Figure 7a:

Increased calf girth

revised in line with the new aims and used to explain the potential advantages and disadvantages associated the subacute phase.

Interventions carried forward PRICE, intermittent compression, massage and hydrotherapy would continue as necessary using the same protocols.

Early controlled mobilisation after injury

Figure 7b: Severe ROM restriction

angiogenesis (formation of new local blood vessels) (9). The ‘active’ effusion and local erythema were no longer present. However, although improved, pain-free ROM of the knee was not within normal limits. The most affected area was found to be the right ankle and calf region which were both very swollen (figure 7a). Ankle dorsi-flexion remained severely restricted (figure 7b). A revised treatment and rehabilitation plan was agreed with the aim to further reduce oedema and pain, work towards regaining normal ROM in the knee and ankle. Additionally we introduced proprioception training and worked on increasing muscular strength, and aerobic fitness within a safe working environment. The SWOT analysis was

tissue overload maximum exercise loading

Although a short period of immobilisation following injury is necessary, early controlled mobilisation is essential for decreased healing time, increased vascular ingrowth, quicker regeneration of scar tissue (30), resulting in stronger mobile tissue (31). Whereas prolonged immobilisation leads to deleterious tissue effects such as random deposition of collagen, excessive cross-link formation and atrophy (22). During the early and intermediate subacute healing phase, new tissue is fragile and easily interrupted, consequently, mobilisation too early or too intensively may re- rupture the injured tissue (32). Thus stretching and exercise loading would remain within the tensile capability of the healing tissue (figure 8).

Controlled exercise Proprioceptive rehabilitation is always required following injury to restore normal sensori-motor control (4). The balance stork-test was used to establish a base-line bilateral comparison (33). Proprioceptive restoration began with weight-shifts from foot to foot, then single-leg balance on a hard surface, progressing to a soft surface (aeromat) with eyes open, then eyes closed. Further progression involved wobble board exercises which continued into to the remodelling phase. Graded controlled progressive

remodelling phase proliferation phase lag phase time

Figure 8: Hypothetical model of the stages of healing in relation to the tensile strength of the healing tissue.

14

stretching was introduced on all the affected muscle groups although performed slowly. The effects of stretching, with regards to duration, force loading, and frequency, remains controversial. Stretching should be performed slowly rather than rapidly, allowing the tissue to undergo viscous changes. During the vulnerable subacute phase, pain levels determined the force of loading to avoid retraumatising the fragile tissue

(22). The agreed stretching protocol was daily, 4 x 30 second repetitions, repeated four times spread over the day. Based on the findings of various trials, this protocol would increase flexibility and accelerate a return to sport (34, 35). When functionally possible, multiple-angle isometric contractions were used to develop early strength throughout the joint range (15), and to reduce atrophy of type I slow-twitch fibres (36). Hydrotherapy was extended to

improve ROM, muscular strength, bilateral co-ordination, and aerobic fitness while adding fun to the rehab plan. Pool-based rehabilitation can be used to reduce swelling and exercise an injured limb without risk of aggravating swelling as well as to develop muscular strength and aerobic fitness (37). During the late subacute phase an indoor cycling ergometer became the primary method of daily aerobic conditioning while introducing sports-specific rehabilitation. Initially intensity was dictated by pain-levels, later a heart rate monitor was used to control continuous progressive increases in aerobic efforts (38).

Manual therapy techniques The repair process and remodelling of tissue is believed to be are highly responsive to mechanical signals such as manual therapy (22). Cross- fibre frictional massage, developed by Cyriax, can be applied to break up adhesions, increase the mobility of scar tissue within damaged muscle as it heals (15) and promote remodelling of healing tissue (25). In addition to using effleurage and petrissage massage, gentle cross-fibre frictional massage was applied at 90º to the targeted muscle fibres for up to several minutes duration, taking the tissues through their full sweep ie. to their end-feel. Sustained myofascial release techniques were applied in a longitudinal direction to the hamstrings and calf muscles using the forearm. The aim was to rupture abnormal cross-linkages between collagen fibres formed as a result of the inflammatory response. The amount of pressure and force applied was regulated to compliment the tissue capabilities for subacute healing.

Therapeutic ultrasound Therapeutic ultrasound can be

sportEX dynamics 2008;17(Jul):11-17