Rehabilitation Program – Primary & Secondary Problems, Diagnosis & Recovery
What is the problem?
The sports medicine professional must define the primary problem and determine all of the secondary issues. Speed of recovery is based upon beginning with the correct diagnosis of the primary problem. The rehabilitation process then involves repairing the primary problem and correcting the associated secondary problems. For instance, an athlete may present with an ankle sprain (primary injury) and strained peroneal muscles (secondary injury usually associated with ankle sprains).
Other secondary injuries to look for would be hand, wrist, forearm, elbow, upper arm, and axillary injuries from prolonged crutch usage. There may be minor secondary injuries to the opposite leg and lower back from the abnormal force distributions (altered weight bearing) if the athlete is not on crutches. Psychological issues should be addressed such as pain, lack of motivation, depression and more. Designing the rehab program with these varibles in mind will help decrease secondary issues and rehabilitate the athlete as fast and safely as possible.
Direction of Attention
Attention should be drawn first to the injured tissue. The primary and secondary injured tissues should be pinpointed. Each tissue should be considered to be targeted with a modality and all the tissues around the injured tissue must be considered. When the injured tissue begins to heal and strengthen, the focal point widens to the limb or surrounding joints. Restoring range of motion (ROM) and strength to the limb or joints should be the focus at this point. Once the limb strengthens, the rehabilitation program should direct its attention on rebalancing the body as a whole.
Areas of Influence:
When rehabilitating an injury there should be three areas of influence. These areas will influence the outcome and progress of the rehabilitation process. The first area is the injured structure involved. Some structures can be injured, but the athlete may still have full ROM. In this case the injury can be treated and the athlete can stay in shape by being able to train. This will allow the athlete to return to play faster. However, some structures can be injured and the athlete will have little to no ROM. The athlete would then not be able to train and keep up his/her cardiovascular conditioning. The surrounding area would atrophy and the athlete would take a while to recover. Therefore, the rehabilitation program will greatly be influenced by the structure involved.
The second area of influence is the physiological condition of the athlete at the time of injury. What is the conditioning level of the athlete? Is there a physiological issue that may decrease the athlete’s ability to rehab? The conditioning level of the athlete will influence the outcome of the rehabilitation program. If the athlete is weak and out of shape to begin with, then it will be much harder to rehabilitate the athlete. Although, if the athlete is in shape and is strong (as they are during competition), then the athlete will usually bounce back faster.
The third area of influence is the psychological state of the athlete during rehab. Most athletes will go through five psychological states while in rehab. Depending on which psychological state an athlete is in, will influence the rehab program. If an athlete is depressed or angry, he/she may not give the rehab program 100% effort. Some athletes may lose the motivation to do the rehab. Thus, the psychological state of the athlete during rehab will in some cases make or break the rehabilitation program.
Tissue repair will depend on the type of tissue involved. The length and success of the rehab program is influenced by the type of tissue that is injured such as bone, ligament, and muscle. The degree of tissue damage will also share the fate of the rehab programs success. If a tissue is injured bad enough, then surgery might have to be performed. This will certainly prolong the rehab. Whether or not an injury is chronic or acute can also have an effect on the outcome of tissue repair.
The prior performance level of the athlete can either hinder (out of shape) or enhance the athlete’s ability to rehabilitate the injured tissues. The age, health, and nutritional habits of the athlete will also help predict how well the athlete’s tissues repair. Finally, the performance expectations of the athlete when he/she is returned to competition will play a large role in the athlete’s rehabilitation program. If performance expectations are high, then the medical team may have to wait to release the athlete for competition until the tissue has healed 90-100%.
Rehab Begins The Moment After Injury
As soon as an athlete is injured on the field rehabilitation begins. Rehab may start with immobilizing the injured joint or taking the athlete to the side lines and implementing the PRICE method (Pressure, Rest, Ice, Compression, and Elevation). The rehab should continue until the athlete sees a sports medicine doctor. Upon the doctor’s evaluation, if the athlete requires surgery, then the athlete should start a rehab program prior to surgery. In some cases doctors may wait up to two weeks to schedule a surgery.
This is done to allow the rehab process to begin and decrease swelling and inflammation, improve ROM, improve neuromuscular control, and strengthen the structures around the joint or injury site. By doing this, the post surgical phase of rehab may be improved. Remember when an athlete is not training they are in detraining period.
