1. REHABILITATION PROCEDURES
Progressive mobilisation
Graduated exercise (stretching, conditioning, total body fitness)
Training
Use of heat and cold

2. How is injury rehabilitation managed is the last critical questions for Sports Medicine. In How is injury rehabilitation managed, you will examine rehabilitation procedures, such as: progressive mobilisation, graduated exercise and the use of heat and cold.
You are also required to justify these procedures for specific injuries such as shoulder dislocations or hamstring tears. Furthermore, as you study How is injury rehabilitation managed, you will learn about the indicators for return to play, such as pain free movement and the degree of mobility. This critical question also covers psychological readiness and the ethical considerations around painkillers.
Here you will also examine physical tests that may be used to indicate readiness to return to play.
You will need to examine sports policies in relation to injury rehabilitation and return to play and consider questions such as: why aren’t policies universally applied to sports? and who should have the final decision and responsibility for whether an athlete returns to play?
How is injury rehabilitation managed? only has two (2) dot points, but they have lots of content, especially return to play. They are:
Rehabilitation procedures
Return to play

3. Progressive Mobilisation
Progressive mobilisation refers to the gradual increase in the joint range of motion/movement. After an injury, and the application of RICER (Rest, Ice, Compression, Elevation, Referral), including the medical check or even surgery if required, joints become stiff as muscles around the joint tighten because they were not used for an extended period of time.
Progressive mobilisation is required because of this tightening of the muscles and stiffening of the joint. Progressive mobilisation, slowly stretches the muscles allowing for a gradual increase in the range of motion at the joint. The gradual progression also helps increase the movement in the ligaments around the joint.
Progressive mobilisation should begin as early as possible, in order to help prevent scare tissue and to reduce the recovery time. The increase in joint range of motion should be as pain free as possible and involves both passive and active movement. Usually passive movement is first, especially if the injury is to a muscle across the joint.

4. Progressive mobilisation utilises dynamic, static and PNF stretching, but NOT ballistic stretching as this can cause further damage.
Often the stretching begins with static stretching before PNF stretches are used (the added contraction during rehabilitation requires greater healing of the muscle).
Dynamic stretching is often used throughout rehabilitation with slow passive movements at the beginning and active and faster (not fast) movements at the end. However, it should be noted that the progression and use of stretching for mobilisation is individualised for each case and the specific injury acquired.

5. Graduated exercise (stretching, conditioning, total body fitness)
Graduated exercise is used in rehabilitation to ensure exercise intensity and activities progress with healing and do not cause further injury.
Graduated exercise refers to the gradual increase in range of motion, intensity, and activities to help ensure the athlete’s recovery is as pain free as possible.
Graduated exercise will progress through three (3) stages:
Stretching,
then conditioning,
then total body fitness
Though these stages will overlap as the athlete recovers and is able to perform various activities.

6. Stretching as Graduated Exercise
There are various forms of stretching, including: static, proprioceptive neuromuscular facilitation (PNF), dynamic, and ballistic.
Ballistic stretching is generally avoided in rehabilitation as it can be unsafe and cause injury by bouncing too far in the stretch causing a muscle strain. This is particularly unwanted in rehabilitation of a muscle strain.
Static stretching is the least intense of the stretches, but also provides the least gain. Often graduated exercises of stretching begin with simple static stretches, before moving onto PNF and dynamic stretching.
PNF stretching is the most common and usually the most beneficial form of stretching during rehabilitation. Gains in range of motion/movement are large, which helps prevent joint stiffness and promotes recovery.
Dynamic stretching is also used in rehabilitation, though usually towards the end as it requires more control. Usually an athlete who is using dynamic stretching has also progressed or graduated to the conditioning phase of rehabilitation.

7. Conditioning as graduated exercise
Conditioning is the process of strengthening muscles and getting them back to their pre-injury levels. This is in relation to muscular strength, muscular endurance, speed, and power. Muscles often lose these while an athlete is injured, especially if it is a muscular strain.
Conditioning is always specific to the injury, and the athlete involved. An injured knee will require conditioning of the muscles around the knee: hamstrings, quadriceps, and gastrocnemius. These muscles will need to be strengthened again as the reversibility effect would have caused atrophy in these unused muscles.
Further loss will occur in muscular endurance and speed, and muscular strength combined with speed produces the muscular power.

