In elite and professional sports there is obvious incentive to ensure athletes make a prompt and successful return to action following injury. There is a clear impetus to push the envelope in an attempt to accelerate the recovery process and minimise the time spent on the sidelines. The impressive recovery times reported with common injuries in professional sports are testimony to the success of the progressive and innovative approaches presently employed. In a ‘high performance’ setting athletes benefit from having a staff of professionals at their disposal on a daily basis to support the endeavour. Given such dedicated support it is perhaps unsurprising that athletes at the top level also show a far higher likelihood of making a successful return to their preinjury level following severe injuries such as ACL rupture, compared to what is reported with performers at lower levels of competition. The stakes involved might differ below the elite level but there are nevertheless lessons to be learned from their approach to performance rehabilitation and return to competition. In this latest offering we explore the advances in how we deal with sports injuries and consider what lessons we might adopt to improve outcomes for performers at all levels.
RECONCILING RISK…
When we approach sports injury rehabilitation we must acknowledge there is inevitably some element of risk. The more progressive approaches employed to achieve an accelerated return naturally tend to elevate the short-term risks involved. Equally, there is risk in all scenarios.
The most consistent predictor of future injuries is previous injury. It follows that simply having suffered an injury renders the performer at heightened risk for future injury. By this logic we might conclude that the safest thing to do is not return to sport at all. That said, ceasing to participate in sport often leads to declining levels of physical activity; and a sedentary lifestyle is a risk factor for chronic disease over the lifespan - so there is risk all round!
One take-home message is that all parties involved need to acknowledge and accept the apparent risks from this outset. From this starting point our task is to employ strategies and countermeasures to mitigate the risks in whatever scenario we opt for.
What is equally crucial to realise is that when we are too conservative in our approach we can paradoxically heighten the risks to the athlete when they eventually attempt to return to sport. Being too protective can have deleterious effects that are manifested in various ways. Removing load entirely causes swift changes in tissue capacity and function. Periods of inactivity likewise quickly lead to detraining and systemic changes to the physiology of our body. These adverse physical and physiological effects clearly render individuals less able to tolerate the rigours of what they are going back to.
Beyond that, when we are excessively cautious and risk averse, inevitably this affects the performer and makes them less confident about making their return. In doing so we create a major problem, as psychological readiness is a big factor in determining whether the outcome is successful. Once again, we should recognise there are risks in every scenario, including iatrogenic risks in relation to the conduct of the practitioner and their handling of the situation.
TRAINING AS TREATMENT…
Aside from guarding against detraining and declining function, various training modalities are increasingly becoming an accepted part of the treatment approach for musculoskeletal injuries. Whilst this is increasingly standard at elite level the message has been slower to spread into general practice.
When dealing with sports injuries it is important to recognise that we are dealing with mechanically sensitive tissues. Bone, ligament, tendon and muscle are all mechanoresponsive, which means they adapt their function and structure to whatever loading conditions they are exposed to. This applies both in health and following injury. Application of mechanical load via modified training modalities can thus help support the repair process.
From a neuromuscular function perspective, timely use of modified training during the rehabilitation process also has neuroplastic effects that support maintaining function and recovering full capability. Training the healthy opposite limb even has benefits that spill over to the injured side due to cross-over effects on input from the motor cortex. Various forms of neuromuscular and sensorimotor training further improves function by helping to restore the disrupted peripheral feedback from mechanoreceptors at the injury site.
Beyond mechanical load and motor function, undertaking exercise throughout the period that follows the injury also elicits physiological effects that help support and augment tissue healing, regeneration and remodeling processes.
Finally, training is an important tool for managing the mental burden of sports injuries, which can be significant particularly with severe or recurrent injury. A proactive performance-oriented approach has notable benefits for the mindset and mental state of the performer as they engage in their rehabilitation and anticipate their return from injury. This especially concerns the initial period following the injury. Finding ways for the performer to continue to engage in some form of physical training during the period when they are otherwise unable to participate in their regular practice and training provides a lifeline and the psychological benefit cannot be overstated.
