S
UZANNEW
ERNERSports Rehabilitation in General
Physically active individuals expose themselves to the risk of considerably higher loads on their bodies compared with physically inactive individuals.
Therefore, high demands are put on the rehabilitation of an active individual after injuries or surgery. Sports rehabilitation should strive to obtain not sole- ly the same physical condition as before the injury but, rather, a better one in order to try to prevent re-injury or a new injury. Exercises for improving range of motion, muscle strength, muscle flexibility, agility, proprioception, balance, co-ordination, and conditioning should be included in the rehabili- tation, irrespective of type of sports injury. Furthermore, the rehabilitation programme should be tailored to each individual based on both physical con- ditioning and his or her specific needs. The rehabilitation protocol design should include the specific demands that the individual athlete is exposed to in his or her sport.
The main goal of rehabilitation after sports-related injuries is to safely return the athletes as soon as possible to their pre-injury level of physical activity. Sports activity puts heavy demands on physical fitness and condi- tioning, and it is especially important to pay attention to them when a recent- ly injured athlete is returning to sport. Rehabilitation should lead to normal function before the athlete is permitted to return to sporting activities. To make this possible, fast and correct acute care as well as optimal treatment and rehabilitation is required. This means concerted effort to eliminate pain and obtain full range of motion, muscle strength, co-ordination, and sports- specific performance.
The rehabilitation protocol should preferably be divided into different
phases, such as the acute phase, the rehabilitation phase, and the sport-spe-
cific phase. These phases are closely linked, each with a variety of specific
goals. For successful clinical outcome and decreased risk of re-injury, it is
important that these goals are attained before the athlete is permitted to move
to the next phase.
Rehabilitation after Common Football-Related Injuries
The definition of football injuries means an injury that occurs during football and leads to absence from practice or games. The most common injuries are ankle sprains, knee sprains, and muscle strains.
Lateral Ankle Sprain
The lateral ankle sprain is one of the most common injuries sustained in sport and physical activities, accounting for 11–25% of all acute injuries [1–6]. The most common mechanism of injury is with the ankle joint in a plantar-flexed and inverted position. The anterior talofibular ligament that most often is ruptured in lateral ankle sprains has been found to be the weak- est ligament in tensile strength when compared with other ankle-joint liga- ments [7]. Ankle-sprain recurrence is common, and among adolescent female football players, it appears as a re-injury in 56% of cases [8].
Lateral ankle sprain should usually be treated with non-operative func- tional rehabilitation, most often leaving only the most serious cases and repeat recurrences for consideration of surgical treatment [1, 9, 10].
Acute Treatment
It is generally agreed that the acute phase should include swelling limitation (compression), pain reduction (local cooling), and range of motion mainte- nance. Compression bandaging during the first 2 days and crutches when needed are recommended. When pain and swelling have subsided, bracing or taping could be considered. The ankle joint should initially be kept in as much dorsi-flexion as possible in order to stabilise the joint and minimise capsular distension.
Subacute Treatment and Rehabilitation
During the first 3 weeks, precaution should be undertaken to prevent ankle-joint inversion in order to decrease the risk of ligament elongation [10]. Absence of pain and swelling direct rehabilitation towards weight-bearing exercises, improvement of full range of motion, balance and proprioceptive training, and muscle strengthening, starting with the use of, for instance, elastic bands or tub- ing exercises. Strength training should focus on the peroneal, anterior, and pos- terior muscles, as well as intrinsic foot muscles. In order to avoid recurrence, a rehabilitation period of 12 weeks is recommended, focusing on muscle- strengthening exercises and balance and proprioceptive training. Return to football might, however, be possible as early as 1–2 weeks after the injury if the ankle joint is supported with an ankle orthosis or possibly with taping [11].
Exercises in all planes are most likely to be of the highest benefit and are there-
fore recommended to be included in the rehabilitation programme.
Proprioceptive training has been found to be an important factor in ankle-joint rehabilitation [12–14]. A normalised proprioceptive ankle-joint function has been found after 10 weeks of proprioceptive training [15].
Additionally, exercises for balance and co-ordination have been reported to reduce perceived ankle-joint instability and to improve proprioception [16, 17]. Training on balance boards has been reported to improve proprioception and balance [1, 10, 18] and should be performed with gradually increased lev- els of difficulty. Standing on one leg on a trampoline while throwing a ball against a wall is one example of a high level of balance activity.
Functional training, which usually means activities performed during weight bearing, is important for improving ankle-joint function following ankle sprain. Activities in a weight-bearing position have been reported to be of great benefit in regaining functional stability of the ankle joint [19].
Functional exercises, such as figure-of-eight runs, single-leg hops, carioca crossovers, and shuttle runs could be used for functional stability training.
Furthermore, in a controlled investigation, we found that the figure-of-eight hop test [20] was the most sensitive test for functional evaluation of lateral ankle sprain patients when compared with a number of other sports-related functional tests and could therefore be recommended when evaluating ankle- joint function [Thoruid M and Werner S (2005) unpublished data].
Knee Sprains
Football players put great demands on their knee joints. The sudden changes of direction, hard cutting and pivoting, acceleration and deceleration, and occasionally violent collisions often put the player’s knees at great risk of injury. The anterior cruciate ligament (ACL) is particularly at risk [21], and ACL injury is one of the most serious injuries in football. An ACL injury leads to a long absence from football and is also the injury that leads to the highest risk of sustaining arthrosis later in life [11].
