How return to running can begin in acute injury rehab

An article for Inform Performance E-Magazine. (Includes brief videos for visual aid, around 1 min long).

Return to running is often discussed in sports rehab and we are getting spoilt with the metrics and objective measures that we can use now to help inform return to running. But what comes before this stage? Before we start achieving jump heights or reactive strength index scores, or even before that with endurance capacity tests like calf raises? There is often a quiet period of rehab, the rarely spoken, often ignored doldrums of acute injury. Priority is rightly focused on pain, range and swelling. But, we usually have a lot of time on our hands with athletes who are used to being busy and who like to move. Speaking from experience in football, a sport where running is vital to performance, fit players don’t often have time to work on their running because they are too busy training or recovering. Especially in youth sport, we can grab some much-needed time with athletes to work on running skills as part of their return to train.

I want to share some ideas and concepts that I have professionally borrowed (sounds better than stolen) that influence a lot of my rehab programs and pay forward when it comes to returning to running later down the line. I’m not going to discuss any particular injury, I’m going to leave that to you to work around with your own clinical reasoning. With that in mind, the order of these interventions will change depending on what tissues you are offloading. With most things that I share, these are concepts and not hard & fast rules.

Return to running

To be clear, I am not a sprint coach, but I want to demonstrate how we can bridge the gap from acute injury to some basic running drills. The main ones I want you to think about are the A-drills and wall drill variations that encourage triple flexion and triple extension.

So, regardless of the injury, we have some key goals that we can work towards in acute rehab (delete as appropriate to your injury):

• Plantarflexion of the ankle & Dorsiflexion of the ankle
• Full knee extension & mid / inner range knee flexion
• Hip extension & inner range hip flexion

I would argue that is not teaching anyone anything new. But part of rehab is to regress some of the demands and build back up. So let’s think about some of the contributing factors that will form the foundations of those movements and then using the rehabilitation progression model that Phil Glasgow and I published in 2017, demonstrate how they interact and develop into something that starts to look like running.

Break it down to build it back up

A big win for me in most rehabs is addressing the coordination and interaction around the femur, the pelvis and the trunk. Firstly, the ability to independently move one segment, in order to focus proprioception, before building to more complex movements that involve multi-segmental coordination. The ability to switch between isolated and involved movements, or your brains ability to handle that information, being called “dissociation”. Rehab is an opportunity to allow these movements to be conscious, with high repetitions, encouraging them therefore to become subconscious and more automated on a return to sport.

Femur & pelvis

This could be a massive discussion as we look at all the variations of how the femur interacts with the pelvis during movement. But let’s go back to thinking about those A-drills. Flexion and extension of the hip should be straight forward. But what about the role of pelvic tilt during that flexion and extension?

Anterior-posterior tilt exercises: https://youtu.be/5VA_ypzeeLA

And not just anterior to posterior, but often the importance of lateral pelvic tilt is ignored.

Lateral tilt? In sprinting? Surely that’s a big energy leak… well.. yes and no. This is different to a hip hitch, which can be a passive movement and demonstrate a lack of control. We can build up awareness of a lateral tilt and learn how to resist against it but also, there is possibly an element of hip extension during running that gets forgotten. The active distraction of the femur from the pelvis.

Hip distraction and lateral tilt exercises: https://youtu.be/zYW5dpw6oi0

Indulge me for a second whilst we talk anatomy.

Psoas:

Don’t worry, I’m not going to ask if you think you can palpate it or not.

Traditionally the iliopsoas (the combined tendon of the broad, flat iliacus muscle and longer thicker psoas muscle) has been considered a conjoint tendon. Recent anatomical studies have started to debate this, with potentially two distinct tendons. There is anatomical variance, what was previously discussed as a rare variant, it is now believed that the majority of cases demonstrate >2 tendons (Polster et al 2008; Guillin et al 2009; Philippon et al 2014). Furthermore, in the cases of more than one tendon, the isolated psoas tendon is significantly thicker than the accessory iliacus tendon. This is of interest in a rehab setting.

The purpose of these studies is mostly surgical, research into the roles of the two tendons in function is not as strong. However, Suzanne Scott (one of my go-to resources for movement and anatomy) believes that the thickened tendon demonstrates a role beyond simple hip flexion, instead acting in much the same way as an Achilles tendon in energy storage. The spring of the hip.

