RESOURCES: 7 Stage of Injury Rehabilitation

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CLASSIFICATION SCHEME:

A 7 stage Injury Rehabilitation classification scheme is set out below which will allow both medical and coaching staff to plan for the return of players from injury to training and playing. At each stage the player has defined goals and the strategies used to achieve these goals are set out. While there is structure to this scheme, the dynamic state of sport and the individual characteristics of the player is acknowledged. Consequently, there may be different approaches to the treatment of the same injury due to individual needs and demands.

STAGE 1: EARLY INFLAMMATION

During the first 72 hours of an acute injury the player may be classified as stage 1.There will be pain, swelling and a redness or bruising surrounding the injury. There will be decreased collagen synthesis and the body will enter a state of phagocytosis where waste and damaged elements caused by the injury are removed. The body will also produce a nerve reaction which will cause players to be extra sensitive to pain. Certain events may conspire to increase the time spent in this phase, but generally speaking the removal of waste should be underway 2-3 days following the injury. Typically there will be no weight bearing on the injured site at this time, and passive treatment and ice will be a main source of treatment. No training or the injured site is permitted but the uninjured body must maintain conditioning.

STAGE 2: LATE INFLAMMATION

Once the removal of waste products has begun and swelling and pain sensitivity have decreased the player may be classified as level 2. While the repair of the site may not yet have begun the removal of waste products is well underway allowing increased movement in the injured site. Contrast baths may now be appropriate, as the blood flow will no longer be bringing inflammatory substances to the injury. This stage will normally be completed by 7 days following the injury. Some low-level stimulation exercises of the injured site may be permitted.

STAGE 3: EARLY REPAIR

The repair phases will typically last from 2 days to 2 months following most injuries. They are characterised by the laying down of collagen fibres (scaffolding for the injury site to use when healing) and the reduction in the number of inflammatory cells. Early repair will see the athlete weight bearing on the injury although strapping and/or bracing may be appropriate still. Although the ‘scar’ tissue is disorganised, it needs to be encouraged to lie correctly for force production purposes. Therefore, activity needs to be increased in this phase to permit this. Proprioception exercises for the joints involved with the injury may be increased.

STAGE 4: LATE REPAIR

Once the level of workload has been stepped up and the body is responding well, the stress on the injured site can be increased. Although still needing some protection, it is vital that stimulation is increased both in strengthening, power development, flexibility, mobility, speed, proprioception and tolerance of workload. All scar tissue should be formed and little of no inflammation should be present. Most training methods should be tolerated now with possible limited movement on some. The player will train at an individual level.

STAGE 5: EARLY REMODELLING

In the remodelling stages, the optimisation of the injured tissue’s function is the main goal. While most activities can be performed pain free, there may not be completed range of motion or force production. The athlete must not do “too much too soon” otherwise they will risk re-injuring the site. Sport specific exercises can be incorporated into the rehab programme (ball work, small training games) to identify the readiness for stage 6. Coaching staff can become involved in testing the player on sports specific exercises and techniques. Treatments may now be few if any with the majority of the work being in the training room and on the pitches. Bracing and strapping of the area may still be needed. Individual training is still used working one-to-one or with small groups of 3-4.

STAGE 6: LATE REMODELLING

The late remodelling stage is the appropriate time for the player to become involved in training exercises on the football side. They may still use bracing although opportunities should be taken to develop non-protected activity. The training load should now be 95-100% incorporating all movements and activities (including tackling, jumping, running, invasion skills and ball work). Group training is now permitted on a gradual scale with reconditioning far more to the fore than rehabilitation..

STAGE 7: FAMILIARISATION

Once the player has entered stage 7, they are ready to participate in matches, beginning with short duration performances, building to full matches. Conditioning should now be as close to pre-injured levels which will of course involve supplemental training.

POST RETURN REHABILITATION

To decrease the number of recurrent injuries and also to increase the work ethic towards staying fit, it is proposed that all players complete a period of rehabilitation after they have returned to playing. It is suggested that, for example, a player who has spent 5 weeks out with a hamstring injury, should attend rehabilitation for 5 weeks after they have retuned to full training and playing. This would have the dual effect of trying to decrease the time spent out with injury (our time) and decreasing the time spent in post return rehab (their time). Therefore for every full week missed due to injury, the player completes the same number of full weeks in post return rehab.

STAFF PARTICIPATION IN REHABILITATION

To maximise the resources of all staff, there needs to be dialogue and cooperation between all of the interested parties. The table below shows the relative involvement of each staff group throughout the rehabilitation period. Obviously sports medicine staff are involved all the way through the programme; sports science staff from stage 3 and football staff from stage 5 / 6.

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