Rehabilitation of the Injured Athlete - Report Example

REHABILITATION OF AN INJURED ATHLETE Introduction Anterior cruciate ligament (ACL) injury is common among professional sports personalities especially rugby players. The injury results from situations where the knee is hyper-extended or twisted forcefully. Rehabilitation is necessary after a constructive surgery of an injured knee or ACL to enable the patient to heal gradually with minimum pain. This paper presents a discussion of the pre-rehabilitative, rehabilitative and return to play criterion of Simon, a rugby player who ruptured his ACL during a game which also caused a small medial meniscal tear of the knee. Pre-Rehabilitation Phase Wahi (2011, p. 94) says that t he pre-rehabilitation of an injured knee is done through the application of the PRICE protocol with an aim of decreasing and keeping effusion as low as possible. Therefore the goals and plan of the pre-rehabilitation phase of the athlete includes protection, rest, application or ice, compression and elevation of the limb. The pre-rehabilitation phase of the injured rugby player is designed to go through the PRICE protocol for a period of two weeks. The protection of an injured knee or a ruptured ACL is made possible through prevention of further injury as explained by Kozanek, et al. (2011, p. 951). Therefore the protection of Simon’s injured knee in the pre-rehabilitation stage will be done through stopping him from playing. This will be the responsibility of the coach who will instruct the player to stop playing. The protection of the player will also be done through the use of padding so that the knee is cushioned and further injury to the anterior cruciate ligament and the medial meniscus. For more protection of the knee, splints and crutches should be used so that the weight of the player’s knee can be taken and thus protected from more damage to the ruptured ligament. Resting is an important aspect in the pre-rehabilitation of a knee injury because it enables the injured individual to start the healing process as said by Wahl, Westermann and Cizik (2012). The pre-rehabilitation process of the rugby player will aim at reducing the pain that he is in and this would be made possible through the application of ice on the injured area. The ice will also reduce the inflammation which would result from the injury. Compression and elevation are described by Escamilla, et al. (2010, p. 214) as pre-rehabilitative measures in injured knee which help prevent swelling at the injury. The injured knee of the athlete will be compressed using a tear tape or bandage. This will be done by a trained medical practitioner. Elevation of the player’s leg will be aimed at reducing the flow of blood to the injured area and thus reduce swelling. According to Acharya, Pandey and Rao (2010, p. 119), the pre-rehabilitative phase of a knee injury involves knee exercises within range of motion of the injury. The knee of the injured player will therefore undergo passive movements on a slide board or a machine during the pre-rehabilitative phase. This should be done by a trained practitioner so that the motion is controlled and maintained within range. Muscle power exercises are also necessary during the pre-rehabilitative phase of the injured player. The goal of these exercises is to ensure that the quadriceps is kept in active contraction but this will depend on the motion limitation of the player. It is also important for the injured player to be given psychological support by the preferred surgeon or doctor in order to enhance his psychological well being during the course of the rehabilitation. Hydrotherapeutic modalities would also be applied in knee injuries to enable athletes increase joint flexibility without imparting a lot of pressure on the joint. Post-Operative Rehabilitation After the reconstructive surgery, Simon will go through a post operative rehabilitation program. The post-operative rehabilitative phase will progress in four phases each of which is planned to run for a specified period of time. The goals of each phase of the rehabilitation program for the rugby player will be aimed at promoting efficient and effective healing and thus allow him to return to the sports activity as soon as possible. The post-operative rehabilitation phases include maximum, moderate and minimum protection phases which are followed by the return into activity phase as explained by Peskun and Whelan (2011, p. 167). Maximum Protection In accordance with Thomee, et al. (2010, p. 200), the maximum protection period of the post-operative phase comprises of the early healing phase and the period of controlled motion. The early healing phase involves total control of forces that would act on the knee joint. The goal of this phase is to prevent possible disruption of the ligament attachment site as demonstrated by Howells, et al. (2011, p. 1198). Additionally, the early healing phase prevents any rupture to the suture line which would result from external or internal forces on the injured area. The therapist therefore aims at controlling any pain or swelling. Simon will thus undergo the early healing phase after his reconstructive surgery