It's one of the more challenging judgement calls to make. When to return to sport or pre-injury activities. Unfortunately, like so many things in healthcare, it is not an exact science.
There are so many things that need to be considered; so many variables. Some of these include:
1. The structure or tissues injured;
2. The severity of your injury;
3. The type of activities that you might be returning to;
4. Your work, living and or playing environment;
5. Your physiological, physical, psychological and social circumstances.
It is estimated that 12-34% of hamstring injuries 1 and 3-49% of anterior cruciate ligament injuries 2 re-occur as a result of incomplete rehabilitation and premature return to sport and their pre-injury activities.
People often severely underestimate the time needed to be able to return to their pre-injury level of performance. Lack of knowledge, lack of experience and lack of perseverance, all play a role.
For example, when a group of runners and dancers were asked to estimate how long it would take for them to return to their activities, the runners replied four weeks and the dancers replied one week. The actual average return was 16 weeks for the runners and 50 weeks for the dancers 3.
For physiotherapists it is a challenge as well. Even if injured tissues should theoretically be healed, trying to determine when they are able to withstand the unpredictable stresses of life and sporting activities is difficult if not impossible.
The Science behind Recovery
The starting point for staging when you can return to pre-injury activities and sport is having an accurate knowledge of the theoretical time-frame that it takes for various tissues to heal. For example, your blood cells turnover every 120 days, your bone building cells every 3 months and your skin cells every 2-4 weeks 4.
The healing time will vary for different tissues and structures but is primarily determined by the blood supply to the area; your age; genes; your general health and nutritional status (e.g. abundance of protein, Vitamin C) and even medication (e.g. Anti-inflammatory medication such as Ibuprofen is known to delay healing).
Soft Tissue Healing as a Guide to Your Treatment
Following trauma and injury, your body will always go through the same phases of healing, the length of each varies depending on the type of tissue damaged, the severity of the injury and the intervening treatment. Healing can be divided into four broad phases which overlap considerably. These phases include:
1. The Bleeding Phase
2. The Inflammatory Phase
3. The Proliferation Phase
4. The Remodelling Phase
The Bleeding Phase
This phase occurs immediately following injury and can last anywhere from 6 to 24 hours depending on the type of tissue injured. In the bleeding phase substances are released which enable the adhesion of various cells. The complication of this phase is excessive bleeding and swelling. This excessive "clot" along with the damaged tissue needs to be removed, thus delaying the laying down of new tissue.
Excessive swelling also delays healing as excessive fluid pressure effectively prevents oxygen from being delivered to the injured cells, leading to increased cellular death and even more debris which has to be removed.
Consequently, it is critical that IMMEDIATELY following trauma or injury, treatment is begun to prevent excessive bleeding and swelling. Treatment such as compression, immobilization, lymphodema massage (massage that removes swelling) and unloading damaged tissue (e.g. crutches), if implemented in the first 24 hours by a competent physiotherapist, CAN SAVE YOU WEEKS IF NOT MONTHS OF TREATMENT.
The Inflammatory Phase
Likewise, the Inflammatory Phase is critical for healing. Inflammation has the classic characteristics of heat, redness, swelling, and pain (which is often constant, throbbing and can wake you at night).
Inflammation escalates rapidly a couple of hours following injury, increases to a maximal reaction at 1-3 days before gradually resolving over the next couple of weeks. Essentially during the Inflammatory Phase, the role of the body's immune system is to act like a demolition company, clearing the 'construction site' of debris and damaged tissue.
The complication of this phase, is that the inflammatory process gets out of control leading to an acidic environment, excessive protein breakdown and further cellular death. Consequently, treatment should include all the same modalities as in the Bleeding Phase with more emphasis on cold packs (15 minutes at least 6 times a day with emphasis on hourly cold packs at the end of the day), compression as well as optimal loading reduce swelling and decrease the activity of the inflammatory cells.
