Injury Rehabilitation through the use of Exercise

The iron game has been around for quite some time. Nowadays weight training is so popular that those of you who are new to it may find it difficult to believe that just 25 years ago most athletes were not permitted to incorporate it into their training. The popular theory was that lifting weights would slow athletes down or make them "muscle-bound."

Unfortunately, as with many things in life that come from one extreme, the pendulum has swung back the other way, and as is generally the case, neither extreme was the correct approach. As a result many athletes today are made to weight train an injured area too soon.

This month's column on that growing problem is specifically aimed at athletes, trainers, physical therapists, coaches, managers, team owners and even physicians.

Over the past several years at the Soft Tissue Center we have noticed an increasing number of athletes, including professionals, who are suffering complications from attempting to strengthen an injured area too soon. There are a variety of sources and reasons for this. In some cases the athletes may have put too much pressure on themselves to get back to the starting lineup, fearing that if they don't rehabilitate the injury, they won't be able to play and thus will not be paid. More commonly, however, the therapists, trainers and/or strength and conditioning coaches have received a tremendous amount of pressure from their head coaches, managers and team owners to return the athlete to action so that the team can have the best starting lineup. If we add the element that the therapist may not have firsthand experience in proper weight training, especially in a clinical setting, we have a disaster waiting to happen.

The best possible scenario, unfortunately, is that the player will not return to action. The worst case is a lifelong disability that will be there long after the upper management, coaches, therapists, media, crowds and paychecks are gone.

I have asked a number of our patients and also a few coaches for their comments to help illustrate just how common this problem is. Most of these men are veterans in their sport.

George McPhee, formerly of the new Jersey Devils, experienced two major injuries while he was playing pro hockey-a shoulder separation and an adductor strain ("groin pull").

He was "checked" (hit) against the boards by an opposing player, and the impact was against his hips and legs. The onset of pain was immediate.

George's "rehabilitation" began a few days later and consisted of adductor (inner-thigh) training with light weights. The prescription was that he would have to be able to perform three sets of 10 reps before he would be allowed to play. There was pressure from the coaching staff, who would be watching the therapy session. Needless to say, the workout was very painful.

George spent nearly two years trying to rehabilitate his injury before he retired in 1989. His was a complicated injury, and retirement may have been the only real alternative, but two years of less-than-optimum therapy was difficult to overcome. We were able to significantly reduce his pain, but not enough to withstand the rigors of hockey.

According to 13-year hockey veteran Ron Duguay, "I have seen much of this same attitude about rehabilitation...both from the coaches and from the trainers. They don't believe in rest. It's push, push-not realizing the importance of relaxing the body and the mind. The goal becomes to strengthen the muscle instead of rehabilitating it.... [They should] let the body do its own work." Brian Holloway, a former offensive tackle for the New England Patriots and L.A. Raiders, is an eight-year NFL veteran with All-Pro honors and was a team representative in the NFL Players Union. He has received numerous injuries during his career and has a great deal of insight into the psychological and physical reasons for high-risk sports performance:

"Inherent in the makeup of an athlete is the ability to do the extraordinary. Successful athletes and great victories are always had amid the greatest of adversities. The greatest sports moments are always when the odds are so heavily weighted against you and there is no margin of error. These moments are the most intoxicating in sports...there is no time when time seems so significant.

"Every athlete knows what this is like and has felt the exhilaration. Perception to reality is very distorted at this point; there is nothing more important than championing the moment....The shooting adrenaline-allows the body to withstand enormous amounts of stress and pain.

"The body keeps tabs though. With every hit, collision, tackle and cut the body gives way. Great care and interest has been taken in conditioning and rehabilitation, and this practice has indeed made a difference in training and building the muscles; but there is little you can do to repair the damage to the structure, the foundation of the body-joints, ligaments, bones....I've learned that you cannot stop the erosion, only contain the eventual for a while-the inevitable physical pain and discomfort."

Brian offers a perceptive profile of the typical coach, who may be inclined to rush training of a player's injury:

"In my football career of four years at Stanford University and eight years of professional football I went through eight coaching staff changes....I've learned [that] it takes a special type of person to be a coach. The hours are the longest of any profession I know; the pay is generally not that good. You work seven days a week during the season, six days in the off-season; and you are fortunate to get a week vacation each year. You spend very little time at home and rarely see the family. Dinner is had at the training table or in the office...while practice preparation goes well into the night.