8. Graduated conditioning of muscles begins with the strengthening of the muscles and developing muscular endurance.
Exercises begin at low intensities and progressive overload is used to ensure the intensity slowly increases as muscular strength and endurance increase. Once the muscles as strong and can keep the joint stable to avoid further injury and they have their endurance back, muscular speed and power can also be redeveloped.
These come last as they cause more stress to muscles and joints requiring a greater level of recovery.

9. Total body fitness as graduated exercise
During injury the reversibility effect causes a loss of total body fitness. Some injuries result in an athlete being unable to exercise for extensive amounts of time, and reversibility begins after 2-3 weeks.
If possible an athlete should be doing any exercise possible while injured. This could be upper body training, while the athlete recovers from an injured ankle, or lower body training if they have just had a shoulder reconstruction.
Often it is possible for the athlete to do some forms of training while injured. Even exercising using the “good leg” when recovering from a knee injury on the other leg.

10. Regardless, this kind of training will only help slow down reversibility, and will not maintain previous total body fitness completely.
This means the athlete will need to restore previous levels of fitness across their body. During this time pre and post injury testing becomes vital. Post injury test should be compared with pre-injury results to determine if the athlete has fully recovered or at least recovered to a level ready to return to play.
Total body fitness refers to each aspect of both the health and skill related components of fitness. This helps ensure a complete recovery in each component, so that no weakness is present when the athlete returns to play after graduated exercise.
As mentioned in graduated exercise, training during rehabilitation is vital to help counteract reversibility. Reversibility affects each component of fitness and each must be trained in order to ensure a safe return to play for the athlete.

11. Training during rehabilitation
During rehabilitation training can be done to help slow down and limit the loss of fitness. While the injury requires rest, this rest does not always have to be to the entire body.
A knee reconstruction only requires that one (1) leg to be rested, and a shoulder dislocation requires only that arm to be rested. The rest of the body can still train to help prevent reversibility.
Often athletes will train using their non-injured side or using their non-injured limbs (such as the arms for an injured ankle or the legs for an injured wrist).

12. Training after rehabilitation
Once an athlete has completed their rehabilitation, they still require training before they can return to play. The athlete may have regained muscular strength, muscular endurance, speed, power, flexibility, and have a full active range of motion, but they have not fully participated in their sport yet.
This lack of engagement in their sport means the sport specific components of fitness, such as coordination, and agility have not recovered. Furthermore, the athlete will have lost their ability to “read the game”, and may not be psychological prepared, or confident to return to play. These are regained through training and competition simulation.
Training after rehabilitation aims to:
Develop sport specific fitness components
Develop sport specific skills
Increase confidence
Safely return the athlete to play
Once the athlete is pain free and performing at pre-injury levels (not just meeting pre injury test), performance should be assessed with objective and subjective performance measures to determine readiness to return to full competition. The athlete should exhibit (if they had it before) the characteristics of skilled performers (kinaesthetic sense, anticipation, consistency, technique).

13. Use of Heat and Cold in Rehabilitation
The use of heat and cold for rehabilitation has been around for many years. Cold is extensively promoted during the immediate “first aid” treatment of soft tissue injuries composing the ice section of RICER. However, you are required to know much more than this for this dash point in HSC PDHPE.

14. Use of heat in rehabilitation
The use of heat in rehabilitation has a number of aims and is done in a number of methods. The aims or benefits of heat application include:
Increased blood flow (delivering nutrients and white blood cells, while removing waste)
Decreased pain
Increased flexibility (increases the elasticity of fibres, especially the new ones)
Decreased joint stiffness (increases fluid to the joint)
Increased tissue repair (by increasing blood flow)

15. The methods for using heat in rehabilitation include both superficial applications (less than 1 cm deep):
Heat packs
There are many different types of heat packs, including microwavable wheat bags, and chemically heated packs. They are applied to the injured area, much like an ice pack.
Hydrotherapy
Hydrotherapy is a heated pool around 40 degrees that is used during rehabilitation. It uses heat to increased blood flow, flexibility etc, while at the same time using buoyancy to limit the force/weight on the injured area during exercise.
Infra-red lamps
Infra-red lamps proceed heat via radiation. The lamp is used to apply heat to the injured area, by being shone on the injury.

