Blog #13 – Rehabilitation Outcomes - Returning to Performance & Re-Injury Prevention

An athletes’ best characteristic is their availability, right? If they aren’t available for selection then they simply cannot perform. This sounds like a basic statement but one which holds truth. Sports rehabilitation and physiotherapy serves to return athletes from injury and therefore regain their availability status.

However, this is just one piece of the puzzle. In most instances, athletes are ‘cleared’ to return to play by passing return to play testing batteries looking to ‘return to symmetry’, achieving clearance by coming within ~10% of the uninjured side.

The issue with this is that it grossly neglects working towards getting the athlete back to pre-injury performance targets or better still, targets that position the athlete to return more resilient where-by the weaknesses that contributed to the injury in the first place are addressed.

As an example, studies have consistently demonstrated some key findings in the rehabilitation of ACL injuries:

• Only 64-76% of athletes return to their pre-injury level of sport.

• Athletes can often take 3-5 years to return to previous athletic performance levels.

• Re-injury rates post-ACLR are reported to be around 9 to 29% for the reconstructed knee with around 10% suffering an ACL injury to the other side.  

• Re-injury or subsequent injuries often occur in the first 12 months after returning to sport.   

True rehabilitation should consider the athlete as a whole and place emphasis on maximising their ability across a range of performance markers as well as the injury site/location and risk factors.

Returning to Performance

 To get a full grasp on what this means in the rehabilitation space, it is essential to first understand what performance truly entails.

What is “Performance”?

Within the context of sports, ‘performance’ depicts how well an athlete/team accomplishes the tactical, technical, physical and psychological components during live competition and training.

This involves many key factors such as:

• Physical qualities: An athlete needs to have the appropriate physical attributes that are significant performance markers within their respective sporting and positional demands. This generally refers to relative maximal strength, rate of force development, speed, endurance, flexibility, mobility and co-ordination.

  
  

• Technical skills: Physical qualities when returning from injury are massively important and dictate the timeline of return for an athlete. However, a huge component of performance are the technical skills associated within their chosen sport. The ability to execute the fundamental technical skills to a high level dictates the standard of performance that an athlete will display. It’s important to encourage technical skill-based training in a performance program as the physical qualities provides the athlete the platform to be in a position to execute their skills.

  
  

• Tactical execution: Another huge aspect of high performance is tactical awareness and implementation. This considers things such as game strategies, decision making under pressure and body positioning and awareness. At the end-stage of an athlete’s rehabilitation, the integration of training with their team or on their sport whilst still training their physical qualities is essential – again the physical qualities provide the athlete the opportunity to be able carry out a tactical game strategy.

  
  

• Mental aspects: Elite performers often display high levels of confidence, focus and discipline. Continually taking measurable action to enhance their psychologically readiness, improving their confidence, motivation and discipline.

  
  

• Outcome/Results: Lastly sports are a results-based business, you either win or you don’t. This is achieved and measured through times, scoring or placements during competition. To achieve positive results requires higher levels of performance displays than your opponent(s) which can be achieved through consistency of all the above factors

With this performance framework and understanding driving the practitioner’s approach to end-stage athletic rehabilitation, the athlete will be positioned towards achieving optimal short- & long-term outcomes.

Resilience & Injury Prevention

The other very important piece of the puzzle is ensuring that the athlete is returning to their sport more resilient than previously. This includes not only addressing the risk factors and drivers of the original injury, but also looking at the athlete as a whole to minimise other weaknesses or areas of potential concern.

This is the key to the prevention of re-injury or the common subsequent other injuries that often occur when an athlete returns not appropriately prepared for the demands of their sport.  

Resilience refers to an athlete’s capability to withstand physical stress and their capacity to recover from repeated intense physical efforts. A resilient athlete has several factors to consider:

• Physical conditioning: As mentioned it is important to have high levels of strength, speed and conditioning relative to the sporting demands and benchmarks. However, repeated intense efforts or long duration sporting demands requires an athlete to be robust in order to withstand these efforts. The ‘resilience’ term highlights the importance of muscular capacity/endurance, joint range of motion and the ability of connective tissues/tendons to reduce impact loads and force dissipation.

• Movement efficiency: Refining good biomechanical techniques help to reduce unnecessary stress and strain on tissues and joints. Athletes within a quality rehabilitation & performance program should always have a focus around movement proficiency in order to gain the maximum benefit from their programmed exercises.

• Injury mitigation strategies: Appropriate movement prep/warm ups including direct mobility work that’s individualised to the athlete are essential in the program. These targeted interventions alongside education around load management helps athletes understand how to reduce the likelihood of potential injuries.

• Recovery practices: There is a need for continued education and support around optimal recovery routines. This includes communication around appropriate rest, nutritional basics, meal timing and fuelling for performance, hydration protocols, sleep for tissue repair, training intensities and gameday tapering.

Rehab Phase 6 – ‘Performance & Resilience’

The above concepts of optimal rehabilitation outcomes are the reason our injury rehabilitation framework at Rehab Advantage has a Phase 6.

All too often we have seen athletes returning to play but not ready to perform or worse still returning to play thinking that the job is done. Stopping engagement in a structured & supported program that addresses underlying weaknesses and risks. The Result - re-injury or another injury somewhere else.

In Phase 6, performance metrics are tested, assessed and evaluated using technology such as VALD force plates. Once measured these performance markers are assessed through comparison to data norms, statistics and benchmarks from previous testing. This gives the athlete clear feedback and direction within their training in order to maximise each of these important physical qualities.

Additionally, communication and education around the ‘why’ behind the program, the recovery practices, the injury mitigation interventions are what makes athletes inside the program better equipped to maximise their performances and enhance their resilience, striving for optimal outcomes in sports injury rehabilitation.

Conclusion

Optimal injury rehabilitation involves returning the athlete to performance, more resilient and able to handle the demands of their sport. The athlete needs to be considered as a whole with an emphasis placed on maximising their ability across a range of performance markers as well as the injury site/location and injury prevention risk factors.

Long-term injuries provide an extended period whereby an athlete isn’t available to participate in their sport. This is the perfect opportunity, when done well, to utilise this time to rebuild the athlete returning them to their sport confident, physically and psychologically ready to perform and resilient to re-injury or further setbacks.