To load this spring, we have two methods:

1. Distraction of the hip
2. Extension.

In both cases, we need to create active stiffness, so this is where our dissociation comes into play. In these examples, we are looking to keep the trunk stiff whilst we load and release through the hip. (Ensuring that trunk mobility and control is addressed elsewhere in the program).

This in turn benefits our ability to “snap” into hip flexion. Adding tension into extension to spring into flexion, with consistent cues around “push the floor away” or “drive into the floor”.

With any inner range, we are inefficient in contraction ability and strength (due to shortened actin-myosin cross bridge formations), we also have the issue over space in the anterior joint, so working into strength positions in this range along with pelvic control, is going benefit that spring later on. From this inner range position, we have a greater ability to drive down into the floor as we start the reloading process of the spring all over again.

Loading the spring: https://youtu.be/EKdEDlkPaPE

Inner range hip strength: https://youtu.be/r3s4pxL7f7A

If we are looking to load that spring when running, I’m thinking here about the foot strike and push off from the ground, then this spring needs a solid frame built around it in order to maximise that energy storage. So, whilst maintain trunk stiffness and exploring lateral tilt of the pelvis, we can also look to resist against it. Our biggest ally in this is the gluteus medius. Where possible, I believe the lateral hip should be loaded as much as possible in a closed chain. I think exercises like “clams” are poorly prescribed and the rational is often flawed. This is why.

Gluteus medius

Gluteus Medius strength and function is an important consideration to running due to the role in coronal plane stability of the pelvis during the stance phase of running. It is another muscle that is grouped together and treated as a singularity, when in fact, morphologically the muscle has three distinct parts, anterior, middle and posterior, each varying in size and demonstrating separate innervation for each part (Al-Hayani, 2009). The direction of the fibres of the anterior and middle parts of the gluteus medius (and the anterior part of the gluteus minimus) suggests that they have vertical pull and initiate (key word) abduction, which is then completed by the tensor fasciae latae.

The middle and anterior gluteus medius is relatively large in cross-sectional area, has a large abduction moment arm and has fascicles that are aligned relatively vertical in the coronal plane (Flack et al 2014). On a fixed lower limb, these morphological characteristics are ideal for generating the large torques required to absorb the vertical ground reaction forces imposed on the body and to support coronal plane pelvic alignment during the early stance phase of running (Semciw 2016).

EMG analysis of gluteus medius during running was typically presented as mono-phasic, with peak activity occurring just after initial contact (Semciw 2016). One study presented a bi-phasic pattern, with a second, smaller burst of activity occurring at toe-off (Gazendam et al., 2007).

So, whilst they initiate abduction, they play a bigger role in the stance phase of walking and running. Therefore, I more interested in their role of pelvic stability. Lets flip that abduction movement around and fix the femur, the movement now begins to look more like a lateral tilt, a much smaller movement through range than abduction but one that will benefit our foot strike and our psoas spring.

Glute med exercises: https://youtu.be/OYXuh2eTuCU

“Coming together is the beginning, working together is success”

So, at differing stages depending on the injury, we have worked individually on pelvic movement, lateral hip contraction, loading the hip flexors as a spring via distraction and also in the inner range, we have encouraged active trunk stiffness throughout to support these processes. As the rehab progresses, it becomes important to move away from isolation and look to combine these drills to increase complexity and transition back to running.

Figure 1: Blanchard & Glasgow 2017 rehab progression model

The options with each progression become greater and depend on your clinical reasoning skills to add variables. The next two suggestions are very basic exercises to demonstrate that progression.

Dead bug:

There are many variations of a “dead bug” exercise but one for me that really translates into what we are trying to achieve from a running perspective. One that combines inner range hip strength, active trunk stiffness, hip extension and distraction and all mixed together into a complex dissociation exercise. A simple, low load drill that can be added to most programs either at the beginning as a familiarisation pattern or at the end to work control under fatigue.

Dead bug: https://youtu.be/M2xldzMgNTs

Hurdle step over:

From what I’ve seen, most sports will build in hurdle drills to some form of gym or warm up session. But how well is it coached? What is the aim and rationale? How passive do most athletes look when they are stepping over hurdles, honestly?