16. Contrast therapy
During contrast therapy the athlete moves the injured area between an ice bath and a warm bath. This provides the benefits of the cold, and the heat.
Ultrasound
Ultrasound therapy applied heat using sound waves and is used during rehabilitation on dense tissue such as bone or ligaments.
Microwaves
Microwaves heat deeper tissue that has high water content such as muscles and blood vessels. The area around the injury is heated for less than 30 min to around 40 degrees.
Heat should not be applied to acute injuries!

17. Use of cold in rehabilitation
The technical term for the use of cold in rehabilitation is cryotherapy. Cryotherapy “is the local or general use of cold in medical therapy.”
There are many methods used to apply cold for rehabilitation. The purpose of using cold in rehabilitation is to reduce pain, blood flow/bleeding and inflammation.
This is applied immediately after the injury occurs and after treatments/exercise during rehabilitation of the injury.
The use of ice-packs is well known and is usually applied to the injured area during the first 48 hours after an injury.

18. Ice massage
During this use of cold, ice is rubbed over the body, or injured area for around 15 min. This is not much different to the use of an ice-pack.
Cold water immersion/ice bath
This use of cold is when immediately following an injury the athlete places their injured area into an ice bath for around 15 min at a time. This depends on the area injured and how long the athlete can withstand the cold.
Contrast therapy
During contrast therapy the athlete moves the injured area between an ice bath and a warm bath. This provides the benefits of the cold, but then the warm bath increases blood flow to the area helping to remove debris and providing nutrients for repair. This is not usually used immediately after injury, but more often during or after a session of rehabilitation.
Vapocoolant sprays 
These are the prays often used during games to provide an immediate cooling to the injured area. Often used for minor injuries, where the player can continue to perform. They are particularly used to prevent muscle spasms around the injury.
Cryotherapy machine
A cryotherapy machine may be used in rehabilitation for larger injuries of the body. They cool the entire body, but do not target specific areas.

19. Rehabilitation procedures for a hamstring tear
The rehabilitation procedures for a hamstring tear (aka strain) include:
Progressive ROM,
Graduated exercise (stretching, conditioning, an total body fitness),
Training, and
Use of heat and cold.
A tear or strain is a tear to any one of the three hamstring muscles. Rehabilitation for a hamstring tear should be individualised, depending on the specific muscle injured and the classification of strain.
This said, there are some basic guidelines that can be followed.

20. Immediate hamstring tear treatment
The immediate treatment for a hamstring strain is RICER (Rest, Ice Compression, Elevation, and Referral). This should be applied for the first 48 hrs as appropriate care during the acute phase.
Once the injury has been assessed by a professional (Medical Practitioner, Physiotherapist, Specialist etc) and surgery completed if required, rehabilitation may begin.
Stretching and increased ROM
There should be no stretching of the hamstring during the initial acute period of injury. This will allow the injury to begin to heal before it is pulled at, which will cause further injury. Once a professional has declared this to be over, stretching becomes the first rehabilitation procedure for a hamstring tear.

21. Stretching should begin using isometric stretching, where the hamstring is stretched with no pain. The muscle should just begin to stretch and then it should be held there, not taken further.
Adjustments to the stretch, such as straight legged, then bent leg, should be used to target each hamstring individually.
Stretching can then progress to PNF and dynamic stretches as functional capacity begins to return to the leg. Stretching will help to increase and restore the range of motion/movement at the knee and hip as the hamstring goes across both joints.
Conditioning
Conditioning is another aspect of the rehabilitation procedures for a hamstring tear. General strengthening exercises should be pain free. The athlete should begin with isometric contractions of the hamstring that are a low intensity to begin with. Isometric exercises should be conducted throughout the pain free range of movement.

22. Conditioning exercises will then progress through a range of dynamic activities as recovery continues. Movements will then become functional, before sport specific exercises are given. During these exercises it is important to minimise pain, and often cold therapy is used if pain occurs.
Total body fitness
After the acute phase of injury, stationary equipment is used to maintain and/or enhance total body fitness. Arm ergometers can be used to help maintain cardiovascular fitness, but also rowing machines and cross trainers can be used, as long as the intensity keeps the hamstring pain free.
From these low impact machines the athlete will progress to light jogging and before agility runs. Finally, the athlete will progress to full sprints.

