Injury Rehabilitation: When is it safe to run or go back to my sport?

Injury Rehabilitation: The Magical 80% Rule

80% is not 100% or 99% or 95%, but is the most talked about number in sports rehabilitation. Why? When you look at the pain scale, the numbers are graded from 0 to 10, with 10 being agonizing pain and 0 no pain. With most injuries, it takes 20% of the overall rehabilitation to reduce the symptoms 80% (normally between 0 and 2), and another 80% of the overall rehabilitation to knock out that remaining 20% (to daily 0 with no reflares). Therefore, sports medicine providers attempt with most injuries to reduce the symptoms to between 0-2 (80% better) and hold the symptoms there for a long time as functioning improves. The patient still has some symptoms as they get back into activity. It can be quite unnerving to some patients to still be experiencing pain while re-attempting to participate in an activity. However, since it takes 20% of the overall rehabilitation to get there, and for simplicity let us say it took 2 months to reduce the pain from 8-10 down to 0-2, then it will take 80% of the time (8 more months) to completely eliminate all the pain. If we wait for no pain to begin activity, the wait is much longer than necessary, and the body gets stiffer, weaker, more deconditioned, and overall, more vulnerable to re-injury when starting up again. So, 80% reduction in symptoms down to levels 0 to 2 pain is considered the gold standard in treating injuries. 

Golden Rule of Foot: When 80% of symptoms are reduced, and normal walking occurs without limping, a return to activity program can be initiated. This is the 80% related to the pain scale.

But, what about the 80% related to activity. 80% better for function is when you can start running again. Running is the basis of almost all athletic endeavors. The way I look at and discuss with patients the function scale is:

0 to 20% bed ridden, or non weight bearing on crutches or Roll-A-Bout/scooter

20 to 40% from beginning to bear weight with the help of crutches to no crutches needed (normally needs removable boot/cast). There will be some initial cross training.

40 to 60% Gradually feeling less pain with walking with or without boot (walking slow). This stage the patient is really finding what activities they can cross train without pain (typically bike, elliptical, swimming, some weights, many other forms of exercise).

60 to 80% Walking with increased speed with mild symptoms, beginning to do sports specific activities like volleying in tennis, or shooting around in basketball (many free throws!!), and flareups are common as the patient tests the waters.

80% Passed the 30 minute hard walk test without setback, can begin a walk/run program, can begin to play sport with some idea of gradation back into full activity. 

It is the magical merging of these two 80% scales that will allow the patient to begin their sport at a high level and begin to feel normal again psychologically. Many patients the scales don't match for a while and the health care provider must have them wait. For example, many patients have 80% pain relief by icing, medications, activity modification, braces, orthotic devices, etc, but when they attempt to walk hard for 30 minutes (standard test), or attempt sport specific activities like solo volleying in a squash court, they have definite increase in symptoms. They are still in the 60-80% range of function. This is the time that physical therapy, injections, changes in orthotic devices, chiropractic, accupuncture, etc, is utilized to get their function off this plateau and onto the 80-100% plateau where they can dramatically increase their activities. A good sports medicine provider is very skilled at this task of raising the plateau. Since the 80-100% plateau can still be filled with flares, minor setbacks, and many good pain/bad pain decisions, it can be the most difficult and challenging time in treating active patients. It is in this time period that most treatment of all the possible causes of the problem occur---short legs, flat feet, lordosis, weak muscles, tight muscles, dietary, etc, etc, etc. It is the fun part of rehabilitation. So you do not have to wait until you have no pain to begin to exercise you love, but there is so much thought on how to return to activity during this 80-100% prolonged plateau safely.

The above is an excerpt from my book “Secrets to Keep Moving: A Guide from a Podiatrist”.

Transitioning from one restriction to less restriction: Email Advice

Hi there Dr. Blake,

 I found your blog while looking for the best way to transition out of a walking boot back to my shoe.  I fractured my Medial sesamoid in my Right foot in March while on the elliptical due to high arches and over-pronation.  Started as a stress fracture which I thought was a soft tissue injury so I treated it that way.  Rest, Ice, NSAID’s, elevation.  No improvement after 2 weeks, so I went to our podiatrist here and she found my fractured sesamoid (my what?).

