REHABILITATION PRINCIPLES

in pain and swelling (7), lower limb closed kinetic chain (CKC) exercises are imple- mented once isolated muscle groups demonstrate maximum muscle strength ≥ 85% of the uninjured limb (10), and lower limb plyometric exercises are implemented once a patient can perform a one repeti- tion maximum single leg press at ≥ 125% bodyweight (10).

Although there is currently little research- based evidence for such progression crite- ria, this clinically-reasoned process ensures that rehabilitation is progressed as safely, effectively, and time-efficiently as possible according to the individual patient (3,6,7,10). While it is important to remem- ber that imposing controlled stresses on an injured body-part can enhance the mechanical properties of the injured tis- sues (1,3,11-13) and that early mobilisa- tion on injured tissue (11,12) (depending on the severity of the initial injury and the magnitude of tissue damage) can be bene- ficial, some form of immobilisation may actually be necessary (12). Clinicians must still acknowledge the ‘gross’ time-frames required for different stages of tissue heal- ing (7,12). In other words, clinicians must find a balance between tissue healing time-frames and evaluation-based progres- sion criteria.

ASSESSMENT OF TISSUE INVOLVEMENT Clinical experience demonstrates that an injury rarely involves a single tissue (ie. just ligament, just muscle etc.). In fact, clinical

STAGES OF TISSUE RECOVERY

General rehabilitation: Rehabilitation should only take place once the acute symptoms have subsided. Soft tissue injuries undergo three stages of recov- ery after injury and careful considera- tion of the physical recovery of the ten- sile strength of the tissue is important before increasing the workload on the structure.

At the point of injury there is a sudden drop in the tissue’s ability to withstand tensile stress. This is followed by three phases: a) Inflammatory phase (up to 5 days post-injury) - this is essential for heal- ing and mainly involves protection of

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the strain and avoidance of tensile stress to encourage a solid foundation from which healing can occur. b) Regeneration phase (from day 5 to day 21 post-injury) - gradual tension applied to the strain in the form of manual thera- py techniques encourages early collagen orientation, vital for a full functional recovery and the prevention of injury reoc- currence. c) Remodelling phase (21 days post- injury onwards) - this phase may continue for up to 18 months and involves contin- ued strengthening of the injury with pro- gressive re-alignment of the collagen fibres. The formation of scar tissue must be avoided to prevent the development of a

tightened, weaker structure that is more prone to re-injury. The real rehabilitation work only commences once the player has returned to full time training, a difficult point to get across to the supposed fit player!

Injury

reasoning proponents recommend that all types of tissue (ie. joint, muscle, nerve, etc.) are routinely assessed in the vicinity of the injury site in order to truly determine the extent of tissue involvement (8,14).

For example, peroneal nerve entrapment, secondary to oedema, following an acute ankle ligament sprain is a common clinical complication (15). Unless it is assessed with the appropriate neurodynamic test and treated with the appropriate interven- tion, the injury may eventually ‘masquer- ade’ as a chronic lateral ankle ‘sprain’ long after the ligament has actually healed (15). Furthermore, since the vast majority of body-tissues are innervated with senso- ry nerves (16), the central nervous system (CNS) is always affected by musculoskele- tal injury (17,18). Consequently, sensori- motor control is always affected following musculoskeletal injury and in addition to traditional rehabilitation (eg. manual ther- apy) (13), some form of sensorimotor rehabilitation (eg. balance training) is always required (17,18). Therefore, for injury rehabilitation to be effective, the clinician must identify all of the tissues involved and eventually, implement senso- rimotor rehabilitation specific to the patient’s needs (13).

CONTROL PAIN There are several reasons why control of pain following injury is a priority of reha- bilitation. Pain is an unpleasant sensation which can affect a patient’s mood and behaviour (19). From a purely compassion-

ate perspective, it is important for the clinician to implement as many pain con- trol strategies as possible. From a time- efficacy perspective, effective pain-control strategies can expedite return-to-function. Pain also results in impaired propriocep- tion (20), muscle inhibition (21), and ‘guarded’ movements (19) which, in turn, all result in abnormal sensorimotor control of joint stability and limb alignment (17,18,22). Therefore to limit patient dis- comfort and impaired sensorimotor con- trol, as well as expedite a return-to-func- tion pain-control should be optimised using advice regarding modification of daily activities and sleeping position, modalities (eg. ice, electrotherapy etc.) (1,3,6), joint mobilisation (eg. grade I-II) (23,24), and analgesia (1,3). For pain thought to be a result of muscle ‘guarding’ and spasm, there is some evidence that low frequency (1Hz) joint mobilisation reduces excitability of corticomotor pathways (25).

CONTROL EFFUSION Control of joint effusion is also a priority of treatment for similar physiological reasons as the control of pain. There is some evidence that acute joint effusion also impairs proprioception (26), and substan- tial evidence that even minor effusions cause major muscle inhibition and muscle weakness (27,28). To further limit the detrimental effects of abnormal sensorimo- tor control, muscle weakness, and pro- longed rehabilitation, effusion-control should be optimised using compression (1),

AB C

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Tensile Strength