SOFT TISSUE TRAUMA

administered throughout the inflammation, proliferation and remodelling phases using an evidence- based setting (39). Although many systematic reviews fail to support the efficacy of its continued use, Watson (39) reports that many studies lack accurate data on clinical settings, and Robertson (40) reports many studies lack evidence of equipment calibration. Furthermore even many authors of these systematic reviews report the quality of studies are often poor, and further efforts are necessary to provide stronger evidence. In support, if one looks critically at the full range of physiotherapy treatments, there is simply insufficient evidence to support or reject many of them in all known circumstances (41). While ultrasound is recognised for its physiological and proproliferative effects on stimulating fibroblasts (42), it can also have a significant psychological placebo effect (43).

Therefore on the above evidence

it was decided to use ultrasound on specifically targeted areas.

PHASE III: REMODELLING PHASE Approximately 2-3 weeks post-injury, collagen maturation and remodelling begin. With maturity, the collagen remodels becoming more obviously oriented in line with local stresses. A portion of the type III collagen is reabsorbed and is replaced by type I collagen with greater tensile strength. The remodelling process continues for months, even years. The primary aim of phase III was to address functional deficits and prepare the cyclist for the sports-specific functional rehabilitation phase to follow. The emphasis was on restoring normal bilateral lower-limb muscle strength and muscle balance, normal pain-free ROM, dynamic proprioception and high levels of general and cardiovascular fitness. This is in addition to encouraging optimum tissue healing, collagen re-alignment, and a mobile scar with high tensile strength. Once again the cyclist was re-assessed, new aims defined and agreed, and a SWOT analysis highlighted the key aspects with respect to patient education. The need to restore normal ankle ROM was identified as the main functional deficit. Figures 9a, b, c demonstrate the progressive improvement achieved in

www.sportEX.net dorsi-flexion. Manual therapy techniques

intensified to reflect tissue healing for the remodelling phase. Cross-fibre frictional massage and myofascial release was applied with increasing pressure and duration. Active and passive stretching continued but with increased force loading. To achieve effective stretching the tensile force used should bring the tissue to its end-elastic-early-plastic range (22) – beyond this range is likely to cause tissue rupture. Lederman (22) suggests a loading that elicits a ‘pleasant’ stretch sensation that feels ‘therapeutic’. Targeted ultrasound continued using evidence-based settings to influence the remodelling and orientation of the collagen fibres in the developing generic scar tissue. Various forms of progressive resistance training protocols were used to address specific strength deficits while strengthening the lower limbs and upper body, using open kinetic chain, closed kinetic chain, eccentric and concentric contractions as detailed in (44). If accessible, isokinetic dynamometry testing is considered the most effective to detect, monitor, and redress muscle weakness, bilateral imbalances and hamstring quadriceps ratio (45).

Time spent on the cycle

ergotrainer rapidly increased, targeting cycling-specific aerobic fitness through progressive increases in frequency, duration and intensity at 75–85% HRmax.

PHASE IV: FUNCTIONAL SPORTS-SPECIFIC PHASE Essentially rehabilitation can be divided into two stages: pre-functional (treatment and recovery) and functional (46). Functional rehabilitation should simulate the athlete’s required sports- specific activities associated with training and competition and can be enhanced by an ‘activity-specific- needs-analysis’ (47). In this particular case the ‘needs analysis’ was designed by both the cyclist and myself to enhance specificity and adherence. Since the lower limb predominately

functions in CKC, functional rehabilitation should employ CKC- biased exercises (47, 48). The energy systems necessary to cycle race are the phospho creatine, anaerobic glycolytic and the aerobic system (38), accompanied by strong core and pelvic muscles to form a solid base (49). Endurance cycling primarily

involves the aerobic system and therefore represented the key area for development in this case study. Cycling comprised of on the road and indoor ergotraining. To ensure strict adherence, exercise intensities were

PROGRESSIVE STAGES

REHABILITATION SHOULD BE SYSTEMATIC, CONSISTING OF CONTROLLED

15 Figure 9a:

22 days post- injury

Figure 9b:

29 days post- injury

Figure 9c:

36 days post- injury