Posts tagged return to sport
Importance Of Muscle Contraction Speed After Injury
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One of the milestones of return to sport or recreational activities after injury is the restoration of strength often measured as a percentage of the involved extremity. Measurements should be at least 90% of the uninvolved limb before returning to sport. Those who have returned from injury know the last 10% can be the hardest to regain emphasizing the importance of high intensity strength training during this return to sport phase of recovery. In addition to strength, another key to returning to sport involves rate of force development (RFD) or the ability of a muscle to produce a maximum contraction in the early phase of an rapid movement. For example, changing directions in response to a defender or righting yourself after losing your balance. Ideally Physical Therapy rehabilitation should facilitate the return of strength and RFD among injured patients.

Experts have argued the combination of strength and contraction speed is more specific to the demands of life, work, and play. Injured athletes and patients often demonstrate significant strength gains through the early and middle phases of recovery but RFD can lag reflecting significant impairments in muscle function. Authors have shown RFD is a reflection of both muscle capacity and activation speed. These measurements have both been shown to improve with short and long term moderate to heavy resistance (60-85% of 1 repetition max strength) training. Interestingly, RFD has not been shown to improve following a similar intensity of aerobic training. As expected higher rates of force development are found after high vs moderate intensity exercise programs focused on powerful multi joint movements. Prior research has shown these progressive exercise intensities and movements are safe in untrained populations and even among older adults.

In addition to performance, RFD may also play a role in tissue healing improving the capacity of injured tissues to tolerate life and sport demands. Often recurrent injuries in high functioning patients reflect a slow RFD instead of a loss of strength. For example, beneficial improvements in lower body tendon stiffness have been reported after both strength and RFD training. In addition, these training methods have also been shown to attenuate the decline in neuromuscular tissues and the loss of independence associated with aging.

Injured patients and athletes are encouraged to work with a local Physical Therapist to determine which exercise programs are most appropriate for their current injury. In additional, when appropriate, patients should work on both strength and power development in the final phases of their Physical Therapy rehabilitation programs.

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Risk Factors for Second ACL Injury with Return to Sport
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We have written previously about the high rates of subsequent knee injuries after an athlete returns to sport and activity after ACL surgery.  Interestingly, the most common site of injury is on the opposite knee indicating athlete's are using a compensatory balance and coordination strategy during play.  Current research is working on developing physical therapy rehabilitation programs to reduce the risk of injury upon return to sport.  Some research has shown delaying a return to sport longer than 9 months can reduce re injury rates by as much as 84%.  A current study has identified other risk factors which may place an athlete at risk for future knee injury after returning to sport following ACL reconstruction surgery.

An article in the Orthopedic Journal of Sports Medicine followed 163 patients who underwent ACL reconstruction to determine risk factors for a second ACL injury (Paterno et al. 2017).  The authors reported 1 in 5 of the returning athletes sustained a second ACL injury.  These athletes were then examined to determine which factors correlated with their injury.  The authors placed these athletes in either a high or low risk pool based on established factors for ACL injury.  High risk athletes for a second tear included one of two groups

1.  < 19 years old, limited and asymmetrical triple hop distance

2. <19 years old, female sex, high knee confidence, limited and asymmetrical triple hop distance

Athletes in either high risk group were 5 times more likely to injure their ACL again compared to a lower risk athlete.

Athletes are encouraged to complete all of their prescribed physical therapy visits up to 9 months as well as successfully pass return to sport testing before considering a return to sport.  

ACL Risk and Re Injury with Return to Sport
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We written many blog posts on ACL injuries as they continue to be a risk to our youth and amateur athletes in Boulder County.  Thankfully, evidence shows we are able to screen athletes at risk for future injury as well as reduce their risk through Physical Therapy strength, balance, and conditioning programs.  Another group at risk of future ACL injury are those athletes who return to sport after surgery and Physical Therapy.  A percentage of these athletes are at risk for re injuring their knee, but they are also at risk for injury to their uninvolved knee.

