotations in each direction [3]. Once this is achieved without difficulty, the athlete is advanced to a standing, partial weight-bearing position, again completing 10 to 20 rotations in each direction. These are followed by single-leg, assisted, partial weight-bearing rotations with the unaffected leg elevated by flexion at the knee and hip, or bstork standing.Q This position is held for 15 to 30 seconds, concentrating on keeping the talus in the neutral position. Eventually, the athlete works up to doing these with the eyes closed. If a patient does not have access to a Biomechanical Ankle Platform System, wobble board, tilt board, or similar apparatus, proprioceptive rehabilitation may be accomplished by having the patient balance on sand, a pillow, a rubber cushion, or a spring mattress, again progressing slowly from 2-legged stances, shifting weight gradually to the affected leg, to single-legged stork standing, and to stork standing with the eyes closed. As always, these exercises should be performed within the patients pain threshold. If pain or swelling develops, the athlete should be held at the current exercise or returned to the previous exercise for a few days before again attempting to advance. When the injured ankle is as stable as its uninjured counterpart and supporting muscles are 90% their original strength (if known) or 90% as strong as the uninjured extremity, the patient should be advanced to phase III. Phase III: Functional Activity Phase Emphasis in strength training is placed on the Achilles, gastrocnemius, and soleus complex. Here the patient starts heel raises with the forefoot on a step, allowing the heel to drop below the surface of the step, and then plantarflexing to elevate the heel to full plantarflexion. Initially, this should be done with both legs. As the athlete becomes stronger, weight should gradually be switched to the affected side until repetitions can be

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performed in a single leg stance on the affected side without eliciting pain or swelling. This serves to preferentially strengthen the gastrocnemius. The soleus can be preferentially strengthened by having the patient sit with 908 of flexion at both the hips and the knees and raising the heel by plantar flexion, placing weight on the forefoot. Once the patient is able to do 10 to 15 repeats of each of these exercises, resistance may be added. For the standing heel raises, dumbbells may be held in the hands to increase resistance. For the soleus exercises, dumbbells may be placed on the distal femur, balanced by the hands, while doing the heel raises. When the patients strength has returned, sport-specific skills should be emphasized. The patient should be advanced from walking to fast-paced walking, to easy jogging, and to running in straight and backward directions only. As this is achieved, single-leg hopping should be added. If these can be accomplished without difficulty, pattern running, figure 8 or Z pattern running, and zigzag running should be started slowly and gradually increased in speed. This is especially important in sports that require cutting and side-to-side motions such as tennis, football, lacrosse, etc. Gradually, the patient should be worked up to full-speed activity. The trainer must be creative in devising skill-specific exercises. Basketball players should start jumping, hopping, and rebounding. Football linemen should start delivering light blows to padded blocking dummies or opponents with padded shields. Return to full activity may be considered when the athlete has achieved full ROM and full strength. Exercises may be facilitated by ankle taping or bracing with an Aircast Stirrup (Aircast). Both have been shown to decrease the number of reinjuries to the ankle after an initial sprain [14,22]. However, taping seems to have several disadvantages. Taping loses up to 50% of its original support after 10 minutes of exercise [14]. Taping cannot be done by the athlete alone and requires the assistance of others. And taping is more expensive in the long run. Furthermore, an aircast ankle brace has been shown to be more effective than taping; therefore, it is the preferred method of ankle support [24].

Back Rehabilitation
Back injuries require rehabilitation that follows the standards of other musculoskeletal injuries. There are 3 essential factors the clinician must grasp in dealing with the young athlete with a back injury. First, one must understand the anatomical area of injury to properly direct the care. Second, one must factor in the abundance of growth cartilage and the changing spinal curvatures that normally occur with growth. Finally, the clinician must understand the different phases of rehabilitation. These include the acute, subacute, rehabilitative, and the sports-specific phases. Optimal care assures the followthrough on each of these phases.

Figure 1 Balance board for proprioception training. Image of Wobble Board with Runners. Reprinted with permission from Fitter First (www.fitter1.com).