The Proliferation Phase
The Proliferation Phase involves the formation of repair material, which in the case of musculoskeletal injuries is mostly scar (collagen) material. At about day 5, the collagen is weak and easily broken with any chemical and physical stress. From day 6 to day 14, this scar tissue gradually becomes more durable to the point that the fibres have knitted and the defect has been bridged.
Consequently, treatment must be geared towards increasing and optimizing the activity of the cells laying down the repair. Warmth and electromagnetic stimulation (which increases cellular activity) along with hands on techniques and easy pain-free movements that optimizes tissue tension to enhance the repair.
The proliferation phase peaks at about 2-3 weeks, (less time for more vascular tissues) before winding down over the next 4-6 months.
The Remodeling Phase
The Remodeling Phase results in a quality, organized, functional scar that can behave like the parent tissue that it replacing. New evidence indicates that the Remodeling Phase begins as early as the first week. Initially, collagen fibres are laid down randomly. However, with the expert application of specific tension, these fibres become aligned along the lines of force.
Collagen molecules also have an electric charge and stress on collagen fibres produces a piezo-electric effect which may also help to re-orientate fibres.
Whilst it is unclear however how much tension is necessary or optimal, it seems that working to the point of discomfort but not into pain, may be a good guide as to what might be the most optimal tension for ideal adaptation.
From this point, gradual, controlled, progressive, specific loading has been found to accelerate early return to sport4. For optimal rehabilitation, this specific loading must be integrated into graduated functional strengthening, beginning with low level, safe, static and progressing to more physically demanding, dynamic, reflexive sport or functional specific activities.
These dynamic, reflexive, functional or sport specific activities can then become the tests which help to determine if you are ready to return to sport or your pre-injury activities.
Special Tests for Return to Pre-Injury Activity
For Shoulder Injuries - Throw and Catch
The throw and catch test consists of the throwing of varying weighted balls at different speeds and angles and durations until the action replicates as best as possible the intensity of the sport.
For all leg injuries - Balance standing on injured leg to progressing to hopping and then to running
These tests involve being able to maintain alignment of your hip bone, middle of your knee cap and 2nd toe with progressively more demanding, dynamic activities.
This alignment is consistent with ideal biomechanical forces being placed on our body tissues and structures and requires adequate core and leg muscle strength and control as well as sufficient hip, knee and ankle mobility.
All of these activities can be progressed in various ways for example by increasing the instability of the surface (e.g. duradiscs), increasing the depth of squat; height of the step as well as the distance, angle and speed of hopping and running.
Other special tests include:
1. Single leg hop
2. 6 Metre timed loop
3. Triple hop for distance
4. Cross over hops for distance
5. Running Drills
The Importance of Ongoing Rehab
Even once you have returned to pre-injury activities, you need to continue with an ongoing conditioning exercise program to ensure that your body is able to cope with the daily demands that you place upon it.
This conditioning exercise program must consist of strengthening exercises for the injured area and associated areas as well as balance and core stability activities. This needs to be completed at least twice weekly for at least four weeks following return to full activities.
A Final Word
There is no doubt that most people have large misconceptions about when they think that they are better and able to return to their full pre-injury activities. Understanding the process and timeline for healing is a starting point for staging the healing of tissues. This however must be supplemented by specific, injury related, objective testing and compared with the non-injured side and valid data.
Finally, it is important that you stay positive and remain engaged and connected with others and that you celebrate the milestones on your journey back to full health.
If you are injured or if you know of someone else who has a physical injury, seek or encourage them to seek treatment as soon as possible. It may just save you weeks if not months of pain, frustration and isolation.
If you are injured or in pain and want to get back to doing the things that you love to do, please call Bodywise Health on 1 300 BODYWISE (263 994) for a complimentary*, no obligation assessment and Recovery Action Plan from one of our expert physiotherapists.
We look forward to helping you get your life back.
Until next time, Stay Bodywise,
* Rebates are available through your private insurance extras cover;
* For complex or chronic conditions, you may qualify for the EPC (Enhanced Primary Care Program) allowing you to receive 5 allied health services each calendar year with a referral from your GP. For more information, please call Bodywise Health now on 1 300 BODYWISE (263 994).
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