Some typical “cheating” movements I look out for in hurdle drills mostly involve flexion where its not wanted. When an athlete is lacking inner range hip flexion strength or control for example, they will flex at the trunk and drop into anterior pelvic tilt as they try to “pull” the femur closer to the body to clear a hurdle.

This is quite commonly combined with a passive flexion of the standing knee, relaxing the proximal portion of the quads to allow this movement. What benefit does this serve? I guess this depends on why the hurdle step overs have been prescribed in the first place, but if its to act as a constraint and encourage good hip mobility, good active hip mobility, in prep for running, then this cheat makes it a waste of time.

Figure 1: Blanchard & Glasgow rehabilitation program (2017)

Using our regressed exercises from above, we have hopefully provided the coordination, control and strength to perform this movement with more purpose. So, focusing on a triple extension of the standing leg, getting terminal knee extension, “pushing the floor away” or “leaving a footprint on the floor” we should also get the hip distraction, loading the spring. In turn, this cueing of the standing leg should therefore transfer into a quick, active “snap” into posterior tilt, clearing space in the anterior hip of the flexed leg and all done with a strong, stiff trunk.. looking much like our A-drills. 

Hurdle drills: https://youtu.be/2LLAAvOfpm8

On you go..

The list of exercise potential is endless, so many variations and constraints that can be added or tweaked. Most people will have their go-to list of drills that achieve exactly what I have explained here. The purpose of this piece today was to add some depth to the acute stages of injury, where we are often left wanting and adding time fillers to the program. Hopefully this has sparked some ideas or direction to where you could go with running drills even in the early days of injury. As the great Phil Glasgow says, “Rehab is training in the presence of injury” and if you can use the time to strip back complex drills knowing that the repetition and coordination will be useful on return to sport, then try and maximise your time and optimally load at every opportunity.

This article was written for the first edition of the Inform Performance e-magazine (here) which includes many brilliant contributions from the leading practitioners in sport.

References:

Al-Hayani, A., 2009. The functional anatomy of hip abductors. Folia morphologica, 68(2), pp.98-103

Blanchard, S. and Glasgow, P., 2017. A theoretical model for exercise progressions as part of a complex rehabilitation programme design.

Flack, N.A.M.S., Nicholson, H.D. and Woodley, S.J., 2014. The anatomy of the hip abductor muscles. Clinical anatomy, 27(2), pp.241-253.

 Gazendam, M.G. and Hof, A.L., 2007. Averaged EMG profiles in jogging and running at different speeds. Gait & posture, 25(4), pp.604-614.

Guillin, R., Cardinal, É. and Bureau, N.J., 2009. Sonographic anatomy and dynamic study of the normal iliopsoas musculotendinous junction. European radiology, 19(4), pp.995-1001.

Philippon, M.J., Devitt, B.M., Campbell, K.J., Michalski, M.P., Espinoza, C., Wijdicks, C.A. and LaPrade, R.F., 2014. Anatomic variance of the iliopsoas tendon. The American Journal of Sports Medicine, 42(4), pp.807-811.

Polster, J.M., Elgabaly, M., Lee, H., Klika, A., Drake, R. and Barsoum, W., 2008. MRI and gross anatomy of the iliopsoas tendon complex. Skeletal radiology, 37(1), pp.55-58.

Semciw, A., Neate, R. and Pizzari, T., 2016. Running related gluteus medius function in health and injury: a systematic review with meta-analysis. Journal of Electromyography and Kinesiology, 30, pp.98-110.

Taking your time with acute injuries

One of the benefits of working in sport is that you usually get to see injuries first hand, the mechanism, the severity, even the initial management. We have discussed pitch sidee management before (here) but what about the day, or days, following? Are we doing enough to aid the healing processes in the early stages, or perhaps too much? With our best intentions of helping an injured athlete, are we over looking the importance of “protection”?

This blog discusses the assessment of those more serious injuries – the ones that require athletes to stop in their tracks, cease the game / training. Not those little niggles that walk in at the end of the day.

