AIMS OF TREATMENT
Physiotherapists involved in the treatment of sports injuries require a clear picture of the aims of treatment. These may be summarised as follows: 1. To enable the injured athlete to return to his or her sport quickly and safely. 2. To regain the strength, mobility and coordination of the muscles of the affected area so that the healing or healed tissues are sufficiently protected. 3. To maintain and if necessary increase the general strength and cardiovascular endurance of the patient. 4. To influence any biomechanical abnormalities such as muscle imbalance, limb imbalance and inflexibility. 5. To gain the cooperation, not only of the athlete, but of the coach or any other influential person to ensure that the patient is discouraged from returning to sport too soon and that the faulty technique precipitating tissue damage is corrected. 6. To make a positive contribution towards the prevention of another injury by advising on further rehabilitation exercises. 7. To provide a psychological ‘prop’. 8. To try to prevent the subsequent development of degenerative disease due to the unavailability of treatment. 9. To provide a prophylactic service.#
With reference to point 7 above – the psychological aspect, Vijay Rajaram of Brackmills Physio Clinic, who works with professional MMA athletes such as Linton Vassell, says that the physiotherapist is often the key link between the mind of an athlete and their body.
The injured sportsman should only return to sport when the doctor and physiotherapist are satisfied that adequate strength and mobility in the affected area have been regained. He should persevere with rehabilitation, even if it is lengthy for some conditions. In top class competition, particularly, a minimal loss of function is not only the difference between winning and losing, it can lead to re-injury or tissue breakdown in a previously uninvolved area of the body because of compensation and resultant unnatural movement.
Exercises to maintain general body strength and cardiovascular fitness should be included in the treatment because they will keep the person as fit as possible until he is ready to resume training. Too many athletes sustain further injury in attempting to regain general fitness too quickly following an enforced lay off. An active physiotherapy approach should enable the person to be concerned with more specific fitness when training is resumed.
Bender et al (1964) investigated strength levels in relation to injuries in new military cadets. They found that athletes with average or above normal strength levels were less susceptible to injury than those with below average strength or with imbalance in excess of 10 per cent between the lower limbs. This must be considered during rehabilitation.
Balance between the agonists and antagonists is also thought to be important both in the prevention and treatment of sports injuries, although more work needs to be done to advise on the pre-requisite strength values for different sports. It is believed that the strength value of the hamstrings should be 60 to 70 per cent of the quadriceps for most running sports.
It appears that weakness in one area of the body can lead to involvement elsewhere. Nicholas et al (1976) have shown a strong correlation between ankle and foot injuries on the one hand and ipsilateral weakness of the hip abductors and adductors. This type of relationship must be accounted for during rehabilitation.
Inflexibility is a prevalent problem among many athletes. Poor flexibility appears to lead to a high incidence of muscle injuries, joint lesions and non-specific aches and pains. The naturally inflexible are helped by carefully performed stretching exercises and they should be encouraged to persevere with these throughout their competitive careers.
Some athletes are excessively prone to injury because of musculoskeletal abnormalities which render them inappropriately equipped for withstanding the demands of certain sports. The physiotherapist should be aware of this: the following two examples may help to explain this. 1. A boy with marked hyperextension of his knees has naturally lax ligaments and therefore contact sports expose him to an unacceptably high risk of serious injury to these joints. 2. A child with several degrees of hyperextension of the elbow is more prone to elbow dislocation than his ‘normal’ contemporaries. He should be discouraged from participating in such sports as rugby, judo and wrestling.
Ideally, a child with an unsuitable physique for safe involvement in a particular sport should be recognised early in school life so that he can be encouraged to adopt a more suitable sport.
The physiotherapist should have a basic understanding of sport so that the mechanics of injury and the stresses to which the performer is subjected can be understood. Coaches have a far greater knowledge of the finer points of technique and the physiotherapist can gain much by liaising with them. If the physiotherapist suspects that an injury was caused by poor technique or biomechanical abnormality, this should be discussed with the coach so that the style can be altered.
Prophylaxis will probably play an increasingly important role in the field of sports medicine as further research is carried out and it is shown that adequate training can prepare the tissues more effectively for the demands of sport. Physiotherapists are ideally trained for this type of work which should enable future generations of sportsmen to avoid many of the lesions that are commonly seen in sport today.
INITIAL EXAMINATION AND ASSESSMENT
When the doctor has examined the patient and, hopefully, been able to make a definitive diagnosis, the physiotherapist should carry out an examination and assessment. This must be done meticulously so that the most suitable treatment can be given. Each injured person should be treated according to individual needs; the physiotherapist should adapt the treatment to the person, not vice versa.
