Rehabilitation Stages & Flexibility Techniques in Sports Medicine

Stages of Rehabilitation (IRSNFR)

Immobilization → Range of Motion → Strengthening → Neuromuscular Function → Functional Exercises → Return to Life

Immobilization Phase

First stage of rehab. Wound space filled with debris and prostaglandin. Goal = debridement, removing necrotic tissue. Very little energy applied.

Range of Motion Phase

Second stage of rehab. Begins with passive ROM (patient = 0% energy, clinician = 100%). Goal = manage pain. Avoid injured plane of motion and unhealed fractures.

Strengthening Phase

Third stage. Focus on building muscle strength after safe ROM has been restored.

Neuromuscular Function Phase

Fourth stage. Retrain reflexive contractions and motor control. Involves muscle spindle, stretch reflex, and GTO.

Functional Exercise Phase

Fifth stage. Includes sport - or activity - specific movements to prepare for return to play/life

Return to Life Phase

Final stage. Distal goal achieved (e.g., full return to soccer)

Chief Complaint

The patient’s stated problem or pain (e.g., “My ankle hurts”).

I am Statement 

How the patient identifies themselves (“I am a soccer player’). Shows identity/self-concept.

Two things you always listen for

Chief complaint, and I am statement

Cardinal signs of inflammation

pain, swelling, heat, loss of function, redness

distal goal example

“by October 12th, Joey will return to 90 minutes of soccer play.” (long-term goal)

proximal goal example

swelling will decrease by 3 cm in one week (short-term goal)

treatment plan format

[short hand goal] + category of modality + parameters (time, frequency, intensity)

example treatment plan (immobilization)

[decrease swelling] immobilization (walking boot, 7 days, all day everyday, 50% weight bearing)

Arnold-Schultz Principle

to change biological systems apply enough energy to cause adaptation but not enough to cause harm

prostaglandin

debris in wound space during immobilization phase. must be cleared with debridement

passive range of motion

clinician moves joint entirely; patient provides no energy. 

near hand rule

clinicians near hand stabilizes the proximal segmentf

far hand rule

clinician’s far hand guides the distal segment

consent in rehab

always ask patient for permission, explain process, and drape/disrobe appropriately. s

stretch reflex

quick stretch of a muscle, activates muscle spindle, reflex contraction of the stretched muscle, inhibition of antagonist

muscle spindle fibers

specialized receptors around intrafusal fibers. detect quick stretch, trigger reflex contraction

Golgi tendon organ (GTO)

located at musculotendinous junction. senses tension after 15 seconds of sustained stretch, inhibits alpha motor neurons, relaxation 

GTO Threshold

high during passive stretch, low during active stretch

conclusion of stretch reflex

quick stretch = contraction, held stretch (15+ seconds) = GTO activation and relaxation

flexibility constellation of exercises

stage where true ROM gains occur. Goal = increase excursion, remodel scar, improve viscoelastic properties

scar tissue properties

moderate density, full but inadequate reach, type 1 and 3 collagen, often disorganized perpendicular fibers

flexibility goals

increase excursion by 3 cm, improve viscoelasticity of scar, increase tissue extensibility

flexibility indications

limited ROM due to scar/adhesion, prevent structural deformities, muscle weakness with tissue shortening, injury prevention, warm-up/cool-down

flexibility contraindications

bony block, unhealed fracture, acute inflammation, tissue trauma/hematoma, sharp pain, hyper mobility, contractures providing stability

flexibility techniques: manual passive

clinician applies external force, hold stretch at discomfort for 15+ seconds

flexibility techniques: ballistic

patient rapidly contracts agonist to stretch antagonist, dangerous - can cause strain

flexibility techniques: active inhibition

use controlled contraction of target muscle to fire GTO and reduce reflexive contraction

flexibility techniques: dynamic 

controlled contraction increases tissue temperature and decreases viscosityne

neurologic inhibition: hold-relax (HR)

passive stretch, 5-10 second isometric contraction, relax, greater stretch

neurologic inhibition: contract-relax (CR)

passive stretch, isotonic contraction, relax, greater stretch

neurologic inhibition: agonist contraction (AC)

patient contracts antagonist to actively lengthen target muscle

neurologic inhibition: HR-AC

combination of hold-relax and agonist contraction techniques

planning flexibility program (steps)

1. identify indications 2. identify contraindications 3. choose modality 4. identify target muscle tendon 5. set short-term goals 6. write treatment plan

example flexibility goal

increase rectus femurs excursion with PROM increase 5 degrees by friday

example flexibility treatment plan

[increase rectus femoris excursion] flexibility (manual passive, hip extension with knee flexed, 3×1 minute hold, 3/day, 1 week, discomfort level)

application of flexibility treatment plan

{increase rectus femoris excursion] flexibility (manual passive, hip extension with knee flexed, 3×1 minute hold, 3/day, 1 week, discomfort level)

application of flexibility treatment (steps)

1. properly drape patient 2. position patient 3. demonstrate motion on self 4. demonstrate on patient’s limb 5. explain treatment 6. instruct sensations to report 7. position clinician body 8. place near/far hands correctly 9. progress through motion 10. hold excursion 11. prevent accessory movement 12. slowly release tensionne

near hand

always stabilizes the proximal segment

far hand

always guides the distal segmentt

treatment plan (flexibility)

[decrease pain] range of motion (passive range of motion(leg extension), comfortable arc of motion for the patient is important here (this is intensity), 3 minutes a day, once per day)