Into the boot, I went for 8 weeks with icing 3 times a day, NSAID ointment for topical use and elevation at night.  Things looked great at follow-up so back into my shoe.  2 weeks later, it was swollen, red and angry again.  Back into the boot and a knee scooter for non-weight bearing for 2 months.  At follow-up, the x-rays showed the bone was knitting with remodeling on the bottom of the bone. 

   There has been general discomfort in the MTP joint for a month, just achiness and occasional tingling in the sesamoid area.  This is Sept. 11 so 5 months out and I will have the knee scooter until the 21^st.   I’m concerned about just going into the boot or my shoe and re-breaking it again.  I do not want to have it surgically removed. 

   If you have any suggestions or anything, I’m open to trying it.  Thank you for your time!

Sincerely,

Dr. Blake's comment: Thank you for the email. Improper transitions, like our US sprinters dropping the baton in the Olympics, can be devastating. You have done a lot to help the sesamoid heal in the last 4 months so I will assume it is healing just fine. Sesamoids are very sensitive as they heal, and with high arches and overpronation, you are going to be putting a lot of stress on a sensitive bone for a while. So, the question is how to minimize that stress on the bone. My blog is full of information on the following: dancer's padding, Hoka One One Shoes for rocker, avoid toe bend in general, spica taping initially to help stop toe bend, get some Dr. Jills Dancer's pads for even sandals as they come in 1/4 inch size, while you are waiting for a good pair of orthotics to be made, use the dancer's padding in an anklizer boot. You may need to use crutches initially also since you have been using a knee scooter and putting no weight down. That typically makes the joint more swollen and sensitive as you begin weight bearing. Contrast bathes nightly should help reduce the inflammation. I would get Neuro-Eze from Amazon and rub in nonpainfully for 3 minutes three times a day. You also need to strengthen your foot again with metatarsal doming, single leg balancing, heel raises. I have a post explaining how to build a well or depression to float the sesamoid while still doing exercises.

I hope this helps. Rich
PS. Why no Exogen Bone stim? 

Generalizations in the Treatment of Athletic Injuries

I hope this short video helps you with the basic principles of treatment in athletic injuries.  

Email Regarding Good vs Bad Pain (Weaning off Crutches after Foot Fracture)

Brooke broke her right fifth metarsal on 6/16/11 and was placed on crutches and a removable boot with accommodation. My initial visit was 6/22/11 and followup on 7/6/11 now 4 days ago.On the 7/6 visit, I discussed with Brooke trying to wean off the crutches with the full protection of the removable boot.

Base of 5th Met Fx

Hi Dr. Blake, I was in last Wed. when you got me started walking without my crutches. All has been going really well until today  (7/9/11) when I woke up with soreness at the site of the break.

Yesterday I tried wearing a Superfeet insole that I had on hand in my boot, and I'm wondering if this is what caused the pain. Or maybe I just overdid it and walked too much yesterday. I was on my feet for a couple hours straight in the afternoon.

It's not sharp pain. I would describe it as slight tenderness when I put weight on it. Probably pain level is around 1.5-2 out of 10. So not really bad, but definitely more than I've had in the last week (which has been 0). Do you think I should stay off if it completely and go back to the crutches for a day or two? Is this amount of pain OK? Can I keep walking on it without crutches?
Dr Blake's Note: Her pain level is less than the restrictions she prescribes needs. However, I find patients are very protective since they want do have no setbacks.I am not wearing the insole today.
Thanks so much for your help!
Best,

Brooke

Here is my response to Brooke. 
Brooke, Hope you don't mind I put your question on my blog this week. Of course no names, but I get this question all the time. Hopefully, you have read the post on good and bad pain, but when it comes to yourself, logic and reality sometimes do not match. It is hard to stay objective with your own body. Definitely level 2 is good pain, even if it is in the fracture area (weakest link in the chain right now). I find people over protective, which is okay because we have to feel good with what is going on as we Listen To Our Bodies. It would be fine to slow down the no crutches by at least bringing them with you for the next several days, or go back on them for a few hours after the pain (but not 2 days back on the crutches with only level 2 pain). Not sure of the role of the Superfeet, but if you feel pain again, take it out, and see if the pain dissipates. Experiment. If the pain increases over the next several days, then we know we have to slow down and go back on the crutches. See yesterday's post on Activity and Pain Scale Log and consider doing one yourself and emailing me. Hope this helps. Rich

