This article is concerned with the problems of fitness following injury in order to prevent or reduce the danger of recurrence when participation is resumed.
The essence of sports injury management is bound up with the problems of ‘fitness to participate’, whether this refers to a resumption in training or to a return to competition. The greater the degree of involvement whether it be with the athlete, the team, the club, or a sport generally, the more difficult it becomes to be completely objective and the greater the tendency to become empirical in reaching decisions. As one’s interest develops the more danger there is of being influenced by the athlete’s changing moods or the team’s needs and demands.
Keen observation and experience will always have a place in the satisfactory outcome of any fitness assessment but these qualities must be integrated with an objective and scientific approach which embodies fundamental anatomical, physiological, pathological and psychological considerations. Experience provides an approximate time schedule for the recovery from any injury, but it also creates sufficient opportunity to realise the individuality of each one and to understand the folly of forecasting the outcome.
The ideal programme of recovery in any injury is one of steady, uneventful progress. Minor deviations from the ideal are frequently encountered and in the field of sports injury these still remain within the limits of normality. Serious set-backs, as presented by recurrence or complete breakdown, represents either a lack of organisation, a lack of patience or a lack of discipline.
GENERAL CONSIDERATIONS IN TESTING FOR FITNESS The nature of the injury
This means that the site, the tissues involved, and the severity of injury will obviously determine the overall time schedule of recovery and will determine the need for more careful testing at every stage.
The stage of pathological improvement
Sight must never be lost of the fact that, following injury, the body’s natural reaction is to attempt to repair the damage. Consequently it is of paramount importance that we are familiar with the subtle changes which occur as recovery progresses through its acute, subacute and chronic stages of inflammation. Failure to observe these stages leads to a singular lack of success.
The sport involved
This factor will determine the emphasis of the tests employed. Tests used will to an extent mirror the specificity of the sport.
The playing position or role of the participant in the sport must be considered. The skills demanded frequently vary within the same team. This applies particularly in field invasive games.
The level of involvement
Generally speaking, the need for higher standards of fitness run parallel with higher levels of involvement, even though motivation, dedication and experience can often disguise the fact.
The validity of the result of any fitness test depends on many factors. Generally speaking we are only concerned with physical fitness because significant mental involvement tends to be confined to the higher levels of sport.
Physical fitness is a relative quality and the standard of this quality can vary from the once-a-week squash player to the Olympic Games decathlete. Regardless of the standard, there are certain basic components of fitness which contribute to the whole. These are mobility, endurance, strength (power) and coordination. In any test of physical ability whether it be general or local, it is these components which should be assessed. It may well be that only one, or perhaps a combination of them, is of particular interest at any one stage in the recovery programme. However, in the final analysis all these individual qualities must be tested before the verdict of ‘fit to play’ can be issued. It must be remembered that to the professional athlete ‘fit to play’ means ‘fit to work’ and the thoroughness of the tests employed must be correspondingly searching. This is not to say that the sprained ankle joint is any different in a member of the ‘Extra B’ team to that sustained by the international team player. One often has to be realistic and accept that the opportunities to avoid potentially dangerous situations are available far more frequently in the ‘Extra B’ game and that the consequences of failing to avoid them are not quite so devastating in their implications.
Fitness testing must be an on-going routine throughout the recovery period in order to detect improvement and chart progress. The psychological effect of being able to demonstrate a measure of improvement by tangible recording is of inestimable value to all concerned. Progress which is seen to be made has a strong motivating effect.
The testing for fitness, or the lack of it, generally takes place in three main areas: 1. the treatment room 2. the gymnasium 3. the field of play.
The significance of an immediate post-injury assessment is minimised by many considerations, not the least of which is the athlete’s own acceptance of pain. Pain is a complex phenomenon and the measurement of it, along with that of pain tolerance, remains the greatest obstacle to the evaluation of treatment methods. It is the difficulty in measuring these factors which prevents the treatment of sports injuries from becoming truly scientific.
As a quality of physical fitness mobility deserves the greatest consideration. Recovery of mobility is the most important yardstick of improvement while a lack of it remains the biggest obstacle to full recovery. A failure to achieve the normal range of movement is the most common cause of injury recurrence because of the limitation in full function which it inevitably creates. The ideal situation for which we should aim is one where active mobility, accomplished by the athlete’s own effort, equals passive mobility (the range achieved by an external force during relaxation of the part), whether we are referring to the stretch of a muscle or the movement of a joint.
It would be irresponsible to produce mobility without the support and protection of muscle strength. In any re-education programme mobility and strength should progress in unison. An important stabilising factor in most of the freely moveable joints of the body is the strength of the approximating effect on opposing articular surfaces by muscle contraction.