which would run for about two weeks. During this phase the therapist will ensure that the player’s suture lines are kept intact and thus prevent the pain and bleeding that is associated with the rupture of suture lines. The anterior cruciate ligament attachment of the player will also be kept intact during the early healing phase. During maximum protection phase of rehabilitation for the player will also aim at preventing muscle atrophy and this will be achieved through static contraction of the Vastus Medialis muscle with limb extension in less than 10 degrees. The range of motion should be restored gradually so that more damage is not caused to the already injured knee. Moreover, hydrotherapy is recommended for the injured knee. During the maximum protection phase, the aim of the therapy will also involve minisquads within the range of motion so that proprioception can be enhanced. Additionally, trunk and upper body exercises will be performed on the rugby player to maintain the muscle tone of the trunk muscles in addition to their strength. It is through the maximum protection that the goals of rehabilitation for the player will be set for the rest of the rehabilitation program. The period of controlled motion within the maximum protection phase of post-operative rehabilitation involves regulated and controlled knee joint motion as explained by Holm, et al. (2010, p. 300). During this stage, the therapist will allow only limited and monitored motion of the player’s knee. The goal of this period of healing is to protect the healing of Simon’s cruciate ligament. The surgical technique on Simon’s knee would determine the period of the controlled motion but this period is programmed to run for about 6-10 weeks. Wahl, Westermann and Cizik (2012) assert that the period of controlled motion in ACL surgery is associated with the inflammatory phase of tissue healing process. Taylor and Murphy (2009) say that his period is thus characterized by the entry of inflammatory cells into the injury site an increased tensile strength of the injured tissue. As a result, RICE immobilization is recommended for Simon in this phase of rehabilitation which the aid of physiotherapist or a medical doctor. The RICE immobilization approach is the most effective way of controlling the movement of an injured knee during post-operative rehabilitation as said by Olofsson, Fjellman-Wiklund and Soderman (2010, p. 50). RICE immobilization means that Simon will be required to rest sufficiently. The player will also be managed through application of ice and compression on the injury site to control inflammation. The therapist will also guide the elevation of the rugby player’s limb during the period of controlled motion in order to enhance blood circulation. Moderate Protection Vauhnik (2011) points out that the moderate protection period of the post-operative rehabilitation phase comprises of crutch-weaning and moderate walking periods. This period is associated with the regeneration phase of tissue healing. Therefore it is characterized with collagen tissue being laid down at the site of the injury and a gradual increase in the tensile strength of the injured tissue. The duration of this period also depends on the extent of tissue damage and the surgical techniques but it runs for an approximate of 12 weeks as demonstrated by Kollock, Onate and Lunen (2010, p. 349). The goal of this period of post-operative rehabilitation is to prepare Simon for walking. The most important consideration during the moderate protection period of an ACL injury is the awareness that walking activities cause significant ACL forces. Since the healing strength of the player’s ACL and medial meniscus is low at this stage, the physiotherapist must carefully control the knee kinetics. This would be achieved through a balance of the hamstring and quadriceps forces. The second phase of the rehabilitation process will also aim at proper limb exercise through closed chain exercises. Cardiovascular exercises will also be targeted through the use of a bike a so that the general fitness of the player will be promoted. The knee muscles will be trained through guided exercises so that motion would be limited and further injury to the knee prevented. The moderate walking for the rugby player during moderate protection phase involves a de-emphasis of quadriceps exercise by the therapist. Even though the moderate protection period involves the strengthening of hamstring and quadriceps muscles, the therapist of ACL injury should ensure that the patient does not exert the quadriceps profoundly because this would rupture the ligament as said by DeJong, et al. (2011, p. 1826 ). To sustain Simon’s walking activities while gradually increasing his motion, the crutch-weaning period becomes necessary during his rehabilitation. The exercise activities that Simon will go through during this period include pushing weights from a flexion angle of 30 degrees. The pushing of the masses will be guided by the physiotherapist or a medical doctor so that the patient is able to reach full extension of the knee joint without causing further harm to the healing joint. Low weights are to be used so that the patient