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

http://www.drblakeshealingsole.com/2011/07/email-activity-followup-excellent.html
Here is Brooke's response on 7/12/11
Hi Dr. Blake, this is very helpful. Thank you. I did read your post on Good vs. Bad Pain. It makes sense, although at the time I read it I wasn't totally sure how it applied to me since I'm not an athlete and my pain isn't happening because of working out. I reread it, and I guess just putting weight on it and walking counts as my work out these days. What you say about sharp pain versus soreness makes sense, and I don't have sharp pain. My pain didn't disapate after a day, but I'll keep an eye on it and consider tracking it.

thanks so much for your response. I'm very eager to be done with these crutches!

By all means, use this for your blog!
Best,

Brooke

Base of 5th Met Fracture Side View

Email Activity Followup: An Excellent Method in Helping to Treat Some Injuries

Joe had severely injured both feet several years ago. For 2 years he hardly walked, and this is when I first met him. He had injured his big toe joints and walked on the heels only of MBT shoes. It was a fantastic adaptation of this shoe. First thing I needed to do was to see if he could begin to walk on his full foot. This took many months to accomplish. It was also hard to wrap my fingers around his problem with our monthly followup visits. The monthly ups and downs of his pain levels based on what he did was hard to follow. So, March of this year, I had Joe email me a activity report based on the standard pain level . I will have a post just on the pain scale. It is based on a scale of pain from 0 to 10. As Joe began to walk, stand, bike, etc I wanted to follow his pain to understand it better. I told him we want to keep him in the 0-2 good pain area, but occasionally drifting to 3 or 4 is okay. Joe had kept his pain level between 0 and 1 for 2 years by not walking, but his muscles and bones were atrophing terribly. The golden rule of foot is if it takes 2 years to heal something, it will take 2 more years to rebuild the strength. I knew Joe and I had a long haul together. We had to do it right. This daily activity log with pain level during really keeps us honest and on the right course. EOD stands for End of Day. PL stands for Pain Level.

This is what Joe sends me and I respond only when I think necessary.


July 1 Walking 45 min Standing 40 min PL1-2 Biking 50 min PL1-2 EOD PL: 2-3

July 2 Walking 40 min Standing 25 min PL 1-2 Biking 25 min PL1-2 EOD PL: 3

July 3 Walking 15 min Standing 30 min PL: 1-2 EOD PL: 1-2

July 4 Walking 1 hr Standing 3.5 hrs PL: 2 Biking 45 min PL: 0-1 EOD PL: 3-4

Here I sent Joe an email to increase his icing and decrease his activity.
July 5 Walking 30 min Standing 1 hr PL: 2 Biking 45 min PL: 0-1 EOD PL: 3

July 6 Walking 25 min Standing 40 min PL: 1-2 Biking 35 min PL:0-1 EOD PL: 1-2

July 7 Birks Walk: 25 Standing: 35 PL: 1-2 Keens Walk: 5 Stand: 5 PL: 1 Biking 45 min PL: 0-1 EOD PL: 1-2

Joe has been walking in Birkenstock sandals without bending his foot to push off the ground. We are introducing Keen enclosed shoes as a step forward towards normalcy. Joe awaits some new tests to see how he is doing. I am ordering a new MRI (last one 6 months ago) and a bone scan. Yet, I think the activity and pain scale log may be giving us a great picture of how well he his doing.

Stationary Bike Seat Height for Injury Rehabilitation

The following video demonstrates the principles of starting a patient on a stationary bike during injury rehabilitation.






With many foot injuries, the stationary bike is an excellent rehab tool. No matter where the pain is normally the foot position on the pedal can be adjusted to find a comfortable spot. With many ankle injuries, the seat height can be lowered so that the ankle does not have to bend. When you do lower the seat height, the knees are bent more than normal, and the gears should be eased up abit to have less resistance.

