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Participants:

Tom Koto, A.T.C. Idaho Sports Medicine Institute Boise, ID	Yvonne Satterwhite, M.D., C.S.C.S. Kentucky Sports Medicine Clinic, PSC Lexington, KY
Bill Prentice, Ph.D., P.T., A.T.C. University of North Carolina Chapel Hill, NC	Delphis Richardson, M.D. Mesa Pediatrics Professional Assoc. Mesa, AZ

KEY POINTS

1. In general, a sports injury follow-up includes first aid, evaluation and diagnosis, administration of treatment/therapy as a part of recovery, re-evaluation for function, and return to play.
2. Modalities that influence blood flow into the injured site, limb mobilization, and the degree of swelling help control the degree of damage and assist in the recovery process. Regardless, time and patience are the most important factors.
3. Heat injuries are the most easily prevented injury if attention is paid to the environmental conditions, the players' acclimatization and hydration levels, and if the coaches are willing to adjust training regimens during hot weather.
4. In addition to working on injury rehabilitation, the athlete must also maintain cardiovascular conditioning, muscular strength and power, and coordination so that when cleared for return, the athlete’s lack of fitness doesn't jeopardize health or performance.

INTRODUCTION

Participation in any sport presents some degree of injury risk. If an athlete is sidelined with an injury, it is critical that the athlete adheres to proper therapy and treatment to help assure a successful and timely return to training and competition. All the athlete may need is a little patience while the guidelines described here by our experts are administered.

1. What is the general sequence of events that an athlete must experience before returning to the field after an injury?

Satterwhite: After an athlete sustains an injury, he or she must progress through two general stages: the psychological and physical stages of healing. Psychologically, these include shock, realization, mourning, acknowledgment, and coping, followed by the setting of specific minor and major goals for return to sport. Physically, an athlete must progress through the stages of initial pain, swelling, and loss of the previous level of control of the injured limb or body part. Once healing has occurred through surgical/nonsurgical means, the athlete faces the challenge of reestablishing strength, balance, coordination, and confidence to a minimum level that is deemed safe and appropriate for return to competition.

Koto: The initial procedures consist of the athlete being evaluated and diagnosed by an appropriate medical professional, such as a certified athletic trainer or physical therapist, followed by a licensed physician. The athlete may then be referred to a specialist, if necessary, or treated by the school/club athletic medical staff. Once the symptoms resolve or the medical staff feels it is safe to return to activity, the athlete must then gradually return to full capacity. The individual must be able to demonstrate, to the satisfaction of the medical staff, that he/she is able to participate without the potential of further damage to the injured area. The medical staff may require the athlete to wear protective padding, bracing, or other modifications to protect the injured area.

Richardson: There are also several elements that the athlete and his support "team" must accept during the recovery process, including sufficient time for reasonable partial healing of the injury. The time interval is not precise, but general guidelines are available for some injuries. For fractures, healing progresses slowly no matter what one does; however, one can protect a fracture sufficiently with bracing or soft cast once it is nearly healed. Also, there must be a program in place to allow continuing rehabilitation to assure that the athlete achieves full strength and performance parameters. Finally, coaches and parents of the injured athlete must be kept informed of the athlete's progress and the risks involved with return to play. As Mr. Koto mentioned, the athlete must be able to demonstrate that he or she has regained functionality at the injured site.

Prentice: To continue on that point, return to activity is dictated through both objective and subjective evaluations. Objective evaluation techniques have made use primarily of isokinetic testing and arthrometry. The advantage of testing with an isokinetic device that indicates levels of strength and an arthrometer that measures joint laxity is that the sports therapist is provided with quantifiable data about the athlete's progress in the rehabilitation program. The question has been raised whether the ability to generate torque at a fixed speed is indicative of the athlete's capability of returning to an activity in which success more often depends on the ability to generate force at a high velocity. For the athlete, it may be more practical to base criteria for return on functional capabilities as indicated by performance on specific functional tests that are more closely related to the demands of a particular sport. Once research clarifies the validity of these evaluation tests, such testing will be a useful and valuable tool for determining readiness to return to full activity. That said, the team physician should be ultimately responsible for deciding that the athlete is ready to return to practice and/or competition. That decision should be based on collective input from the therapist, athletic trainer, the coach, and the athlete.

