Physical therapy in the sports medicine setting focuses on rehabilitating the active patient, with the goal of returning them to their previous level of function. We have a responsibility to both the 16-year-old female basketball player who complains of patellofemoral pain with jumping, as well as the 55-year-old male who has medial knee osteoarthritis that limits his jogging and weekend golf. Lower extremity injuries most commonly result from either trauma or repetitive overuse. In either case, rehabilitation must expand beyond only addressing the injury, and include finding the weak link in the chain. In doing so, we can hope to prevent recurrence.
The most common ankle injury seen in the sports medicine setting is the inversion sprain. Whether it is due to landing on someone else’s foot from a jump or attempting to cut laterally, excessive inversion can range from a sprain to a fracture requiring surgery. With knee injuries, there is more variety. The most common nontraumatic injury will be patellofemoral pain, usually associated with squatting and running. Others include iliotibial band (ITB) syndrome and hamstring strains. Common traumatic knee injuries include anterior cruciate ligament (ACL), medial collateral ligament (MCL), and meniscal tears.
The evaluation begins with taking an accurate history and determining if the patient is appropriate for physical therapy. Recorded details include, but are not limited to, date and mechanism of injury, any previous injuries to the lower extremity, symptom description, and activities that exacerbate or relieve symptoms. A gait assessment and palpation over the injured area are performed. Active and passive range of motion is assessed, as well as strength, flexibility, and joint mobility. Special tests to both rule in and rule out specific diagnoses are completed.
INDIVIDUALIZED TREATMENT PROGRAMS
A comprehensive rehabilitation program is constructed post-evaluation that is tailored to the patient’s specific impairments and goals for returning to their previous level of function. The last thing that should occur is a patient receiving a “cookie cutter” treatment program, including a list of the same exercises that everyone with a specific diagnosis gets. Careful consideration should be given to which stage of the healing process the patient is in. Treatment should initially focus on controlling pain and inflammation as needed. Then, the primary impairments, whether quadriceps weakness or a lack of ankle dorsiflexion, should receive the most attention. When the patient is making good progress, treatment should expand to look at contributing factors at joints above and below the injury. For example, you may be treating a patient with lateral knee pain when running with primary impairments of quadriceps weakness and ITB tightness.
Treatment must expand beyond focusing on just the knee and include assessing core strength and hip mobility, flexibility, and strength, as well as foot and ankle mobility and flexibility. Too commonly, the patient with knee pain may be receiv-ing treatment only to the knee and the underlying problem could be elsewhere. The solution could be fitting the patient for orthotics and addressing hip weakness.
Patellofemoral pain syndrome is a common cause of anterior knee pain in the physically active patient. A multitude of reasons, ranging from quadriceps weakness to decreased flexibility, arthritis, and poor biomechanics, can cause patellofemoral pain. Complaints in activities of daily living include stair negotiation, squatting, and prolonged walking; whereas complaints with sports include pain with running, squatting, and jumping. The physical evaluation includes assessing global lower extremity strength and flexibility, with special attention given to quadriceps and gluteus medius strength and iliotibial band, hamstring, quadriceps, and gastrocnemius flexibility. Patellar taping can be applied to medially glide, tilt, or rotate the patella if a trial of taping or manual patella gliding causes a decrease in pain in knee extension muscle testing, squatting, or stepping up or down. If the patient’s pain is relieved, the physical therapist can either teach the patient how to tape their own knee or give them a brace to stabilize the patella. Quadriceps strengthening for patients with patellofemoral pain is different than in other knee diagnoses in that it should be in protected ranges for both closed and open kinetic chain exercises to not cause pain or engage a patellar lesion. Treatment may also include a detailed foot and ankle biomechanical evaluation. For example, if the patient overpronates, they may be a good candidate for custom orthotics.