Injury Rehabilitation Priniciple: Going Alone is Never Good

http://www.dreamstime.com/stock-photo-mountaineer-rimagefree1313536-resi2565486

The Alone Hiker

I have spoken to 2 patients today that I sense are feeling alone and scared with their injuries. They both have significant disabilities with their injuries, and I am struggling to help them without much luck so far. They are always on my mind and I can not help but feel alone too in helping them. I am lucky to be surrounded by gifted health care providers to help me, but sometimes they say nothing can be done. But, I have been around too long to believe it. I recognize my limitations, and I see so many gifted souls out there. My soul tells me "one step at a time." One step of progress, one change in direction, one lesson learned, and we are able to take another step.

I wrote a poem once about this progress which I will retell now. It is entitled "On Death Experienced". The death is the darkness we feel in our hopelessness at the loss of who we are, the loss of our identity as athletes, or as healthy individuals. Some of you will relate.

ON DEATH EXPERIENCED

The fist is hard

As it explodes so deep

The emotions so high

Talk seems so cheap

Death of self plays a sour note

A loss so deep that everything

Is affected and actions in remote

Continue the self while the soul begins

In that very death, flowers bloom

Priorities shifted

As inward

we drift

The self being sifted

When death is experienced

The grief cycle will play

Inner strength must end it

With friends we can say

I'm ready to go on now

At least for another day

To work with you in the garden

And accept my stumbling along the way.

Rich Blake

WaterGym (for athletic rehabilitation): Recommended Website

http://www.watergym.com/

     One of the best exercises we can do when injured is swim. Injured runners, cyclists, hikers, etc, for years have been getting into pools as part of their training and found it a great source of relaxation, muscle toning, stretching, and cardio. The watergym program, started by sensational Susanne Paynovich, has definitely taken water exercise to a new level. If you have access to a pool, have a foot or ankle injury (this is a podiatry blog)  which is limiting your ability to perform your normal workouts, or if you have the desire to add another dimension to your workouts, try watergym. You can go online, signup, watch some neat videos for free, enjoy other offers from watergym and feel the excitement. Good luck!!

Watergym Weight Loss Water Aerobics

WaterGym - System for Weight Loss and Strengthening

Injury Rehabilitation: Am I looking at The Tip Of The Iceberg?

http://commons.wikimedia.org/wiki/File:Iceberg-Antarctica.jpg

http://en.wikipedia.org/wiki/User:Kils

Each week I have patients that present with their first foot or ankle injury and I wonder whether I am looking at the Tip of the Iceberg of this and other future injuries. No matter how minor the injury appears, I wonder if it will be followed by another and another and another. What can I do as a health car provider to eliminate or at least minimize the onslaught of future injuries? How serious should I take these initial injuries which will heal relatively quickly? Should I always follow the KISS Principle (see separate post) and Keep It Simple Stupid when I think some of these injuries are definitely the Tip of the Iceberg? More pain is on the way.
What goes into the thought process of deciding who should get more treatment when relatively simple injuries present into my office? The treatment of any overuse injury (without an acute single episode) should always be directed at the one or two common causes, or the several possible causes for this individual patient. Take Achilles Tendonitis for example. The common causes of Achilles Tendonitis are:
1. Straight overuse situation in which the Achilles Tendon is put in major stress (i.e. stair running for the first time, or working out too many days in a row, etc.)

2. Very tight Achilles Tendons.

3. Worn out shoe gear with lack of stability or cushion at impact.

4. Unstable shoes, or excessive wearing of shoe gear with inadequate support (i.e. too much time in the flip flops, etc.)

5. Short leg with compensation of early heel lift.

6. Excessive pronation of the foot/ankle with excessive torque on the Achilles.

7. Excessive supination of the foot/ankle with lateral instability and over firing of the Achilles Tendon to stabilize the ankle joint complex.

8. Very loose Achilles Tendons from over stretching or patients with loose ligaments in general. This produces a weakness in the tendon (see future post on the force/length curve).

9. Weak Achilles Tendons from many reasons (just returning to regular exercise program, following prolonged casting, aging process, genetics, dietary, etc.)

10. Achilles Tendonitis secondary to another problem (heel spurs, ankle injuries, sciatica, tibial stress fractures, etc.)