The product of time and distance gives a measure of power and is the characteristic of complete fitness to be finally restored in a rehabilitation programme following injury. Power is exhibited in propulsive actions involving either propulsion of the body itself or of sporting implements. Apart from the fact that it is measurable by virtue of performance, power also bestows a certain quality to movement.
If there is normal mobility and strength it is highly probable that coordination is reasonably efficient. Coordination in sport is tied up with the skills of a particular sport, and the level of involvement will determine the standard of these skills. Skills have to be practised in order to establish neuromuscular patterns. In considering the long-term injury, it is vital that we should consider the effects which immobilisation and disuse have on these important mechanisms. In some sports, e.g. weightlifting, slight lapses in coordination often result in serious injury.
The principles advocated in the text are illustrated by referring to the tests which can be employed in assessing the fitness of three common sites of injury in three different major sports. These include a hamstring injury in a sprinter, a shoulder injury in a rugby football player and a knee injury in a soccer player.
HAMSTRING INJURY IN A SPRINTER
A typical injury of this kind tends to follow a time schedule of three to four weeks before full activity is resumed. Full participation should not be allowed until the muscle is pain free on: 1. deep digital pressure on the specific site of injury 2. full stretch application 3. strong contraction against heavy resistance 4. performing all the skills of the sport.
EARLY STRETCH TESTS FOR INJURED HAMSTRINGS 1. This involves sitting with one leg extended out in front and the other fully flexed . An attempt is made to touch the toes of the extended leg with both hands. The distance from the finger-tips to the toes is measured and the result compared with that recorded when the leg positions are reversed. 2. This test involves lying on the floor and raising a straight leg while the other leg remains perfecdy flat . The angle between the raised leg and the horizontal is measured at the point where either the knee begins to flex or the position of the other leg is unable to be maintained. 3. This method is to lie on the unaffected side and flex the knee and hip of the injured leg to 90° while the trunk and the other leg remain in the same alignment . While the thigh is retained in the same position, the lower leg is passively stretched and the degree of movement measured.
LATE STRETCH TESTS FOR INJURED HAMSTRINGS 1. With the heel of one foot resting on a chair seat, an attempt is made to touch the toes with both hands while retaining a fully extended knee. The distance from finger-tips to toes is recorded and compared with the other leg when their positions are reversed . 2. A slightly more exacting test is that of repeating (1) but with the leg raised to a higher level as on a table top . 3. A very demanding test of the hamstring group of muscles to withstand stretch is that of crossing the legs and retaining the feet close together while stooping forwards and downwards in an attempt to touch the toes of the rear leg . Measure from fingertips to toes and compare both legs. The leg which crosses behind is the leg under stress.
STRENGTH TESTS FOR INJURED HAMSTRINGS 1. The simplest test and one which allows safe progression to be made is that of lying face downwards and with an initial weight of 2kg fixed to the ankle or foot of the injured leg. Bend the knee to 90° and then slowly lower it back to the starting position. Progress is made by increasing the weight by 1kg and repeating the exercise . 2. Another specific test of hamstring integrity is that of assuming a kneel-standing position with the feet anchored firmly under a wallbar, or even held manually. The athlete leans forwards from the knees beyond the vertical and then pulls back to recover his position .
FUNCTIONAL TESTING FOR INJURED HAMSTRINGS 1. Stand sideways to a support which can be grasped. Swing the injured leg forwards and backwards progressing to a gradually increasing level. In this initial test bend the knee on the forward swing . 2. This is a variation on (1), but is a much more demanding test. The injured leg in this test is maintained in a fully extended position throughout the swing. To avoid recurrence of injury the height of the swing forwards must be increased gradually. The trunk must be kept in an upright posture throughout . 3. The athlete performs a high-kicking action by stepping forwards for two paces and on the third step swings the leg forwards and upwards to successively higher levels .
Running on the spot should initially be at a slow pace with a low knee action, progressing to a quicker pace with a high knee action. It is essential in practice to acquire even timing by virtue of symmetrical leg action.
The actual running stage is a vital one because it is now that recurrence most frequently occurs. There should be a progressive schedule over a period of at least one week which should be discounted if there is any semblance of pain. A sharp stabbing sensation is an untoward sign of recurrence, while a dull heavy feeling suggests that progress should be halted at that stage and previous tests of mobility repeated and compared with earlier recordings. Efficient running entails considerable reflex coordination. This is shown by the innate ability to take perfectly even strides with each leg. Consequently, uneven pacing suggests an interruption of this ability by virtue of pain resulting from the demands made when full bilateral mobility is lacking. Uneven pacing can develop into a running habit which, if established, becomes difficult to eradicate.