The physiotherapist must acquire information from the patient before carrying out a physical examination; this should include what is his sport, the actual event and level of competition. The mechanics of the injury should be clearly understood as this aids the rehabilitation as well as the diagnosis. The physiotherapist should enquire about past injuries; if a similar injury has occurred previously, it is helpful to discover the patient’s opinion of the value of previous treatment because this may point towards a particular course of treatment.
The equipment used by the player/athlete merits attention because ill-fitting or unsuitable footwear, for example, may be a contributory factor which, if ignored, will precipitate further problems.
A thorough physical examination can then take place. The damaged structure should be carefully investigated; where there is a limb injury the opposite side should be used for comparison. The joints proximal and distal to the injury should be examined, particularly if the injury is a chronic or an overuse lesion because adaptive changes may have taken place; failure to include this aspect can mean that the player returns to sport ill-prepared and further breakdown almost inevitably ensues. The spine should always be included in the examination because poor strength and/or mobility in the trunk seem to contribute to some sports injuries.
The general strength and flexibility of the patient should be assessed; exercises may be required to influence either or both of these. Cardiovascular fitness should also be tested, provided that in so doing the patient does not impose stress on the lesion.
Continual assessment enables the physiotherapist to provide effective treatment. Sophisticated electrical equipment can be used but more than adequate treatment can be provided by a competent physiotherapist used to handling soft tissue injuries.
Full range of efficient muscular and joint motion, including accessory movements, must be regained before the patient can be considered to be rehabilitated for sport. Controlled exercises are introduced 24 to 48 hours post-injury for most conditions. In the first instance, the activities are selected so that the damaged tissues are not subjected to any pressure which could lead to further inflammation, increased scar tissue and adhesions. Initially, the movements are performed to enhance drainage and gently mobilise the tissues. The severity of the exercise is increased as healing advances and this enhances resolution provided that the player avoids excessive stress by never pushing the movement through pain. Pain is a warning signal that must not be ignored.
The physiotherapist must adapt the treatment to the stresses of the patient’s sport. A prop forward and a full back will require subtly different exercises if both sustain similar ankle sprains, because of their dissimilar roles on the rugby pitch; a female gymnast with a similar lesion would require the emphasis to be placed much more on fine balance and coordination.
The physiotherapist may employ many techniques. Familiarity with the feel of injured tissues is essential as this guides the treatment. Massage and transverse frictions certainly have a place; vertebral and peripheral mobilisation and manipulation techniques as described by Maitland (1977a, and b) and Cyriax (1977; 1978) are useful methods of treatment. Connective tissue massage (Ebner, 1977) is also useful in the manage- ment of many of the soft tissue lesions seen in sport. Proprioceptive neuromuscular facilitation techniques (Knott and Voss, 1968) and other means of applying manual resistance have a major part to play because they enable the therapist to guide the movement and adjust the resistance according to the ‘feel’ of the tissues.
Muscular atrophy occurs quickly as a result of injury; the resulting weakness means that the patient cannot safely participate in sport. During rehabilitation, a wide variety of exercises are used aimed at improving (a) strength, (b) endurance, (c) power and, (d) flexibility.
Modified circuit training should be used whenever possible to maintain a degree of cardiovascular endurance. The exercises must be selected carefully to ensure that they do not affect the damaged structures, for example, an arm and trunk circuit may be given to a patient with a leg injury. Work on a static bicycle may be possible when the pounding effect of running is contra-indicated. There are many injuries that benefit from work in a swimming pool – an athlete may even be able to run in water when it would be injurious to do so on dry land.
A suitable warm-up should be performed at every level of rehabilitation to ensure that the muscles are ready for work.
The physiotherapist should be familiar with the injuries where exercise may be contra-indicated. The list includes Achilles tendinitis, patellar tendinitis, intramuscular haematoma of the quadriceps femoris and tenosynovitis.
The use of ice for the initial management of injuries has already been mentioned in 4. It must be stressed that the following methods of treatment are used usually in conjunction with exercises or some other form of therapy, and not as a treatment on their own.
Contrast bathing is an effective method of reducing swelling and it may be introduced 24 to 48 hours post-injury. Heat, in the form of a hot pack or hot water bottle, is applied to the tissues for one minute to cause vasodilatation and so increase the circulation; this is followed by an ice-pack towel or iced water bath for two to five minutes to induce vasoconstriction and thus encourage drainage. The process is repeated five times. The advantage of contrast bathing over more sophisticated electrical treatments is that it is both effective and cheap, as well as being something which the patient can easily do at home several times during the day.
