Dual Rehabilitation for Return to Sport

Andy Bradford

Independence Health Outpatient Rehab at Norwin Square

November 10th, 2023

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 Table of Contents

Background of Study 3

Background of Athlete 4

Planning Prior to Intervention 5

Intervention 7

Evaluation 8

References 10

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Background of Study

This study will be conducted in the Outpatient Rehabilitation department of

Independence Health, specifically at the clinic in Norwin Square. The clinic itself, houses a large

gym with a variety of equipment ranging from machines, free weights, and an Alter G treadmill.

The clinic has anywhere from four to eight physical therapists and physical therapy assistants

who see roughly fifty to eighty patients per day. Throughout the study the selected athlete will be

working with the supervisor of the study Dan Schaus, the lead physical therapist and of the clinic

who specializes in orthopedic and sports medicine rehabilitation. The clinic sees a variety of

athletes and sports related injuries who work in a collaborative way to motivate each other in

their recovery.

The subject of the study is a 20-year-old male college football player at Seton Hill

University, originally from the Cleveland Ohio area. Over the course of the last three months, he

has had a surgical reconstruction of his ACL and a repair of the labrum in his shoulder, both of

which are reinjuries and required repeat surgical intervention. The athlete initially injured his

knee in a football game a year ago but suffered a reinjury while rehabilitating the knee

performing sport specific movements. Similarly, the athlete suffered an injury to the labrum a

few years ago but has since had recurring dislocations that the surgeon felt would benefit from a

surgical procedure. When selecting this individual as the intended subject of the study, I

discussed at length with Dan about his upcoming patient load and any interesting sports related

injuries that he has to evaluate on his upcoming schedule. After discussing a few possibilities, we

decided that the rehab process of our selected subject would present the best learning opportunity

as the case had a lot of different aspects to it.

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Background of Athlete

The athlete that we selected for participation in the study is a current division two

football player at Seton Hill University. Prior to college athletics, he was a member of his high

school basketball and track team. Due to his extensive participation in athletics, he is regularly

involved in sport specific training and conditioning programs. Since his injuries his is restricted

from any sport related activity due to the injury and repair of both a lower and upper extremities.

With this in mind, it does present some considerations of the exercises and activity that we are

able to perform in his sessions. Additionally, with him being from out of state, there were some

presented challenges faced in terms of insurance and the number of times that we are able to treat

him in the clinic. Throughout the study, we were in constant communication with the orthopedic

surgeon and physician assistant who performed both operations discussing and planning a proper

plan of care to safely return him to athletic competition. Current medications that the subject

takes can be found in the chart below:

Medication Purpose Side Effects Impact

Ibuprofen NSAID used for pain Abdominal pain, nausea, Relieves pain post-

control after surgery and indigestion, shortness of surgery and after

after rehabilitation. breath rehabilitation to improve

ability to perform rehab

exercises.

Tylenol Pain reliever used to Stomach pain, loss of Reduces pain post-surgery

reduce pain after surgery appetite, fatigue, itching and rehabilitation and

once he was off opioid improves ability to

medication. perform daily activities

pain free.

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 Creatine Improve performance Weight gain, dizziness, Improves ability to

when training by nausea, hyperhidrosis perform training

increasing energy to the exercises.

muscles.

Vitamin D Doctor recommended Nausea and vomiting, Promotes calcium

to improve vitamin D poor appetite, weight absorption in the body.

levels in the body. loss

Planning Prior to Intervention

Football is a very demanding game and requires a variety of physical attributes to be

successful on the field. These skills include explosiveness, speed, acceleration, and strength to be

skilled at any position. However, some other positions require additional skills such as hand-eye

coordination, agility, and jumping in order to be considered for a “skill position” like a wide

receiver (Fullagar et al., 2017). While football is an extremely common sport, there is a very high

risk for injury with 10-35 injures occurring per 1000 playing hours (Hernandez et al., 2022).