DEFINING THE OBJECTIVE AND SETTING EXPECTATIONS…
What defines performance rehabilitation and the return to performance approach is not simply compressed timelines but more importantly the outcome we are striving for. A guiding principle and something which is often overlooked is that it is not sufficient to return the athlete to their pre-injury baseline. The athlete will be exposed to higher odds of injury upon their return simply as a consequence of having suffered an injury. If we remain content to just return them to their pre-injury level of function they will still be at greater risk in relation to their status prior to the injury.
From a practitioner perspective it follows that we need to aim higher as we set our objectives for the rehabilitation and return to performance process. To counteract the significant risk factor they will be carrying with them moving forwards we need to create reserve capacity and develop additional capability to provide a buffer and offset the added risk.
Clearly we also need to be guided by what the athlete is aiming for as they contemplate the journey ahead following an injury. We should therefore begin with an initial briefing to establish what outcome the athlete is aiming for and what timelines they have in mind. This provides the forum to outline the range of potential scenarios and what will make the difference in determining the eventual outcome.
From an early stage and periodically thereafter we also need to establish the athlete’s risk tolerance. Bold aims and compressed time-frames will clearly require a higher tolerance to risk on the athlete’s part. We nevertheless need to inform the athlete of the risks associated with each option. We also need to make it explicit that the available options include not returning to the sport; after all that is the option that carries the least risk (in the short term at least). When dealing with more severe injuries we need to put this option on the table from the start and make it clear this option remains open to them thereafter.
What also needs to be clear from the outset is the degree of investment required on the athlete’s part. We need to be honest and transparent about what it will take from them in order to have a chance of achieving their desired endpoint within whatever time-frame they have indicated. This is a conversation that should be revisited during the periodic debriefs that occur throughout the process that follows.
THE ARC THAT FOLLOWS INJURY…
If we use acute muscle injury as our example the typical healing process commences with initial regenerative inflammation response (lasting until around day 3 post-injury), followed by a regeneration phase (4-7 days post-injury), which gives way to remodelling phase that is generally complete by around day 28. The healing processes for other tissues (tendon, ligament, bone) differ somewhat and the timelines are more extended, according to the degree of plasticity and regenerative capacity of the respective tissues. Traumatic injuries also often involve damage to multiple tissues and so we need to factor in the varying timelines and healing processes for the respective structures.
Beyond the healing process of the tissues affected, there is often disruption of both sensory feedback and motor function following an injury. There are second-order effects to these changes. Injury leads to a cascade of secondary effects, including compensatory changes in motor patterns and altered movement strategies. The way athletes employ their senses to control and regulate their movement may also be different following the injury — for instance, they might use vision to guide motor control, rather than relying on ‘feel’ and other sensory feedback as before.
The point of this discussion is that we need to consider a host of factors in order to understand what problems we need to solve. In doing so we can identify clear outcomes for the injury rehabilitation process.
A central aim is to support and augment the natural healing process, whilst guarding against scar tissue formation, chronic inflammation and persisting pain. Another objective is to restore sensorimotor function, encompassing various forms of sensory feedback as well as motor control. A key part of the process is to address the cascade of secondary effects, which may include the uninjured side, including neuroplastic training and restoring movement patterns and motor control strategies.
Finally, when we think of secondary effects, we also need to consider the psychological and emotional effects of the injury. These aspects need to be accounted for in our delivery; as practitioners we need to remain mindful in how and what we communicate.
PERFORMANCE REHABILITATION…
The differences in how sports injuries are handled in an elite sport environment tend to be evident from the outset. What we have termed ‘performance rehabilitation’ simply describes a proactive approach that encompasses the use of an array of modalities to achieve identified outcomes in a timely fashion. The fact that many of these modalities are more commonly associated with performance training is however a characteristic feature.
Another notable difference is how soon after injury the athlete is engaging in activity in a supportive environment and performing assisted exercise. During the acute phase the primary objective of therapeutic exercise is to support the natural healing process. What this looks like in practice clearly depends upon the injury in question. In general it begins with non-weightbearing movement either fully supported or in aquatic environments (floating in deep water) and progresses to partial weight-bearing using aquatic exercise and other weight-supported environments and modalities.
Similarly there is an early drive to get the athlete engaging in whatever conditioning and modified training is permitted by the injury. Besides guarding against detraining, there are apparent benefits to training the opposite (uninjured limb) to help restore motor function (eccentric strength training modalities appear to be particularly potent). Motor imagery can also be used to complement physical training - even doing the training in our minds is beneficial!
