Part II: Injury Rehabilitation

Despite all your best efforts, you acquired an injury along your training journey.  Do not let this scare you.  It happens to the best of us.  In fact, it happens to most of us.  In Lemoyne’s cross-sectional study of collegiate athletes, she reported an injury prevalence of 91%.¹  You are not alone, and we are here to help you.  The big question now is, what do you do?

• Step 1 which will never change, is to seek out skilled medical help, and identify the problem.  Know what you are up against before you work on developing a solution.
• Step 2 is to develop a comprehensive rehabilitation plan with your medical professional, whether that be an orthopedic doctor, physical therapist, or athletic trainer.
• Step 3 is to attack your rehabilitation plan with as much tenacity and devotion as you would your training.  This can be a difficult step.  Remember to be patient and be completely honest with the medical professional that is helping you in this journey.  You are not alone, we are here to help.
• Step 4 is to monitor your progress and make adjustments with the guidance of your medical professional until you have completed a full return to activity program.
• Step 5 is to adjust your strength & durability training accordingly, so you do not have to repeat and go back to step 1.
  
  

For the purpose of this blog, we are going to focus on steps 2 through 4.  Step 1 is strictly a job for your own medical professional, and helpful tips for step 5 can be found in Part 1 of this blog post.

Disclosure Statement: Keep in mind that every injury and individual is different.  What may work for one individual, may not work for another.  If you ever suspect that you are experiencing any of the injuries discussed in this blog post, I fully recommend that you seek out a skilled medical help.  Be sure to clear any new exercises with your medical profession, particularly if you are in the process of treating or rehabilitating an injury.

Step 2: Developing a Comprehensive Rehabilitation:

“Comprehensive” is key when it comes to developing a rehabilitation program.  Rehabilitation is often confined to a box with 4 corners, RICE (Rest Ice Compression and Elevation).  RICE is only the tip of the iceberg when it comes to rehabilitation and results on effectiveness have been mixed.^5,6  A true comprehensive rehabilitation requires a wider range of components.  Programs may include, but are also not limited too, education, strengthening, mobility, posture, balance, hydration, gait, psychology, and many more.  Everything in your body is connected.  Fascia, or connective tissue, connects in a chain from the top of your head to the bottom of your feet.  Therefore, when looking at an injury it is vital to search up and down the chain for contributing factors.  For example, you may have daily calf cramps.  Yes, this could be due to something directly in your calf, but it could also be due to hydration, hormone or electrolyte imbalances, or weakness in your glutes.  The cause and solution are not always in the same part of your body, or even limb.

Believe it or not, one of the best signs of a comprehensive lower extremity rehabilitation program is core strengthening exercises.  Core muscles being defined as, those surrounding and attaching to your trunk and pelvis.  You may be wondering how a muscle so far away from your lower extremity injury could possibly help.  Here’s how: your core muscles are to your lower extremity as your brain is to your body.  Your core muscles provide stability for your lower extremity, which allows your legs to function properly.  Each muscle in your legs has their own support system of other muscles, ligaments, bones, and tendons that aid in stabilization for dynamic and static activation, but the ultimate tool for stability is core strength.  Here are a few of our favorite core strengthening exercises to try.  Ask your doctor about core strengthening, and be sure to clear these exercises with your own doctor for safety.

First, let’s look at the Wall Press Iso w/ Alt. Dead Bug.

It's one of the first exercises you will see in our Dead Bug progression series that focuses on connecting lower extremity movement and the trunk. It's a great way to improve core and trunk strength & stability. 

Here are 5 coaching cues we use for the Wall Press Iso w/ Alt. Dead Bug:

1. Head a few inches from the wall, eyes up. 
2. Actively press hands into the wall throughout the duration of exercise.
3. Avoid a rib cage flare and arching your back.
4. Knees bent, toes back toward your knee caps.
5. Alternate through each leg extension in a controlled pattern.

Next, we will take a look at the Band Half Kneel Pallof Press

This amazing anti-rotation core exercise in the half kneel position in which the inside knee is down in this variation. This is a great challenge to some of the smaller core muscles.

