competition after rehab

Brandi Smith-Young, PTPerfect 10.0 Physical Therapy

Perfect10PT@gmail.comwww.perfect10physicaltherapy.com

Competition after Rehab

Brandi Smith-Young

Competitive gymnast 2 time USAG Collegiate National

Champions at TWU Bachelors in Kinesiology at TWU Masters in Physical Therapy at Tx St Fellowship trained in Orthopedic

manual physical therapy Board certified orthopedic specialist in

PT Specialize in treating gymnast last 6

years

Injuries are inevitable It’s not a matter of

when or how, it’s a matter of how do we manage them

Even with the best injury prevention there are still variables out of our control– Growth spurts, wrong

place at the wrong time, clumsy athletes, genetics

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Photo from: trouw.nl

Controllable Factors

Equipment in the wrong place Cracks in mats Class kids running across the runway Athletes doing skills when they are not

ready– use drills and progressions – don’t rely on spotting as injury prevention

Nutrition Lack of Sleep or fatigue Stress (use Meditation) #1 OVERTRAINING

Overuse Injuries

30-50% of youth sports injuries are overuse

As the rise in sports participation occurs so has there been a dramatic increase in injuries.

We are seeing young athletes with adult injuries (we cannot train immature skeletal systems as we train a mature adult).

Most gymnastics injuries occur on the floor and most occur during practice

The higher the level the greater the risk

How to prevent Over Training

– Macrocycle training (per Dr. Bill Sands)– Give athletes recovery time– Maximize training time (quality not

quantity)– Allow for a transition period post season– Do periods of general fitness which look

nothing like gymnastics.– Cross training, including lower impact

activities (trapeze, arial silks or hoop, swim, diving, bike, eliptical)

The first season post injury the athlete is at highest risk for re-injury

With the risk directly correlated to the severity or chronicity of the injury (ie ACL repair vs 1st ankle sprain vs chronic ankle sprains)

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Optimal Performing Athlete

Nutrition

Mental Health

Physical

Health

SPORTS PSYCH

Get Sports Psychology on board early Even minor injuries can use a Sports

Psych to keep them moving forward Keep short and long term goals fresh

on their mind Keep their brains engaged and on

track

Loose mental monkeys can come out to play and pull the athlete off the rehab track

Or derail a championship train! Having mental chorography,

mental sets, and mental assignments as part of workout will keep the mental monkeys away and the train on track!

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Nutrition Key to tissue healing Key to injury prevention Key to optimal muscle performance Get a nutritionist involved… it’s not just are they eating enough calories,

fat, protein, carbs…it’s also the quality of food, the timing of food in relationship to training regimen and training days. (competition nutrition should look different than summer training nutrition)

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Physical Phases of Rehab

Pain phase:Goal: Resolve pain & any inflammation present

Mobility phase:Goal: Normalize ROM

Stability phase:Goal: Normalize strength

Proprioception phase:Goal: Normalize balance and proprioception

Sport Specific Training Phase:Goal: higher level speed, agility, and sport specific skills

Sports Specific Training

Unfortunately many Physical Therapist don’t address this with gymnast.

It is key to break down shapes and parts of skills to address biomechanical errors, technical errors, or faulty movement patterns that in most cases created or set the athlete up for injury.

This where the coach can help work with the PT or medical provider.

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Injuries: Understanding what your athletes are going through

physically They key is tissue healing Each phase of rehab is determined by the healing

properties of the tissue involved– Healing timeframes:

Muscle: 4-8 weeks (minor sprain 100% strength) (Partial tear 80% strength)

Bone: 6 weeks (100% strength) [immobilize to allow growth] Ligament: 8-9 weeks (100% strength) [40-60% 1 RM 100-200

reps per set] Tendon: 11-12 weeks for micro tears & 15-18 months for partial

tear/repair (80% strength) [40-60% 1 RM 100-200 reps per set] Cartilage/growth plate: 6-12 weeks depending on extent of

damage (80% strength)[20% 1 RM 1000s reps slow speed comp/decomp]

Progression can only occur as quickly as the tissue heals.