After performing an initial history and physical examination, and making the diagnosis if possible, the clinician will try to assess the reasons this individual patient developed their injury. It is the experience of the clinician that separates them from other health care providers in getting to the cause(s) of some injuries. Some “reversal of cause” treatment must be initiated in all cases. But for some patients, looking below the surface level of water, below the Tip of the Iceberg, is really what is crucial. What factors could lead, if not addressed, to either prolonged injury/treatment, or frequent recurrences of the symptoms. This is so crucial, but in a busy medical practice, often times not proactively explored. The patient and clinician only stumbles into the discoveries.



When a ship’s captain looks at the iceberg approaching, the captain scrutinizes the situation, assesses the severity, and then makes an appropriate plan. Health care providers, and proactive patients, can be slower than the sea captain at final making these decisions, but must look at possible severity of the injury, and severity of the cause of injury, to come up with an appropriate plan. Since we can grade the severity of anything 3 typical ways—mild, moderate, and complex—let us look at these 2 factors in injury treatment from this angle. Perhaps then you can understand when under the Tip of the Iceberg danger may be lurking in the forms of prolonged treatment, possible incomplete healing, and frequent recurrences of the symptoms. After the initial assessment (history and physical), and perhaps after several follow up visits, the clinician will place the patient in one of 9 categories. These are:
1. Mild Injury/Mild Severity of Cause

2. Mild Injury/Moderate Severity of Cause

3. Mild Injury/Complex Severity of Cause

4. Moderate Injury/Mild Severity of Cause

5. Moderate Injury/Moderate Severity of Cause

6. Moderate Injury/Complex Severity of Cause

7. Severe Injury/Mild Severity of Cause

8. Severe Injury/Moderate Severity of Cause

9. Severe Injury/Complex Severity of Cause

With the Severe Injuries, the treatment is usually prolonged enough that the patient and doctor/therapist gradually work at recognizing and correcting all possible causes of the injury along the way. It is the Mild and Moderate Injuries, that the KISS principle and Tip of the Iceberg principles must be reconciled. It is when the injury is classified as mild or moderate that the health care provider must decide when to look under the Tip of the Iceberg and explore the depths of moderate to complex causes. It is in the 4 categories below that I find most problems in dealing with these injuries. These are:

1. Mild Injury/Moderate Severity of Cause

2. Mild Injury/Complex Severity of Cause

3. Moderate Injury/Moderate Severity of Cause

4. Moderate Injury/Complex Severity of Cause
In these cases, I see the most patients for 2nd opinions. Why is the injury not healing? Why does the injury keep coming back? The mild and moderate nature of the initial injury makes the health care system relax and not look to deep into cause of injury.


     I will end this discussion with one example of this dilemma. Since I already used Achilles Tendonitis above, I will finish using an example of Achilles Tendonitis. The patient had pain in the Achilles for 3 months prior to seeing the initial doctor. The patient was a runner who pronated too much, rarely stretched the Achilles, when stretching only did Negative Stretching off a curb (see separate post), was a vegetarian (not to pick on you guys too much!) but ate well, ran a lot of hills after moving from Dallas to San Francisco, and was told he had one leg shorter but never did anything about it. The initial treatment addressing the possible causes of the injury were Orthotic devices for the pronation, new motion control running shoes, power lacing see separate post), Achilles stretching 3 to 5 times a day, and running on flat ground, not hills until the symptoms got better. The doctor had categorized the patient mild injury/moderate cause of injury and had addressed the causes on the surface well. Was he/she just looking at the Tip of the Iceberg? What was below the surface that needed to be addressed? The patient after six months of treatment still was not much better in function. Running was still very limited. The initial treating doctor told him to stretch more and give it more time at their last visit (of 6 visits overall). This patient then sought a 2nd opinion.