In order to regain good knee-joint stability, most orthopaedic surgeons agree that ACL injuries should be treated with an ACL reconstruction. Today, no consensus regarding the optimal rehabilitation programme after ACL reconstruction exists. We know about the importance of early motion and weight bearing [22, 23]. However, only little is known about how much activ- ity will promote adequate rehabilitation of an injured knee without perma- nently elongating the graft, producing graft failure, or creating damage to articular cartilage. More than 30 years of research at the Karolinska Institute into ACL rehabilitation has led to the rehabilitation protocol we use today.
Based on new research, we are continuously updating our rehabilitation pro-
gramme. The goals of rehabilitation after ACL reconstruction are presented
in Table 1 and the rehabilitation protocol in Table 2.
Return to Football
The following criteria are universally suggested for allowing the ACL-recon- structed patient to return to pivoting sports such as football:
- Full range of motion of the knee joint;
- Stable knee joint and absence of giving way;
- Thigh-muscle strength ≥90% compared with the contra-lateral leg;
- Good results in physical performance evaluated with knee-related func- tional tests;
- No pain or swelling in connection with playing football.
Table 1.
Goals of rehabilitation after anterior cruciate ligament (ACL) reconstruction
Time Goals
0–5 weeks Reduce pain and swelling
Improve range of motion Achieve full knee extension Achieve ≥90° of knee flexion
Regain quadriceps and hamstring muscle control Improve proprioception and balance of the lower extremity Achieve normal gait
When the goals above are achieved
6–11 weeks No swelling
Achieve full range of motion
Further improve muscle strength of the lower extremity Further improve proprioception and balance of the lower extremity
When the goals above are achieved
3–4 months Improve thigh muscle strength, power and endurance
without painGradually return to functional activity and/or sport- specific training
Achieve a normal running pattern
When the goals above are achieved
5–6 months No pain or swelling during football specific exercises Maximal muscle strength and endurance
Good neuromuscular co-ordination
Return to football, training, and gradually to games
Table 2.
Rehabilitation protocol after anterior cruciate ligament (ACL) reconstruction
Time Exercises
0–2 weeks Pain control; cold and compression Passive knee extension exercises to 0°
Patellar mobilisation – when needed Active knee-flexion exercises
Electrical muscle stimulation – when needed Closed kinetic chain exercises
Two-leg calf raises
Balance and proprioception exercises Gait training - preferably in front of a mirror
3–5 weeks, add Stationary bicycling – when 110° knee flexion attained Open kinetic chain exercises
6–8 weeks, add Eccentric quadriceps training Step-up and step-down exercises Lunges with weights
One-leg calf raises
Two-leg trampoline exercises Slide-board exercises Stair-master exercises
Gait training with different types of steps Overall stretching exercises
9–11 weeks, add One-leg trampoline exercises
Functional training, different jumps on the floor, skip the rope Jogging and running on even surfaces – in a straight line
3–4 months, add Quadriceps training, in open and closed kinetic chain, concentric and eccentric actions in full range of motion
Increased intensity of strength training in general Balance drills and coordination exercises Plyometric training
Sport-specific exercises with emphasis on thigh-muscle training
5–6 months, add Jogging and running on uneven surfaces Jogging with turns 90°, 180°, 360°
Cutting with 45° changes of direction Acceleration and deceleration exercises
Football-specific exercises with increased intensity
Muscle Strains
Too much stretch or tension in the muscle leads to an indirect muscle injury, a muscle strain [24], that may be graded into mild (grade I), moderate (grade II), and/or severe (grade III). Strains occur in muscles that are being stretched while undergoing strong activation to decelerate a motion, that is, an eccen- tric action [25, 26]. However, as well a sudden acceleration for extra speed during running, a sudden deceleration might result in a muscle strain. These situations are common in football when sprinting, kicking the ball, and stretching the leg to trap or tackle [24]. The athlete experiences local pain and tenderness and, a grade III strain will also appear with swelling and bruising.
The healing time is 2–12 weeks, depending on the grade (mild, moderate, or severe).
Basic Concept of Acute Management
- Encourage rest, which means temporary cessation of sports activity;
- Apply immediate compression, a tightly drawn elastic bandage tied as firmly as possible for approximately 15 min, in order to limit the amount of muscle bleeding and thereby minimise the range of injury. Continue with compression, bandaged half as hard, for another 1–3 days;
- Keep the injured extremity immobile during the first minutes;
- Cool the affected area in order to limit pain. However, do not apply the cold pack (or ice) directly on the skin;
- Keep the injured extremity elevated for 1–3 days;
- Relieve load, especially if the injury is moderate or severe. Crutches can be used until a definite diagnosis has been made.
One should pay attention to the following questions 48–72 h after a mus- cle injury:
- Has the swelling resolved?
- Has the bleeding spread and caused bruising at some distance from the injured area?
- Has the ability of muscle contraction returned or improved?
If the answers are “no” to these questions, an intra-muscular bleeding is most probably present, and the patient should therefore be referred to an orthopaedic surgeon.
Subacute Treatment and Rehabilitation
Activity improves durability in healing muscle tissue. Progressive physical
therapy is therefore recommended as soon as possible after the injury. As
motion is restored, gentle muscle strengthening is started, with isometric
training and preferably also with electrical muscle stimulation, isotonic
dynamic training, and isokinetic training (if available) at low intensity.
Concentric exercises should be introduced before eccentric ones. Gradually, running exercises such as sprinting, cutting, and ball drills can be added when tolerable (Table 3).
Table 3.Treatment protocol for muscle strains