Reasoning with the history:

Knowledge of the mechanism of injury can greatly aid your management throughout the later stages of your treatment. Muscular injuries for example, can be simply divided into two traumatic categories; direct (laceration and contusion) and indirect (strains) (Huard et al 2002 (here); Petersen & Holmlich 2005 (here)). Appreciating the differences in these mechanisms will certainly influence your return to train criteria later on, but what about in the acute settings? Would your treatment change on day 1 or 2 with these different mechanisms? Skeletal muscles are built of basic structural elements, myofibers. Individual myofibrils are surrounded by the endomysium and bundles of myofibrils are surrounded by the perimysium (Haurd et al 2002). Lower grade injuries such as exercise induced muscle fatigue, will only affect the myofibrils, resulting in raised creatine kinease levels (Ahmad et al 2013 here). Regardless of the mechanism, damage to the fascia and extracellular matrix would be consistent with a higher grade injury and would see the release of muscle enzymes, destruction of collagen and proteoglycans as well as the presence of inflammation (Huard et al 2002; Ahmad et al 2013). The formation of haematomas in combination with inflammation can create an ischaemic environment, increasing the risk of further muscle damage (Ahmad et al 2013).

There seems to be an false sense of urgency created in these acute situations, especially at the elite level where time lost to injury means big money and with that brings an extra level of stress and pressure to the therapist, the athlete & the coach. But the injury has happened.. we can’t change that! We can certainly make it worse though. What are we expecting to find and see with our immediate objective tests? Lets say we have just seen someone recoil, fall to the floor clutching their hamstring, unable to walk off the field of play.. is a straight leg raise or resisted knee flexion test going to tell us something we didn’t already know? OK, so maybe we want to give all parties an idea of how bad this is.

“Do you think its grade one or two?” 

“Yes?”

There are numerous injury classification systems currently used in practice, although traditional classifications can be confusing. Ahmad et al (2013) describe 3 grades of injury from mild to severe, with one set of definitions relating to clinical presentation but with differing definitions depending on the influence of Magnetic Resonance Imaging (MRI). When I was training, we used the Gr I, II & III system that was disseminated by Peetrons in 2002 (here). In 2012, the Munich consensus group (paper here) sought to clarify the term “strain” and provide a structured classification system for clinicians. Table 1 is an overview of the existing classification systems pre-2012 that are widely used in the literature as well as clinical practice.

	O’Donoghue 1962	Ryan 1969 (initially for quadriceps)	Takebayashi 1995, Peetrons 2002 (Ultrasound-based)	Stoller 2007 (MRI-based)
Grade I	No appreciable tissue tearing, no loss of function or strength, only a low-grade inflammatory response	Tear of a few muscle fibres, fascia remaining intact	No abnormalities or diffuse bleeding with/without focal fibre rupture less than 5% of the muscle involved	MRI-negative=0% structural damage. Hyperintense oedema with or without hemorrhage
Grade II	Tissue damage, strength of the musculotendinous unit reduced, some residual function	Tear of a moderate number of fibres, fascia remaining intact	Partial rupture: focal fibre rupture more than 5% of the muscle involved with/without fascial injury	MRI-positive with tearing up to 50% of the muscle fibres. Possible hyperintense focal defect and partial retraction of muscle fibres
Grade III	Complete tear of musculotendinous unit, complete loss of function	Tear of many fibres with partial tearing of the fascia	Complete muscle rupture with retraction, fascial injury	Muscle rupture=100% structural damage. Complete tearing with or without muscle retraction
Grade IV	X	Complete tear of the muscle and fascia of the muscle–tendon unit	X	X

Table 1: Descriptions of muscle classification systems used clinically From Mueller-Wohlfahrt et al (2012)

The Munich consensus established that there was disparaging definitions amongst clinicians regarding the term “strain” and also the classification of injury. The rise of imaging to support clinical findings further added to the confusion of defining a Grade I injury that may not be present on MRI. Amongst many irregularities with the classification systems in Table 1, there was the vague nature of defining when one grade becomes another. As a result, Mueller-Wohlfahrt et al (2012) produced a new classification system that included delayed onset muscle soreness (DOMS) & contusions and allowed clinicians greater manoeuvrability in diagnosing muscle injuries. In 2014, this was taken a step further by Noel Pollock and colleagues at  British Athletics (paper here) (he explains why much better than I could, here on this BJSM podcast).

