Sports injuries: How to support the re-entry of your clients
After a sports injury timing the re-start to training is of paramount importance. “Not too much too early and not too little for too long,” agree Dr. Philipp Appelmann, orthopaedist, sports physician and team physician for German premier league club FSV Mainz 05, and Simon Roth, physiotherapist and EMG specialist working for inter alia Mainz 05. Furthermore, after-injury care should be of a functional nature and include multi-disciplinary exchange.
body LIFE:Which training is suitable for rehabilitation?
Dr. Philipp Appelmann: There are three different phases to the healing of ligament and muscle injuries, for example: during the acute or inflammation phase, which lasts up to four days, the metabolic processes mainly focus on repair. During the proliferation phase – from day 5 to 21 – there is non-directional tissue growth, which can be controlled by such physiotherapy technologies as mobilisation and stretching provided the patient does not experience pain. Muscles are accustomed to performing their functional tasks again later. The third phase is the so-called re-modelling phase lasting from day 21 to one year. Here the tissue recovers again. The right choice and dose of therapeutical stimuli applied to the tissue are key here. To this end a physician should draw up a personalised therapy plan while a physiotherapist takes charge of the implementation. As functions are increasingly regained, therapists can also transfer to personal exercises and/or exercises overseen by fitness trainers. For the duration of the whole rehabilitation process close communication between physicians, physiotherapists, athletics or fitness trainers and patients is decisive in order to avoid delayed healing or compensation mechanisms.
Are there new practical approaches for the most effective training after injuries?
Appelmann: There is a plethora of studies dealing with different training methods. Over the past few years there has been an increasing trend towards treating injuries functionally at an early stage. In the ideal case – depending on the type of injury – a mobilisation-stable or load-stable situation is created so that patients can start exercising again right away. In future, such technology areas as electromyography, thermography and Virtual Reality will be of interest. It is key to work out training protocols specifically geared to the injured individuals. These should be oriented towards their type of sports, age, activity level and co-morbidities. From the medical viewpoint the task is to find operating and treatment methods that optimally support the healing process and permit functional movement as early as possible.
Roth: This is precisely the important approach: performing functional movements again at an early stage. In the case of a bone fracture, the surrounding muscles and joints can be exercised despite the injury. And the role of nerves should not be underestimated either; neglecting their exercise can entail pain and coordination problems. In this context, proprioception, i.e. the feedback of receptors within the context of targeted muscle stimulation is particularly important. The close coordination between doctors or surgeons, therapists and trainers is indispensable to efficient aftercare.
When is it advisable to take a break from sports and how long should this break be?
Appelmann: If the symptoms are caused by an overload it is important to adapt or reduce training intensity and/or modify the training. Short-term breaks from exercise can make sense depending on the symptoms in order to put patients in a pain-free and/or low-pain state. In the event of acute injuries or after surgery the focus in the inflammation phase is first on decongestant measures – physical, drug-based etc. – rest and strain relief. This is followed by passive and active joint mobilisation. Excess strain on structures should also still be avoided during this phase. From the third week an adapted, progradient strain can be applied to the tissue. Once the full loading capacity has been achieved, the actual rehabilitation phase can start. Resuming sports activities in the event of major injuries such as cruciate ligament rupture only makes sense after performing specific functional tests and once approximately the same function of the affected extremity has been achieved.
Roth: Especially when specific sports injuries require operation, physicians and surgeons are often inclined to tell patients to suspend their training for weeks. However, those not doing anything for too long and not moving at all, run the risk of also losing their non-affected, healthy muscles. This is why the healthy structures should be particularly strengthened and stabilised from the day of the injury; this is essential for, and conducive to, rehabilitation. It’s about targeted strain progression in line with the principle: not too much too early and not too little for too long!
How important do you think fitness clubs and physiotherapy practices are for sports injury aftercare?
Appelmann: They are essential in order to avoid a cause-and-effect chain. What counts here, of course, is the trainer’s knowledge about the respective clinical pattern and the multi-disciplinary communication between all parties involved – i.e. physician, physiotherapist, trainer and patient.
Roth: I see fitness clubs at the very forefront when it comes to prevention. I view the trend towards health providers with a holistic training as a very promising development, both in terms of preventive and aftercare.
What should trainers know if they train an injured customer?
Appelmann: They should have a basic knowledge of the clinical pattern as well as strain and training control. In the event of injuries, consultation with the treating physician or physiotherapist always makes sense.
Simon Roth: There is already a lot going on in trainers’ continuous education when it comes to “sports injuries”. But I would also like to see a stronger focus on anatomy in the curriculum for young sports scientists. More profound knowledge in this field could substantially ease communication with physicians and physiotherapists later on. As long as the individual cooperation partners do not go beyond their areas of expertise, everybody will benefit from the interaction at the end of the day – not least the patient.
Is there still “room for improvement” in terms of cooperation to your mind?
Appelmann: Working as a doctor and/or surgeon at a hospital you unfortunately only have very little time and, hence, little contact with out-patient rehabilitation centres and fitness clubs. There is definitely lots of “room for improvement”. As an established orthopaedic physician with a focus on sports medicine and a team of physiotherapists and sports scientists, I will try to close precisely this gap in future.
Roth: At the doctor’s practice where I work, multi-disciplinary cooperation is key. For training control the treating physician must be consulted at regular intervals. The healing of an injury is always an individual process – at times faster, at others slower. Patients’ pain never subsides in a linear manner – there are always fluctuations; this is perfectly normal with sports injuries. Training and intensity then have to be adapted to these fluctuations. The interplay between physician and trainer and/or therapist is just as important as the patient’s education and involvement. To my mind this education component is often missed in daily practice, and that’s why there is still so much room for improvement in future.
The interview was published in the German special-interest magazine body LIFE.