Why this injury?
Designing rehabilitation programmes for athletes with long term injuries is a professional passion of mine. In 2014, with the help of Phil Glasgow, I published a theoretical model to outline the optimal progression of a single exercise (here). A pretty simple model, that described the opportunity to regress a variable of an exercise knowing that you have progressed the demand of the exercise in a different, but logical way. In effect saying its ok to reduce something knowing that the aims and goals are moving towards the bigger picture. I attempt to explain this model here in my blog: Plinths and platforms.
Whilst in the USA working in Ice Hockey, I attempted to apply this model to a longitudinal case study for a groin injury as part of an in-house training day. However, it wasn’t possible to apply this model to a bigger program with multiple goals. But I knew that I was applying the same principles of progression and regression underpinned by clinical reasoning, so the model just needed adapting.
In 2017, Phil and I published an editorial in the BJSM (here) to outline this theory. What I would like to do now is present a case study that uses this model to help apply some context.
The purpose of this blog is to present a theory, a guideline on clinical reasoning and decision making for exercise progression. I do not want to publish a blueprint. This is not a recipe but more a method or thought process. Think of a protocol as providing the boundaries to work within (figure 1), instead this allows the clinician or strength coach to follow a golden thread of a theme that runs from acute injury to end stage, but allows fluctuations and deviations according to the individual (figure 2).
Figure 1: Progressions and regressions working within a protocol
Figure 2: A golden thread of continuity that runs through an exercise program
To help with this, I’ve selected an injury that is not common. Firstly, I hope it is interesting, but secondly I want to encourage people to focus on the thought process behind the design and take the tools to their own practice and injury population.
An international footballer in their mid-20s with no significant previous injury and a good level of training history on the pitch and in the gym. The player jumped to defend a high ball in a crowded penalty area and was challenged mid-air by an opponent from the left hand side and simultaneously from their own goalkeeper who reached above their head from behind. The player lost balance in the air and fell towards the grounds with their head and hands first, upon landing, their right foot landed in a fully plantaflexed position with added external force of an opposition player landing on their heel. This mechanism of axial load and forced rotation on a plantaflexed foot is recognised as the most common cause of Lisfranc disruptions (Gupta et al., 2008).
Day 1 post injury, the player was scanned in their native country for the following differential diagnosis:
- Suspected Lisfranc disruption of the right midfoot
- Suspected 1st metatarsal fracture
A CT scan showed no bony damage. An MRI scan indicated “disruption of the short flexor muscle under the 2nd phalanx.” No other injury was noted.
Upon return to their club on day 3 post injury, the foot appeared deformed with significant dorsal and plantar swelling and bruising. A subsequent MRI reported by a different radiologist highlighted a full-thickness tear of the Lisfranc ligament complex between the medial cuneiform and 2nd metatarsal base, a 3 mm of lateral subluxation of the metatarsal base with respect to the lateral margin of the intermediate cuneiform. The medial cuneiform- 3rd metatarsal base component of the planter ligament was also disrupted. In addition, there was a tear of the planter capsule and a sprain of the dorsal capsule of the 1st tarsometatarsal joint. Interestingly the second radiologist reviewed the initial MRI from day 1 and agreed the Lisfranc complex was intact, however was inflamed. It is noted that up to 20% of Lisfranc injuries are initially missed (Gupta et al., 2008).
The player was a strong candidate for surgery. Under anaesthetic, the player had considerable instability of both 1st and 2nd tarsometatarsal joints (TMTJ), the 3rd TMTJ was stable. Both 1st and 2nd TMTJ’s were reduced and fixated with plates. Despite this reduction, instability of the intermediate and medial cuneiform existed and a screw was placed between these to achieve stability.
The plates and screws were successfully removed after 14 weeks as planned. This created two distinct stages of rehabilitation focus, post op 0-3 months (P-O1) and a second post-op 3-7 months (P-O2).
Establishing the route.
The most daunting thing about long term rehabilitation is trying to predict where and when you will introduce key landmarks.
“When can I run?” will often be heard as you are explaining the process to the athlete. With the (significant) help of colleagues at Scottish Rugby, Ally Little and Jamie Coffey, we designed a template to help outline stages of rehab and the guidelines for variables within those stages.
Establishing these goals helps to keep your exercise selection on track. It refines the process and reduces the habit of keeping “nice” exercises on an ever growing list. Returning to the goals and asking, “does this exercise still help achieve that goal or aim?”
A quick and potentially boring caveat:
For the sake of keeping this blog concise, I have not included all of the exercises from the rehabilitation plan. Alongside the progressions presented, the athlete completed cardiovascular conditioning throughout, at appropriate stages this was done via running, they also worked closely with strength and conditioning coaches for compound and Olympic lifts – none of which are discussed in these video.
Also, for the sake of confidentiality of uninvolved athletes, the videos include different athletes throughout. The plan and exercises used were consistent for the case study.
In this case study, we established the following goals:
- Limit atrophyàcalf activation àhypertrophy
- Range of movement: Maintain range of non-affected joints àincrease range of affected joints
- Load bearing: Non-weight bearing àControlled weight bearing àloaded weight bearing
- Balance:Static balance àdynamic balance àmulti-directional balance àreactive balance
As the goals described above become less distinct, new goals and aims are established in video two as the athlete builds towards return to training.
- Load into plantarflexion
- Running mechanics
- Movement variability:
- Rate of Force Development (RFD): Force acceptance –> force production –> reactive force production
Within video two, there is mention of a mini series of progressions for foot intrinsic muscle control, inspired by anatomist and movement therapist, Suzanne Scott. This can be viewed here (Foot intrinsic video).
Deconstructing the goal
If you were to look at a finished rehab plan and rewind the sequence, there should be clear devolution of the exercises, with that golden thread evident all the way through. The easiest way to do this is to establish the end goals at the beginning of the rehab process. Not a hard and fast rule, but for any injury that may take longer than 4 weeks, I would set out the template above and establish objective markers that would determine transition from rehab àreturn to train àreturn to play àreturn to perform. In elite sport, we are lucky enough to be surrounded by strength and conditioning coaches, tactical coaches, sports scientists and psychologists that would help to establish these goals, along with the athlete themselves.
I would not expect anyone to draw or map out this model for rehab at any stage, it serves as a mental picture to establish a framework. But hopefully the process is clear and easy to translate regardless of the injury in front of you. When writing your daily or weekly rehab sheets for athletes, visualising these steps should help create clarity on appropriate progressions and even put you one or two steps ahead – for those times when athletes surprise you and master an exercise very easily. Again, it is hoped this will enable your clinical reasoning and creativity and not be a protocol.
Methods are many, principles are few – understand your own principles and create your own methods.
Yours in sport,