This is a popular piece of equipment for treating soft tissue injuries, whether they are acute, due to overuse or chronic. The mechanical effect of the sound waves is thought to encourage re-absorption of extravasation at cellular level and to reduce sensory stimulation, consequently affording pain relief.
The two frequencies of sound that are commonly available in Great Britain are three and one megacycles, penetration being greater with the lower frequency. The choice of frequency and intensity is very much according to the preference of the physiotherapist. The ultrasound may be given as a continuous or pulsed beam. The pulsed beam is favoured by some operators because it ensures the dissipation of any heat which is desirable in the presence of acute inflammation.
This medium frequency electrical equipment has been used for some time in Europe to manage many soft tissue lesions and is now becoming popular in Great Britain. It is used in the treatment of acute injuries to produce an analgesic effect. The patient must be warned that it may only afford temporary relief which will permit natural movement; it must not be used to allow immediate participation in sport.
The currents can be adjusted to cause an increase in circulation which is valuable for sub-acute and chronic lesions. Interferential can also be used to stimulate muscle and this is useful for the management of chronic muscle injuries such as groin strains which sometimes prove resistant to other forms of therapy.
Hot pack and infra-red
The main effect of these modes is to raise the temperature in the superficial structures; the thermal effect in the deeper tissues is minimal. An infra-red lamp or hot pack can be used as a prelude to exercise to ease the pain, relieve muscle spasm and increase the superficial circulation. From the psychological aspect, the patient may benefit from heat because most people associate warmth with a feeling of well-being.
Short wave diathermy and microwave
Physiologists have shown that the most effective way to elevate joint temperature is to exercise the area. Both short wave diathermy and microwave cause an increase in temperature of those body tissues that are positioned within their electric fields. The heating effect is produced in the deep as well as the superficial structures and this can be made use of for treating some sub-acute and chronic lesions, particularly in circumstances where full range exercise is temporarily undesirable, for example, chondromalacia patellae.
This machine, which emits pulsed electro-magnetic waves, is said to shorten the time taken for tissue to heal. It was developed in the United States of America and now European firms have introduced equipment following similar principles. Healing is said to be enhanced by the pulsed electro-magnetic waves which can be used immediately after injury because a thermal effect, which is undesirable in the early stages of inflammation, is not produced.
Faradism may have an occasional place in the treatment of sports injuries. It can be used to overcome muscle inhibition which is sometimes present following an injury or operation. For example, it can be applied to the quadriceps femoris if adequate contraction cannot be gained actively. Some physiotherapists also use faradism during the early treatment of muscle strains; the affected muscle is supported in a shortened position and the current used to produce alternate contraction and relaxation so that the formation of adhesions is discouraged and the drainage of exudate encouraged.
It is not practicable to mention the specific physiotherapy for many sports injuries, but four injuries involving different structures will be discussed.
Klein and Allman (1969) have shown that ligamentous weakness in the knee leads to joint instability. This applies to other joints as well and it is therefore important that ligamentous injuries are diagnosed and treated early so that chronic disability is avoided. Adequate muscle function must be ensured to protect the damaged ligament and encourage resolution; proprioception must be re-educated as it is so vital in the avoidance of further sprains.
Sprain of the lateral collateral ligament of the ankle (inversion sprain) is one of the most common sports injuries. Minor sprains involve one or more bands of the lateral ligament. More serious sprains can be associated with capsular damage, interference with the inferior tibio-fibular syndesmosis, the calcaneo-cuboid joint or the base of the fifth metatarsal. Intracapsular injuries inevitably require more treatment than extracapsular injuries. The muscles traversing the joint may be implicated in ankle sprains. The physiotherapist must examine all the joints of the foot to eliminate the presence of any unrecognised lesion elsewhere which could have contributed to the injury and may adversely affect rehabilitation. The strength of the muscles of the hip and knee should be assessed and suitable exercises prescribed if weakness is proven.
Contrast bathing is used 24 to 48 hours after injury; ultrasound, diapulse or interferential may be chosen by the physiotherapist to encourage re-absorption of inflammatory exudate and relieve pain. Foot and ankle movements are then carried out with the leg supported in elevation to further encourage drainage; inversion and eversion must be performed gently within the limit of pain. Intrinsic foot exercises must be included because the integrity of the arches is essential for the normal functioning of the foot. A strapping, holding the ligament is a shortened position, may be indicated between treatments.