Sports rehabilitation of the injured athlete

Anatomically, the vertebrae may be separated into the anterior and posterior columns. The anterior column is made up of the vertebral body and the intervertebral disk, whereas the posterior column consists of the bony neural arch with the facet joints, the pars interarticularis, and the spinous processes. In the young athlete, there is the addition of the growth cartilage of the physeal endplate and the circumferential ring apophysis where the anulus of the disk attaches. Compressive and shear forces may produce disk protrusion into the endplate with a Schmorl node or an anular avulsion of the ring apophysis as well as a more adult pattern disk herniation. When these vertebral endplate injuries occur at the thoracolumbar juncture, they are often referred to as atypical Scheuermann disease. Anterior arch injuries often present with pain aggravated with flexion with or without radicular symptoms. Posteriorly, there is a weaker part of the arch at the pars interarticularis. With growth, the normal lordosis increases most significantly during the growth spurt, which is often the time of heavy participation in sports that emphasize extension such as ballet, gymnastics, and for interior linemen in football [25]. These factors may combine to produce a stress fracture at the pars interarticularis, called spondylolysis , and one with bilateral fractures and slippage, spondylolisthesis . Another pain generator in the posterior arch is the spinous process apophysis that is subject to tensile and compressive forces. This apophysitis, although benign, can be quite painful and limiting. Posterior arch problems are often aggravated in extension. Sacroiliac and transitional vertebrae pseudoarthrosis inflammation may also be aggravated with extension maneuvers.

51 kyphosis or lordosis. These are addressed throughout this entire phase. Peripelvic flexibility, core and lower extremity strength, and aerobic conditioning are progressed. Flexibility addresses hamstring, hip flexor, and thoracolumbar flexibility to allow for shared hip and lumbar motion that is restricted with inflexibility. Strength addresses the entire core including abdominals, extensors, and rotary torso groups. The specific injury will initially limit motion in the direction of the affected area. Peripelvic strength is also a major factor with attention to the hip abductors and extensors (gluteus medius and maximus). Finally, excessive kyphosis should be addressed with postural upper back exercises. These will often complement antilordotic exercises. During this rehabilitative phase, exercises are often initially directed to each isolated muscle group. With progression through this phase, coactivation with balance ball exercises or Pilates is helpful (Figure 3). Aerobic conditioning is also emphasized during this phase. Cycling and rowing place more stress anteriorly, whereas running places more posterior stress. Neutral aerobic activity that is usually well tolerated include the elliptical machine and freestyle swimming without flip turns. Once the athlete has demonstrated good healing, the sports-specific phase is engaged. This will include more aggressive motions that mimic their sport. For instance, in tennis, this may include resisted rotational pulleys. Plyometrics and medicine balls are often helpful. It is often critical for the young athlete to pay close attention to sports-specific technique. The pitcher should have a good pitching coach to review his style. Bracing can often be helpful. There are different types of braces. The thoracolumbar sacral orthosis (TLSO) secures the chest wall as well as the pelvis (Figure 4). This limits some excessive motion of the lumbar spine. This can be in a position of 08 of lordosis (antilordotic) to protect the posterior elements or incrementally more

Components of Back Rehabilitation

The rehabilitation tools available to the clinician essentially fall into 6 categories: physical therapy, bracing, medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, occasionally surgery, and complementary medicine. Proper utilization requires an accurate diagnosis. For a simple muscle strain, no diagnostic test may be needed. However, for pain that lasts for 3 to 4 weeks or has ominous findings, a magnetic resonance imaging or single photon emission computed tomography bone scan may be needed as well as laboratory analysis for inflammatory and infectious causes. Physical therapy is often the primary mode of intervention. During the acute phase of the first couple of days, relative rest is used. As the pain and swelling subside, the subacute phase will allow some isometric strengthening with simple floor calisthenics and possible bridging exercises (Figure 2). Light aerobic activity such as walking or treading water may be possible. The rehabilitative phase is the longest in duration. One must start this phase with an appreciation of biomechanical inflexibilities and weaknesses as well as excessive

Figure 2 Simple floor calisthenics and bridging exercise.

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and joint mobilization may be very helpful in the acute setting as well as with chronic pain. When myofascial pain syndromes, fibromyalgia, and pain amplification syndromes are entertained, these complementary methods can be extremely valuable.