On review of the injury itself, the right diagnosis had been made. The plan of treatment initiated was good, but never improved upon when the patient was struggling. Each of the treatments initiated were subpar in retrospect. The pronation was only partially corrected with the new Orthotic devices (but they were easy to modify to greatly improve), the running shoe store had convinced him to not get a motion control shoe since he had Orthotic devices (and the doctor never evaluated his running after the first visit), the power lacing was been done incorrectly (and was also modified), diet counseling came up with non optimal protein intake (something that will help the patient forever), measurement of his flexibility showed him off the charts in over flexibility (too flexible means too weak and this was improved with 6 weeks of no stretching at all—he thought I was crazy when I proposed that one), and exact measurement of his legs showed over ½” short leg on the injured side (treatment with heel lifts helped him immensely). Within several weeks, he was feeling much better, and by 8 weeks was back running regularly with a better diet, heel lift for the short leg, sensible stretching routine before and after exercise, no negative achilles stretching, stable Orthotic devices, stable shoes, proper power lacing, and a gradual re-strengthening home program under a physical therapist with 6 one/month visits to up the ante. Yes, under the Tip of the Iceberg for this athlete was a considerable short leg, a considerable dietary problem, slightly harder to treat pronation, and an Achilles that could become over flexible too easily. His mild injury did not initially respond since the cause of injury was misread as moderate, when it really was complex.


The Golden Rule of Foot: When treating athletic injuries, if the symptoms and function plateau, look under the Tip of the Iceberg to a deeper level of possible answers.

Philosophy of Treating Athletic Injuries (Part IV)

Problems arise when the doctor treats the patient on a slow course, cutting expenses, when the patient wants to be cured today. Some patients must face reality. If they want the best, more effective treatment of their problem, they must give the time and energy and expense to accomplish it. Medical care costs are getting out of control, and paying for it more of a burden.

The second purpose of this 4 part article is to minimize the patients for going elsewhere when their treatment is slow or recurring. Again, communication is the key. The doctor or therapist must respect the patient as a person and the patient must view the doctor/therapist as someone truly concerned. Sometimes, there are no good answers. I try to limit those to a small percentage. I find that if I can communicate with a patient, treatment goes well. If the patient never trusts me, communication will not go well, and the treatment will be shaky with constant problems.

A patient should already have answered in their mind the following thoughts at the initial visit. These are:

1. How serious do I think the problem really is?
2. Do I want only home remedies or can I afford the time and expense of physical therapy done 2 or 3 times a week for 3 or 4 weeks?
3. Could I totally rest from my sport if advised? Would that devastate me physically and emotionally?
4. Do I need to know exactly what is wrong on the first visit, or can xrays, bone scans, MRIs, etc wait if initial treatment does not work?
5. Do I want to take the necessary steps to prevent recurrences if lifts, shoe inserts, daily exercises, prolonged therapy is recommended, or do I think of this as a one-time occurrence?
6. Is the cost of care a big issue? What does my insurance cover? What is my deductible?

Without knowing the answers to these questions, the doctor or therapist may make some wrong decisions in your care.

So, you have an injury and want freedom from it. Some of the basic rules that everyone must follow are:

1. No running, dancing, etc, if you can not walk without pain.
2. Never exercise with pain; if you have an injury, you can not do anything that keeps producing the pain cycle (see the separate post on Good Pain vs Bad Pain)
3. If there is swelling, you must work on that daily to reduce as soon as possible with compression, massage, elevation, contrast (see post on Secrets of Contrast Bathing).
4. If there is stiffness, full return to activity is restricted until the stiffness is greatly improved.
5. If the decision to start your activity has been made, and you are experiencing a return in symptoms, you must rest again for minimum of 2 weeks. You are just not ready.
6. Alternative activities to cross train are normally encouraged to maintain cardiovascular fitness.

With some injuries, the sequellae of scar tissue accumulation and muscle weakness, joint instabilities and stiffness, chronic swelling and nerve hypersensitivities, all can play a role in a slow return to normal activity. Rest alone may not help some injuries, and treatment may be prolonged in addressing these issues. Of course, no athlete wants to deal with that. If there has been permanent damage as the result of the injury, only partial rehabilitation may occur.

