Author: Giulio Braga

The primary purpose of this chapter is to review selected concepts pertaining to the treatment of sports injuries. The evaluation and treatment of some common injuries will also be presented. Overuse injuries will be discussed in a separate chapter in this textbook. The reader should understand that the area of sports medicine is broad; therefore, for those interested in treating sports injuries, additional reading of current textbooks and journals is essential. In addition, clinical experience gained through preparticipation physical examinations, sports clinics, and on-field coverage is invaluable to anyone who desires to care for injured athletes.

BASIC PRINCIPLES OF NONOPERATIVE FUNCTIONAL REHABILITATION

Several basic principals can be applied to almost any acute sports injury. These are outlined in Table 23-1. These rehabilitation phases provide a stepwise approach to treat and assess the progress of an athlete with an acute injury. Immobilization is avoided as much as possible because of its multiple detrimental effects on tissue healing (e.g., scar formation, contracture, and atrophy).

Phase I: Decrease Pain and Control Inflammation

The initial phase of treatment is to control the inflammatory reaction that occurs after an acute injury and its associated pain, which inhibits muscle function. It should be noted that mediators involved in the inflammatory response are also important factors involved in the healing of soft-tissue injuries. Therefore, although the goal is to control the inflammatory response, eliminating it completely would be detrimental to tissue healing. The PRICE (protection, rest, ice, compression, elevation) approach is well known to those who care for athletes.
After an injury, the area is protected either by splinting, bracing, or taping/wrapping. It is very rare that any ligamentous or musculoskeletal injuries would require casting, which is usually avoided. Crutch ambulation (usually weight bearing as tolerated) for lower extremity injuries can be very helpful until a normal, pain-free gait pattern can be reestablished. Bracing should be limited to that which protects the specific area while allowing for full motion at other areas. It is often possible to use the same brace to facilitate early protective motion as well as return to functional activities later in the rehabilitation process (e.g., a double upright hinged knee brace following a medial collateral knee sprain).
Rest should be prescribed carefully, as it is important that the athlete does not become deconditioned during the rehabilitation of an injury. Fatigue results in a decrease in neuromuscular functioning and joint control, thereby placing greater dependency on the static stabilizers of joints (i.e., the ligaments), placing them at greater jeopardy for injury. Therefore, the proper term is relative rest, which means that while the affected area is rested, the remainder of the body is exercised. In particular, cardiovascular conditioning must be maintained. This can be done by alternative exercises that allow for protection of the injured area while stressing the cardiovascular system at the same intensity, duration, and frequency as the athlete had previously trained. For example, a running athlete who suffers a lower extremity injury that must be unloaded can use deep-water vest running at the same intensity level as before the injury. This has allowed athletes to maintain their cardiovascular fitness level while their injuries heal, allowing for safe return to play at close to the preinjury level and possibly prevention of additional injuries.
Ice controls the initial inflammatory response and facilitates pain control immediately following an injury. The affected areas should be generally iced 20 minutes four to five times a day, or more often if possible. Ice is used for its properties of vasoconstriction, which limits the edema as well the release of vasoactive and pain factors, such as bradykinins and leukotrienes. Ice also can decrease conduction along pain fibers and act as a counterirritant to assist in pain control and to reduce muscle spasm. There are various methods of icing that include ice pack, ice massage, ice immersion, and devices that combine both ice and compression.
Compression is also used in an effort to limit the edema in the injured area. Ace wrapping is often used but can be problematic because of the difficulties in getting uniform or gradient (from distal to proximal) compression. A compressive stockinette (e.g., Tubigrip) can be very helpful in this regard. A sleeve can be cut to whatever size is necessary and simply applied. For additional compression, it can be folded over onto itself. Care must be taken to avoid excessive pressure over bony protuberances or superficial nerves. Compressive braces can also be effective (e.g., air splints for ankle sprains). Finally, devices that combine icing with compression have been found to be very useful and effective in the postinjury as well as postoperative rehabilitation of athletic injuries. They can be used not only by therapist and athletic trainers but also at home by motivated athletes.
Elevation is yet another means to control postinjury swelling. The injured limb should be elevated above the level of the heart to optimally assist with venous and lymphatic drainage and therefore control edema. Keeping the lower extremities out of a dependent position is helpful as well in limiting the pooling of inflammatory and posttraumatic products.
Additionally, nonsteroidal antiinflammatory drugs (NSAIDs) for a short period of time, if not contraindicated, and electrical stimulation can assist with both inflammation and pain control. Whether they offer clear advantages over using just the above program is a matter of debate, but if available and not contraindicated, appear reasonable.