2. How do the modalities used in therapy speed up the recovery process? What new therapies truly assist in the injury recovery process?

Richardson: Therapeutic modalities denote mechanical, electrical, and thermal interventions used by athletic trainers and physical therapists during injury rehabilitation. These modalities may speed return to play by controlling or reducing swelling, reducing pain, and maintaining strength. Standard therapies such as ultrasound, electrical stimulation (E-Stim or transdermal electrical nerve stimulation), parafin baths, and hot/cold whirlpool have a proven track record for lessening the time lost to injury. Among the novel physical therapies, acupuncture has been shown to produce some positive effects. Nonsteroidal anti-inflammatory drugs (NSAIDS) have been shown to shorten recovery time, but it is now recommended that their use is delayed until after 72 hours. If used too early, NSAIDS may block platelet aggregation and accentuate the initial swelling at the injury. Use 72 hours or more after the injury can reduce pain and provide anti-inflammatory benefits. Also, oral NSAIDs can cause side effects such as gastrointestinal distress. The use of anti-inflammatory steroids (glucocorticoids) such as prednisone and decadron in an acute injury is common, but not yet well studied to prove effectiveness. Some injured athletes have tried anabolic steroids on their are own without medical supervision. They should know that anabolic steroids are illegal in most states and banned by all national and international sports governing bodies.

Satterwhite: Besides being illegal, anabolic steroids serve no function to the injured athlete. Although anabolic steroids have been shown to contribute to an increase in muscle mass, the integrity and healthy function of a musculotendinous unit is dependent on muscle strength not exceeding tendon strength. In the treatment of a tendon injury in particular, the use of anabolic steroids would be severely detrimental.

The physical therapy modalities identified by Dr. Richardson can, when used in the correct combination, decrease pain, reduce swelling, and accelerate recovery of injured joints. Swelling is particularly worrisome in an injury because it contributes to a spinal cord reflex that inhibits muscle function (i.e., joint motion, shock absorption, and balance). I do not recommend oral corticosteroids under most circumstances due to a potential side effect of avascular necrosis (death of bone along the joint surfaces). Regarding the diet, athletes should consume a healthy balanced diet such that appropriate nutrients will be available during the recovery process. Nutritional supplements are not necessary unless an athlete has a specific deficiency. Studies are pending on the effect of creatine in influencing recovery, particularly when muscle atrophy is present.

Koto: Some modalities are of benefit by influencing blood flow to the injured area and modifying the pain response. At times, too much emphasis may be placed on such passive therapy when simply time and specific exercises/rehabilitation (active therapy) are the keys to recovery. Sports medical professionals often feel obligated to treat athletes multiple times a day with an electro-modality. Both the athletic medical staff and athlete often feel the need to do as much as possible, during that "down time." The use of electro-modalities then helps make everyone feel they are doing something to progress towards recovery.

Regarding use of medications, athletes should be warned that mixing off-the-shelf anti-inflammatory medications with prescription medications will not speed recovery. In fact, such mixes have lead to irreversible organ damage. A licensed medical doctor should monitor the athletes, and appropriate routine blood tests should be performed if treatments with medication are chronic.

Recent applications of non-traditional therapies such as magnets have infiltrated the sports medicine community. This particular example is very similar to the passive therapies mentioned earlier. It has allure because of putative healing powers, but I have not seen solid research in this area, and little from any other researchers besides from the companies who sell the products. Still, the mind and body have incredible healing powers. The question remains whether therapy such as this only treats the symptoms and not the cause of the injury. Upon return to activity, the athlete may continue to stress the injury in the same manner that initially caused the problem. This is especially true in overuse injuries.