Generally when an athlete is injured on the field the medical team will immobilize the injured structure. This provides two advantages, (1) it will allow no further harm or injury, and (2) it will provide support and allow the athlete to move or be transported. Athletes often want to walk off the field under there own power and not immobilized. This is a very brave and noble thing to do, however it is stupid and idiotic. More damage can occur if the athlete is not immobilized. Tissue can tear and fractures can become worse. The best thing to do is allow the medical team to immobilize the limb.
If an athlete is immobilized, two major variables must be addressed. The athlete will have one or possibly a combination of immobilized joints, and the athlete will not be able to stay conditioned. Thus, the athlete will enter a detraining period. This means the athlete will loose flexibility, strength, power, neural control, the muscles will atrophy, the muscles will undergo cellular alterations (e.g. decrease mitochondria, decrease protein synthesis), and the athlete will suffer a decrease in cardiopulmonary endurance.
A good post injury rehabilitation program may employ aqua therapy to counteract the affects of immobilization. The program may also include isometric contractions. This can be done by the athlete or by electrical stimulation. It will provide the advantages of keeping the joint stabile and allowing the muscles to contract. This will retard muscle atrophy.
Arnheim and Prentice pinpoint the following considerations when immobilizing a structure.5
. Muscles will atrophy less in the neutral or lengthen position.
. Immobilization of joints causes loss of normal compression. The result will be a decrease in lubrication with in the joint that can lead to degeneration. A decrease in lubrication causes a decrease in nutrition to the articular cartilage.
. When stress is decreased or eliminated, bone and ligaments become weaker. Please refer to Wolf’s Law in the Biomechanics Section.
. The cardiopulmonary system is affected by immobilization. The resting heart rate increases, stroke volume decreases, maximum oxygen uptake decreases, and vital capacity decreases. Please refer to cardiopulmonary system in the exercise physiology section.
Variables to Consider in the Formulation of a Rehabilitation Program?
. Is it in season or out of season?
. What are your rehabilitation goals?
. What are the best modalities?
. What type of strength and conditioning exercises are best for the affected and non-affected joints?
. What type of secondary injuries may occur from the rehab?
. Minimize Down Time
. Keep up Cardiopulmonary Conditioning
. Keep up Psychological aspects of the Athlete
. What can the parent or spouse contribute at home in the rehab process?
In Season or Off Season
. In Season the sports medicine specialist has to be aggressive and minimize down time. The athlete will need to compete.
. Off Season the sports medicine specialist can be more conservative. The athlete will not be competing.
Rehab During Competition
. Your rehab program may go on while the athlete is still competing because the injury may not be performance affecting (but the therapy could), or the athlete may be playing injured. In the later case the athlete may only be competing at 80% -90% of his/her true uninjured capabilities.
. Will the therapy prescribed by the sports medicine professional affect the athlete’s performance?
. If so what are alternative methods?
. Example: Pain meds may decrease performance----Ice or Electrical Stimulation may be able to be used prior to performance to decrease pain. This will desensitize nerve fibers and or release endogenous opiates.
What are your rehab GOALS?
Each rehabilitation program should have rehab goals. The goals should be set long term (e.g. return to full knee flexion in 60 days) and short term (e.g. increase knee flexion by 5 degrees every week). The goals should be obtainable. The following are a few goals both long and short term that should be established and obtained during the rehabilitation process.
. Pain Management: One of the first goals is to minimize pain. If the athlete is hurting, he/she will not want to complete the rehab protocol.
. Reestablishing Full ROM: Many factors contribute to a decrease ROM after injury. Swelling can cause a mechanical blockage of a joint. Such factors as swelling, muscle spasm, and more should be addressed in order to increase ROM.
. Maintaining or Reestablishing Muscular Strength and Endurance: Whether it be isometric, eccentric, or concentric contractions, one of the major rehabilitation goals should be muscular strength and endurance. The goal should be to match or exceed pre-injury strength levels.
. Maintaining or Reestablishing Cardiopulmonary Endurance: The medical staff must become innovative and come up with ways for an injured athlete to maintain or gain back the athlete’s cardiorespiratory endurance. This goal is often overlooked in the chaos of the rehab process. If an athlete is to return back to off season training or in season competition, his/her fitness levels must be met.