Anterior Column Injuries

These injuries often present with pain aggravated on lumbar flexion. As such, the therapy usually involves an initial extension biased therapy program that progresses to a full neutral zone program [26]. At times, a central disk herniation may produce extension pain; the therapy in such cases will engage a more neutral zone. The physical examination will usually dictate the direction of the program. Temporary bracing can often alleviate the pain especially with acute endplate injuries. A TLSO with 158 to 208 of lordosis will often add comfort and allow for increased activity and core conditioning. These can be used for activities as well as situations of prolonged sitting. A disk herniation is often an inflammatory problem and often responds well to anti-inflammatory medication. Severe radicular pain may benefit from oral corticosteroids. Pain that is refractory to these measures may benefit from an epidural corticosteroid injection. These do not change long-term outcomes but are somewhat effective in limiting sciatic pain in the short term [27]. They may assist in the progression of rehabilitation. Conservative management of a lumbar disk herniation is somewhat variable, but conservative management is successful in up to 90% of cases [28]. It is difficult to predict the timing of symptom resolution, but sciatic symptoms will often abate in 4 to 6 weeks [29]. It is important to progress through all of the stages of lumbar stabilization during this time and focus on the sportsspecific issues as the athlete returns to play.

Figure 3 Balance ball exercise.

lordosis such as 158 to 208 to address more anterior element injuries. Smaller braces such as transitional braces or corset braces will offer some proprioceptive value in returning the athlete to competition. Anti-inflammatory medication can be an adjunct when the injury involves inflammation. The NSAIDs are a first-line choice. Single-day dosing is often an advantage with compliance. Ketoprofen SR is usually well tolerated when taken with meals. Naproxen twice daily is helpful during acute phases of pain. Ibuprofen also has easy access and good tolerability. The NSAIDs probably should not be used in the fracture situation because there is some suggestion that they may limit healing. Severe inflammation may be addressed with oral corticosteroids. Analgesics and muscle relaxants may also be used. Narcotics may be quite helpful in the acute phase of injury but should be limited in duration. As severe pain subsides, tramadol may be used but has not been tested in children. Muscle relaxants such as metaxalone and cyclobenzaprine act adjunctively with NSAIDs as analgesics. Sleep should always be addressed. Tricyclic antidepressants in small doses can be helpful as well as serotonin reuptake inhibitors. Short courses of somnolents such zolpidem can be used safely. When neuropathic pain is a consideration, gabapentin or pregabalin may be useful. Injection therapy is often helpful in the refractory cases of back pain. They may also be used as both diagnostic and therapeutic interventions. Disk herniations may benefit from an epidural injection. Facet injections may be helpful to diagnose and quiet a refractory facet arthropathy. Finally, sacroiliac injections may be needed to diagnose and address the inflammation of this joint. All of these injections have the purpose of enhancing the physical therapy stabilization program. Complementary medicine includes acupuncture, joint mobilization, myotherapy, and a variety of other entities. These have a strong role in several situations. Myotherapy

Figure 4 Thoracolumbar sacral orthosis.