For most injuries, reversal of the cause is often helpful, and even mandatory. Without finding the cause, the injury may chronically recur over and over. But for many injuries, that can be overdone or misused. For example, flat feet can cause knee pain, or prevent knee pain from getting better. So, should all patients with knee pain and flat feet get corrective inserts? If you realize 90 + percent of all patients with knee pain get better without correcting the flat feet, you can perhaps see that treating flat feet in all cases of knee pain would be improper. The clinician needs to select only those patients that really need it. This is not always a simple task to accomplish. Temporary orthotic devices, like Your Sole, which can be modified for greater support if needed, have created a wonderful diagnostic test to see what patients may need permanent corrective devices. The patient's response to the insert will help make the decision on custom orthotic devices easier. But, this is just a small example of cause reversal. With every injury, there are a myriad of common causes, and some not so common causes, that may need to be treated as treatment goes along.

So the doctor and therapist must have free communication with the patient each step of the way in rehabilitating the injury. The patient must understand the doctor or therapist's plan of attack, but help advise on the limitations of time, expense and energy. The patient should be given clear guidelines on the present activity level allowed, the proposed treatment plan, and options for further treatment if needed. With this communication, injuries can become a learning process for the patient, and a guideline for further injury prevention.

I sure hope this 4 part blog on the Philosophy of Treating Athletic Injuries helps if you develop an injury, or if you are presently experiencing an injury and communicating with a doctor or therapist.

Philosophy of Treating Athletic Injuries (Part III)

     Here are some basic principles in the treatment of athletic injuries. The first priority is to decide on the severity of the problem. The two important categories are major and minor. A major injury needs no guesswork in treatment philosophy. The patient may develop permanent injury if not treated quickly, accurately, and intensely. This is the first type of injury we discussed with the inability to walk, severe and intense pain, etc. Diagnosis is important. Xrays are taken, and MRIs, or other tests are considered quickly. Physical Therapy is initiated. Expense, time, risk of radiation become minor concerns or no concern of all. These, in a way, are easier to initially treat. Cookbook teaching is present for most. Follow the book and success in treatment is usually obtained. It may take months or years to rehabilitate, the patient may never run or ski or dance again, but the doctor is the hero. He/She prevented it from getting worse, taking longer, etc. Hopefully, you are completely cured and can resume all activities.

Fortunately, 90 percent do completely recover!!!

And, fortunately, less than 5 percent of all injuries are considered in this major category.

The patient's outlook on their injury varies according to:

1. outlook on severity: major or minor problem to them
2. expense of possible treatment
3. time and energy of possible treatment
4. speed of recovery desired

     Therefore, with 95 percent of all injuries considered minor in consequences,  the doctor/therapist must come to grips with the patient's perspective. The doctor or therapist then maps out a plan of attack after the initial evaluation. Always important to have, this plan of attack  has different variables. These are:

1. Further diagnostic testing ---now or only if not getting better
2. Initial treatment plan---with physical therapists, with home exercises, with medications, with casts, with lifts or other shoe inserts, with training adjustments (ie. rest, alternative exercise), and with taping and other treatment modalities
3. Back-Up treatment plan---if patient does not get better, if patient is better but wants faster relief, and if patient wants insurance to prevent reflares
4. Patient Education Advice---how to prevent recurrence of injuries by knowing the cause of a particular injury (and the causes of most injuries)

As the doctor or therapist maps out the proposed treatment plan, it is based on what the majority of patients with the same or similiar problem became better with. Dr Blake tries to point out all the possibilities of diagnosis, cause, and treatment, and then allow the patient to decide how much expense, time and energy he or she wants to build into the rehabilitation plan. Most patients are started on a home exercise program and other self-help ideas (KISS principle). X rays are not routinely performed, with 90 percent of the time the injury limited to soft tissue. Casting is done when walking is difficult, but removable casts are revolutionizing the process. Much less muscle atrophy is seen with removable casts than the traditional permanent casts. Cortisone shots should be limited to only mandatory situations due to their possible weakening effects. Never have tendons injected with long-acting cortisone since possible ruptures can occur.