. Maintaining or Reestablishing Proprioception, Kinesthesia, and Neuromuscular Control: Proprioception is the ability of an athlete to determine the position of a joint in space, kinesthesia is the ability to detect movement, and neuromuscular control relies on proprioceptive and kinesthetic information. These help in producing coordinated movement.5 Athletes must have coordinated movements to complete sports specific skills, therefore this must be an established goal.
. Maintaining or Reestablishing Sports Specific Skill Execution: In order for the athlete to return to play, he/she must be able to execute all the skills needed in his/her sport. Therefore, goals should be set such as maintaining or gaining the ability to sprint, to cut, weave, jump, dive, throw, and such.
A successful rehabilitation program will consist of knowing what secondary injuries have occurred from the primary injury and what secondary injuries may occur from the rehabilitation program. It is highly recommended to offset any secondary injuries that may result from the program. These injuries will further complicate and lengthen your rehab program. The therapist may have to plan ahead to try and avoid secondary injuries that they know will occur.
. Modalities can cause secondary injuries. (e.g. Ultrasound can cause periostitis to the bone).
. Pain, muscle weakness, joint guarding, splinting/bracing and more, can cause an abnormal force distribution, which will lead to secondary injuries.
. Bracing, splinting, or casting can cause irritation to skin, muscles, tendons, and structures around the ends and edges of the materials of the brace or splint.
5 Strength and Conditioning Variables
Mode, frequency, duration, intensity, and specificity are the five strength and conditioning variables that when manipulated in different combinations produce physiological changes within the tissues. These five variables must be manipulated in order to rehabilitate an athlete. When a therapist can master the manipulation of these variables the effectiveness and efficiency of their rehabilitation programs will increase. These five variables are crucial to a rehab program.
. Mode (type of exercise)
- -Aqua Therapy
- -Core Strengthening
. Frequency- How many times per day, per week?
. Intensity- How hard is the Exercise?
. Duration- How long is the exercise period?
. Specificity- Exercise pertains to the athletes sport, it is a sports specific exercise.
The overload principle states that a tissue must be stressed in order to cause a physiological change. This means that it must be overloaded with a stimulus that it is not accustom to. Adaptations such as strength gains, and hypertrophy will occur until the tissues are no longer overloaded.
Minimize Down Time
. When the athlete is not training, he/she is in a detraining period. If the athlete detrains too long, he/she will loose muscle mass, strength, power, and endurance.
. Down time will make it harder and longer for the athlete to come back. However, the athlete may have to accept that they may not make it back this season. The sports therapist may have to be conservative and safe by extending the down time and allowing tissues to heal properly.
It is Imperative for the athlete to maintain cardiovascular conditioning during therapy. If at all possible sports specific conditioning should be implemented throughout the rehab program. This is done so that when an athlete’s injured tissues have healed, he/she will be able to immediately return to play. Thus, the athlete will not have to spend extra time added on to the rehab program to get back in shape. Once the injured tissue has healed back to 100%, then the athlete can simply return to play.
For example, an athlete with a stress fracture of the foot or an ankle sprain, can wear a jogging vest and can be placed in a pool. The athlete may then run in a virtually weightless environment. The water will apply resistance throughout all the movements the athlete makes and the hydrostatic pressure will compress the injured tissue. Thus, the athlete will be able to keep up his/her cardiopulmonary conditioning and not apply high amounts of force to the injured tissue while it heals.
Psychological Aspects of Injury
When an athlete becomes injured, they don’t only experience physical injury, but mentally they become injured as well. For some athletes, the psychological issues of injury decrease their ability to rehabilitate. An athlete is a special breed, they thrive for competition. When their ability to compete is taken away by injury, they can go through five known psychological states.
1. Denial and Isolation- In this state the athlete will deny that the injury has occurred, they will refuse treatment, and they will try to participate, which may cause further injury.
2. Anger- Once athletes realize that they are injured, they will become angry at themselves or may be angry at the coaches or team.
3. Bargaining- When the athlete calms down he/she usually tries to bargain his/her way back on the field. They say “tape up the injury it does not hurt anymore”. This state can be dangerous because if the athlete goes back out on the field, he/she will cause even more damage to his/her body.
4. Depression- Sometimes athletes will think that their season or career is over and they will stop rehabilitation. At this point the athlete must be motivated to rehabilitate or they may never make it back from the injury.
