Return to sport: stage one
Return to sport: stage one
The Red Pill team have a wealth of experience to draw upon when getting people back to training, whether it be the elite athletes or 5-a-side weekend footballers — the same principles apply. This will aim to give you a greater scope of knowledge, particularly looking at the first stage of an injury. I will endeavour to cover as broad a spectrum as possible, for the sake of safety, I’ll assume that the injuries you are thinking of have been assessed by a medical professional and you’re cleared to get started with some work.
There are many variables and factors to consider when working with an injured athlete. The ones I consider to be most important are:
Who they are: what is their sport, what level were they at previously, what is their history with this injury? How are they feeling?
One of the first things I will consider is where they are in terms of healing. Healing times will vary for different injuries, however the basic considerations for soft tissue healing times are as follows:
BLEEDING: 6-8 hours or up to 24 hours after a crush injury. This will depend on how vascular a structure, for example cuts on heads bleed a lot, as the skin on your head is highly vascularised, lots of blood vessels. However, the medial meniscus – the semi-circular cartilage on the inside of the knee, is considered poorly vascularised (10-25% vascularised in the periphery of the cartilage 1), therefore you rarely see large bruising if this is torn.
Why is this important? You may not see this athlete at the time of the injury, therefore how does it affect you as a coach? Have you ever noticed if a child falls over, they often don’t cry until they see the blood on the grazed knee? There is going to be an emotional response to this injury, huge stubborn bruising may be innocuous, but the athlete is likely to be concerned about it and addressing those fears is important. Conversely, no bruising doesn’t mean no injury or pain.
INFLAMMATION stage begins at 6-8 hours to help stop the bleeding, this peaks at 1-3 days and resolves over the weeks. During this phase the blood vessels constrict acutely to slow the blood flow, fibrin (a protein that helps provide a mesh to stop bleeding) is deposited and clotting begins. The clean-up crew arrive: a process called Phagocytosis – neutrophils and macrophages flow to the injury site and rid the body of debris and infectious agents. Other cells in the body stimulate the release of chemical mediators such as serotonin, adrenaline, noradrenaline and histamine, all used to help the healing process.
Again, this may not seem overly relevant to you as a coach, but it’s important to be armed with knowledge. If the inflammation stage can last a few weeks, you may aim to start a programme of movements to help reduce the inflammation, movement increases the blood flow which helps the body get rid of excess substances that might be hanging on. Additionally, there has been debate about the use of ice with acute injuries. However, to clarify, there is no direct evidence that ice impedes healing after acute trauma (2), a systematic review of 10 studies suggested that it may have a positive effect on return to sport (3). So, in my experience, reducing the swelling when possible is helpful. This may also help pain, some of the chemicals moving around that injury can stimulate our pain receptors as well as the excess fluid increasing pressure in a joint, for example.
During the PROLIFERATION stage, collage is produced for scar tissue and can start from 24-48 hours after the injury, but can last up to 3 weeks. Initially immature tissue is formed, as the inflammatory process subsides the granulation tissue matures and less of the weaker type III collagen is produced and more of the stronger type I cartilage.
REMODELLING describes the reorganisation of new tissue and production of more organised and stronger type III collagen to behave more like the tissue it is trying to repair. This begins two to three weeks after the onset of the lesion and can last for more than one year. The aim of the remodeling stage is to achieve the maximum tensile strength of the tissue (4).
These final two stages are where, as therapists and coaches, we should respectfully get to work. I say respectfully as I think there are areas of concern here: there is a high rate of re-injury with some of the most common sports problems. For example, the rate of reinjury for an Achilles tendon is 44% (5) and 22-34% for hamstring problems (6), with re-injury occurring within the first few weeks. Therefore I would certainly be assessing and reassessing the injury, movement, and pain levels on a regular basis and I would be guided by this, within that time period. There are scenarios where pain is not a good representation for tissue damage, this is more relevant for chronic problems, whereby the tissue is healed, but other factors are influencing pain. Perhaps a discussion for another blog.
Whilst being cautious is recommended in the early stages of an injury, it is also important to recognise the negative effects of extended periods of non-play on the athlete. The importance of that sport or activity to the athlete cannot be underplayed, for high level athletes this is an income source, a perceived risk to this could be incredibly stressful. Athletes may also marry their own identity into their sport and find it difficult to dissociate their own identity with their sport or prowess within their field. Another example is the recreational runner who uses this to manage their mental health. At each level of performance, it is important to acknowledge the effect that this may be having, which is why giving the athlete a ‘success’ or focusing on something that they are able to do, is invaluable.
In order to appropriately manage an athlete within the first stage of an injury, I would recommend considering the following:
Who is in front of you
Know where they are in terms of time
Do what you can do, well
Give success
Listen
The knee meniscus: structure-function, pathophysiology, current repair techniques, and prospect for regeneration. 2011. Biomaterials. Makris, Hadidi and Athanasiou.
The effects of Hypothermia on Inflammation and Swelling. Athletic Training. 1975. 11(1): p 7-10. Knight.
The effect of ice on blood flow and bone metabolism in knees. AM J Sports Med. 1994 p537-40. Ho et al.
Wound healing - A literature review An Bras Dermatol. 2016 Sep-Oct; 91(5): 614–620. Costa, de Araujo Andrade, Medrado.
Three considerations of return to sport decision making. BJSM
Hamstring injury rehabilitation and prevention of re-injury using lengthened state eccentric training. International Journal of Sports Physical Therapy. 2012. Schmitt.