3. What approach do you suggest for preventing heat injuries?

Prentice: One of the keys to prevention is having an awareness of the conditions that will cause such an injury. This includes knowing the environmental conditions, the temperature, humidity, and radiant heat in the playing arena; the medical history of the athletes and whether prior illness or fainting has occurred in the heat; whether athletes are well hydrated and physically adapted for heat stress; whether dress and equipment that can impede body heat dissipation are appropriately modified; and the intensity and duration of exercise planned for the practice, both of which can influence the extent of sweat loss. Return to play after a heat injury depends on several things including the type of injury, be it heat cramps, heat exhaustion or heat stroke. For those athletes who suffer heat injury, a normal body temperature and normal body weight are signs that the athlete is on the road to recovery.

Richardson: Heat injury prevention has been promoted for decades and there are well-established parameters relating to environmental risk factors and fluid replacement. To know the environmental conditions, I encourage high schools to use the sling psychrometer. I also encourage daily weigh-ins and weigh-outs at every training session of each sport, and scheduled fluid breaks every 20 minutes as well as free access to fluid at all times. Fluid must never be withheld by the coach or athletic trainer. Water alone is no longer felt to be the best rehydration even for less than one hour of activity. There is convincing evidence that electrolytes and carbohydrates are necessary for energy and fluid replacement (rehydration) as early as 15-20 minutes after the onset of activity.

If a heat injury occurs, an athlete must not return to play with heat illness until his cognitive functions are normal, heart rate is normal, and further heat can be dissipated (dry clothes and the athlete is able to sweat.) Therefore, immediate or rapid return is limited to the two minor heat illnesses, specifically heat syncope and heat cramps. Heat exhaustion usually requires a few hours for recovery. Heat stroke is a serious illness that requires hospitalization.

Satterwhite: The adaptation or heat acclimatization mentioned by Dr. Prentice is essential prior to an athlete's full-go participation in hot environment to which they are not accustomed. During activity in the heat, the athletes should wear light colored clothing, use visors, and have access to shady or cool areas.

Coaches and athletic trainers should enforce a hydration schedule with guidelines posted in the gym and locker room to serve as a reminder of the amount of fluid to be consumed daily, pre-practice/game, during practice/game, and after practice/game. Ideally, each athlete should have his own sports bottle that he or she fills and drinks completely prior to leaving after a practice session and at least 30 minutes prior to the start of the next practice session, in addition to several times in between. Research has shown that sports drinks are better than water for rehydration. If sports drinks are not available, then certainly water should be utilized and any products containing caffeine, alcohol, or concentrated fruit juices should be avoided. Athletes should not take salt tablets. Lightly salting their foods at meals, eating a nutritionally balanced diet, and consuming sports drinks and water are the best strategies.

Coaches and athletes need to be educated on the early signs of heat illness. There should be a heightened awareness in any athlete who has had a recent cold, viral illness, sore throat, gastric illness, or limited access to fluids. After major heat exhaustion occurs in an athlete, return to play is allowed when the athlete's weight has normalized and they are asymptomatic, usually within 48 hours. If the athlete has a cold or flu, then he or she should not be allowed to return to a competition until that illness has resolved. Upon return to sport, an athlete must be allowed an opportunity for re-acclimatization, frequent beverage breaks, and access to shady or cool areas.

4. What do you advise for injured athletes to maintain their readiness to play while they are sidelined with rehabilitation?

Prentice: Maintaining cardiorespiratory fitness is perhaps the single most neglected component of a rehabilitation program. An athlete spends a considerable amount of time preparing the cardiorespiratory system to be able to handle the increased demands during a competitive season. When injury occurs and the athlete is forced to miss training time, levels of cardiorespiratory fitness may decrease rapidly. Thus the sports therapist must design or substitute alternative activities that allow the athlete to maintain existing levels of cardiorespiratory fitness as early as possible in the rehabilitation period.

Depending on the nature of the injury, there are a number of activities that can help the athlete maintain fitness levels. When there is a lower-extremity injury, non-weight bearing activities should be incorporated. Pool activities provide an excellent means for injury rehabilitation. Cycling also can positively stress the cardiorespiratory system.