"Anyone who starts down the road of being a coach must resign himself to the fact that he will not be able to do much else in life. He is gaining no job skills or employable characteristics, and he is not associating with others to branch out to other possibilities. He lives in a very closed world, very detached from the sensibilities of society.

"He can be relatively assured that he will be fired, replaced or resign within two to three years. His success is determined by the team performance as well as the performance of the individuals that he is coaching and the temperaments of the management, athletic director and alumni. One word describes his precarious life-style: 'desperate.' "

These two points that Brian addressed-the athletes' distorted perception of reality and the fact that coaches live in a detached world- may be the catalysts for many muscle tears, sprains and strains; so much tendinitis, bursitis and post-surgical rehabilitation may not be completed successfully in what are for the health care staff high-stress situations.

Jim Johnson of the Pittsburgh Penguins has been an avid weight trainer for years, as evidenced by his 330-pound bench press. "Weightlifting is important to me," Jim stated. "I performed weight training to rehabilitate my own knee as soon as I could."

Explaining that he had designed the rehab program for his knee himself, Jim added, "I believe what my body tells me. Pain should make you stop until the pain subsides. Today pro sports means 'X dollars for X games.' We try to get back after an injury as soon as possible. Most of the time they use sense and will take an extra week to get over the injury, considering the investment in the player; but sometimes the 'as-soon-as-possible' approach can cause problems. The position and the player can be the key in rehab. Mario Lemieux would not be rushed to play."

The specific investment may, in fact, reveal preferential treatment for one individual over another based on the player's salary and revenue generation. Such a policy is not intentionally malicious, but it is simply a fiscal priority for the team.

That is what professional sports teams are all about: the team and finance, not the individual. It is for this reason that athletes must assume the responsibility for overseeing the type of rehabilitation they get and, consequently, what happens to their career. This applies to college and high school athletes (and their parents) as well.

Art Still, a defensive end with the Buffalo Bills and a 12-year veteran with multiple All-Pro honors, feels that the Bills have a slower approach to rehabilitation than some of the other teams. In addition, he observed, "The times and the money have changed. Football and basketball may be different from some of the other sports because of the large salaries. The players are too much of an investment today to rush rehab."

A team's investment in a player can be a conflict of interest in itself. According to Dean Kennedy of the Buffalo Sabres, "It's a business, not just a game. Maybe it was like that before, and I was naive. So many guys have great potential in the junior leagues, and [the management] burns them out in five years....

"Every guy in the game wants to have the respect of his fellow players. Who can play in pain is an issue. Some players will say that they can play, and the team knows they shouldn't be playing. One friend of mine had a severe neck and head injury. The coaches asked if he could play, and he is so tough that he said, 'Yeah, I can play.' He had no business being on the ice."

Remember that the therapist and trainers, as well as the coaches and even the physicians, are under excessive pressure to perform too; their work is in the sports section of every newspaper in the country whether the athlete is able to play or not.

Another example of an athlete in pain is one that we have all been reading about for several years- Mike Marshall, who was recently traded by the L.A. Dodgers to the New York Mets. For at least two years the Los Angeles Times has reported on the strengthening exercises Marshall has been performing to help his low-back problem. Mike Marshall is not a patient of ours, and I have not had the opportunity to review all of his data. Considering that he more or less plays professional baseball part-time and is in such excruciating pain, one would think that two years of strengthening exercises would have had a more significant effect. Yet Marshall returns to play, and his in-jury suffers another setback. It is a tragedy to see a talented player with such drive go through this.

"Sometimes coaches don't believe you," Ron Duguay explained. "The coaches and players question your heart and character."

Heart and character should only be questioned after the injury is rehabilitated and then strengthened, not when it has never been addressed properly or is chronically re-injured. This relates directly to Brian Hollo-way's comments regarding the players' distorted perception and the coach's closed world.

Ken Baumgartner of the New York Islanders suggested that a rookie's idealism can cause him to train in such volume, without thought of possible injurious effects. "We just thought that the more training we did of any kind, the better," he said. Perhaps this line of thinking precedes the excessive and sometimes unjustified confidence in harmful rehabilitation practices.

