Facing the Unknown

No matter how many athletes you’ve treated, chances are you’ll encounter a handful of rehab situations in your career that have you drawing a blank. From a veteran in the field, here’s a guide to handling any new situation with confidence.

By Maria Hutsick

Maria Hutsick, MS, ATC/L, CSCS, is Head Athletic Trainer at Boston University, as well as Head Athletic Trainer for the USA Hockey Women’s National Team. She can be reached at loon102@hotmail.com.

Training & Conditioning, 13.3, April 2003, http://www.momentummedia.com/articles/tc/tc1303/facingunknown.htm

Like most athletic trainers, I hate feeling that I don’t know how to handle something. But we’ve all been there. It’s simply not possible to know everything about every conceivable injury and rehab protocol.

When presented with an unfamiliar injury, we still need to treat the athlete and get him or her back in the game. Unfortunately, athletes often return from surgery accompanied by only a brief description of what the rehab should include. If this happens to you, what resources can you access to educate yourself about this particular operation in order to have a successful outcome?

I’ve been in the field for over 20 years, yet periodically I’m still presented with cases where I’m not immediately sure what to do. But at this point, I have a firm game plan for how to put a rehab protocol together even when I’m starting from scratch. The following thoughts will illustrate how to go from a blank slate to a fully realized rehab protocol.

In 2002, while I was working with the U.S. Olympic women’s ice hockey team, an athlete came to me with an injury I wasn’t familiar with. Sara DeCosta, a 26-year-old goalie, was struggling with chronic hip pain in her right joint. She had sustained an injury to the area in 1999 during her college career. She continued to have pain that increased during the Olympic tour, but declined treatment until after the Games. Sara had competed in the 1998 Olympics, helping the U.S. team win a gold medal, then returned to win a silver medal in the 2002 Olympics.

Even though she was able to compete at a high level, she did so with a lot of pain. Once the Olympics had ended and she had some time to slow down, Sara contacted me about revisiting her hip pain. Since we live about 40 miles apart we were able to see each other and begin to have her hip pain diagnosed.

I sent Sara to see Timothy Foster, MD, the orthopedic surgeon who works with the athletic program at Boston University. He evaluated her, and ordered an MRA and plain x-rays. The MRA revealed a large anterior superior tear of her labrum. Dr. Foster recommended a consult with Joseph McCarthy, MD, of New England Baptist Hospital, a surgeon in Boston who specializes in this type of injury.

This surgery is not performed widely, and many people are skeptical about the results. So, I called several athletic trainers I know at both the college and professional levels who have had athletes with this type of injury to get their opinions. They all felt Sara needed to have this procedure done. In addition, my colleagues who had athletes treated by Dr. McCarthy recommended him as their first choice.

Sara, her mother, and I met with Dr. McCarthy in early December 2002. We spent a considerable amount of time talking with him about the injury and the proposed surgery. Dr. McCarthy assured Sara that he had performed the procedure many times before, and he gave her names of some of the professional hockey players he had performed it on. He also told us he had played football at Notre Dame and that he understood what she was going through as a competitive athlete eager to recover from injury. Based on his reputation and our initial impressions, we decided to go with Dr. McCarthy.

Also at this meeting, I asked for some basic information I would need to start designing Sara’s rehab, and to help me communicate with her coach about how long she was going to be out of commission. I needed to know what the surgery would entail; what side effects might occur; what the recovery rate was; how long it would take Sara to get back on the ice; whether there was a danger of recurring injury; whether Sara had any degeneration in the hip; and what the rehab would entail.

Dr. McCarthy informed us that Sara had a huge tear of her labrum that was getting pinched up into the joint, which is why it was always irritated and sore. The procedure would involve arthroscopically removing the tear of her labrum. Because she didn’t have any degeneration in the joint, it was going to be a pretty straightforward rehab. He reassured Sara that although she would be really sore for the first two or three days, she would feel a lot better very quickly after that. He also told me that, in the early part of her rehab, it was important to stay away from hip extension and extreme hip flexion.

At this stage, Sara was hoping to be ready for the World Championships in April 2003, so Dr. McCarthy scheduled her surgery for two weeks after our meeting. This would give us a little over three months to get her ready for the competition. Sara was too sore at this point to do any strengthening or any type of “prehab,” but the time allowed me to start working on her rehab protocol.

One complication was that I was not going to be able to act as Sara’s primary athletic trainer for her rehab. However, because she lives fairly nearby, I would see her once a month, and she would work with another athletic trainer that she had a previous relationship with, Mark Stephenson, ATC, CSCS, who runs North East Sports Training and Rehabilitation, in Warwick, R.I.

The plan was that we would use a team approach. I would design Sara’s workouts, but she would do her day-to-day rehab with Mark. I would go to Sara’s follow-up visits with Dr. McCarthy and call Mark with any relevant information. Then we would consult about where to go from there.

A Little Help From Friends
When I begin a rehabilitation program with a doctor who I have not worked closely with in the past, or with a surgical procedure that I’m unfamiliar with, I utilize as many resources as possible. Talking with other professionals helps me learn the best approach and makes me aware of potential problems.

In general, I first talk to other athletic trainers I know, as well as to ATCs at schools with good programs in that sport, and ask if they have seen this injury and how they treat it. Athletic trainers at all levels are almost always willing to help.

In this case, my phone calls went to an athletic trainer with the Boston Bruins and to the Pittsburgh Penguins team doctor, because I knew they’d had experience with this type of surgery. They told me the rehab is pretty straightforward, and pretty much like any joint rehab. The only bad experience the Penguins doctor had had was with a player who was not conscientious about doing his rehab. The Bruins athletic trainer talked to me at length about what the surgery entailed. And, of course, I got suggestions from my colleagues about elements of rehab protocols that had worked for them. We talked about how long the rehabilitation should take, pitfalls, and any other tips that they had.