A recent study in The American Journal of Sports Medicine documented the incidence of second ACL injuries either to the involved or uninvolved knee after the athlete returned to sports (Schilaty et al. 2017).  The authors followed over 1000 athletes over a ten year period to determine the number of 2nd ACL tears.  They reported 66 (6%) of repeat ACL injuries with a surprising 67% occurring on the opposite side.  A few factors including graft type, reconstruction vs. conservative care, and an athlete's sex were correlated with this 2nd injury.  Allografts were associated with higher re injury risk compared to ACL autografts with patellar tendon autografts having the lowest risk of re injury.  The highest risk of re injury was found in females younger than 20 years old.  This study highlights the importance of completing a full course of post operative Physical Therapy after ACL surgery as well as delaying return to sport until 9-12 months.  

Return to Play after Achilles Tendon Rupture

Achilles tendon ruptures mainly occurs in middle aged adults, males > females, participating in sports with high levels of jumping or high force activity.  The repair and recovery time of these tendon ruptures is lengthy due to the post operative immobilization, weight bearing, and exercise restrictions.  Prior research has shown only 1 in 2 athletes returns to play at 1 year post op.  Among these athletes who do not return some may either choose not to return to their previous sport due to fear of reinjury while others have placed themselves at greater risk of injury due to not restoring their leg's strength, balance, agility, and coordination to pre injury levels.  

A recent article in the British Journal of Sports Medicine reviewed the available evidence to determine an athlete's ability to return to play after achilles tendon repair.  (Zellers et al. 2016).  The authors reviewed 108 studies of over 6500 patients and found on average 80% of athletes return to play at pre injury levels.  The average time to return to sport after a course of Physical Therapy was 6 months.

Athletes are encouraged to use Physical Therapy following an Achilles Tendon injury to accelerate their healing and improve their chances of recovery.  

Reducing ACL Reinjury Risk

Athletes often return to sports around 6-9 months after ACL reconstruction and Physical Therapy.  In a previous ACL post we described how important these Physical Therapy sessions are to an athlete's recovery.  Each session after surgery is designed to move the athlete closer to the all important return to play.  New research is showing how instrumental this path to recovery is to reduce the risk of ACL re injury.  

Grindem and colleagues studies 106 pivoting sports athletes who underwent ACL reconstruction and Physical Therapy.  The athletes were followed for 2 years to document their rehabilitation, functional performance, and finally return to play.  The authors reported athletes who returned to high level sports had 4 times the risk of re injury compared to lower and mid level sports participation.  Among all athletes, those who did not pass their functional testing before returning were 8 times more likely to re injure their ACL.   Importantly, this re injury rate was cut in half for each month the athlete stayed in rehabilitation and delayed their return to sport up until 9 months.  In short, having athletes who complete 9 months of Physical Therapy and pass their functional tests can reduce their reinjury risk by 84%.

Athletes are advised to work with a local Physical Therapist for 9 months to allow a safe return to competitive sports.  

Return to Professional Basketball after Surgery

“In life there are no guarantees” and this is certainly the case with return to sport after surgical procedures.  Unfortunately, the commonly held belief is surgical repairs of muscles, tendons, ligaments, etc. guarantees a return to sport at prior levels of play and competition.  The odds of returning to competitive levels of sport can be improved dramatically through pre and post operative Physical Therapy.   A new review article highlights the lower than expected odds of returning to high level basketball competition after orthopedic surgery.  

We assume professional athletes have a greater likelihood of returning to sports following surgery given their athletic gifts and high levels of resources directed at their care including money, time, and medical staffs.  A recent review article of close to 350 NBA basketball players was conducted to determine the likelihood of these athletes returning to high level play after surgery (Minhas et al. Am J Sp Med. 2016).  The return to sport ranged from 70% in achilles repairs to 98% after hand/wrist surgeries.  Across all procedures older (>30 years old) and heavier (BMI >27) athletes were 3 times less likely to return to sport.  In addition, those undergoing arthroscopic knee surgery or achilles tendon repairs suffered the greatest reduction in performance at both a 1 and 3 year follow up.    Athletes at greatest risk of decreased performance should work closely with a Physical Therapist to facilitate an optimal return to sport.