“If you can’t help them, at least don’t hurt them” – Dalai Lama

I’m pretty sure he just referenced the Dalai Lama…

So with all this confusion regarding classification ,what are we supposed to say to the athlete and what are we to do? Things always look bad in the initial stages. Generally if there is pain on the way to the treatment room (if they have stopped playing, then there almost certainly will be) how much more do you need to know? This is where the mechanism & history is key. It may be required to rule out any bony injury at this stage, but again, if you have seen them pull up and clutch a muscle belly then that may not be essential – a bonus of being pitch side to observe such things. What about ligamentous injuries? Well do we need to assess instability today? Is there a chance that we could make something that is stable unstable by repeatedly testing it in the early stages? Even if we think its severe, like a complete ACL, most surgeons won’t operate while there is active swelling anyway. Some specific injuries DO require this, hand injuries for example may require more immediate attention from an orthopedic surgeon. Or total syndesmosis ruptures that usually require an operation within 2 weeks. (A good discussion on this injury was had recently by the PT Inquest guys here)

In the very acute stages (I’m talking first day or two) our role is to help reduce and minimize pain, reduce risk of secondary injury and ensure the athlete is safe to mobilize at home independently. What do we gain by giving them a classification of injury there and then?

“Lets let the swelling and pain settle down, get you comfortable and in a day or two we will be able to be more accurate with our assessment and diagnosis” – I think thats a pretty reasonable thing to say on the day of an injury and I’m yet to have any complaints from athletes, providing you explain why you are doing this. I’m not going to expose myself to sensitivity and specificity of tests because I will undoubtedly get it wrong, but in the heat of the moment, when everything hurts, you will almost certainly find false positives in tests – resulting in inaccurate diagnosis.

I’ll admit, this takes a bit of confidence. When the treatment room is full of staff, other athletes, the injured athlete themselves. To stand there and hardly do anything seems counter intuitive. But take a breath and ask yourself, “what do I NEED to know at this very moment?” It shouldn’t be, “What tests do I know that I could use here” – these two questions are very subtly different but the actions that follow them are huge. You aren’t there to show the room what assessment skills you have, not on day one. Respect the injury.

The next couple of days can also tell you a lot of information without you needing to pull and prod on the table. Whats the 24 hour pattern of pain? Any sign of inflammation? Yes? Then whats a prolonged assessment going to do other than promote more inflammation. Check Aggravating / easing factors or limiting ADLs – getting on and off the toilet seat without excruciating pain may be enough info that you don’t need to assess a squat today. Again, be comfortable treating what you do know, treat the inflammation and the pain. When that settles, we can begin to explore a bit more specifically. Will a positive test today get them back to training quicker? No.

What about treatments?

The classic PRICE guidelines have now been superseded by the POLICE (Protect, Optimal Loading, Ice, Compression, Elevation) guidelines (here). I’ve previously debated the clinical relevance of ice here and regular readers of this blog (mum and my mate Conor) are probably familiar with my interest in Optimal Loading. Regardless of if you use PRICE or POLICE, one thing we seem to overlook is the very first letter. Protect. Protect the injury from secondary damage and unnecessary pain. This may mean not doing very much at all. Consider the nociceptive input of us repeatedly prodding the injury, whether its part of assessment or treatment. Again, we go back to the pressures of sport – to have an athlete sat there doing nothing can be uncomfortable for the staff and boring for the athlete. This is where the creativity of “optimal loading” comes in handy. Protect the injury, keep the rest of the athlete busy.

Summary

I’m not suggesting we just sit and wait for weeks hoping they get better on their own, but just try and think about why you want to assess something and how is that answer going to influence your management on this day. I appreciate that objective measures are going to be beneficial, but just take the ones you need. Now obviously, if symptoms drastically improve over night, we can be a bit more direct with our assessment. It’s here we can start to expand our objective measures.

• Don’t rush to a diagnosis or classification (have the differentials in the back of your mind or discuss them with colleagues / club doctors)
• Don’t over assess for the sake of it (do enough to keep the athlete safe but minimize effects of injury)
• Don’t over treat (sometimes, less is more!)

 

Remember, this isn’t aimed at those little niggly injuries that DO warrant further assessment – in these cases a thorough assessment may actually help reduce the risk of a full blown injury. Instead, this is for those injuries that you know in the back of your mind are out for a few days / weeks. If anything, the more severe (duration) the injury, the less acute assessment required perhaps? Just remember to exclude all those nasties!!

I appreciate I’ve probably given more questions than answers in this blog, but that was the aim. This wasn’t supposed to be a recipe but has hopefully sparked some questions about your clinical reasoning.

 

Yours in sport,

Sam