I also talked to a few of our former BU hockey players who had had this surgery, and asked about their experiences to get the athletes’ perspectives. And I gave Sara their phone numbers so she could talk to them before her surgery. But I didn’t stop there.

Digging Deeper
There are many other places to go for helpful information. If your university has a medical school or school of allied health professions, you could network with specialists there. Or consider speaking with a former professor you had in undergraduate or graduate school.

The Internet can also be a great resource. There are several Web sites that offer good information, such as MedLine.com and Virtual Hospital (www.vh.org). You may even just try going to a search engine like Google or Netscape.

Many colleges have their own search engines—at Boston University we use OVID. This accesses our medical libraries and a variety of sites. Find out what your school offers.

There are also orthopedic and arthroscopic message boards. For example, Google’s can be accessed through Google Groups by typing in “sci.med.orthopedics” or following the links under “sci”. Once there, you can type in “Re: hip labral tear” and ask questions about anything regarding this surgery or any others. Also, Wheeless’ Textbook of Orthopaedics has a good Web site (Wheeless.orthoweb.be). For Sara’s case, I started by searching PubMed (www.ncbi.nlm.nih.gov/pubmed), where, I came across an article entitled “Hip Arthroscopy for Acetabular Labral Tears” by Laith Farjo, MD, James Glick, MD, and Thomas Sampson, MD, published in Arthroscopy (1999 Mar; 15(2):132-7).

And don’t neglect the old-fashioned, trusty textbook. One in particular is Therapeutic Exercise for Athletic Trainers by Peg Houglum (Human Kinetics: Champaign, Ill, 2001). Ecampus.com is a good Web site that lists a variety of textbooks that may prove useful.

From Plan to Action
After you have gathered as much information as possible you can begin to put together your rehab protocol. With every rehab, you work on range of motion first, then basic strength, then you go to balance and coordination, and, finally, to sport-specific types of activities. You have to understand the biomechanics of the particular joint or area you’re dealing with and how it’s used in the athlete’s particular sport, and you proceed accordingly. Every rehab is going to be based on those principles.

Part of any rehab protocol will be dictated by your available resources, including both equipment and time. I had visited Mark’s clinic and knew the equipment he had available for Sara. Together, we planned a program incorporating our expertise, our newly learned information, and the outline that the surgeon’s nurse provided as a basis for rehabilitation. The program we came up with is shown in Table One below.

When following any protocol, it’s important to use your athlete’s pain and swelling as a guide. If the athlete is sore and not progressing, you are doing too much and need to adjust the volume, intensity, and perhaps an exercise or two. Stay in close touch with your surgeon and ask for help if you need it.

Sara’s original intent was to return to the ice in time to play in the World Championships in April 2003. She would have needed to be skating at full strength and participating in full goalie practice at least three weeks prior to those games. At the end of February, Sara and her coach decided that even though she was progressing well and would probably be ready in time for the Championships, her long-term outcome would be better if she moved the end-point of her rehab. So, while she won’t be wearing the red, white, and blue in goal during the 2003 Championships, her recovery is going well and she expects to be out on the ice skating competitively in the near future.

Table One: Rehab Protocol

The following is the sample rehab protocol we put together for Sara DeCosta, a USA Hockey Women’s National Team goalie who underwent arthroscopic surgery to repair a hip labral tear. Note that you could do a lot of this rehab without special equipment and machines, by just using bodyweight step-ups, exercise bands, walking, and some pool workouts, before progressing into weight training. Also note that there can be considerable overlap between some of the phases.

PHASE I: Focus on range of motion. No conditioning work. Should last one to three weeks.

Range of Motion
Avoid hyperextension
Ankle pumps-circles
Active IR/ER seated
Active Abd/Add
AA flexion-heel slides
Single knee to chest
Seated trunk flexion
Hip flexor stretch to neutral
Pelvic tilts

During this time, the athlete iced her hip several times a day and was weaned off her crutches. Within the first couple weeks after surgery, the athlete was nearly pain-free while walking and sitting.

PHASE II: Focus on strength and endurance. Still no conditioning work. Lasts roughly three to six weeks.

Resistance training
Isometrics and abdominals supine only
Standing isometric abduction
Unilateral bridging
3-way straight-leg raise (flex, abd, add)
Prone knee flexion
Seated hip flexion
Abdominal bracing
PNF pelvic patterns
Upper-body strengthening
PNF diagnosis full range LE patterns
Closed kinetic chain exercises:
heel raises, 1/2 squats, lunges, full squat, step-ups
Multi hip machine
Theraband exercises for groin
Miniband exercises
Squats with ball between knees

Balance coordination
Unilateral stance
Rebounder (plyo back)
BAPS board, airex pad
Go from bilateral stance to single leg
Four-way touches on single leg

PHASE III: Start conditioning work. The timeline varies from athlete to athlete, depending on how hard they’re willing to push themselves, how dedicated they are, and how they’re healing. Generally, Phase III lasts three to six weeks.

Stationary bike
Swimming (flutter kick only)
Upper-body cycle

Pool Activities
Deep-water walking with aqua jogger
Buoyancy-assisted ROM
Buoyancy-resisted ROM
Shallow-water walking

PHASE IV: Progression to return to sport. The length of this phase can vary depending on how well the athlete is healing and how hard he or she is willing to work.

Sport-Specific Activities
Skating without equipment in oval; no crossover
Speed track machine
Shuttle machine
Skating, add crossover
Backward skating
Power skating, working edges and tight turns
Dry-land splits
Dry-land and hockey drills
Gradually work up to full running program

Return to ice with full goalie equipment dependent on full pain-free ROM and strength 90 percent of opposite limb.