23. Training
One of the final rehabilitation procedures for a hamstring tear is training. Once the athlete has been given the clear from a professional, they may return to training. It will take a while for the muscular endurance and power produced by the hamstring to return. The athlete will also become more confident to use the hamstring to their full potential through training drills.
Use of heat and cold
This rehabilitation procedure for a hamstring tear is used throughout the recovery process. Cold therapy is used when pain occurs, especially during the acute phase of injury, or after rehabilitation exercises.  
Heat is not used in the acute phase, but may be used to enhance blood flow to the hamstring before stretching or rehabilitation exercises in order to increase flexibility, and to provide blood flow to the area in order to speed up the healing process.
The use of these rehabilitation procedures for a hamstring tear, will help provide a speedy recovery, while maintaining athlete safety and reducing the chance of re-injury.

24. Rehabilitation procedures for a dislocated shoulder
The rehabilitation procedures for a dislocated shoulder include: increasing the range of movement/motion, graduated exercise (stretching, conditioning, and total body fitness), training, and the use of heat and cold.

25. Immediate treatment of a shoulder dislocation
The immediate treatment for a shoulder dislocation is immobilisation of the shoulder and its arm, and to apply ice packs if it does not cause further pain.
The athlete is then taken to a professional (medical practitioner, specialist, physiotherapist, etc) who is responsible and trained to put the shoulder back into place (often after an MRI to ensure no nerves or blood vessels are destroyed during the relocation process).
After relocation a sling is usually worn for 5-7 days. If the athlete requires surgery then this should also be done before rehabilitation begins.

26. Range of motion/movement stretching
After a dislocated shoulder injury rehabilitation procedures will begin by increasing the range of motion at the shoulder.
Often the shoulder is stiff and tight after the sling being worn and the arm being immobilised for so long. Range of motion exercises include a range of stretches that are isometric, PNF and dynamic.

27. Conditioning
Rehabilitation procedures following a dislocated shoulder will include strengthening the rotator cuff muscles as soon as it is possible (pain free). The rotator cuff muscles are used to stabilise the shoulder joint and are often damaged and weakened following a dislocation.
At the beginning of rehabilitation exercises for a dislocated shoulder abduction and lateral rotation of the shoulder are avoided as these are more likely to re-injure the shoulder.
Strengthening exercises begin with isometric contractions. Actions such as: extension, adduction, external and internal rotations and abduction when possible, are all done as isometric contractions. Internal and external rotations particularly target the rotator cuff muscles, strengthening the stability of the shoulder joint.
Movements are then added to the strengthening routine as the shoulder progresses. The first movements are usually external and internal rotation exercises. These then progress to flexion, abduction and extension to strengthen the shoulder. Exercises such as a shoulder press come at the end of the strengthening rehabilitation procedure for a dislocated shoulder.

28. Once the shoulder is strong, and more importantly stable, general conditioning exercises may be added. Light rowing on a machine may begin, and then progress to arm ergometer. Activities such as swimming are not used until the end, after the athlete has complete range of motion that is pain free and the shoulder has regained strength and stability.
Total Body Fitness
The rehabilitation procedures for a dislocated shoulder take time and result in reversibility occurring in the body. Athletes will need to resume training as soon as possible. During rehabilitation a stationary bike could be used to help maintain some levels of total body fitness. However, running should be avoided during the early stages of rehabilitation because of the jolting through the body and the usual swinging of the arms.
As pain permits, the athlete will begin to engage in other activities such as jogging, running, or cross-training to develop total body fitness. After rehabilitation has been completed the athlete can resume normal training.

29. Training
Training specific to the sport is always at the end of rehabilitation procedures, and a shoulder dislocation is no different. Coaches will often want their athlete returning from a shoulder dislocation to engage in normal training before they return to play. Athletes need to get their timing back as well as develop their confidence and skills specific to their sport. This is particularly going to be the case if the sport involves tackling, such as: rugby league, rugby union, or AFL.
Use of heat and cold
Cold therapy is used throughout the rehabilitation procedures for a dislocated shoulder. Cold is often used in the acute phase of the injury, which includes the relocation of the shoulder, and after surgery if needed. Cold may also be used after rehabilitation exercises to help reduce the inflammatory response.
Heat may be used initially to help warm up the shoulder before stretching exercises or the initial isometric and dynamic strengthening activities. This is to promote elasticity around the shoulder, and increase blood flow before exercises begin.