As the swelling and discomfort subside, weight-bearing exercises are performed within the limit of pain. A correct walking pattern must be encouraged from the first because bad habits become established rapidly and are difficult to correct. When the patient can perform a good range of active inversion and eversion, resistance is applied to the invertors and evertors; particular emphasis is placed on the peronei which are inevitably involved in the injury and must be strengthened to protect the healing ligament. Repeated balance and coordination exercises are essential to re-educate effective proprioception; without these activities, a sprain could re-occur at the slightest provocation. A Jonas board or other balance boards are useful pieces of apparatus for retraining balance. Running, jumping and hopping activities are only introduced when the patient can demonstrate controlled balance during single leg exercises; poor landings due to insufficient muscle control will otherwise lead to further injury and ligamentous laxity. Rotational and side-stepping activities are included in final rehabilitation.
A small or large number of muscle fibres may be damaged in the injury and the number will dictate the speed of recovery. Rest is inadvisable because the inevitable muscular atrophy as a result of injury is further enhanced by total inactivity. The muscle should be gently encouraged to work as soon as pain permits.
The injury may involve the upper or lower attachments or the mid-belly; the latter usually resolves more rapidly because of the greater blood supply. The physiotherapist is asked to treat acute and chronic lesions. Chronic lesions are often long established -they may be due to repeated minor pulls which the athlete has considered too trivial to warrant attention. By the time that help is sought the muscle has shortened, and adhesions, excessive scarring and fibrosis may be present. These lesions are inevitably difficult to treat and progress is often slow; graduated stretching and strengthening exercises must be done until maximal function is regained.
With an acute injury, after the first 48 hours contrast bathing, ultrasound, interferential or faradism may be used for the reasons mentioned previously. Ice may be required to relieve associated muscle spasm.
Management is dictated by the physiotherapist’s assessment of the severity of the lesion. Early treatment is directed towards the re-absorption of inflammatory exudate, relieving pain and muscle spasm and encouraging pain-free muscular activity, albeit in a limited range. It may be desirable to carry out active assisted exercises to ensure that the damaged muscle is not subjected to excessive stress.
Resistance techniques – designed to encourage relaxation by working the antagonists then contracting the affected muscle – are valuable because they help to relieve muscle spasm, overcome inhibition and regain extensibility. The severity of the exercises is gradually intensified but again it must be stressed to the patient that the activities must be done properly and they should not be painful. Manual techniques are very useful because the operator can regulate the effort demanded of the muscles, while a weak arc of movement can be appreciated and rectified. Stretching and resistance exercises which provide for all the needs of the muscle, endurance, strength and power, must be performed. The movements must be accomplished slowly at first, but later increased speed of motion and rapid alteration of pace are included in the rehabilitation programme.
Exercises can usefully be carried out in water a few days after incurring a muscle strain but the athlete may need to avoid certain movements. For example, it is undesirable for a patient suffering from a groin strain to attempt breaststroke for the first two to three weeks.
Exercise is often contra-indicated in the initial management of these lesions be they acute, chronic or through overuse. They can be slow to resolve because of the inherent poor blood supply of the tendon.
Injury to the Achilles tendon or the paratenon is common in sport. A definitive diagnosis is required but ultrasound is often the treatment of choice: when swelling exists, contrast bathing is also useful. The tendon should be maintained in a shortened position because repeated stretching will lead to further irritation. A heel pad should therefore be incorporated into the patient’s shoes or one inch (2.5cm) heels may be worn. A strapping is occasionally necessary. As healing progresses and the pain and swelling diminish, the tendon can be subjected to manual stretches which should not elicit pain. Later, a strengthening and flexibility programme is introduced. Balance and coordination exercises for the ankle and foot are included in the regime.
Chronic lesions often require transverse frictions and firm mobilisation techniques as well as electrical treatment to soften the scar tissue and enhance the circulation.
Recurrent lesions of the Achilles tendon and surrounding structures are common and it is important that the physiotherapist ensures that the patient has adequate strength, flexibility and muscle balance in the region to reduce the chances of re-injury. All the joints of the foot must be checked, as should the more proximal joints, to ensure that possible contributory factors are not overlooked. The patient’s footwear, both sports and every-day shoes, should be inspected for signs of excessive or uneven wear. Training and competition surfaces must be considered and the patient should be encouraged to do a large proportion of his training on grass rather than road or composition flooring. The physiotherapist should watch the patient’s running to ensure that a fault in style has not precipitated the lesion.
Many athletes who require a meniscectomy do not present with symptoms and signs that necessitate an immediate operation, although the indications are such that the surgeon can make a definitive diagnosis. A pre-operative strengthening regime is advisable for these athletes, firstly because many have experienced repeated insult to the knee with ensuing muscle weakness and second, because adequate strength before the operation should reduce to a minimum the resultant muscular atrophy. This means that in normal circumstances, rehabilitation can progress more rapidly. All the muscles surrounding the knee should be considered by the physiotherapist when preparing an exercise programme. The quadriceps, hamstrings, gastrocnemius, ilio-tibial tract, gracilis and sartorius require special attention as all play a part in stabilising the joint.
