Ankle joint injuries and hamstring injuries

Two cases of treatment for damaged female rugby players - one with a bad ankle, the other with a dodgy hamstring.

Serious injuries that keep athletes out of their sport for a significant time, especially during the season, are very frustrating, to say the least. For the athlete, half the battle can be simply keeping one's spirits up and staying positive. This is why, if you're a trainer or therapist, you must ensure that your athletes have goals to achieve and programmes to follow while they are rehabilitating. This keeps the athlete focused and helps him/her maintain their health and fitness.
The goals of the programme for an injured athlete are:
» to progressively regain full function of the injured muscle or joint
» to improve stability, balance and co-ordination skills to help reduce risks of a recurrence of the injury
» to maintain aerobic fitness using methods that do not affect the injury
» to develop other areas of fitness that are not affected by the injury
» once symptoms are gone and function is regained, to progressively re-introduce normal training and competition.

Case study 1:
a damaged ankle joint
The following are examples of how I achieved the above goals with some members of the England Women's Rugby squad with whom I work.
One player suffered an ankle ligament injury during the tour of New Zealand in the summer. Even after a few weeks off, she had not fully recovered in time to begin pre-season training since she could not run. By the time the season was almost beginning a scan revealed that the injury was still very serious, suggesting that she would be out of action for some time.
With this fairly bleak prognosis in mind, we decided to take the opportunity to focus on muscle hypertrophy for one month. The reason for that is that she is small for her position and if she gained some weight it would help her keep her place in the team once she is able to play again. This period was also realistic for her to regain most of her ankle function with a series of exercises her physiotherapist had prescribed.
Her training week comprised the following components:
Six strength sessions in the gym. This was a split routine of three different workouts, each focusing on different body parts. Each workout was performed twice each week. The focus was on gaining muscle and so three sets of 10 reps with only one minute's rest was used to maximise this effect.
Two pool running workouts. These were included to help maintain aerobic fitness without stressing the ankle joint.
Injury rehab exercises, every day. Various exercises focusing on flexibility, balance, and strength of the ankle (see also SIB 6, February 2001).
Core stability routine, six days a week. Various exercises to improve control of lumbar spine, improve upper body posture and stomach strength (see also SIB 7, March 2001).

This month's programme was very successful. Specifically, she gained 4 kg of muscle mass as well as improving her ankle function to the extent that she was able to introduce slow jogging on the treadmill into her rehab programme. Psychologically, the improvements were important, to balance the disappointment of watching her team mates start the season without her.

The current programme
Now we have started a new programme which aims to maintain the increases in muscle mass but also includes power training. The reason behind this is twofold: first, we are hoping she will be playing again soon and so the training must prepare her more specifically, and, second, the power training allows us to introduce exercises that will train the ankle more dynamically, helping to regain its full strength and proprioception.
Her weekly training routine is currently:
Monday - Leg power and upper body strength A.
Tuesday - Leg strength and upper body strength B.
Wednesday - Pool running, upper body power and core strength.
Thursday - as Monday
Friday - as Tuesday
Saturday - as Wednesday
Sunday - rest

In addition to this routine, she will introduce slow jogging, starting with just five minutes, three or four times a week. Her other ankle exercises are completed every day on top of this routine.
I am hoping that the jogging can progress safely up to the point where she can run continuously for 20 minutes without pain. Once this occurs we can start to think about introducing faster running and agility drills to finally complete the rehabilitation process before she plays once again.

Case study 2:
the strained hamstring
This was a less serious injury than that described above but no less annoying for the athlete. This injury occurred during a pre-season training kicking session. The hamstring was strained slightly and the player could not run at full speed or perform her leg strength exercises.
During the few weeks that the injury was troublesome her programme was as follows:
l one or two hard interval sessions on the rowing machine to improve aerobic fitness;
l one or two slow 30 minute jogs to help her stay in shape and also provide a low-stress way of working the hamstring;
l three strength sessions, working mostly the upper body and core areas.

In addition, I had identified that she had very poor gluteal stability and endurance. I surmised that this was related to the cause of the injury and the physiotherapist supported this idea and prescribed a series of gluteal exercises. The exercises were performed each day.
After three weeks the injury started to ease and we re-introduced some leg-strength exercises that did not strain the hamstring. In addition, she started to include a few fast running sections to her 30-minute jogs to get the muscles used to more dynamic exercise once again. At this time she also completed a squad training session without doing any full-out sprints.
Ten days after this she played her first game of the season, without any problems. The hamstring was slightly weak afterwards but no damage was sustained. With correct warming up, cool downs and plenty of stretching, she is now able to resume full training again, which includes power exercises for the legs and sprint workouts.
Part of the success of this rehabilitation programme was due to the inclusion of the gluteal stability exercises. This meant that when the injury had healed and more demanding movements were performed there was less strain placed on the hamstring than before.

The bottom line...
Rehabilitating athletes can be a tricky business, but if you think about setting goals and programmes then your chances of success are much higher. The combination of specific exercises for the injury itself, maintenance aerobic training using a non-stress activity and extra training to develop other fitness and injury prevention areas seems to be best for both rehab success and the psychological state of the athlete.
Once you feel the injury has healed and function is back to normal, always remember to introduce sport-specific activities gradually and progressively to ensure long-term rehab success.

Raphael Brandon