can be enabled to reach a full range of knee joint motion and thus facilitate the walking process. Minimum Protection The main aim of this phase of rehabilitation will be to improve the mobility of Simon’s body and the injured limb in particular. Therefore heavy weights are recommended and it is during this phase that the player would be allowed to jump and run so that cardiovascular fitness and limb mobility are improved. According to Shimokochi (2008), minimum protection is characterized by endurance and coordination of the knee joint movement in ACL injury. The goal of this phase in Simon’s rehabilitation is to allow him to develop his dynamic stability and increase the strength and coordination of the knee joint muscles. The physiotherapist therefore will aim at ensuring that the player is able to undergo endurance exercises and training for effective coordination and movement of the knee joint. This period should also take an average of 12 weeks but will be influenced on the abilities of the rugby player of enduring the rehabilitation activities within this phase. The therapist must put some restrictions on the player so that running would be prevented until later. In this period, Simon will not be allowed to jump either and the use of a brace at all times will be recommended. The minimum protection of the minimum protection of the post-operative rehabilitation is associated with the remodeling phase of tissue healing as illustrated by Mook, et al. (2009, p. 2946). Therefore Simon’s ACL and medial meniscus is characterized with increased strength, connections and cross bridges of muscle fibers in addition to the contraction of the scar. The player’s minimum protection phase of rehabilitation can be managed by his physiotherapist, coach or a biokineticist. During the minimum protection, the role of the rehabilitation manager is to ensure that the strengthening of the injured structures increases gradually. Tibor, et al. (2011) asserts that at this phase of rehabilitation, stretching becomes an essential process and light activity for the patient is a must. However is important to note that the period of the minimum protection can be shorter or longer depending on the goals and conditions of the patient. Return to Activity The return to activity of the player would be made possible if he is allowed to play with the team but under close supervision. Game simulations can be used so that the confidence of the player on the game can be enhanced. The return to activity of an ACL injury patient usually starts at the 8th to 11th month of the rehabilitative process as illustrated by Edson, Fanelli and Beck (2011, p. 162). The progression of this stage of rehabilitation would run for 12 weeks or more depending on the patient’s willingness to return to normal activities. Vauhnik (2011) adds that the return to activity period comprises of advanced rehabilitation and running periods. Therefore, this stage of Simon’s rehabilitation will be aimed at allowing him to achieve maximum knee strength. Moreover, the player’s endurance and neuromuscular coordination will be enhanced during this period of his rehabilitation. It is recommended that Simon’s coach or trainer takes a leading role in managing his rehabilitation at this stage. The coach should put into consideration that Simon can be allowed to run only after the operated leg has sufficient energy which is usually 75% power as compared to the player’s normal leg. During the return to activity and maintenance phase of Simon’s rehabilitation he will be allowed to return into his rugby sport. The resuming of the full sporting activity must be controlled by the player’s coach so that it is gradual. The sports activities of the patient at this level of rehabilitation starts to advance as the player becomes better each day of the return to activity phase. The maintenance period involves programs that are designed to improve the player’s strength. Three sessions per week are recommended for Simon when he would be engaged in strength building activities. In addition, brace protection during sports activities is part of the return to activity and maintenance phase of rehabilitation for the ACL injury as explained by Schriver and Engelsrud (2011, p. 22). Most importantly, the coach should ensure that Simon avoids any high risky sporting activity until he is fully recovered. Conclusion The rehabilitative progression of Simon who injured his anterior cruciate ligament of the knee joint and the medial meniscus has been discussed in phases. The pre-operative management of the patient includes the application of the PRICE protocol. After the reconstructive surgery of the player’s ACL, the post-operative rehabilitative process progresses through the maximum protection, moderate and minimum protection. This is then followed by the return of the patient to sporting activities and maintenance of the strength of the injured leg. 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Westermann, R, and Cizik, A. 2012, An Association of Lateral Knee Sagittal Anatomic Factors with Non-Contact ACL Injury: Sex or Geometry?’ Journal Of Bone and Joint Surgery, American Volume, 94-A, 3, pp. 217-226 Read More