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rehabilitation process, rehabilitation period, knee injury rehabilitation

Rehabilitation process - so what exactly is the coach meant to do during the rehabilitation period? Here are a few pointers.

The Sports Injury Doctor

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Exercise is a vital part of the rehabilitation process for most sporting injuries. The idea that an athlete is completely cured once the treatments on the therapist's couch are over is simply outdated. Instead, when athletes visit physios, in conjunction with receiving a course of treatment, they will be set specific strengthening and flexibility exercises. Exercises are included in rehabilitation programmes to ensure the injury site returns to a fully functional state and/or to ensure that the original cause of the injury is eliminated.

For example, an athlete recovering from tennis elbow will need to strengthen the wrist extensor muscles to prevent the injury recurring. The extensor muscles are often weak compared to the wrist flexor muscles and so are susceptible to overload. Or, an athlete recovering from a hamstring strain would need to stretch and strengthen the injured hamstring to ensure that flexibility and strength are equal for both injured and non-injured sides. Because exercise is intrinsic to the rehabilitation process, trainers and coaches need to be aware that they have a significant part to play in helping their athletes back to full fitness. This article will discuss each stage of the injury management process in the hope of providing a few useful pointers for coaches and trainers.

First aid
If the athlete suffers an 'accident'-type injury, eg, a pulled hamstring or a sprained ankle, the trainer can help by carrying out the correct first-aid procedures. The familiar RICE protocol should always be followed: REST the injured part immediately; ICE the injury site; COMPRESS the injured site with strapping, and ELEVATE the injured limb. This protocol helps with pain relief and to control the inflammation and swelling. If it is done quickly, it can speed up healing time. For more serious injuries or bone fractures, eg, a broken leg, only those with proper training should attempt first-aid treatments. In serious cases, try to get professional help as quickly as possible.

If the injury is a 'chronic' type, eg, shin splints or tennis elbow, then it has occurred because the injured site has been overloaded during the athlete's exercise programme. The trainer must respond to the athlete immediately and stop the training to prevent any further damage. Remember, the quicker the athlete stops, the quicker the athlete recovers.

Diagnosis and treatment
The next step in injury management is getting an accurate diagnosis. The trainer needs to know where to take the athlete for expert help. In my experience, this is often where an athlete can come unstuck, as they can receive an inaccurate diagnosis and thus waste time following an inappropriate treatment plan. Only use your GP to refer you on to a sports-injury specialist because GPs are rarely experts in sports medicine unless they have a personal interest. Often the best people to see are physiotherapists specialising in sports injuries since they deal with such injuries on a regular basis. Even orthopaedic surgeons are not always sports-injury specialists, often spending most of their time with more general patients.

The sports-injury specialist will then plan and implement the treatment required. Usually, the initial stage of treatment involves reducing pain and promoting healing. As the trainer, you need to question the practitioner so you are aware of what is being done and why. Once pain and any swelling are reduced, the treatment will begin to involve more exercises. At this point, the physio will set exercises to target specific goals that will help solve the athlete's problems. Initially, this is likely to be mobility and flexibility training and then, later, strengthening work. This is where the athlete and trainer can work together.

Case study: a chronic knee injury
An interesting example of this process of diagnosis and treatment in my coaching experience comes from an athlete with a chronic knee injury. I took her to a sports-injury specialist and he diagnosed her complaint as Chrondomalacia patella, which, translated into English, means a mal-tracking of the kneecap which causes a roughening on the underside of the knee and thus pain. The cause of the injury was pinpointed to the athlete's gait while she was running. Specifically, there was over-pronation at the foot and instability at the hip, both of which were leading to excessive internal rotation at the knee.

The physiotherapist prescribed complete rest from running and any activity that aggravated the problem. This would allow the knee to heal. In addition, orthotic inserts for the athlete's running shoes were prescribed to control the excess pronation and a strengthening programme was prescribed for her legs, hips and abdominals to help stabilize her pelvis and control the internal rotation. Thus her treatment plan and exercise programme were related to eliminating the cause of the injury.

As her coach, I supervised her strength workouts to ensure she performed the exercises correctly and increased her strength in the relevant areas over the following weeks. As I've said, injury rehabilitation training is goal-related. The physiotherapist sets the specific goals - in this case, improving leg, hip and stomach strength - but it is the coach's job to encourage the athlete to achieve the goals. Because you are still closely involved, the athlete will feel you are still the coach, even though he or she is injured. Part of a coach's job is to help his athletes recover to full fitness after injury, not simply to train them when they are 100 per cent healthy.