5. Acceptance- the athlete accepts that they are injured and that hard work will need to be applied to rehabilitate the injury.
An athlete’s emotional state will have a direct impact on his/her rehab program. More importantly the rehab program will have an even bigger impact on the athlete’s ability to perform. If the athlete does not give maximum effort in rehab, he/she will not get back to 100% as fast, and the athlete will miss games. Also by not putting forth maximum effort in rehab, the athlete can decrease his/her performance for the remainder of the athlete’s career.
Athlete’s Return to Play
Physicians have a responsibility to evaluate an athlete and determine when he/she should safely return to play. The criteria for return to play will include an evaluation of strength levels, hypertrophy, ROM, muscular and cardiovascular endurance, sports specific skills, agility, psychological factors, and healing of the damaged tissue.
The medical team will collaborate with the coaches and athlete to help make the decision. All these factors must be addressed. If the athlete is returned to play to soon, then he/she may have an increased risk of re-injury, causing further insult to the injured tissue, or injuring another tissue due to an insufficiency of one or a combination of the above parameters.
Athletes will be returned to competition in two ways: return to play with restrictions or limitations, or return to play with no restrictions. Athletes can return to play with no restrictions meaning they can compete unconditionally. However, a physician may return an athlete back to play with a restriction such as no tackling, must tape or brace a joint, or only playing half a game for the next month.
Variables that must be evaluated before an athlete can be returned to play
. Strength: Strength can be evaluated by manual muscle testing, weight lifting, and isokinetic machines such as KIN-COM and CYBEX. Strength levels will be compared to the opposite uninjured side and strength variations will be evaluated in the antagonist/agonist muscle groups. This helps determine if strength ratios are balanced and will help to further prevent injury.
. Hypertrophy: Usually with injury, the athlete will suffer from atrophy. One of the rehab goals should be to restore hypertrophy. A decrease in hypertrophy can result in further injury. Hypertrophy can be evaluated by girth measurements, and those measurements should be compared to those from the initial injury evaluation.
. ROM: Range of motion can be measured with a goniometer. Measurements should be compared bilaterally and measurements should be compared to the initial injury evaluation. The athlete should not be returned to play until full ROM is recovered.
. Muscular and Cardiovascular Endurance: Muscular and cardiovascular endurance is very important for the athlete to have when returning to play. It can be tested by having the athlete complete a sports specific task such as a sprint or series of jumps or throws. If an athlete becomes fatigued on the field they do run the risk of injury and a fatigued athlete will not perform as well.
. Sports Specific Skills and Agility: Athletes need to be able to complete sports specific skills like diving on the ground, throwing, kicking, sprinting and switching direction, jumping, and more. If the athlete is still injured, he/she may run the risk of further insulting the injury.
. Psychological Factors: Athletes should be evaluated to determine how they feel about an injury. Sometimes athletes form tendencies and a lack of confidence on the previously injured tissue. This makes them more successable to becoming injured again. Athletes fear the rehab again and will favor and protect the previously injured tissue. This will throw off their mechanics, decrease their performance, and cause them to re-injure themselves. They should be evaluated to make sure these fears have passed and that the athlete has total confidence in the rehabilitated tissue.
. Healing of Injured Tissue: The physician should take x-rays, manual tests, and any other means of diagnostically testing the injured tissue to make sure it has healed properly. If the tissue has not healed properly, then the athlete will re-injure the tissue.
By: Craig Angle - ME.d, ME.d, ATC, CSCS
Author of the book: How to Raise a Successful Athlete
Former CEO: The Athlete Project
1. Prentice , William. Rehabilitation Techniques in Sports Medicine. Mosby:
2nd Ed. Missouri; 1995.
2. Starkey, Chad. Therapeutic Modalities for Athletic Trainers. F.A. Davis
3. Merrick, M. A., Jutte, L.S., Smith, M. E. Cold modalities with different
thermodynamic properties produce different surface and intramuscular temperatures.
J of Athletic Training Research. 2003, 38: 28-33
4. Knight, K.L. Cryrotherapy in Sport Injury Management. Champaign, IL: Human
5. Arnhiem, D. D., Prentice, W. E., Principles of Athletic Training. McGraw-Hill:
9th Ed. Boston; 1997