Active Rehabilitation

The final hurdle to a complete recovery

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Last week, we reviewed an often over-looked component to successful soft tissue injury rehabilitation; "Scar Tissue Removal" and discussed its' effectiveness in speeding up the recovery process for soft tissue injuries like muscle and tendon pulls, and ligament strains. To review last week's issue, click here.

If you were to follow the advice in last week's issue, your injury would have healed to about 80% of its' original capacity. You may even feel that your injury is fully recovered. Your treatment so far may have stopped the swelling and bleeding, it may have reduced the amount of scar tissue at the injury site and it may have even started to heal the soft tissues that were injured. But there is still one more important thing to do.

The last 20% can be the most crucial to your complete recovery. If you've ever suffered from a sporting injury in the past, you'll know how annoying it is to think you're recovered, and then out-of-the-blue, you're injured again and back to where you started from. It can be one of the most frustrating and heart-breaking cycles an athlete, or anyone else for that matter, can go through.

Active Rehabilitation
Most people refer to this phase of the recovery process as the active rehabilitation phase, because during this phase you will be responsible for the rehabilitation process. You will be doing the exercises and activities required to speed up your full recovery.

This phase of the injury rehabilitation process should only be implemented after the initial healing process has been completed. For more information, click here.

The aim of this phase of your rehabilitation will be to regain all the fitness components that were lost during the injury process. Regaining your flexibility, strength, power, muscular endurance, balance, and co-ordination will be the primary focus.

Without this phase of the rehabilitation, there is no hope of completely and permanently making a full recovery from your injury. A quote from a great book called "Sporting injuries" by Peter Dornan & Richard Dunn will help to reinforce the value of active rehabilitation.

"The injury symptoms will permanently disappear only after the patient has undergone a very specific exercise program, deliberately designed to stretch and strengthen and regain all parameters of fitness of the damaged structure or structures. Further, it is suggested that when a specific stretching program is followed, thus more permanently reorganizing the scar fibers and allowing the circulation to become normal, the painful symptoms will disappear permanently."

The first point to make clear is how important it is to keep active. Often, the advice from doctors and similar medical personnel will simply be; rest. This can be one of the worst things you can do. Without some form of activity the injured area will not receive the blood flow it requires for recovery. An active circulation will provide both the oxygen and nutrients needed for the injury to heal.

Any form of gentle activity not only promotes blood circulation, but it also activates the lymphatic system. The lymphatic system is vital in clearing the body of toxins and waste products that accumulate in the body following a serious injury. Activity is the only way to activate the lymphatic system.

A Word of Warning!
Never, Never, Never do any activity that hurts the injured area. Of course you may feel some discomfort, but never push yourself to the point where you're feeling pain. You've come a long way from first being injured; don't take a step backwards now. Be very careful with any activity you do. Pain is the warning sign; don't ignore it.

Now it's time to make that injured area strong again. The main areas you're going to be working on are your range of motion, stretching & strengthening, and co-ordination. Depending on your background, and what sport you're involved in, these elements should be your first priority. As you start to regain your strength, flexibility and co-ordination, you can then start to work on the more specific areas of your chosen sport. Let's start with range of motion.

1. Range of Motion
Regaining a full range of motion is the first priority in this phase of the rehabilitation process. A full range of motion is extremely important, as it lays the foundation for more intense and challenging exercises later in the active rehabilitation process.

As you work through the initial stages of recovery and your injury begins to heal, start to introduce some very gentle movements. First bending and straightening the injured are, then as you get more comfortable with this simple movement, start to incorporate some rotation exercises. Turn the injured area from side to side, and rotate clockwise and anti-clockwise.

When you feel comfortable with these range of motion exercises and can perform them relatively pain free, it's time to move onto the next phase of the active rehabilitation process.

2. Stretch and Strengthen
Now it's time to add some intensity to the range of motion exercises. The aim here is to gradually re-introduce some strength back into the injured muscles, ligaments and tendons.