POSTOPERATIVE TREATMENT Adequate rehabilitation is important following any surgical procedure if a patient is to return to sport without exposure to an unacceptably high risk of further injury.
Most surgeons advocate immediate postoperative isometric quadriceps contractions for their meniscectomy patients. There is a variance of orthopaedic opinion regarding the duration of the patient’s stay in hospital, the type of support used, the time at which weight-bearing is introduced and so on. However, the patient usually commences outpatient physiotherapy following removal of the stitches.
Ideally, outpatient physiotherapy should be provided daily. After a careful examination of the knee and associated structures, the early treatment in the department is aimed at reduction of any swelling and contrast bathing can be useful. Effective quadriceps contractions must be achieved with particular attention being paid to the vastus medialis for it is most important that final extension of the knee is gained at this stage. General hip and foot exercises are also performed, both legs being worked. The knee should be bandaged between treatments, and between home contrast bathing and exercise sessions, until the effusion has cleared. The patient should be instructed to keep weight-bearing to a minimum as it can increase the swelling and retard progress.
Knee flexion and weight-bearing exercises begin as soon as the swelling has subsided but the knee must be carefully observed for any signs of irritability. Resistance exercises may be given either manually or by using weights, pulleys or springs. These exercises must be performed correctly.
The strength of the uninvolved leg must be considered when assessing the weight requirements for the operated knee; if a footballer can straight leg raise 301b (13.5kg) with his unaffected leg, then ultimately, he should be expected to perform similarly with the involved knee. Obviously, a 120kg rugby forward needs to use far greater resistance to adequately rebuild his quadriceps as compared with a marathon runner or a young footballer.
Table 1 shows the rough guide which is used in the Sports Clinic at St James’ Hospital at Leeds, to assess whether a patient’s quadriceps are considered strong enough to attempt running.
These values are adjusted according to each patient’s physique. At all times the lifts are performed slowly and extension is held for three to five seconds. Lighter weights with higher repetitions are used to build up endurance.
Exercises must also be carried out to strengthen the hamstrings, gastrocnemius and the hip muscles. Klein and Allman (1969) described hip adductor exercises which appear to favourably influence the medial ligament of the knee and these would seem advisable following a medial meniscectomy. Similarly, hip abductor exercises seem to be of some benefit to the lateral ligament and should be included following a lateral meniscectomy.
Before the patient returns to sport, the physiotherapist must ensure that his muscles have been reeducated to cope with twisting and turning, as well as sprinting or jumping. Further injury seems very likely if this vital stage is omitted because the various structures need training to work efficiently; this appears to be the phase that is often forgotten, yet it is a vital stage to rehabilitation.
The physiotherapist, working in conjunction with a doctor, has much to offer the field of sports injuries. There is much to be gained from meeting the coaches, trainers and athletes to discuss certain aspects of sport and a great deal can be learned from their opinions. A considerable amount is yet to be discovered about the management of many of the lesions that are commonly seen. This is a challenging field of physiotherapy because, generally, the patients are very well motivated and are willing to cooperate in endeavours to find a more scientific and effective approach to treatment. This should be to the benefit, not only of the sporting fraternity, but of all patients with a similar injury.
Bender, J. A., Pierson, J. K., Kaplan, H. N. and Johnson, A. J. (1964). Factors affecting the occurrence of knee injuries. Journal of the Association of Physical and Mental Rehabilitation, 18, 130-134.
Cyriax, J. (1978). Textbook of orthopaedic medicine, Volume 1, 7th edition. Bailliere Tindall, London.
Cyriax, J. and Russell, G. (1977). Textbook of orthopaedic medicine, Volume 2,9th edition. Bailliere Tindall, London.
Ebner, M. (1975). Connective tissue massage. Robert E. Krieger, Huntingdon, New York.
Klein, K. K. and Allman, F. (1969). The knee in sports. Pemberton Press, New York.
Knott, M. and Voss, D. E. (1968). Proprioceptive neuromuscular facilitation patterns and techniques. Harper and Row, New York.
Maitland, G. D. (1977a). Vertebral manipulation, 4th edition. Butterworths, London.
Maitland, G. D. (1977b).Peripheral manipulation, 2nd edition. Butterworths, London.
Nicholas, J. A., Strizak, A. M. and Veras, G. (1976). A study of thigh muscle weakness in different pathological states of the lower extremity. American Journal of Sports Medicine, 4, 241-248.