Recently I introduced the three different general goals of fitness; rehabilitation, basic fitness and performance. Today we will discuss the first of these goals…rehabilitation. How many of us have been injured in the past? Probably everyone over the age of five can remember a significant injury. What do we normally do after the injury? Most people wait until the pain and swelling resolve, assume it has healed, and go on about their normal activities, never thinking about the injured part of their body until it is hurt again. Whether we are competitive or part time athletes, everyone needs to know some basics about rehabilitation.
An ankle sprain is a classic example. Many people wear shoes with little support, roll their ankles when they walk, and fail to exercise the muscles in their feet and ankles. As a result, they are vulnerable to ankle sprains. The ankle is the most frequently injured joint in the body and accounts for 30-50% of all athletic injuries. After an ankle sprain, people hobble until the pain goes away, wrap the ankle until the swelling is better, and figure that it is back to normal. Actually, the ankle is not nearly back to normal and another injury may be around the corner.
Rehabilitation involves five stages. First, the pain must go away. Second, the swelling must resolve. Third, involved joints must regain at least their pre-injury range of motion. Fourth, muscles must regain at least their pre-injury strength. Fifth, muscles and nerves involved must relearn how to work normal together (normal proprioception and neuromuscular function). We will consider each of these in turn.
Immediately after an injury, whether a twisted knee or a strained hamstring, the most important thing to do is to PRICEM the injured area:
- Protect (from further injury)
- Rest (to avoid worsening the injury)
- Apply Ice (to decrease swelling)
- Compress (wrap the area to decrease swelling)
- Elevate (the injured part above the level of the heart while seated)
- Medication (use acetaminophen or a non-steroidal anti-inflammatory medication such as ibuprofen to limit pain)
People with severe pain, joint instability or swelling and bleeding should seek medical care promptly. Those with mild injuries can usually self treat at home. Athletes should continue PRICEM for as long as necessary to control the pain and decrease the swelling. Pain usually resolves after a few days and swelling after days to weeks, but the injured area is not back to normal. Tendons and ligaments lack a good blood supply and take a long time, often weeks or months, to heal. Muscles have better blood supply and heal faster.
Shortly after the pain resolves and even before the swelling is gone, people with joint injuries should begin range of motion exercises. Healing often involves swelling and scarring and both processes can decrease normal range of motion. As long as there is no pain and no further damage, gently moving injured areas decreases swelling. Moving a recovering joint through its range of motion and gradually increasing as tolerated helps prevent long term stiffness. No joint should be considered fully healed until it has regained pain-free motion over its complete range.
As the swelling begins to diminish and range of motion begins to return, injured athletes at all levels should begin light resistance training to increase the strength of the muscles that support the injured area. This helps to prevent atrophy, weakening of muscles from disuse during the healing process. Isometric training, pushing or pulling against an object that doesn’t move, such as a wall, is the first step. In isometric training there is no change in the length of the muscle during the exercise. Such training should be done at multiple static angles during rehabilitation. For example, an athlete with a wrist sprain should apply pressure with the wrist extended, wrist neutral, wrist flexed, and wrist to either side.
Once movement is pain-free and swelling is notably diminished, people with athletic injuries should begin strength training in which the length of the muscle changes. Concentric training, in which the muscle shortens, and eccentric training, in which the muscle lengthens, are equally important. Chin ups, for example, shorten the biceps and are concentric. Letting yourself slowly down from a chin up lengthens the biceps and is eccentric.
The last part of proper rehabilitation is ensuring that the nerves and muscles in the affected area work together properly. Regaining neuromuscular function and proprioception is especially important in weight bearing joints. Drawing the letters of the alphabet with pointed toes can help restore neuromuscular function around the ankle. Balancing on a single leg, especially with closed eyes and while moving the arms, also helps.
As the injured area approaches normal, people with injuries should gradually increase normal and sporting activities until they have no pain, no swelling, full range of motion and strength, and normal neuromuscular control. If pain or swelling worsen during rehabilitation, stop the process and start over again. If the injury continues to worsen or even if it stops improving, seek medical care. Physical therapists and other sports professionals have many other useful techniques. Finally, athletes at every level should keep the rest of their bodies fit while their injuries recover. I’ll discuss fitness next time.