Muscle, tendon, and ligament injuries heal according to the stresses imposed on them. The athlete who rushes to return prior to sufficient healing will likely cause an inflammatory response and delay healing, or get reinjured. The athlete who prescribes to increased rest during recovery will increase the amount of scarring within the healing tissue and render it weak, thus increasing the chance of re-injury. The athlete who stresses the injured tissue in a way that is not deleterious to the healing environment will limit the amount of scarring and increase the tensile strength of the healing tissue, thereby optimizing return. The goal for return is to strive for a balance between tissue healing and rehabilitation. This approach allows the athlete to progress in a more linear fashion.
“The whole is greater than the sum of its parts,” is a phrase that can be applied to the goal of the rehabilitation program. When designing and executing the program each component is built on the previous one so the end result is a coordinated effort of all of the components working together. The trick is to know when to incorporate each one into your rehabilitation program. Once pain is under control, a basic progressive approach utilizing the following components is initiated:
Range of Motion
Pain, Range of Motion, and Strength
Pain affects the rate of progress in all phases of injury rehabilitation. If pain is present it must be dealt with first, before incorporating additional rehabilitation components. Trying to increase the tempo of the rehabilitation program on top of pain is detrimental to healing. The athlete should not be allowed to “push through pain.” That stated, the athlete may work within the available PAIN FREE ranges of motion. Working strength and motion within a pain free environment will set the pace for the rest of the rehabilitation program.
To better understand; let’s use the hamstring strain as an example. Many factors can contribute to the cause of hamstring strains and a proper assessment is warranted, but the purpose of this article is to focus on return to play. Hamstring strains are one of the most frustrating injuries for athletes and rehabilitation specialists. We generally see a pattern where the athlete’s range of motion and strength return, but their speed and burst are limited complicating the process. Most hamstring strains take a minimum of 2 weeks to heal but the majority last longer, and may take as long as 6 weeks. Knowing the injury is helpful when determining a time frame for return.
During the initial phase of injury rehabilitation the emphasis is on pain control through the use of various modalities: cold therapy, compression, elevation, electric stimulation, pain free gentle massage, etc. The goal is to protect the injured hamstring and decrease the athlete’s pain and swelling. The range of pain free motion is usually limited and must be respected. This initial phase may last from a few days to more than one week. During this time the athlete can focus on maintaining strength and function in his core, upper body, and non-injured areas as long as it does not compromise the injury.
Once pain, swelling, and inflammation are under control the athlete progresses to gentle knee flexion and hip extension exercises within the pain free ranges of motion. Examples include hip mobility, treadmill forward or backward walking, stationary bike, pool therapy, or elliptical machine. The key is to perform them without pain. Light strengthening exercises are incorporated and are performed within the pain free range of motion. These may include body weight squats, deadlifts and single leg variations performed with good technique. Stability exercises may include glute bridge variations and quadruped or “bird dog” extension variations. Pain assessments are performed for each exercise the athlete attempts. A simple “does it hurt?” will provide immediate feedback. If the response is “yes” the range of motion is reduced, or the exercise is discontinued from the routine.
As pain decreases, and range of motion and strength improve, the athlete may introduce load and volume into the program. Increasing load (ie. adding weight) will allow better motor control of the injured hamstring. Increasing volume (sets/reps) will assist in redeveloping the necessary strength and stamina for return. The athlete may progress to different squat, deadlift, and single leg variations within the pain free ranges of motion available. Additional mobility, stability, strengthening, core training, and eccentric components are introduced during this phase. Again, each exercise is assessed for pain.
Speed is introduced into the program after adequate range of motion and strength has been developed. Increased motion and strength allow the athlete to generate greater force into the ground. The greater the force generated into the ground, the faster the athlete moves. However, one must err on the side of caution when introducing speed into a rehabilitation program. Linear jogging is the first stage of speed training. The athlete needs to progress from a slow pain free jog to full speed in percentage increments of his perceived maximum speed. A good practice is to work up to 25% of his perceived maximum, and then increase in 25% increments until 100% is achieved. Proper running mechanics are essential to the rehabilitation process and return. Progress must be carefully monitored. If the athlete complains of soreness, the session is stopped. Tempo runs and interval training are great for progression and may assist in evaluating technique, but a video camera is the best tool to examine deficiencies in running mechanics. Once speed has been established, working on controlled short sprints (10-20 yards) from different starting positions is another good progression. As with strength, load and volume are increased gradually into the speed component. Loaded speed drills may include sled push/pulls, resistance tubing, or hill running. Hill running is an excellent strengthening exercise that also protects the athlete from over striding. Since these drills incorporate both strength and speed they allow the athlete to transition into the power phase of the program.
Power and Sport Specific
Strength, speed, power, and sport specific drills may be worked in unison once the athlete achieves a good strength and speed base. Power or explosive components include plyometric jumps, hops, skips, and bounds. Sport specific components include multi-directional or agility drills progressing to more advanced position specific drills and situations.
As with previous components a gradual progression is utilized. Plyometric training may begin with basic line and ladder drills and progress to more advanced box jumps and hops, then to depth jumps and hurdles. Multi-direction patterns include shuffling, crossover, and stopping or deceleration patterns and drills. Again, these drills must be executed with good technique and form. Begin with closed loop drills which have a predetermined start and finish. These drills allow the athlete to work on mechanics and technique making it easier for them to provide feedback. Progress to open loop drills which require the athlete to react to an external stimulus. The general goal is to improve reaction and response times to prepare them for return to play. Many times the athlete will feel “good” during a session and be tempted to “push the envelope” by increasing speed and/or volume. Again, err on the side of caution. Remember, the athlete has not yet built the necessary stamina for safe return.
To build stamina, conditioning drills are incorporated into the program as a single entity or coupled with sport specific drills. Single entity conditioning drills primarily focus on timed work/rest intervals of the rehabilitation components (strength, speed, agility, etc.). One of the problems the athlete encounters upon return is the amount of practice or game volume required. They have built strength, power and speed but have not built the necessary endurance to sustain these components over the course of a practice or game. An excellent drill is to simulate practice with position specific pattern training whereby the athlete is performing exact drills and assignments he would perform in practice with designated work/rest ratios. The athlete will progress from a closed loop environment where he performs the designated assignment on his own, to an open loop environment where he plays against an opponent.
Returning to Play
Nothing prepares the athlete better to return than actual practice. Prior to return his range of motion, strength, and power must be symmetrical for both limbs. Various tests and drills may be incorporated to test deficiencies. These may include single leg squat testing and the triple hop test. When the athlete demonstrates proficiency in all components, return to practice is recommended. To better control the athlete’s safety a gradual return is recommended. At the Giants, we use the following guidelines for safe return:
Athlete returns to Warm-Up and Individual portions of practice. If the athlete shows proficiency then:
Athlete returns to Individuals Plus meaning athlete participates in 7 on 7, 9 on 7, and team portions with limited repetitions. If the athlete shows proficiency, then:
Athlete returns to single full practice. If athlete shows proficiency, then:
Athlete returns to multiple full practices. If athlete shows proficiency, then:
Athlete returns to game.
Return to play, therefore, is similar to the rehabilitation components in that each phase of the return is built on the previous one in a progressive fashion.
Many factors affect injury and return to play. By following an organized and progressive approach to injury rehabilitation, the athlete will optimize the healing environment while building the necessary components for safe return to play.