Phase II: Restore Normal/Symmetric Range of Motion

Pain and swelling can inhibit motion or produce altered motor patterns that, if established, often require retraining to restore proper motor control. An example would be an athlete with an antalgic gait following a knee or ankle injury. This movement pattern must be discouraged while the area is gradually mobilized. Immobility will result in scar and contracture and therefore is not recommended. Range of motion (ROM) allows for controlled stress to a joint, which will stimulate proper collagen deposition. Motion provides sensory input to the central nervous system, which stimulates the proprioceptive system as well modulates pain via the Gate theory. In the early phase, pain-free movement of a joint and stretching that prevents contractures is encouraged as the motion that results in stress on the injured area is avoided. As the pain and inflammation subside, more aggressive stretching and mobilization continues until symmetric (to the unaffected limb) motion is achieved with normal movement patterns.

Phase III: Restore Normal/Symmetric Strength

Strengthening a painful, inflamed limb that lacks normal ROM can result in further problems that can delay recovery from injury. Therefore, a stepwise approach toward strengthening must be used. In the early postinjury phases, pain-free isometric contractions are encouraged in an effort to retard muscular atrophy. They should be performed several times throughout the day. A simple method can be to recommend 10-second contractions, with 10 repetitions, 10 times a day. These isometric contractions may need to be performed through multiple angles as the strengthening is specific to the manner and position that it is trained. As the injured area recovers and ROM is restored, isotonic strengthening can begin if possible. Currently, there is no significant role for isokinetic strengthening because of poor functional carryover. To that end, closed-kinetic chain exercise should begin as soon as possible and progressed as able. Resistance training can be in the form of exercising against gravity, free weights machines, and resistance tubing. The strengthening should be as functional as possible, attempting to match the demands of the sport. Resistance tubing strengthening is attractive because of its ease and simplicity; however, the greatest tension with resistance occurs at the end ROM, where the muscle is usually weakest and the joint is most vulnerable. Therefore, this should be reserved for later stages of the strengthening program. In addition, the use of plyometric exercise should be included as the athlete is preparing to return to sport, because such training may ready the athlete for explosive bursts that are often a necessary part of many high demand sports.

Phase IV: Neuromuscular Control (Proprioceptive) Retraining

In order to dynamically control a joint during sport activity, there needs to be not only full ROM and normal strength, but also adequate dynamic motor control. Specifically, the injured joint needs to be stabilized by synchronous activation of appropriate muscle groups so that the larger, more powerful muscles may safely produce the necessary force required in sports activity. Many injuries can result in proprioceptive loss that may predispose an athlete to repeat injury. As in other areas addressed in the rehabilitation process, the proprioceptive system needs to be progressively challenged in order for progress to be made. Simple proprioceptive training can include seated exercises with a wobble board for lower extremity injuries or loading exercises of the arm either on a table or wall. As the athlete recovers, and assuming that there is near full ROM and strength, the proprioceptive system is progressively challenged (e.g., balancing on a single leg while catching and throwing, balancing with eyes closed). Proprioceptive training requires a great deal of one-on-one work with a therapist or trainer and often creativity in developing ways to challenge the proprioceptive system that corresponds to the athlete’s sport (8).

Phase V: Return to Sport Activities

As the athlete completes these phases, then the therapist or trainer must begin the transition to return to sport. This occurs as the athlete successfully meets the challenges of the previous phases. The athlete then is put through activities that replicate the demands of the sport. For example, a basketball player will be given various drills that include running, cutting, and jumping (and landing) using optimal biomechanics. Once the athlete demonstrates that he or she can successfully negotiate the various drills and challenges that will occur in the sport in a controlled situation, then it will be clear to everyone on the team (including the athlete) that he or she can safely return to their sport.Copyright: Copyright©2005 Lippincott Williams & Wilkins – Physical Medicine & Rehabilitation: Principles and Practice – Joel A. Delisa

Pain is purely subjective, difficult to define, and often hard to characterize or interpret. It is currently defined as an unpleasant sensory and emotional response to a stimulus associated with actual or potential tissue damage (1,2,3). However, pain has never been shown to be a simple function of the amount of physical injury; it is extensively influenced by anxiety, depression, expectation, and other psychological variables. It is a multifaceted experience, an interweaving of the physical characteristics of the stimulus with the individual’s motivational, affective, and cognitive functions. The pain experience is in part behavior based on an interpretation of the event, influenced by present and past experiences.
Acute pain is a biologic symptom of an apparent nociceptive stimulus, such as tissue damage that is due to disease or trauma. The pain may be highly localized or may radiate. It is generally sharp, crushing, or burning and persists only as long as the tissue pathology itself persists. Acute pain is generally self-limiting, and as the nociceptive stimulus lessens, the pain decreases. Acute pain usually lasts a few days to a few weeks (2). If it is not effectively treated, it may progress to a chronic form.
Chronic pain is a disease process in which the pain is a persistent symptom of an autonomous disorder with neurologic, psychological, and physiologic components. Differing significantly from acute pain, it is defined as pain lasting longer than anticipated within the context of the usual course of an acute disease or injury. The pain may be associated with continued pathology or may persist after recovery from a disease or injury. As with acute pain, treatable chronic pain that is due to organic disease is managed by effectively treating the underlying disorder. Chronic pain is often poorly localized and tends to be dull, aching, and constant. Associated signs of autonomic nervous system response may be absent, and the patient may appear exhausted, listless, depressed, and withdrawn.
Proper management of pain requires an understanding of its complexity and knowledge of the nonneurologic factors that determine its individual expression. The treatment of pain with physical modalities is as ancient as the history of humanity, but the use of interdisciplinary rehabilitation techniques has gained acceptance only within the past few decades.