Alternative training
Athletes can continue to train even when they are injured. It means adopting different types of training or training methods that do not stress the injury. One of the major goals of the rehabilitation process is to maintain aerobic fitness levels by using alternative training methods. For instance, instead of running, athletes can try water running with a flotation belt, or cycling. As the coach, you should implement this alternative aerobic training programme as soon as possible. It is vital that athletes believe that even though they are injured, they can stay in shape.

In addition to maintaining aerobic fitness, the athlete can use the injury period as an opportunity to strengthen other areas of the body. Remember, it is only the injured part that needs to be rested, not the whole body. For example, a footballer with a groin strain can use the injury period to improve leg, trunk and upper-body strength. It's up to the coach to set an appropriate, and safe, strength programme.

The athlete I mentioned earlier who was suffering from a knee injury used alternative training methods while she was injured. She performed water-running workouts as her alternative fitness activity while she had to rest from running. In addition, as well as following the physio's prescribed strength exercises for her injury, we added some upper-body exercises and some extra, but safe, leg exercises to the workout. She came out of the injury period feeling that she had not lost too much fitness and had gained an all-round strength that she did not have before.

Progressive return to full training
Once the pain has subsided and the athlete has started to meet the flexibility and strengthening goals, the physiotherapist will be able to advise on when normal training can start again. This is the point when clear communication between therapist, coach and athlete is vital. One of the major reasons why athletes suffer a recurrence of an injury is that they have started training too hard, too soon. What they fail to understand is that, just because the injured part is pain-free, it doesn't mean they are fully fit.

Once the athlete is able to use the injured part, he or she must gradually retrain the endurance, strength and coordination of that part so that it can withstand full competition conditions again. Thus, the goal at this stage in the rehabilitation process has moved on from healing the injury to regaining full function. To achieve this, the rehabilitation programme must be specific to the athlete's sport. For example, for the injured footballer, strength exercises should be functionally related movements, such as single-legged squats, jumps and plyometric drills.

The programme must also include proprio-ceptive training. This is very important because, in basic terms, proprioception is the coordination of balance and joint positioning sense. The brain must know accurately which position the joints are in so that movements can occur smoothly and effectively. Often, after a period of injury, especially joint injuries, the athlete can lose this ability. Any deficiency in this area, unless retrained, is likely to cause a recurrence of the injury. Therefore, exercises such as hopping on a trampette, unilateral balance drills, wobble-board exercises and hopping and jumping drills are important to retrain any lost proprioception. As well as being sports-specific, the rehabilitation programme must be progressive - for example, starting at 10 minutes running three times a week and then building slowly to 30 minutes running five times a week.

The final stage
A good example of the necessity for this final stage of the rehabilitation process is a footballer recovering from a hamstring injury. The player has completed a successful treatment period and the hamstrings' flexibility is equal both sides, as is their strength on the hamstrings curl station. The player can now jog pain-free. However, when he tried to join in a game, his hamstring felt weak. It is at this point that the player needs to slowly build up the training and include more specific exercises to bridge the gap between healing the injured part and making the injured part fully functional.

To do this, the player must gradually increase the amount of running he can do, as well as slowly increasing the speed he can run at. First, he must start with half-pace sprints, then three-quarter pace, until gradually increasing to full efforts. The player also needs to include more closed-chain multi-joint strength exercises, such as squats or dead lifts, where the hamstrings work in conjunction with other muscles. He will also need to include dynamic and eccentric hamstring exercises, because this is how the hamstrings must work hard during sprinting. Both these types of exercises will strengthen the hamstrings in a sports-specific fashion. The player will also need to introduce kicking, ball-skills work and agility drills into his training, first at three-quarter speed and then full-out. This will ensure that all the skilled movements involved in the sport will have been slowly retrained.

After a period of this specific training and progression, the athlete will be ready to try playing a game. Once again, even this should be built up gradually, and the rehabilitation programme will need to be continued to ensure the problems do not recur. During this final stage, it is the coach's job to make sure the therapist is giving the athlete the right kind of rehabilitation programme, and also to make sure that the athlete continues to follow the programme set. The athlete cannot do too much but, at the same time, if he/she does too little then there will be no improvement in the areas that need to be worked on. This is where the coach must be fully involved, communicating with the therapist, and supervising the athlete. During this period the coach needs to invest as much time in the athlete, if not more, than in normal training.

Raphael Brandon

rehabilitation process, rehabilitation period, knee injury rehabilitation

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