I can site two further examples of hockey stars who requested to remain anonymous. One was a recent first-round draft choice. He injured his left knee at the point of the quadriceps insertion and was diagnosed as having Osgood-Schlatter disease (a pulling away of the bone at the quadriceps insertion that usually occurs in youth). This diagnosis was possible, although not likely. At the Soft Tissue Center we felt that tendinitis was definitely a factor.

This player had missed half of last season due to his injury, and his rehab had primarily consisted of explosively performed leg extensions at maximum output on a Cybex-type unit-exactly what he should not have been doing for either diagnosis.

We restructured his exercise program and treated his knee, and he is playing hockey now.

My other example is a rising superstar who sprained his ankle in a unique manner during the 1989 Stanley Cup Playoffs. His strengthening rehab was to perform isometric movements of his ankle and foot against the wall, and his ankle had not yet recovered when he started these exercises. That was the extent of his therapy.

The player subsequently came to the Soft Tissue Center, and his ankle was treated properly. He voiced a question that I found alarming. "Strengthening an area is great," he said, "but shouldn't I get over the injury first?"

It is a sad commentary when an NHL All-Star is being treated by his team physician and a question like that has to be asked.

NFL veteran Pete Koch reiterated the recurring theme. "I've seen some mistakes in college and in the pros where athletes were rushed to the field too soon," he related. "Athletes are being given xylocaine in a game...like that is supposed to be a substitute for a player. The common denominator is money. In the pros it is easy to see the money [but] college football generates revenue on that level too."

The inclusion of college sports in this discussion is well-taken. Two top college tennis players (names and schools must be withheld due to NCAA rules of eligibility) prove the point. One had an elbow injury, and the other had a rotator cuff injury. Both were placed on a strengthening program, both had been on the program for one year, and both had missed one year of play when they came to the Soft Tissue Center.

The strengthening rehab hadn't worked for two reasons: First, the injuries were never resolved and then the weight training continually aggravated them; and second, the exercises chosen were biomechanically incorrect. Again, a familiar theme. Both are now representing their school in tournaments.

According to Bob Ward, strength and conditioning coach of the Dallas Cowboys, his team considers two aspects of any rehabilitation: the knowledge/science aspect and the art aspect. Proper rehab is the combination of both.

"We have an aggressive rehab program here; however, some people [not with the Cowboys organization] have exaggerated the idea of work," Coach Ward said. "Factors that must be monitored include pain, lack of progress and boredom. I am the conditioning coach on and off the field, so I can monitor their patterns. If a ballplayer had a shoulder injury, he may have favored his shoulder. He needs to be retrained because of the residual overhang of the nervous system. If these criteria can be read right, it is more powerful than any instrument. No one can tell you the progress of your own body better than you can-if you listen to it."

"Doc" Kreis, Ph.D., strength and conditioning coach at Middle Tennessee State University, takes a hard line on the "too-much-too-soon" approach-and the coach's role: "To lose an athlete at the pro level is nonsense. They must be watched over hours, days and weeks. The coach must be with the athletes and see them as much as he can.

"A veterinarian friend of mine always said, 'My patients can't talk to me and tell what hurts, so I have to watch the nature of the animal.' If he can watch the nature of an animal that can't talk, then there is no excuse for training a painful, injured area on an athlete. [The coach] would have to be blind to not look.

"The mental aspect and the lack of progress must be watched. Some of these coaches and trainers don't have the exposure or the knowledge, and too many have an ego problem with a 'cure it all' attitude....I have talked to at least 20 physical therapists across the country since you brought this to my attention about this new trend [and] they all have noticed the same changes."

As Brian Holloway observed, "Athletes will play when injured because they want to. Athletes will play when injured because in the unspoken truths of the game...they have to. They are playing the sport and competing on this level because they've demonstrated the ability to do the unnatural...to keep 'charging despite the sting of the blades.'

"It was called courage and toughness at the time; guts maybe too. In time it will be called foolish, irresponsible and stupid. I am saying to myself...how did it happen so fast?"

It is my hope that the athletes begin to assume more responsibility for their rehabilitation and health and that the health care providers begin to find the direction they have lost. Don't lose everything you have worked, lived and dreamed for by subjecting yourself to erroneous thinking or even borderline neglectful rehabilitation. Your superstar abilities are something that you were born with. Your ability to return to action after an injury rests largely in someone else's ability, in someone else's hands. You may not be in the best available hands.