EPIDEMIOLOGY

Nearly everyone experiences acute pain. Its incidence approximates the cumulative total of all acute diseases, trauma, and surgical procedures. In studies of the general population, patients have identified the head and lower limbs as the most common sites of acute pain and have identified the back as the most common site of chronic pain (4).
Chronic pain is less frequently experienced, but is reaching epidemic proportions in the United States. There are more than 36 million individuals with arthritis, 70 million with episodic back pain, 20 million with migraine headaches, and additional millions with pain that is due to gout, myofascial pain syndromes, phantom limb pain, and complex regional pain syndromes (5,6). The pain resulting from cancer afflicts approximately 1 million Americans and 20 million individuals world wide. Moderate to severe pain occurs in about 40% of patients with intermediate stage cancer and in 60% to 80% of patients with advanced cancer (7,8,9). Back pain, as a general condition, episodically affects nearly 75% of the population in most industrialized nations. It is estimated that at least 10% to 15% of the working population of industrialized nations are affected by back pain each year (6,10).

ETIOLOGY

Chronic pain is not merely a physical sensation. In the affective component of chronic pain, most patients show a degree of depression, and many show anger, jealousy, and anxiety. For many individuals, depression is the primary factor in the perception or experience of pain. Fifty percent to 70% of patients with chronic pain have either a primary depression or a depression secondary to their pain syndrome. Chronic pain, with accompanying depression, often leads to extensive periods of reduced productivity as well as inactivity. Prolonged inactivity alters cardiovascular function, impairs musculoskeletal flexibility, and causes abnormal joint function (11,12,13,14). Prevention involves the encouragement of patient activity as soon as it is reasonable.
The motivational component of chronic pain is concerned with the vocational, economic, and interpersonal reinforcement contingencies that contribute to the learning of pain behavior and the maintenance of chronic pain. More than 75% of patients with chronic pain display adverse behavioral characteristics, including problems with job or housework, leisure activities, sexual function, and vocational endeavors (15). The patient also may have significant functional limitations as a result of multiple previous surgeries with little success and prolonged convalescence, disuse/physical deconditioning syndrome, or narcotic medication (16).
Chronic pain’s cognitive component involves how patients think and the part that pain plays in their belief system and view of self. The more the patient perceives pain as a signal, requiring a reduction of activity and protection of the affected part, the more difficult it is for the physician to achieve compliance with exercise, stretching, and other elements of the treatment program. The memories of pain from acute pain episodes may significantly hinder a patient’s recovery and contribute to chronic pain syndrome (17,18,19). Pain is often the result of sensory input, affective state, cognition, motivational, and memory factors, which require a multidimensional evaluation process, including treatment interventions directed at those components most responsible for the pain experience (20,21,22).