The re-education of running begins with jogging and finishes with all out sprinting. In this gradual process three variables need to be considered – speed, footwear and surface. Initially, the athlete jogs at a slow pace in flat ridged-soled training shoes on a dry yielding surface and builds up by increasing the pace until he is running in spiked shoes on a firm surface. This is the only safe way of reaching maximum sprinting ability. The only other factor to be considered is the ability to make an explosive start; hitherto the speed running being executed from a gradual build up of speed in a ‘rolling-start’.
A conclusive test to convince one of the ability to withstand the stretch involved in the push-off and the strong contraction in the pick-up action is to attempt some progressively faster shuttle-runs. Starting from blocks in an explosive start would be an important final test to convince one of the injury’s full recovery.
To give the injury, as well as the athlete, every consideration, each running session should be preceded by a sensible preparatory warm-up period of progressive mobility and strengthening exercises.
SHOULDER INJURY IN A RUGBY PLAYER
EARLY MOBILITY TESTS FOR SHOULDER INJURY 1. Grasp a pole or brush handle with the arm stretched sideways. While the elbow is maintained in a fully extended position, the stick is rotated forwards and backwards . 2. A second test is similar to (1) but with the arm stretched upwards above the head . 3. A third test is another variation of (1) but with the arm stretched forwards .
These three exercises with a pole can also be used as early strengthening activities, particularly if the hand is moved towards one end of the pole, or if the pole is replaced by a brush so that one end is weighted.
A useful test of progress in the early stages of recovery is to attempt to touch the finger-tips of both hands behind the shoulder blades using the injured arm alternately above and below . The distance between the finger-tips is measured.
LATER MOBILITY TESTS FOR SHOULDER INJURY 1. Hold a light barbell (Skg) at arm’s length above the head then lower it behind the neck . 2. Grasp the ends of a rope which pass over a pulley, hook, or bar and move each arm alternately up and down to full stretch . 3. Hold a light barbell at arm’s length overhead while lying astride a bench. Lower the barbell beyond the head while retaining straight arms .
EARLY STRENGTH TESTS FOR SHOULDER INJURY Any progressive system of dumb-bell or barbell exercises for the arm beginning with light weights would be a satisfactory measurable test.
LATER STRENGTH TESTS FOR SHOULDER INJURY 1. A useful test is that of raising bodyweight in a modification of the press-up exercise. The feet are placed at a higher level than the arms on the seat of a chair. The shoulders are raised to full arm’s length . 2. A more strenuous modification is that of dipping between two benches. The feet and the arms are placed on each bench and the body is lowered between them . 3. Another test using bodyweight as resistance is by sitting between two benches with legs outstretched and the hands flat on each bench. The buttocks are then raised from the floor by extending the elbows . 4. A similar exercise test is that of raising the buttocks and pulling backwards to sit on a stool or chair .
In all these examples of strength tests, it should be realised that either the starting position or the eventual finishing position are also making demands on mobility.
FUNCTIONAL TESTING FOR SHOULDER INJURY Progressive weight transference to the arms is a necessary inclusion, not only because of the demands on mobility and strength but also as a test of the athlete’s confidence. 1. Initially the hands are retained in contact with the floor while the legs are simply kicked upwards into the air . 2. As a progression the player is asked to drop on to the hands and kicks into the air simultaneously from a crouched position . 3. The natural sequence from this is a straightforward handstand from the standing position . 4. Wheel-barrow walking in various directions is a searching test to employ . 5. In a similar manner, crab-walking in all directions is also a severe test of shoulder integrity . 6. A gymnastic forward roll is a necessary functional skill to be tested both from a standing and a running start.
The basic skills of the sport itself must now be practised. Rugby skills consist of passing and catching a ball, tackling, being tackled and avoiding tackles, scrummaging and scoring points by kicking goals and scoring tries. These skills are performed by players in all positions. However, there are certain positional skills which make particular demands. An example of this is the hooking position which has relevant demands so far as the shoulders are concerned. Therefore, the hooker with a doubt about his recovery from shoulder injury must be tested thoroughly in his particular skills, no less than his ability to suspend his body mass from the adjacent supporting prop forward.
KNEE INJURY IN A SOCCER PLAYER
Injuries affecting the knee joint require application of a deeper knowledge of anatomy than most others. The testing of knee joint integrity centres on both its mobility and stability under varying conditions.