Rehabilitation training modalities similarly seek to provide a complementary mechanical stimulus to support and direct the repair process during the regeneration and remodelling phases. Essentially this involves applying graduated load to the injured site in a way that stimulates and direct adaptation in the absence of pain and whilst avoiding any persisting adverse reaction in the tissues. Clearly this a delicate balance that relies on the athlete being a partner in what is an ongoing discovery process that inevitably involves trial and error. This requires both full disclosure and courage from all parties.
As part of the performance rehabilitation process there is also a need to restore function for day to day activities. For instance, restoring normal walking gait is crucial, not least given that will impact both the motor patterning and loading on weight-bearing structures during the hours when the athlete is not with us. Part of this involves restoring dexterity at the injured limb and on the uninjured side and working on general coordination or whole-body movement dexterity.
Movement training is a major emphasis of the performance rehabilitation approach. This begins with fundamental movements and progresses to more complex athletic skills such as running and jumping, and finally sport skills under conditions of increasing complexity. In other words, coaching for skill acquisition and refinement is central to performance rehabilitation.
THE RETURN TO PERFORMANCE PARADIGM…
The return to performance paradigm is an extension of the performance rehabilitation approach we have outlined. As such, a guiding principle is striving to over-prepare the athlete and ensure they are better equipped than before the injury once they make their return. The other clear differentiator is that this process extends beyond the point when the athlete first makes their return to competition.
The need for a more evolved return to performance approach is evident even at the highest level. Whilst elite athletes do show a much better rate of return to their previous level, what we see thereafter suggests there is a need to do better. Having made their return many fewer are able to endure as we can see with follow up studies that document the reduced numbers who are still competing at their previous level three years on from making their return.
As implied in the title, the aim of providing additional individual support following the athlete’s return from injury is to restore their ability to express their full performance capabilities under live conditions. But beyond that we are seeking to build in reserve capacity, additional capability and enhanced athleticism so that they have the tools to get out of trouble. Continuing to provide dedicated support to the athlete once they have made their return also accounts for the fact that the remodelling process that follows injury is often still ongoing at that point.
From a process point of view, this is a phased approach. At the outset we manage the injury, then restore function, develop capacity and capability, prepare the athlete for what they are returning to, allow a period to consolidate these changes before making a full return and once they make their return continue to provide individualised support until they are back to their best.
The lengths of the respective phases will clearly differ according to the injury. For instance, the manage phase for a muscle injury might only be a few days. Whilst the timelines for making a return to competition are relatively shorter at elite level, it bears repeating that the process extends beyond that - hence return to performance, as opposed to simply return to competition.
PASSING THE BATON…
The return to performance process in its entirety is somewhat akin to a relay race. There are transition points within the respective phases outlined where the lead practitioner up to that point passes the baton onto a colleague to lead the next portion of the race. In general, the process in full will typically involve two hand-over points (arguably three if surgery is involved). This means that three practitioners (or four if this includes an orthopaedic surgeon) will take their turn in the lead role at different points on the journey that follows the injury and culminates with returning to perform at their best.
The practitioner’s race does not end once they have passed the baton onto a team-mate; typically they remain involved thereafter. Rather than a serial process, whereby one thing ends as another commences, in reality this is a parallel process. Each phase comprises different strands that commence at various points and progress alongside each other, so that multiple elements involving different practitioners are in action at any given point in time.
Practically it is also a collaborative process throughout and each member of the tight team (to use a term from the previous post) will have continual input during each phase. However, it remains critical that there is a single designated lead who has ultimate decision-making authority at any given time.
It is also appropriate that the individual who takes the lead should transition as the performer progresses through the respective phases. These transition points are in part simply a reflection of the shift in primary emphasis as we progress through the process. Equally, another driver is the need to support and increase the psychological readiness of the performer as they anticipate first returning to practice and competition, and then switch to a performance focus once they are back competing.
More specifically, we need to avoid any sense of dependency as we seek to develop a growing sense of confidence and facilitate a shift in mindset. To that end there is a particular need to lengthen the leash and create some separation between the performer and treating practitioner; hence the first transition. At the later return to performance stage both the therapist and rehabilitation coach will necessarily become increasingly peripheral figures as the focus of the performer shifts entirely to performance goals.
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