Overuse Injury Prevention: Physical Therapy Rehabilitation Protocol (Sports Medicine)

This protocol outlines a comprehensive physical therapy rehabilitation program designed to prevent overuse injuries in athletes and active individuals. It emphasizes a phased approach focusing on education, addressing predisposing factors, restoring movement, building strength and endurance, and safely progressing back to sport or activity.

Pathophysiology of Overuse Injuries

Overuse injuries result from repetitive microtrauma to musculoskeletal tissues. This occurs when the rate of tissue breakdown exceeds the rate of tissue repair. Contributing factors include:

• Training Errors: Sudden increases in intensity, duration, or frequency of training. Inadequate rest and recovery.
• Biomechanical Factors: Malalignment, muscle imbalances, poor flexibility, altered movement patterns.
• Equipment Issues: Improper footwear, poorly fitted equipment.
• Environmental Factors: Training on uneven surfaces, extreme temperatures.
• Individual Factors: Age, gender, previous injury history, nutritional deficiencies, stress.

Common tissues affected by overuse injuries include tendons (tendinopathy), bones (stress fractures), cartilage (chondromalacia), and muscles (strains). The inflammatory process plays a significant role in the initial stages, followed by potential chronic changes if the underlying causes are not addressed.

Phase I: Protection and Pain Management

The primary goals of Phase I are to reduce pain and inflammation, protect the injured tissue, and prevent further damage. This phase typically lasts for 1-7 days, depending on the severity of the injury.

• Activity Modification: Reduce or eliminate activities that provoke pain. Cross-training with pain-free activities is encouraged to maintain cardiovascular fitness.
• Pain Management:
  • RICE (Rest, Ice, Compression, Elevation): Apply ice for 15-20 minutes every 2-3 hours. Compression should be comfortable and not impede circulation. Elevate the affected limb above the heart.
  • Pain Medication: Over-the-counter analgesics (e.g., ibuprofen, acetaminophen) may be used as directed by a physician. Consult a physician regarding prescription pain medication.
• Range of Motion (ROM): Gentle, pain-free ROM exercises to maintain joint mobility. Focus on active-assisted ROM if needed.
• Patient Education: Educate the patient about the nature of their injury, contributing factors, and the importance of adhering to the rehabilitation protocol. Provide guidance on proper posture, body mechanics, and activity modification techniques.
• Bracing/Support (if needed): Use of a brace, splint, or tape to provide support and limit motion.
• Isometric Exercises: Gentle isometric contractions of the surrounding muscles to maintain strength without aggravating pain.

Phase II: Loading and Early Strengthening

Phase II focuses on gradually increasing the load on the injured tissue, restoring muscle strength and endurance, and improving joint stability. This phase typically lasts 1-4 weeks.

• Progressive Loading: Gradually increase the intensity and duration of activities based on pain levels. "Pain with activity, but pain subsides quickly after" is generally acceptable. Pain that lingers indicates too much load.
• Isotonic Strengthening: Introduce light resistance exercises to strengthen the muscles surrounding the injured joint. Focus on proper form and controlled movements. Examples include:
  • Theraband exercises
  • Bodyweight exercises
  • Light weight training
• Proprioceptive Exercises: Begin proprioceptive exercises to improve balance and coordination. Examples include:
  • Single-leg stance
  • Balance board exercises
  • Mini-trampoline exercises
• Flexibility Exercises: Continue stretching exercises to improve flexibility and ROM. Hold stretches for 30 seconds, repeat 2-3 times.
• Cardiovascular Training: Continue cross-training activities to maintain cardiovascular fitness. Gradually reintroduce sport-specific activities as tolerated.
• Biomechanical Assessment & Correction: Identify and correct any biomechanical deficits that may have contributed to the injury. This may involve:
  • Gait analysis
  • Movement pattern analysis
  • Postural correction exercises

Phase III: Return to Function and Injury Prevention

Phase III focuses on returning to sport or activity at a pre-injury level, maximizing functional performance, and preventing future injuries. This phase typically lasts 2-8 weeks.

• Sport-Specific Training: Gradually reintroduce sport-specific activities, starting with low-intensity drills and progressing to full-intensity training.
• Plyometric Training: Introduce plyometric exercises to improve power and explosiveness. Examples include:
  • Jumping jacks
  • Box jumps
  • Bounding
• Agility Drills: Incorporate agility drills to improve coordination and reaction time. Examples include:
  • Cone drills
  • Shuttle runs
  • Ladder drills
• Endurance Training: Gradually increase the duration and intensity of endurance activities.
• Maintenance Program: Develop a maintenance program that includes regular stretching, strengthening, and proprioceptive exercises to prevent future injuries.
• Return-to-Sport Criteria: Establish clear return-to-sport criteria based on pain levels, functional testing, and physician clearance.
• Functional Testing: Conduct functional tests to assess readiness for return to sport. Examples include:
  • Hop tests
  • Agility tests
  • Strength tests
• Education and Long-Term Prevention Strategies: Reinforce education on proper training techniques, warm-up and cool-down routines, nutrition, and injury prevention strategies.

Common Special Tests (Examples - Specific tests depend on the injury location)

• Shoulder: Hawkins-Kennedy test, Neer's test, Empty Can test
• Elbow: Tennis Elbow test, Golfer's Elbow test
• Wrist/Hand: Finkelstein's test, Phalen's test, Tinel's sign
• Hip: Thomas test, FABER test
• Knee: Anterior Drawer test, Lachman test, McMurray's test
• Ankle/Foot: Thompson test, Talar Tilt test

Important Note: This protocol provides general guidelines. It is essential to consult with a qualified healthcare professional (physician or physical therapist) for an individualized rehabilitation program based on your specific injury and needs. Progression through the phases should be guided by pain levels and functional abilities. Do not attempt to self-treat without professional guidance.