In the sporting world it is inevitable that injuries are going to happen during a long-term athletic career – whether they be chronic, acute, catastrophic, or just minor niggles. While it is true that the risk of sustaining injury can be minimized through proper loading and mechanics, perfection in either of those categories is likely unattainable. So, the well-meaning athlete – who can generate massive amounts of force – needs to only make one mistake at an inopportune moment, and BANG … something blows up. We have all seen this happen many times in our careers, and if you haven’t … just keep doing what you’re doing.
One of the questions most frequently posed during our Apprentice Coaching Programs and Performance Therapy Programs goes along the lines of: ‘How do you go about bringing back athletes from injury in a responsible manner – while avoiding re-injury, and minimizing missed Plan A training time?’
In this post I will give oversight on the pieces of the puzzle we look at when faced with an injury scenario to provide athletes with the best possible guidance and inputs as they return to play. Please note that although I list points in sequence, there are overlaps and several layers within this process. Rehabilitation is not linear in nature, and should not be thought of as a one size fits all ‘check the box’ process.
Part One – Gather Information
Firstly, it is imperative to learn about the history of the injury. Ask pointed questions that provide insight into what happened:
– How were sleep patterns leading up to the injury?
– How were nutrition and hydration leading up to the injury?
– What other life stressors were in play leading up to the injury?
– Was there travel prior to the injury?
– Did it occur at practice, competition, in the weight room, or simply by stepping in a hole in the side walk?
– Are there previous injuries at this location?
– Are there compensatory injuries that may have led to this injury?
Be specific and detail oriented – we must learn as much about what actually happened as possible. In some cases, a detailed movement and gait analysis of the athlete may be performed as soon as possible, by an experienced therapist or coach to provide answers to such questions as:
– Where did the damage occur?
– What is the extent of the damage?
– Is radiology needed to provide greater detail?
– How are the structures around the injury reacting?
– What compensatory patterns has the athlete already begun to exhibit that we should be aware of?
This list is not exhaustive but should give you an idea of the types of questions you need to ask. Many of these questions lead to other questions, which in turn provide greater detail and understanding. Rarely is an injury an “out of the blue” phenomena – there are often multiple factors conspiring together which can be tracked down to pinpoint the likely cause.
Part Two – Have the entire Performance Staff on the same page
Once information is gathered it should be shared openly and transparently with the entire staff. This includes therapists, coaches, doctors, and anyone else who may have an influence on the situation – most importantly THE ATHLETE (although in some cases athlete sharing is done strategically). This performance team then needs to have a nominated gatekeeper who makes sure that all parties are on the same page, and monitors progress with unified direction and a clear voice.
Simple lack of communication between involved parties can oftentimes be the culprit when it comes to delaying return to play for athletes: So, if you work or operate in an environment that has a void in communications … start knocking down the walls and bring the involved groups together! Don’t let your ego, or lack of open-mindedness derail the recovery process for an athlete that is counting on you to make the right choices.
“Don’t let your ego, or lack of open-mindedness derail the recovery process for an athlete that is counting on you to make the right choices”
Now to more of the nuts and bolts of the process…
Part 3 – Keep the training gaps small!
At ALTIS we abhor training gaps! One of our main priorities post-injury is to find a way to get the athlete training as soon as possible. Minimizing training gaps is critical for a variety of reasons: First of all, it keeps the athlete engaged and plugged in (not removed to a rehab facility and separated from the team). Secondly, it prevents a dump of blood chemistry and hormone levels; this is really the biggest danger, as when this system goes offline it takes a long time to bring it back online (not to mention that it can actually slow the healing process by reducing the number of blood markers available to aid in proper remodeling of tissue).
What does this mean in real terms?
It depends on the injury, the pain level, and the range of motion allowed. As soon as possible post-trauma, our athletes are walking through as many of our warm-up menu items as they can. Our warm-up also serves as a movement screen; we get detailed information on how the athlete is doing in specific movements on a daily basis. Once they can easily walk the warm-up then we have them jog it, and we gradually add velocities as key movement landmarks allow (see next topic). We also use an array of bike workouts to replicate training themes for each day (acceleration, speed, speed endurance, endurance). These are specific routines with detailed sets, reps, intensities, and rest intervals.
We bang the same drum in the weight room: Keep the training gap small! If an athlete has a lower leg issue on one side then we are free to train upper body as normal, and we will do single leg exercises for lower body or Olympic lifts. The same could be said for single arm exercises for a shoulder/elbow/wrist injury (some studies have shown a 10-30% cross education factor). Another strategy is to use a mirror to trick the brain into keeping the “Plan A” movement patterns firing. An example would be an athlete coming off of an Achilles injury placing a mirror between their lower legs, and doing seated calf raises and toe raises while watching the “injured side” in the mirror. For various tendon injuries research is showing that earlier appropriate loading of these structures facilitates healthier remodeling of the tissue. Rest is not the answer. These are just some examples, but you should get the idea that we are trying to do activities that are as close to Plan A as possible, and we are trying to do those activities as early as we can. We are progressive and aggressive.
Part 4 – Use Landmarks not Timelines
Part of the reason that we can be progressive and aggressive is because we follow a landmark-based advancement protocol instead of timelines. If an athlete can perform a movement that we determine is quality in nature with minimal compensation, then they are ready for the next step in the process … no matter if it’s been 2 days, 10 days, 30 days, or 60 days post-injury or post-surgery. These movements are often progressed on a force/velocity continuum. The warm-up is begun walking, then probably a hybrid walking/jogging, then maybe all jogging, then velocities increase, etc.
Once the warm-up can be done at a normal level we add on accelerations at the end of the warm-up. Once the athlete is able to do accelerations and run successfully with minimal compensation or pain we institute a 10x50m protocol.
Part 5 – Quality Therapy Inputs
The final topic covered in the scope of this blog-post pertains to Quality Therapy Inputs. I have not mentioned therapy very much thus far because it is over-arching, and is part of the process from Day 1 of injury. It permeates every single other part of this process and must be monitored by the aforementioned gatekeeper. At ALTIS we use the term ‘Performance Therapy’. Performance Therapy is many things, but at its core is the Athlete-Coach-Therapist Triad. This triangle of communication must flow in all directions all the time but is especially important in a return-to-play situation. Therapists need to see the athlete move, discuss with the coach which movement patterns are being seen, which compensation patterns are being seen, and above all … which aspects should or should not be addressed on the therapy table, and at what bandwidth should they be addressed.
The human body is magnificently designed, and it is designed to be intelligently redundant. When one system goes offline, it will immediately and automatically re-route movement patterns to find a way for the body to move while the injured system is being repaired. It is the job of the Performance Therapy Team (including the Athlete) to understand that therapy inputs guided by movement landmarks, quality reporting, and minimizing training gaps can dramatically improve the repair time of injured systems. This team working together can then restore the re-routed redundant system to the original “Plan A” movement pattern. This is often referred to as ‘brain mapping’ or ‘motor re-education’ and can be particularly challenging in the chronically injured athlete whose own intelligently redundant system has turned the “Plan B” route into the new “Plan A”.
I hope this information has been helpful in providing insights into our model of returning to play. Each athlete will present a new puzzle, and a new challenge to the Performance Team. The use of your network when you get stuck in situations can prove to be priceless information. So, grow your network, contribute to your network, and remember that the long-term best interests of the athlete must be paramount.