Rehabilitation – Bringing Injured Bodies Back to Health

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:

  1. Protect (from further injury)
  2. Rest (to avoid worsening the injury)
  3. Apply Ice (to decrease swelling)
  4. Compress (wrap the area to decrease swelling)
  5. Elevate (the injured part above the level of the heart while seated)
  6. 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.


How to Pick Your Fitness Goals

For the past two weeks many Americans have enjoyed the Olympic Games.  Watching the fastest runners and swimmers, the finest gymnasts, and the best teams in the world is both an inspiration and a thrill.  It stirs the heart to see the athletic prowess that these young stars can reach.  So moved, many people commit to improve their own physical fitness and set goals to achieve that end.

To get fit, people need first to decide what their goals are.  The first goal is rehabilitation.  Injured athletes, and even injured couch potatoes who wish they were athletes, need to have healthy and normally functioning muscles, bones and nerves, not to mention organs such as heart and lungs, to be fit. How many of us sprain our ankle, strain our back, or bruise our muscles, and when the pain goes away think that we have fully rehabilitated?  Some people exercise despite having a bad cold, the stomach flu, or a headache.  You might say that the first goal in fitness is to move from abnormal health to normal health.

The second goal in fitness is to optimize health.  Many people have normally functioning bodies but still are not in good physical condition. The American College of Sports Medicine recommends 30 minutes of moderate cardiovascular exercise five days per week, resistance exercise two days per week, and flexibility exercises three days per week.  Such a routine will not produce Olympic champions, or even local tennis club champions, but will provide a good level of fitness for day to day life in most people.

The third goal in fitness is performance.  Long distance runners run 50 or more miles per week, in addition to other exercises, to be the best in their sport.  Swimmers, cyclists, gymnasts, and other athletes spend hours more practicing to perform at whatever level they need to be competitive.  To most military members, “performance” may be limited to successfully doing their jobs, keeping up on unit runs and passing physical fitness tests.  To competitive athletes, “performance” may mean practicing their sport 8 hours per day, five or six days per week.  Olympians may work at that intensity for decades.

Keep in mind that sometimes high performance impairs fitness.  Swimmers who specialize in the butterfly stroke and baseball pitchers can develop shoulder instability.  Long distance runners burn so many calories that if their food intake doesn’t increase enough, they can get muscle wasting and brittle bones.  One of the most important goals in sports medicine is to help athletes achieve their performance goals without compromising their overall fitness.

While you sit on the couch and watch sports after the Games, think about how to change your lifestyle to improve your personal fitness.  Do you have an ankle or knee that has never been quite right since that injury a few years back?  Get it checked out and get a personalized rehabilitation plan.  Are you pretty normal but just don’t get out and move?  Figure out how to change your schedule to make time for exercise and good fitness.  Then get with a friend and go for it. Do you want to be an Olympian, or at least champion of next month’s golf tournament at your local course?  Talk to a local trainer and sports medicine professional to get a personalized performance plan.

Fitness and prevention are two of the most important topics any of us can learn for our health.