Satterwhite: Besides maintaining cardiovascular fitness, one should not forget about strength, balance, and hand-eye coordination when sidelined with rehabilitation. Creativity and cross-training are keys to success. Swimmers with upper extremity injuries can use a stationary bike, Stairmaster, or similar equipment. They can work on trunk balance using a large medicine ball in addition to performing their daily upper extremity rehabilitative exercises. Runners with a lower extremity injury can utilize a UBE (upper body ergometer that resembles a bicycle for your arms). If the lower extremity injuries are not severe, an elliptical transporter or stationary bike can be utilized in addition to performing the appropriate lower extremity rehabilitative exercises. These devices also provide cardiovascular conditioning for athletes with upper body injuries. For hand-eye coordination, anything from putting in golf to throwing darts or shooting pool can be useful in the continuous stimulation of these neuromuscular pathways. In general, guidelines for the return of sport can be outlined by a physician, physical therapist, and athletic trainer working in conjunct. Guidelines should be sports-specific, i.e., runners should be on a walk/run program, baseball players should be on a light toss, short-distance, limited-number-of-throws program and advance as tolerated and as indicated by performance and any symptoms. It is important when an athlete has advanced to a pre-competition phase of rehabilitation, that he or she not forget to perform their basic rehabilitation program on a maintenance basis as well.

Koto: My advice is to rest the injured body part and work the rest of the body. Many times athletes use injuries to take a "time out." Our policy is to work the athlete during the recovery stage, especially if it is during the season, but protect the injured body. This includes hydro-therapies, such as swimming, water aerobics, non-impact (gliding) exercises for lower extremity injuries (e.g. stationary bikes, nordic track, elliptical trainers upper body ergometers, etc.).

As far as return to activities, it depends on the phase of the season and the type of sport (anaerobic vs. aerobic). If an athlete is in-season, the injury is of short duration, and the athlete is training daily, there usually is little training loss, and the athlete may return with very little loss of conditioning. However, if the injury or surgery is in the off-season, the athlete may be significantly deconditioned, and may require gradual return to activity.

5. What can be done to minimize injury risks in the first place, and what can the rehabilitated athlete do to prevent a reinjury?

Koto: The best advise is to follow directions of the health-care professionals charged with a safe return to activity. Continue to rehabilitate the injured area, even though the symptoms may seem to have resolved, especially if it is during the season. Wear protective padding or braces if prescribed. Continue to communicate with the medical staff as to the status of the injury. There are specific actions to be taken, too. Proper technique in an activity plays an important role in preventing injuries. Proper stopping and cutting techniques are critical in preventing injuries. Making certain the playing and practice fields are free of equipment or objects that may cause injury. It is the role of the athletic departments, coaching staff, medical staff, and the athletes to make the athletic arena safe for play. Adequate hydration before, during, and after activities will help in preventing heat-related injuries. Probably the best thing to remember in preventing injuries is to be prepared for the activity. Preparation comes long before the season, not the week or two prior to the beginning of training. Our motto is, "you get fit to play sports, you don't play sports to get fit".

Satterwhite: For an athlete to stay healthy and not sustain a reinjury, he or she must first try to identify how or why the injury occurred in the first place. If the injury occurred because the athlete was not adequately conditioned, then attention should be paid year-round to conditioning. If an injury occurred because an athlete did not perform the activity correctly from a biomechanical standpoint, then that athlete must work with a coach to improve and master the technique of the sport. If an athlete has musculoskeletal problems such as lower extremity malalignment or congenital abnormalities that were not appropriately supported, i.e. through the use of braces or orthotics, then the athlete should ensure that they maintain the use of and good condition of those devices. If an injury can't be explained and seems to have happened as a quirk of fate, I recommend that the athlete incorporate into his or her weekly routine a maintenance rehabilitation program in which they perform three days per week those exercises and activities that aided them in recovering and returning to their sport. To minimize the occurrence of injuries, coaches and parents need to ensure that an athlete has proper-fitting equipment for participation in their sport, a safe playing field to play on, and appropriate precompetition instruction in the techniques of the sport. One must keep in mind that very few of us have the physical makeup to participate in all sports. It is important that coaches and parents identify the strengths and weaknesses in their athletes and help guide them into sports in which these athletes can perform maximally and gain the most enjoyment.