“To push or not to push, that is the question.”

5b

WARNING: PROCEED WITH CAUTION

• With every injury there is a “re-injury window”• The time where the athlete is out of

pain but not back to full strength, proprioception, and sport specific motor skills/coordination• Varies from injury to injury

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• It is imperative to have open communication with the PT/doctor to determine this window of time.

• There should be a graded progression guided by the PT/doctor. (you can push within these parameters)

• Once the PT/doctor releases the athlete to full sport, you may begin the push keeping in mind their mindset and proper skill progression to prevent re-injury

• Recommend getting medical release in writing (risk management issue)

Active Recovery Allows the athlete to do as much

training as possible, painfree, while still allowing for the injury to heal appropriately and efficiently.

This is defined by the tissues involved, aggravating activities, and proper healing times.

Modifications are arrived at by a close interaction with the coach and PT.

Benefits of Active Recovery Physical Benefits

– Continued overall fitness, strength, cardiovascular & anaerobic capacity

– Continued progress in strength & skill level on the non injured areas

– maintain body composition Mental benefits

– Proven benefit of maintaining team environment. Maintains structure for the athlete.

– Prevent/decrease development of mental blocks

Return to competition sooner

Coach & PT relationship Open lines of communication are

important to achieve maximum recovery while maximizing time and training in the gym

Speak with the PT about the reasons for modifications (tissue healing, impact, loading, immobilization, etc)

Educate the PT on possible training tools or modification which meet the recovery criteria.

Coach & PT relationship Together with your gymnastics and

coaching knowledge and the PTs knowledge of healing time frames and biomechanics you can create a successful active recovery program.

Use your relationship with the PT to improve training regimens and develop injury prevention programs.

Treat each gymnast like aprize race car

Fill it up with the best quality fuel. (and refuel frequently!)

Make sure all the parts are running as close as possible to 100% efficiency

Give it a rest some times Frequent tune ups

Use of Assistive Devices There may be a period of

using assistive devices to improve proprioception or decrease pain to allow for increase activity.

Tennis shoes to help supporta collapsing arch post ankle sprain or give a lift to decrease stress on Achilles during healing of Sever’s, or improve knee control with Osgood Schlatter Photo by: Steven Lane, The Columbian

Knee sleeve in the presence of knee pain or ligament disruption.– Research has shown that a knee sleeve

or no brace offers equivocal proprioception as ACL custom brace depending on the sport looked at (football vs soccer)

– Many orthopedics still issue the hard ACL brace for a shorter period of time them progress to the sleeve and then nothing

Ankle brace post grade 2 or 3 ankle sprain– Increase proprioception

Bracing for longer periods in the presence of structural hypermobility or instability may be necessary.

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BRACING ALONE WILL NOT PREVENT AN INJURY!!!!

Bracing is only utilized for increased proprioception to the joints, muscles and tendons and to help with pain (which improves muscle firing patterns)

RULE: if you are wearing a brace you are doing PT for that body part!!!!

Many times we use tennis shoes, bracing, or taping for practice only due to all the repetitions and the fatigue factor in practice.

In this case have the athlete do their workout with the bracing and then do 1 competition set without the bracing so they can still feel confident outside the bracing (AS LONG AS THERE IS NO PAIN).

PT EXERCISE TIME

Carve out time for your athletes to do PT exercise.

This is easy at first when they’re not doing everything.

Ideas for when they do more: before and after practice or add a PT station or a few at each rotation.

Have athlete make a PT folder which goes from event to event

Fitting PT in: Stations

Progression Back Repetitions Progression:

– (ex: 50% numbers if painfree 2 workouts in a row then progress to 60-70% numbers, if painfree 2 workouts then 80-90%, and if painfree 2 workouts then 100% numbers)

Impact progression:– Low impact to High impact– Use low impact equipment– Progress lower impact

events first, save highest impact for final phase

Example post grade 1-2 simple ankle sprain

Achieve >10 degrees dorsiflexion, strength >3+/5, fair+ to good balance, able to run and jump no pain.