Common injuries that are found within the game of football include concussions, ankle sprains,

and knee injuries. Knee injuries are especially commonly found within the game of football, with

54% of players in a study of 322 are found to have a history of knee injury due to participation in

football (Bradley et al., 2008). In addition to these injuries, shoulders are also commonly injured

when participating in football activity. Similar to the studies conducted about knee injuries, a

cohort study was conducted looking at injuries to the shoulder. In a pool of 336 athletes, half of

them had a history of shoulder injuries with 73 of those injuries requiring surgical repair (Kaplan

et al., 2007). Shoulder injuries are rehabilitated to return the athlete to competition safely by

restoring most of the athlete’s strength and range of motion prior to the injury. Most

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rehabilitation programs are broken into three stages. Stage one work to restore range of motion

both passively and actively, while preventing stiffness of the shoulder. Next, stage two

incorporates light strengthening while also working to restore range of motion. Lastly, both

strength and range of motion are worked till restoration of prior capabilities. A consideration for

the subject of this study is the presence of a prior ACL reconstruction within the past four months

of the conduction of rehabilitation to the shoulder. This can limit his capability of performing

some exercises and rehabilitation modalities due to his prior surgical history (Marques et al.,

2020).

The purpose of this study is to observe the rehabilitation goals and process of multiple

injuries prior to returning a high-level athlete to competition. With this purpose in mind, the staff

as a whole look to provide high-quality care for the patient. For the athlete one of the intended

outcomes, we laid out for him is to return to play safely once rehabilitated from both injuries. To

fulfill this outcome, he will be able to perform football specific agility movements by the

beginning of next season and will be able to return to upper body strength training to restore full

shoulder strength. We also intend to educate him on his injuries in the time that he spends in the

clinic. By the end of his time spent with Dan and I, he will become educated on mechanisms that

can lead to reinjury, ways to prevent the recurring injury including exercises and stretches, and

exercises and stretches to continue outside of the clinic. While there are no “formal” tests that we

will be conducting throughout the rehab process, the most important aspect will be monitoring

his progress in terms of degrees of motion, weight for certain exercises, and repetitions

performed for each exercise. Especially for the initial phase out of surgery, it is crucial to

monitor the range of motion as it dictates the pace at which we can move through the treatment

plan. Throughout the program to this point, considerations needed to be made regarding the pace

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we could move through the program with regards to each injury. For example, at the time where

the ACL program was scheduled to start jogging, we could not progress to jogging due to the

shoulder being in the sling and unable to perform a safe and effective jogging motion. Outside of

the sessions in the clinic, the only activity he performs are recommended exercise at the gym at

school as well as working with the Seton Hill athletic training staff.

Intervention

In order for adequate rehabilitation to occur, a proper exercise program was designed for

our selected athlete to safely return to athletic competition. The first part of our plan was a

scheduled initial evaluation of the patient in order to gain an understanding of his medical history

and history of previous injuries that would affect his therapy regimen. We also used this time to

educate the individual on prevention of future injury, mechanisms that could have caused his

injury, and outline a return to play/activity timeline in coordination with the referring physician.

Once the initial evaluation was completed, a three-stage protocol was developed. Stage one is to

restore proper range of motion of both the shoulder and the knee. This stage progresses in

developing passive, active-assisted, and finally active range of motion of both extremities before

progressing into stage two. One consideration to note is the knee is further out from surgery, so

was able to be progressed into stage two quicker than the shoulder. Stage two then implements

light strengthening of the shoulder and knee, while further continuing to restore full range of

motion. As noted, the shoulder surgery being closer to the initiation of the program placed a limit

on the exercises capable of being completed. The final stage of the protocol involves progression

into sport specific exercises and movements. This includes plyometrics and cutting movements

to continue development of the knee, and increased strength training and lifting with the affected

shoulder.