EARLY MOBILITY TESTS FOLLOWING A KNEE INJURY 1. In a prone lying position, attempt to bend the affected knee . Either the angle between upper and lower legs is measured or the distance between the heel and the buttock. 2. In a high sitting position on a table, bend the knee and simply measure the angle attained . 3. A third test is employed to assess the ability to fully extend the knee by either relaxation or active contraction of the quadriceps muscles. The gap between the back of the knee and the table is measured . 4. Sit on the front edge of a stool with the toes of both feet against a wall. Raise the buttocks and thrust the knees forward towards the wall. The heels must be maintained in contact with the floor . The distance between the knees and the wall is measured.
LATER MOBILITY TESTS FOLLOWING KNEE INJURY 1. While kneeling on a firm surface attempt to sit on the heels . Measure progress by recording the distance between buttock and the heel of the affected leg. 2. Place the foot of the injured leg on the seat of a dining chair. The heel should be level with the front edge of the seat and must be retained in contact with the seat. The knee is now thrust forwards towards the back of the chair . The distance between the knee and the back of the chair is measured. This should be compared with the other leg and progress charted. 3. The simple squat position and its variations are the ultimate in knee mobility tests. The ability to progress forwards while squatting, either by moving alternate legs or by hopping on both feet together is a severe test of full flexion . 4. Stand alongside a bench with the foot of the injured leg flat on top of the bench. While this foot remains stationary step to the opposite side of the bench with the other foot and then return . 5. Stand alongside a bench as before, but while extending the injured knee twist around quickly to finish facing the opposite direction and with the sound leg on the opposite side of the bench . Then reverse the procedure.
EARLY STABILITY TESTS FOLLOWING KNEE INJURY Any sensation of instability or the actual evidence of it by locking or giving way is the warning sign that further testing should be halted. 1. Long sitting on the floor with the knee fully extended. Initially a plastic ball is kicked with the inside of the foot and ankle . Progress using a football and then a medicine ball. The routine is repeated with the outside of the foot. 2. The previous test is repeated but with the knee flexed to varying degrees . 3. These two tests should be repeated in the more functional position of standing but still progressing from straight leg to flexed, and from plastic ball to medicine ball . confidence. The three variables to be considered in making the test progressive are the height, the landing surface and the method of landing. Initially, a gymnasium bench may be of sufficient height and the landing made on a rubber mat. The ultimate requirement would be to jump from a height of 3 feet (lm) on to a firm surface and in a crouched position. The important aspect of jumping tests is to ensure that the landing is made with equal weight on both feet. An understandable reluctance and apprehension can be overcome by reducing the height to a minimum and by making the landing surface as reasonably soft as possible to encourage the taking of body weight on the affected leg only. 2. An invaluable test of lower limb fitness is that of ‘bounding’ over a series of benches. If the benches are so placed as to allow only one footstep between them, there is no escape from using the affected leg . The test is a modified hurdling exercise and can 4. Hopping exercises are particularly useful in testing knee stability because of the strain placed upon the joint by making it support the weight of the body. Hop in a circular direction around an object. The specificity of the test is increased by reducing the diameter of the circle or by reversing the direction. 5. A variation on (4) is hopping around a square but making sure that the foot is pointing forwards throughout and that the direction is changed at 90°. Another variation is by describing a figure-of-eight around two objects. Progression is made by decreasing the distance between the objects.
LATER STABILITY TESTS FOLLOWING KNEE INJURY 1. Jumping from heights is another excellent method of testing stability as well as restoring be performed at an increasing speed. Power and coordination are essential qualities in executing a flowing rhythm.
The essential skills of soccer are passing, dribbling, trapping, shooting and tackling. These are useful individual tests in themselves and form a necessary preliminary before progression into the training modifications of the game itself.
Reaction to these tests may be a recurrence of pain, swelling and an increased temperature of the joint area; these are indications of negligence either in observation during the tests or in too rapid a progression.
Testing for fitness is a fascinating challenge which requires careful organisation. Athletes should be made to feel that, in the physiotherapist, they have an ally who is concerned only for their interests and welfare. They must not be made to feel that every test is a personal battle where every deficiency is to be used as evidence to support a pre-determined decision to prevent them from participating. Varying degrees of elation and disappointment are the inevitable companions of fitness testing. Experience is the only tutor in learning to recognise whether a situation demands support and encouragement or guarded optimism and a restraining influence.
The attitude towards injury of athletes varies considerably. The acceptance of pain and physical defi- ciency with the consequent limitations on skill and ability is often exhibited to remarkable levels. However, experience will also teach one to realise that the decision on fitness which will benefit the athlete in the long-term will be the best decision to make for the short-term.