+ still in PT. wear tennis shoes while beginning

tumbling and vault (maybe beam, depending on ankle control)

May wear a brace first 1-2 wks EVERYTHING MUST BE PAINFREE

Vault: 1st wk drills 50% numbers progress to 50% vault use trampoline board 2-3rd wk

Bars: Full, dismount with shoes or landing in the pit (progress to landing on firm mat)

Beam: 50-60% numbers leaps and jumps, flight, dismount into pit.

Floor: 50% numbers tumbling passes/leaps/jumps tumbl trak with shoes, floor basics

Progress numbers on floor and vault with shoes as there is no pain 2 workouts in a row.

DO NOT PROGRESS VAULT and FLOOR in the same workout.

Achieve 15-20 degrees dorsiflexion, strength 4/5, good to good+ balance, able to run and jump with good foot, knee control

+ still in PT. Begin weaning from shoes or any

bracing May start by first 5 tumbling passes

or vaults no shoes and then finish the last 5 with shoes.

Gradually workout of the shoes EVERYTHING MUST BE PAINFREE

Vault: Progress 50%, 60-70, 70-80, 80-90, 100% numbers every 2 workouts without shoes (may have to do first part of workout no shoes and shoes as begin to fatigue)

Bars: Full; dismount on to firm mat no shoes or bracing.

Beam: Progress to 60-70, 70-80, 80-100% numbers every 2 workouts starting leaps, jumps, then flight series. Dismount on to firm mat no shoes or bracing.

Floor: Progress 50%, 60-70, 70-80, 80-90, 100% numbers without shoes (may have to do first part of workout no shoes and shoes as begin to fatigue)– if do 50% on the floor complete the rest

of the assignment on the tumbl track.

Skill Selection

Choose appropriate skills at the appropriate time in tissue healing time frame.

Take into account how they injured themselves (likely that movement is aggravating and will be one of the last to add in)

Respect what forces are put on the tissue in different skills

Example Skill Selections

If hyper extended the knee; stay away from front landings or blind landings until completely healed (do 1/1 instead of 1 ½)

If lateral ankle sprain stay in straight plane movements…no twisting while healing

torn/sprain MCL in knee, stay in fwd backward planes… no twisting or sideways movements until healed. (fine to do a double back but no doublefulls)(fine switch leap no switch sides)

ACL repair: stay away from double arabians, or 1 and ½ twist punch front. Stick with double lays, double tucks, front fulls, double fulls (avoid blind landings, avoid landing twisting) first 1-2 years depending on type of graft

SI joint back pain (early on avoid switch leaps and splits, running and step out things) If chronic do flic lay two foot landing instead of step out.

Return to competition status and skills depends on:– Written Medical release (ie tissue

healing)– Athletes Fitness level– Athletes confidence – Development of any fears

10 Keys to Return to competition

Continue ALL Physical Therapy exercises– If pain arises make sure being consistent

with therapy exercises with proper form. – If so check form– If not, get back on the program. – If pain not improving within 3-5 days of

doing exercise, go back to PT or MD. – If pain worsening immediately go back

to PT or MD Address any minor issues quickly

with PT or MD

Respect tissue healing Assistive Devices: utilize based on

tissue healing, wean slowly keeping in mind fatigue factor.

Skill Selection Quality vs quantity Athlete listen to their body. Coach

listens to the athlete.

Nutrition Sport Psych Rest (sleep) and recovery time

Contact Information

Perfect 10.0 Physical Therapy & Performance Training

www.perfect10physicaltherapy.com

perfect10pt@gmail.com 512-426-6593Follow Perfect10PT on gymanstike, facebook, and twitter

All information from:The Manual Therapy Institutewww.themanualtherapyinstitute

.com

Shirley Sahrmann.Diagnosis and Treatment of

Movement Impairment Syndrome.