Athletes are passionate about pushing their bodies to the highest level. The difficulty occurs when this athletic passion runs directly into a fracture, tendon rupture or other potential need for surgery (elective or not). The athlete’s mindset is to keep going and keep pushing forward while our desire is to put on the brakes and give the body the rest it needs to heal.
Often we cannot rush the timeline for healing and this is where patience comes into play. The desire to return to activity or training may override common sense, and we need to manage this in order to prevent further injury to the athlete.
The simplest way to describe how an athlete thinks is the saying “What does not kill you makes you stronger.” Athletes do not want to stop training. Therefore, an injury they cannot truly “see,” such as a stress fracture, does not instill in them the need to stop their activity. The physician’s role must be one of protecting the athlete from further injury and this sometimes means making the tough decision to tell the athlete to stop his or her activity.
We need to explain to athletes the risks of continued activity or returning to sports too early, and the potential for even longer downtime. This may help convince an athlete of the appropriate treatment plan. Working together and ensuring open communication will assist in transitioning the athlete back to activity at an appropriate time.
Our expectations in treating patients are for them to get better and return to a level of function equal to what they had prior to injury. The athletes’ expectation is to return to pre-injury activity as soon as possible and not lose any time in training or lose any of the skills they have developed. A meshing of the two must occur and communication is the key to fostering this plan.
Most athletes know and understand their bodies well. They want to understand what happened or what is going to happen, and get a relative idea of how long it is going to take to recover. When dealing with stress or acute fractures, we can establish a general treatment timeline based on past experience. Tendon injuries may have an extended timeline as do sprains and strains, depending on the severity of the injury.
When surgery is involved, it is important to detail to the patients the initial limitations and educate them on the normal complications that may occur. Complications include stiffness, edema and residual pain that may often delay their return to function. This may be very frustrating for the athlete. However, if one is able to clarify expectations and develop appropriate protocols, the physician and athlete may make progress and maintain some level of fitness.
Emphasizing The Importance Of Active Rest And Alternative Fitness Activities
Active rest may seem like an oxymoron. When an injury occurs, one must incorporate a period of rest into the treatment plan in order to stabilize and prevent further progression of the injury.
Active rest allows the injured extremity to rest while the patient maintains fitness through alternative methods. This occurs through the principle of cross training or the implementation of other activities. Many methods of active rest are available and patients can adapt them depending on the injury. A patient with a stress fracture must avoid stress on the injured area but is not required just to sit.
For example, a runner with a stress fracture has the following alternatives:
• using an elliptical trainer;
• deep water running (water has over 700 times the resistance of air and therefore helps the athlete maintain fitness and strength);
• cycling or spinning (ensuring the athlete is staying in the seat to eliminate the driving pressure); and
• weight training.
Patients can modify many of these activities and use them during the postoperative period after many forefoot surgeries. This may require shoe modifications and activity modifications to ensure patients do not do too much too soon.
Give patients a detailed list of what activities are acceptable. Explain that running, aerobics, fitness walking and many sports are impact activities. The activities described above (swimming, cycling, elliptical, etc.) are non-impact activities and athletes can begin these much earlier without risk of further injury.
This phase of active rest transitions the athlete from immobilization (stabilization) to maintaining fitness while the injury or surgical site heals appropriately. During this phase, one should further address the underlying etiology of the condition (assuming it is not an acute fracture or rupture).
One can address issues such as osteoporosis, nutrition, biomechanical abnormalities as well as equipment or training problems. It is important to identify these issues early in this phase so when athletes are ready to return to activity, they do not need to await further evaluations. As the athlete progresses, it helps to develop a plan for return with both the athlete and coach in order to facilitate an appropriate gradual return to play.
Pertinent Pointers For Easing Patients Back Into Activity
One of the biggest mistakes one can make is to attempt to return athletes to their activity of choice too quickly. Many physicians tell their patients
to “take it easy.” Unfortunately, this is very vague and the competitive athlete often does not know how to accomplish this safely.
The most effective method for returning to activity is to gradually increase stress on the body and the healing limb while allowing time for recovery. This can occur through a variety of methods and the athlete must understand the need for patience in this return.
One key in rehabilitating athletes is to remember that they may still effectively perform other aspects of their sport (free throw shooting, weightlifting, catching) without the need for significant stress on the lower extremity.
A major component of most athletic activities is running and the following example outlines the return to running activity. Returning a runner to running should begin with active walking to begin to place stress on the body. The athlete should then begin a run/walk and progress to full running with a written plan to follow. If limping occurs, the activity level should decrease so as not to create compensatory injuries. Continue to monitor the athlete for healing through clinical and radiographic evaluation.
Retraining of the body in the competitive endeavor is important to prevent recurrence of the injury. It is important to discuss the normal pain that may occur with osseous or soft tissue injury so patients will have an understanding of what is and is not a concern.
Crossing The Finish Line
Returning to full activity may seem like a slow progression for the athletic patient. However, by ensuring effective communication and providing activities they can do to maintain fitness, athletes can return to full activity with limited downtime.
When athletes have injuries, their normal activities take on a completely different meaning given that the demands on the body are much greater with athletic activities and the lack of patience many athletes have. It is essential to not only properly diagnose these injuries but provide opportunities for active rest and a progressive return to activity. The coordination of the patient’s expectations and the physician’s experience allow athletes to resume their passion in the most effective and expedient way.
Dr. Peebles is a Fellow of the American Academy of Podiatric Sports Medicine and the American College of Foot and Ankle Surgeons. He is the team podiatrist for the Atlanta Hawks and has a private practice in Atlanta.
Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine.
1. Heaslet MW, Kanda-Mehtani SL. Return-to-activity levels in 96 athletes with stress fractures of the foot, ankle, and leg: a retrospective analysis. J Am Podiatr Med Assoc 2007; 97(1):81-84. 2. Kelly AKW, Hame SL. Managing stress fractures in athletes. J Musculoskel Med 2005; 22:463-472. 3. McInnes BD, Bouche RT. Critical evaluation of the modified Lapidus procedure. J Foot Ankle Surg 2001; 40(2):71-90. 4. Shwayhat AF, Lineger JM, Hofherr LK, Slymen DJ, Johnson CW. Profiles of exercise history and overuse injuries among United States Navy Sea, Air and Land (SEAL) recruits. Am J Sports Med 1994; 22(6):835-840.