Here are 5 coaching cues we use for the Band Half Kneel Pallof Press: 

1. Legs hip width apart, toes tucked under ankle dug into the ground.
2. Hips forward while keeping a short core.
3. Band set up at chest height in the kneeling position right out to the side of your body.
4. Inside hand holds the band starting at your chest.
5. Avoid slouching forward and/or arching back

Step 3: Attack Your Rehabilitation Plan:

It is vital to take your rehabilitation plan seriously.  Being patient and honest are just as important to the rehabilitation process as consistently doing your physical therapy exercises.  Return to play too soon and improper rehabilitation can lead to increased symptoms, and even additional injury.  Your medical professional knows that you want to return to being back on the track, field, court, or pool as soon as possible.  It is important to be patient with yourself and honest both to yourself and your designated medical professional.  If you find yourself getting anxious, impatient, or any slew of emotions, take a deep breath.  Know that it is common to have these thoughts and feelings.  You are not alone, and we are here to help.  Be sure to express these concerns and emotions to your doctor as that is more than a significant part of the process of rehabilitation.

Breathing techniques and muscle activation have been proven to decrease anxiety and increase body awareness.^2,3  By accomplishing both of these tasks, you are able to better prepare your mind and body to properly attack your rehabilitation plan.  Here are a couple of breathing and muscle activation techniques that may help you to better focus.

2. Wall 90/90 Breathing:

Both of these instructional videos will give you the tips and tricks to mastering these breathing techniques on your own. 

Step 4: Monitor Progress & Adjust Accordingly:

Medical professionals may give you a generic timeline for your rehabilitation plan, but keep in mind that these are flexible time periods.  Rehabilitation plans do not progress as a single, linear, positive slope.  Some weeks you might increase in strength and speed exponentially, while other weeks, you might have to take a couple steps backward.  The important factor is that over time, you are generally progressing in the right direction.  This is why monitoring your rehabilitation process is vital to progression.  Some weeks you may feel discouraged by taking a step back, but if you are able to look at your overall progress from your starting point, it may offer a bit of comfort.  Monitoring progression additionally helps you and your medical professional make proper regressions and progressions according to your progress.

Proper exercise progression is a significant part of a research-based, comprehensive return to play protocol.  Measuring the workload of each exercise session with Perceived Rate of Exertion (RPE) can give you insight to injury risk.⁴ Technology also can come to our aid here. There are now apps, equipment, and other technological aids that will help you track your progress, like Plantiga. Simply monitoring workload measurements can help avoid common mistakes like increasing overall activity too fast. Exercise progression is much more complex than simply increasing resistance for weight training or speed for conditioning. For example, progressing from a traditional squat to a single leg squat is a progression of both stability and proprioception. 

So if a lower extremity injury happens to you despite all of your efforts. Remember: You are not alone, it happens to the best of us. Though it may seem like a long and difficult road ahead, use this blog series as a guide to help you better navigate your rehabilitation journey. 

Resources:

1. Lemoyne J, Poulin C, Richer N, Bussieres A. Analyzing injuries among university-level athletes: prevalence, patterns and risk factors. Journal of Canadian Chiropractic Association. 2017;61(2):88-95.
2. Decker J, Brown J, Lipscomb A, et al. Mindfulness, meditation, and breathing exercises: reduced anxiety for clients and self-care for social work interns. Social Work with Groups. 2019;42(4): 308-322.
3. Harvard Health Publishing. Relaxation techniques: breath focus. Harvard Medical School. July 2008. Accessed June 10, 2020. https://www.health.harvard.edu/newsletter_article/relaxation_techniques_breath_focus
4. Gabbett, Tim J., et al. “To Couple or Not to Couple? For Acute:Chronic Workload Ratios and Injury Risk, Does It Really Matter?” International Journal of Sports Medicine, vol. 40, no. 09, 2019, pp. 597–600., doi:10.1055/a-0955-5589.
5. Martimbianco, ALC, Gomes-da Silva, BN, de Carvalho, APV, Silva, V, Torloni, MR, and Peccin, MS. Effectiveness and safety of cryotherapy after arthroscopic anterior cruciate ligament reconstruction. A systematic review of the literature. Phys Ther Sport 15:261-268, 2014
6. van den Bekerom, MP, Struijs, PA, Blankevoort, L, Welling, L, van Dijk, CN, and Kerkhoffs, GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? J Athl Train 47:435-443, 2012