Richardson: Once an injury has occurred and the athlete is back to play, reinjury is less likely if you have included successful performance of sports-specific functional testing. Bracing and taping can offer protection during participation. On-going rehabilitation using hydrotherapy and electrical modalities is also quite useful to prevent recurrence of swelling and soreness and to maintain muscle tone. The best advice for staying healthy and preventing injury in the first place is to stay well conditioned and to play with controlled intensity. This includes consistently having good nutrition, solid emotional balance, endurance, and neuromuscular function and strength prior to and during the playing season.

Prentice: To compete successfully at a high level, the athlete must be fit. An athlete who is not fit is more likely to sustain an injury. Both coaches and athletic trainers recognize that improper conditioning is one of the major causes of sports injuries. Thus coaches and athletic trainers should work cooperatively to supervise training and conditioning programs that minimize the possibility of injury and maximize performance. It takes time and careful preparation to bring an athlete into competition at a level of fitness that will preclude early-season injury. Truly being fit really means choosing a healthy lifestyle. Living healthy means that the athlete is able to express emotions effectively; have good relations with others; be concerned about decision-making abilities; and pay some attention to ethics, values, and spirituality. Paying attention to aspects of a healthy style of living such as physical fitness, adequate nutrition, stress management, control of alcohol consumption and avoidance of drug abuse, smoking cessation, and weight control management can all contribute to preventing injury.

SUGGESTED READINGS

American College of Sports Medicine (1996). PositionStand on Exercise & Fluid Replacement. Med. Sci. Sports Exerc. 28:i-vii.

American College of Sports Medicine (1996). Position Stand on Heat and cold illnesses during distance running. Med. Sci. Sports Exerc. 28:i-x ii.

Arnheim, D. and W. Prentice. Principles of Athletic Training. Dubuque, IA. WCB/McGraw-Hill, 1997.

Borsa, P. A. and C.L. Liggett (1998). Flexible magnets are not effective in decreasing pain perception and recovery time after muscle microinjury. Journal of Athletic Training. 33 (2): 150-155.

Bracker, M. Environmental & Thermal Injury. Clinics In Sports Medicine. 11:2, April, 1992, p 419-436

Murray, R. Fluid replacement: The American College of Sports Medicine Stand. Sports Science Exchange. 9:4, 1996.

Prentice, W. Rehabilitation Techniques in Sports Medicine. Dubuque, IA. WCB/McGraw-Hill, in press 1999.

Starkey C. Therapeutic Modalities for Athletic Trainers. Philadelphia. F.A. Davis Company, 1996.

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Pain status		Has pain disappeared or is the athlete able to play within his/her own levels of pain tolerance?
Swelling		Is there still a chance that swelling may be exacerbated by return to activity?
Physiological Healing Constraints		Has rehabilitation progressed to the later stages of the healing process?
Range of Motion (ROM)		Is ROM adequate to allow the athlete to perform both effectively and with minimized risk of re-injury?
Functional Testing		Does performance on appropriate functional tests indicate that the extent of recovery is sufficient to allow successful performance? This includes: Strength - Is power strength, or muscular endurance great enough to protect the injured structure from re-injury? Neuromuscular control/Proprioception/Kinesthesia - Has the athlete "relearned" how to use the injured body part? Cardiorespiratory fitness - Has the athlete been able to maintain aerobic fitness at or near the level necessary for competition? Sport-Specific demands - Are the demands of the sport or a specific position such that the athlete will be at a high risk of re-injury?
Prophylactic Strapping, Bracing, Padding		Are any additional supports necessary in order for an injured athlete to return to activity?
Responsibility of the Athlete		Is the athlete capable of listening to his/her body and recognizing a potential re-injury situation?
Education and Preventive Maintenance Program		Does the athlete understand the importance of continuing to engage in conditioning exercises that will reduce the chances of re-injury?
Predisposition to Injure		Is this athlete prone to re-injury or a new injury when they are not 100%?
Psychological Factors		Is the athlete capable of returning to activity and competing at a high level without fear of re-injury?