When attempting to increase the strength of the injured area, be sure to approach this in a gradual, systematic way of lightly over-loading the muscles and tendons. Be careful not to over-do this type of training. Patience is required.

The use of machine weights can be very effective here, as they provide a certain amount of stability to the joints and muscles as you perform your rehabilitation exercises.

Another effective and relatively safe way to start is to begin with isometric exercises. These are exercise where the injured area does not move, yet force is applied and the muscles and tendons are contracted.

For example: imagine sitting in a chair while facing a wall and then placing the ball of your foot against the wall. In this position you can push against the wall with your foot and at the same time keep your ankle joint from moving. The muscles contract but the ankle joint does not move. This is an isometric exercise.

It's also important at this stage to introduce some gentle stretching exercise. These will help to further increase your range of motion and prepare your injury for more strenuous activity to come.

Remember, while working on increasing the flexibility of the injured area, it's also important to increase the flexibility of the muscle groups around the injured area. In the example above, these would include the calf muscles, and the anterior muscles of your shin.

Stretching is one of the most under-utilized techniques for improving athletic performance, preventing sports injury and properly rehabilitating sprain and strain injury. Don't make the mistake of thinking that something as simple as stretching won't be effective.

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3. Balance and Proprioception
This phase of the rehabilitation process is often overlooked and is one of the main reasons why old injuries keep re-occurring. When a soft tissue injury occurs, there is always a certain amount of damage to the nerves around the injured area. This, of course, leads to a lack of control of the muscles and tendons, and can also affect the stability of joint structures.

Without this information the muscles, tendons and ligaments are constantly second-guessing the position of the joints and limbs around the injured area. This lack of awareness about the position of the limbs (Proprioception) can lead to a re-occurrence of the same injury long after you thought it had completely healed.

Once you feel some strength returning to the injured area it's time to incorporate some balancing drills and exercises. Balancing exercises are important to help re-train the damaged nerves around injured area. Start with simple balancing exercises like walking along a straight line, or balancing on a beam. Progress to one-leg exercises like balancing on one foot, and then try the same exercises with your eyes closed.

When you're comfortable with the above activities, try some of the more advanced exercises like wobble or rocker boards, Swiss balls, stability cushions and foam rollers.

4. Final Preparation
This last part of the rehabilitation process will aim to return your injury to a pre-injury state. By the end of this process the injured area should be as strong, if not stronger, than it was before the injury occurred.

This is the time to incorporate some dynamic or explosive exercises to really strengthen up the injured area and improve your proprioception. Start by working through all the exercises you did above, but with more intensity. For example, if you were using light isometric exercises to help strengthen your Achilles and calf muscles, start to apply more force, or start to use some weighted exercises.

From here, gradually incorporate some more intense exercises. Exercises that relate specifically to your chosen sport are a good place to start. Things like skill drills and training exercises are a great way to gauge your fitness level and the strength of the injured area.

To put the finishing touches on your recovery, I always like to do a few plyometric drills. Plyometric exercises are explosive exercises that both lengthen and contract a muscle at the same time. These are called eccentric muscle contractions and involve activities like jumping, hoping, skipping and bounding.

These activities are quite intense, so remember to always start off easy and gradually apply more and more force. Don't get too excited and over-do-it, you've come too far to do something silly and re-injure yourself.

Conclusion
These last two issues of The Stretching & Sports Injury Newsletter have been a very comprehensive account of the correct treatment for most soft tissue sports injuries. If followed correctly, you will find that most minor injuries, like mild sprains and strains, will heal within a day or two. While most major soft tissue injuries will heal within a week or two.

If you enjoyed this issue of The Stretching & Sports Injury Report, please feel free to forward it to others, make it available for download from your site or post it on forums for others to read. Please make sure the following paragraph and URL are included.

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Article by Brad Walker. Brad is a leading stretching and
sports injury consultant with nearly 20 years experience
in the health and fitness industry. For more articles on
stretching, flexibility and sports injury, please visit
The Stretching Institute.
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