Sports rehabilitation of the injured athlete

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6. Kocher MS, Waters PM, Micheli LJ. Upper extremity injuries in the paediatric athlete. Sports Med 2000;2:117235. 7. Wilk KE, Arrigo C, Andrews JR. Rehabilitation of the elbow in the throwing athlete. J Orthop Sports Phys Ther 1993;17:305217. 8. Walton J, Paxinos A, Tzannes A, et al. The unstable shoulder in the adolescent athlete. Am J Sports Med 2002;30:758267. 9. Buss D, Lynch GP, Meyer CP, et al. Nonoperative management for in-season athletes with anterior shoulder instability. Am J Sports Med 2004;32:143023. 10. Rowe CR. Acute and recurrent dislocation of the shoulder. Orthop Clin North Am 1980;11:253270. 11. Rowe CR, Zain B, Cuillo JV. Recurrent anterior shoulder dislocation. Am J Sports Med 1984;12:19223. 12. Deitch J, Mehlman CT, Foad SL, et al. Traumatic anterior shoulder dislocation in adolescents. Am J Sports Med 2003;31:758263. 13. Neer II CS, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: a preliminary report. J Bone Joint Surg 1980;62A:8972908. 14. Micheli LJ, editor. The sports medicine bible: prevent, detect, and treat your sports injuries through the latest medical techniques. New York (NY): Harper Collins Publishers; 1995. p. 60 - 70. 15. Kocher MS, Micheli LJ. Partial tears of the anterior cruciate ligament in children and adolescents. Am J Sports Med 2002; 30:6972703. 16. DiGiovanni BF, Partal G, Baumhauer JF, et al. Acute ankle injury and chronic lateral instability in the athlete. Clin Sports Med 2004; 23:1219. 17. Wilkerson L. Ankle injury in athletes. Prim Care 1992;19:377292. 18. Tropp H, Asklin C, Gillquist J, et al. Prevention of ankle sprains. Am J Sports Med 1985;13:259262. 19. Glencross D, Thorton E. Position sense following joint injury. J Sports Med Phys Fitness 1982;21:2327. 20. Huber BH, Gottleib DJ, Roos E, et al. Muscle reaction and joint motion changes in the chronically unstable ankle. Trans Orthop Res Soc 1996;42:268. 21. Jackson DW, Ashley RL, Powell JW, et al. Ankle sprains in young athletes. Relation of severity and disability. Clin Orthop 1974; 101:201215. 22. Dettori JR, Pearson BD, Basmania MC, et al. Early mobilization, I. The immediate effect on acute, lateral ankle sprains. Mil Med 1994;159:15224. 23. Eiff MP, Smith AT, Smith GE. Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med 1994;22:8328. 24. Boyce SH, Quigley MA. Management of ankle sprains: a randomized controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace. Br J Sports Med 2005;39:9126. 25. Akin C, Muharrem Y, Akin U, et al. The evolution of sagittal segmental alignment of the spine during childhood. Spine 2004; 30:932100. 26. Nwuga G, Nwuga V. Relative therapeutic efficacy of Williams and McKenzie protocols in back pain management. Physiother Pract 1985;1:992105. 27. Derby R, Kine G, Saal JA, et al. Response to steroid and duration of radicular pain as predictors of surgical outcome. Spine 1992; 17(6 Suppl):S176283. 28. Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy: an outcome study. Spine 1989;14:43127. 29. Saal JA. Natural history and nonoperative treatment of lumbar disc herniation. Spine 1996;21(24 suppl):2S29S.

Posterior Column Injuries

Spondylolysis is a common adolescent injury to the posterior elements. This will typically present with extension-based pain on examination. Patients will often benefit from antilordotic bracing with a 08 TLSO brace. The protocol at Childrens Hospital, Boston, is to place the athlete in this brace for 4 months. However, the sports limitation is only for the first 4 to 6 weeks until all pain has resolved at rest and with extension testing. Gradual return to sports while in full-time bracing is often accomplished. Physical therapy is initiated with an antilordotic abdominal strengthening program along with peripelvic flexibility. At the 6-week mark, neutral core stabilization is engaged as tolerated. Other posterior arch problems include spinous process apophysitis, facet impingement, and inflammation of transitional vertebrae pseudarthrosis. These are managed also with an initial phase of antilordotic exercises and peripelvic flexibility. Athletes are limited from extension activities until the symptoms resolve. Corset bracing in this situation is often proprioceptive to minimize extension. Occasionally, a full TLSO may be used with severe cases. Anti-inflammatory medication may be helpful here. A corticosteroid injection into a facet joint or inflamed transitional pseudarthrosis may also be helpful. Sacroiliac pain often presents with unilateral buttock pain at the region of the sacral sulcus. Rehabilitation involves correction of biomechanical deficiencies such as limb length discrepancy. Mobilization therapy can be quite effective with this entity. Physical therapy addresses stabilization of the core as well as peripelvic musculature with attention to gluteus medius and maximus as well as full lower extremities.

Summary
Rehabilitation is an often overlooked aspect of treating sports injuries in the emergency department. Although the emergency physician is adept in acute injury diagnosis and treatment, techniques to restore strength and ROM are extremely important for the athlete to return to activity.

References
1. Canavan PK, editor. Rehabilitation in sports medicine: a comprehensive guide. Stamford, CT: Appleton and Lange; 1998. p. 173 - 213. 2. Gustafson C. General principles of rehabilitation (Lecture). Boston, MA: Sports and Physical Therapy Associates; 2006. 3. Losito JM, ONeil J. Rehabilitation of foot and ankle injuries. Sports Med Rehab 1997;14:533257. 4. Wilk KE, Reinold MM, Andrews JR. Rehabilitation of the throwers elbow. Clin Sports Med 2004;23:7652801. 5. Balduini FC, Vegzo JJ, Torg JS, et al. Management and rehabilitation of ligamentous injuries to the ankle. Am J Sports Med 1987; 4:364280.