Resolution of Pain

Acute pain is frequently the result of tissue damage in which the initial pain leads to an increase in anxiety, which magnifies the pain experience. The amount of anxiety generated and possibly pain seems to be more influenced by the setting in which the pain develops rather than personality variables. With the healing process comes a reduction or termination of the anxiety and acute pain perception. When acute pain, which functions as a warning signal, fails to respond to treatment with conventional medical therapies, illness behavior and chronic pain develops. The anxiety characteristic of acute pain is replaced by depression with hopelessness, helplessness, and despair. When pain relief fails, physical activities decrease, and suffering and depression increase.
Acute pain usually resolves when the source of nociception is removed or cured. Acute pain, by definition, resolves quickly and is often readily treated by a single modality. The cause of acute pain can be documented by physical examination findings and diagnostic procedures. When indicated, appropriate operative intervention can be performed on the basis of these findings. A short course of analgesic medication usually controls postoperative pain, and a return to full painless function can be anticipated in a matter of weeks. Acute pain control requires the administration of an efficacious analgesic dosage. Too little analgesia promotes suffering and anxiety, thus defeating the purpose of prescribing medications. Fear of drug addiction contributes to the underutilization of analgesic medications, and physicians tend to undermedicate in terms of frequency and dosage of pain medications (32,33). By prescribing low oral doses of narcotics at infrequent intervals, physicians inadvertently force patients to adopt pain behavior in order to obtain adequate narcotic analgesia. Pain behavior is characterized by high verbalization of pain, dependency, and the inability to work. Addiction in the acute pain situation is very rare, approximating less than 0.1% (34,35).
Unfortunately, a significant minority of acute pain patients continues to experience pain, which may progress into a more complex disease entity. Pain, a symptom of physiologic malfunction, now becomes the disease itself. Chronic pain represents a complex interaction of physical, psychological, and social factors in which the pain complaint is a socially acceptable manifestation of the disease. The etiology of chronic pain may be persistent nociceptive input, such as arthritis or terminal cancer; psychological disorders, such an anxiety, depression, and learned behavior; or social factors, such as job loss, divorce, and secondary gain.
The optimal treatment for chronic pain is prevention. Once the disease state of chronic pain commences, reinforcers such as monetary compensation, presence of job-related problems, manipulation of the environment to satisfy unmet needs, and retirement from the competitive world obstruct disease resolution. Therapies designed for acute pain are often contraindicated for chronic pain.
Prevention of chronic pain requires identifying contributing factors and resolving them early in the acute stage. Aspects worthy of attention include psychological stress, drug or alcohol abuse, and poor posture or muscle tone, as well as significant psychological and operant pain mechanisms. Physicians should set a reasonable time frame for the resolution of the acute pain process. Patients should be advised when the pain medication will no longer be needed. The patient’s attention should be directed to a gradual return of full activity on a prescribed schedule. Follow-up appointments should be planned at specified intervals so the patient does not need to justify a visit. Work intolerance and job conflicts should be resolved.

Pain-Reinforcing Factors

Chronic pain syndrome is a learned behavior pattern reinforced by multiple factors. These behaviors are frequently found in individuals who are depressed and inactive and lack the skills or opportunity to compete in the community. These environmental factors promote pain behavior, regardless of the etiology of the pain, thereby distinguishing the patient with chronic pain from the population at large. Patients often develop a new self-image and see themselves as disabled by their pain. This self-perceived disability justifies their inactivity, manipulation of others, and attempts to collect compensation. The typical patient often has been unemployed, has low job satisfaction, or has been on sick leave for long periods of time (36,37,38,39). Our data indicate that individuals who have been removed from the labor market because of pain for less than 6 months have a 90% chance of returning to full employment; those removed from the labor force because of pain for more than 1 year have less than a 10% chance of return to full employment (37).
Individuals with chronic pain syndrome receive gains from their pain behavior; hence, they continue this behavior to maintain those positive reinforcers. Physicians reinforce the pain behaviors by lacking knowledge of this chronic disease process, failing to identify the chronic pain behavior, and prolonging prescription of inappropriate medications, inactivity, and work limitations. The physician’s failure to acknowledge and direct the patient toward recovery tends to validate the chronic pain syndrome by providing an undiagnosable and untreatable problem. Family members also frequently reinforce the chronic pain behavior. They allow the individual to become inactive and cater to the patient’s requests and needs over prolonged periods of time. In some instances, patients with chronic pain provide role models for pain or disability behavior for other family members (40,41).

WORKER’S COMPENSATION

In 1911, worker’s compensation laws were enacted in the United States that required employers to assume the cost of occupational disability without regard to fault. These laws have dramatically influenced the recovery from injury. In many instances, they have become counterproductive; financial compensation may discourage return to work, the appeal process may increase disability, an open claim may inhibit return to work, and recovering patients may be unable to return to work. Often the accident and resulting symptoms represent the patient’s solution to life’s problems (42). The pain literature suggests an enhanced pain experience and reduced treatment efficacy in patients with chronic pain who are receiving financial compensation (43).

LITIGATION

Disability, along with pain and suffering, greatly determines the amount of compensation awarded in worker’s compensation cases. The patient/client’s pain behavior may be reinforced, maximized, and groomed with the hope of a large cash settlement. As a result of this reinforcement, the pain behavior develops into a learned response. The pain also becomes the
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disability for which the patient/client is seeking compensation. Therefore, a learned behavior becomes a determining factor in the amount of compensation awarded (44,45).
Alteration of the disability laws could decrease the number of acute pain patients who develop the behavioral disease of chronic pain syndrome. Changes that might discourage the development of chronic pain include allowing an injured worker to continue working at a job he or she is physically able to accomplish during the recuperation period, rapid adjudication of disability and compensation claims, and physicians restricting the patient’s use of addicting and depressant medication to less than 1 month. The extensive use of conservative intervention to include physical therapy and stress management early in treatment also could prevent the emergence of a chronic pain syndrome (46,47). For additional information on disability determination and medical-legal aspects, the reader is referred to Chapters 7 and 10.Copyright: Copyright©2005 Lippincott Williams & Wilkins – Physical Medicine & Rehabilitation: Principles and Practice – Joel A. Delisa