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Evaluation

As the program has progressed, the subject has made tremendous strides to returning to

athletics. At the point of completion of the internship, the individual is roughly five months out

from ACL reconstruction and three months from glenoid labrum repair. To this point, he has

achieved full range of motion of the knee including 130 degrees of flexion and full extension. He

has since started to progress into light plyometric movements and strengthening exercises,

including 140 lbs with three sets of ten reptations on the leg press machine with a wobble board

placed at his feet. He has also begun to jog outside of the Alter G treadmill, with three-minute

intervals of jogging and running for fifteen minutes. With the shoulder, range of motion met

expectations with 110 degrees of forward flexion, and minimal pain with abduction to 90

degrees. He has begun light strengthening with light weight dumbbells focusing on some internal

and external rotation of the shoulder. Throughout spent with the athlete, we were able to achieve

proper education on prevention of future history. This was a main objective of our protocol due

to his significant injury history and hope that he can use what he has learned as he continues his

athletic career. At this point in time, he is not yet ready to return to full athletic competition as

both injuries are not adequately rehabilitated. With more time spent in physical therapy, I hope

that he is able to achieve our outlined goals of returning to sport specific movements and

resistance training. At the conclusion of his time in physical therapy, I would discuss how he has

improved in both range of motion and strength of both injuries by presenting his starting

measurements and data and comparing them to his finalized data at the time of clearance.

Throughout the time of my internship, the subject has demonstrated interest in the development

of the project and has expressed his gratitude for the additional input that he has received

throughout the sessions that I have been apart of. When discussing the study with Dan, the

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supervisor of the study, I have received tremendous feedback about the content of the study, the

questions that I asked throughout the sessions, and the overall progression and adaptability of the

study. Overall, the study conducted went very well with very little barriers. This has been made

possible because of the support that I have received from the Outpatient Rehabilitation

department from Independence Health, my supervisor Dan, and the participation of the subject.

The subject displayed 100% attendance to all sessions, which made the process much easier to

observe progression and development over the course of the semester. Through this process, I

have gained invaluable insight into the rehabilitation process that I hope to take with me in my

future career.

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 References:

Bradley, J., Honkamp, N., Jost, P., West, R., Norwig, J., & Kaplan, L. (2008). Incidence and variance of

knee injuries in elite college football players. Journal of Orthopedic Surgery and Research, 37(6).

Fullagar, H. H. K., McCunn, R., & Murray, A. (2017). Updated Review of the Applied Physiology of

American College Football: Physical Demands, Strength and Conditioning, Nutrition, and Injury

Characteristics of America’s Favorite Game. International Journal of Sports Physiology and

Performance, 12(10), 1396–1403. https://doi.org/10.1123/ijspp.2016-0783

Hernandez, R. J., Lamplot, J. D., Hammond, K. E., Joshi, N. B., Wong, P. K., Umpirrez, M., Singer, A., &

Gonzalez, F. M. (2022). Knee Injuries in the Elite American Football Player: A Descriptive

Pictorial Imaging and Mechanism of Injury Review. Journal of Computer Assisted Tomography,

46(2), 197–211. https://doi.org/10.1097/RCT.0000000000001259

Kaplan, L., Flanigan, D., Norwig, J., Jost, P., & Bradley, J. (2007). Prevalence and Variance of Shoulder

Injuries in Elite Collegiate Football Players. Yearbook of Sports Medicine, 33(8), 36–37.

https://doi.org/10.1016/s0162-0908(08)70039-4

Marques, F. da S., Barbosa, P. H. B., Alves, P. R., Zelada, S., Nunes, R. P. da S., de Souza, M. R., Pedro,

M. do A. C., Nunes, J. F., Alves, W. M., & de Campos, G. C. (2020). Anterior Knee Pain After

Anterior Cruciate Ligament Reconstruction. Orthopaedic Journal of Sports Medicine, 8(10),

232596712096108. https://doi.org/10.1177/2325967120961082

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