THE ACL CONTINUUM
Whether it is from a traumatic blow to the knee or an episode of giving way, ACL tear and subsequent reconstruction is often treated in the sports medicine setting. Postoperative rehabilitation is broken down into phases; the first extends to 6 to 8 weeks following surgery. In phase 1, the primary goal of physical therapy is to decrease pain and swelling, and increase range of motion (especially extension), patella mobility, and quadriceps strength. Modalities that should be used in this phase include ice to reduce swelling, and neuromuscular electrical nerve stimulation to the quadriceps to increase strength and aid in superior patella mobility. Phase 2 lasts until the patient begins to run, usually at 4 to 6 months after surgery.
Exercises should include both open and closed chain, and remain in ranges that protect the healing graft. Prior to running, the patient needs to demonstrate adequate concentric and eccentric strength, as well as normal pain-free gait. Running typically begins on a treadmill instead of the road, due to decreased ground reaction forces. Once the patient has clearance from their physician and can tolerate running 1 to 2 miles without any signs or symptoms of inflammation, the patient can begin sport-specific exercises.
Progression should be from low level agility drills such as forward-backward and lateral shuffling, and carioca to plyometric activities. The patient should begin at low, comfortable speeds, and careful attention should be given to deceleration to ensure dynamic control. Jumping (two feet) should occur before hopping (one foot). Jumps should begin forward at short distances that are individual before the patient begins repetitive jumps in all planes of motion. Hopping should follow the same progression. Cutting should be practiced at submaximal speeds with curves and larger angles before attempting sharper cuts at full speed.
Throughout the duration of physical therapy post-ACL reconstruction, the patient must demonstrate adequate neuromuscular control in hopes of avoiding a reinjury. Returning to sport should be a collaborative decision between the physician and physical therapist based on factors such as time after surgery, strength, neuromuscular control, and functional performance. The patient can return to sports when they are able to practice and perform all factors associated with that sport at 100% effort without any increased pain, signs and symptoms of inflammation, or episodes of giving way.
Lateral ankle sprains are extremely common in the physically active patient. In the acute phase, treatment should focus on decreasing swelling and pain. Ice or commercial gel packs should be used several times per day, along with compression wraps and elevation. If needed, an ankle splint or walking boot should be donned along with use of crutches. In the subacute phase, treatment focuses on restoring active and passive range of motion, flexibility, mobility, and proprioception. The patient must demonstrate a pain-free and normal gait in order to ambulate independently.
Strengthening and proprioceptive exercises should progress as the patient can tolerate, ie, no increase in pain or signs and symptoms of inflammation. During the last phase of rehabilitation, treatment focuses on restoring full ankle strength and function including agility and power. The patient can return to sport when they have full range of motion and can perform all functional tasks at 100% effort without increased pain or inflammation.
While the injured tissue is remodeling, some physical therapists will use moist heat or ultrasound to reduce pain and to repair the damaged tissue. These modalities should not be used while active inflammation is present. To reduce pain and swelling after treatment, ice and transcutaneous electrical nerve stimulation can be used. When the patient is preparing to return to sport, the physical therapist can tape the ankle to increase stability. The main drawback with taping is that it loosens as activity increases. Another option would be to wear an ankle brace, such as an ASO.
HELPING TO PREVENT RECURRENCE
During the rehabilitation process, the patient should be educated about how to be independent with an individualized home exercise program. The ultimate goal for the active patient is to safely return to their previous level of activity. Even after discharge from physical therapy, the patient should continue with the exercises on their own.
One of the most difficult tasks will be educating the patient to limit their activity so they have time to heal. The best example is patients who run. Runners love to run and rarely want to stop running. You may have to convince the patient to either limit mileage, perform run/walk cycles, or stop altogether for physical therapy to be effective. The opposite may also hold true for the patient who is deconditioned and returns to sport. Patients who golf may not exercise or practice hitting golf balls in the winter. Once the first warm weekend in spring comes, they immediately play 18 holes without warming up and complain of pain the next day. An important task for the physical therapist is patient education to train/exercise during the off-season and adequately warm up and practice before an activity.
Rick Joreitz, PT, DPT, ATC, is a physical therapist at the University of Pittsburgh Medical Center’s Center for Sports Medicine, and an adjunct instructor at the University of Pittsburgh, Department of Physical Therapy. For more information, contact or .