     The patients are advised what the next step would be if they are not responding. Sometimes there are so many possibilities of treatment that they all can not be covered in the initial visit. Surgery rarely is needed for a particular problem, so it is not mentioned at the initial visit normally. The doctor or therapist tries to discuss with the patient:

1. his/her immediate concerns at the full diagnostic examination (if the diagnosis is still questionable, does the patient want xrays, MRIs, etc)
2. the patient's ability to begin therapy now, speeding up the process of healing (I can think of very few injuries which would not be helped by therapy)
3. their concerns for a rapid (as fast as possible) recovery

For some, it will seem strange that some patients do not want the "best", fastest care. The problem is that with this "fast" care comes with expense, time, and energy. These are commodities some patients, most patients, are short on. Most of the time we settle on a slower, but still effective, course of action.

Philosophy of Treating Athletic Injuries (Part II)

The patient’s main goal is to rid himself or herself from the problem as soon as possible with no recurrence. The health care provider’s main goal is to safely rid the patient of the problem with no recurrence. Should the patient rest a day, two days, two weeks, three months, etc? Should the patient self treat the problem at home to save expenses, or be seen in therapy daily, weekly, etc? Should an elaborate work-up on the cause be pursued? Should every ache and pain be x rayed, bone scanned, MRI ed, casted, injected, etc? Should every possible cause be treated, even if this would entail months of treatment and huge expenses to the patient?




The purpose of these several posts is to bring the patient closer to the doctor/therapist in making decisions on treatment care. It is a joint venture and both must know what the other is thinking.



There are a few common athletic injuries in which the doctor or therapist immediately realize that the patient’s problem is very serious. The crack or snap that is heard, the amount of sudden swelling, the severe intense pain, the total inability to walk without pain, the inability to bend a joint without severe pain, the history of years of pain without relief, all signal the doctor/therapist to regard this injury as almost special and definitely serious. Complete investigation should be performed in all of these cases.



Fortunately, these are the rare injuries. Definitely, five percent or less of all athletic injuries fall into this category. Most of the time, the injury was gradual, with no to minimal swelling, only moderate aches (level 5 pain at most), with no limping with walking, running, skating, dancing, etc.

All body parts are freely movable. The symptoms have existed for 3 months maximum. Should be easy to treat? Sometimes. All those other variables play so much of a role.



The doctor or therapist must have basic rules that guide them in their treatment of athletic injuries. A starting place with most injuries develop from there. For each doctor or therapist, these basic rules are very different. Hence, the reason that some are successful at treating sports injuries, others not. But even the best doctor/therapist cannot put all the pieces together all the time for every patient. And, of course, the patient feels let down, misdiagnosed, ripped off, etc. Can this be prevented? Sometimes it can. If the basic trust in the doctor and therapist is there, the patient will communicated his or her frustrations. This forces the health care provider to re-evaluate the course of action and accept failure, change directions, etc. Usually the doctor/therapist is busy treating 1000 patients actively at any one time, all in different stages of healing, without the ability to individually check on the progress of each patient. The patient must follow up, inform if there is no change for the better, and positively help in the healing. There can be physical reasons a treatment regimen fails. We must avoid failure from patient frustrations and lack of communication and distrust in the doctor/therapist and patient relationship. Fortunately, 90% plus of patients get better when communication is free flowing.

Philosophy of Treating Athletic Injuries (Part I)

The treatment of athletic injuries is based on many principles that must be applied to the individual with his/her injury. The experience and knowledge base of the doctor and therapist become very important to the patient. The decisions of diagnosis, cause, when to cast, when to x ray, when to inject, and when to stop all activity must be carefully thought out.



Why is it not a cook book lesson plan to be easily followed by any doctor or therapist? Understanding the individuality among athletes is the key to understanding the complexity of treatment of athletic injuries. Each similar injury has a different set of circumstances associated with it. There may be differences in:

1. severity of injury

2. severity of the cause

3. length of time that the injury has been present

4. amount of residual weakness, swelling, scar tissue accumulation, or stiffness

5. suddenness of the injury

6. individual’s sport

7. individual’s physical, psychological, or emotional need to return to activity

8. previous treatment

9. speed of return to activity

10. pain tolerance, and

11. multiplicity of the problems, etc.

Does this give you a hint of the complexity?



The patient is a stranger to the doctor or therapist on the first visit with sometimes a limited amount of time to sense the patient’s problem, frustration, cause or causes, and possible treatment plans, etc. Many decisions are then made. Part 2 tomorrow.