There is nothing more traumatic for the amateur athlete than to experience a catastrophic sports injury. Because when this occurs, it's not just the athlete and not just the sport itself that is affected. These injuries impact every aspect of life, especially during the Traumatic and Immobilization Phases, which I've addressed in my previous two articles in this series.
Speaking from my personal experience of fracturing my tibia & fibula in April 2016, it was overwhelming to me how so many of my friends, family, teammates and co-workers had to adjust their lives to accommodate my situation. Even my three children were deeply affected by the sight of Dad being unable to all things they were used to. I suppose it wasn't convenient either that we bought a house and moved six weeks after my big break. And despite living over an hour away from the club, it was my rugby mates that came out in force and got the job done for my family.
The response of all my supporters was very motivating for me. Their sacrifice and effort to serve myself, my wife and my children in what has been the most trying season of our lives, inspired me to put in the work day in and day out to get back on my feet and find my stride again. But I had a long trek ahead of me. Part III of this series will highlight the Mobilization Phase, where I will break down how the amateur rugby player can regain joint flexibility, muscle mass, and gait mobility. All essential components for building the foundation needed before returning to rugby.
Early mobilization wins
Returning to work was a high priority for me. Thankfully I work for a health care provider and had the flexibility to work from my desk with my leg elevated. This accommodation allowed me to return to my post a mere two weeks after my injury. Returning to work quickly was psychologically huge for me because it not only brought back a sense of the familiar, but it also gave me the opportunity to contribute at the office, which was good for my spirits.
Another big step was getting off the crutches. I remember it was 21 days after my surgery that I took my first unassisted paces. My wife was out for the day, and I was feeling adventurous. I only made five shuffles forward and back, but it felt like I'd scored an 80m try. It was enough of a surge that I was able to permanently rid myself of crutches within just two more days.
Just because I was up on my feet, though, didn't mean walking was easy. I had a massive gimp, and my right knee would regularly give out on me, so every stride was a cautious one. I had lost a tremendous amount of muscle mass both in my quads and my calves, and my ankle only had about 75% flexion.
If I was going to successfully make it back to the pitch for the fall season, I needed a plan. I discovered that there are two primary goals of rehabilitation:
- Restoring Normal Mobility
- Restoring Normal Stability
Restoring normal mobility
Every joint has a normal range of motion, but when a joint experiences a change in normal movement patterns, mobility becomes constricted. This temporary restriction of mobility impacts the flexibility of the joint creates stress on connective tissue and manipulates how the surrounding muscles work. Many factors affect joint mobility such as swelling, soft tissue contractures and adhesions, tight muscles, and more. (1)
During your immobilization phase you should have begun a self-administered myofascial release program, this is something you'll want to continue when mobilizing with either your hands or a roller-bar to break up the tissue and heal the broken fascia.
Effective treatment will result in:
- Pain reduction
- Feeling of ease and smoothness in motion
- Increased range of motion
- Reduced inflammation
I primarily used resistance bands to continue to work out my leg. Every day I would work for about 15 minutes doing leg extensions, calf extensions, and ankle rotations, gradually increasing the band strength.
Restoring joint stability
Musculoskeletal stability is both a matter of tissue and psyche. Our bodies naturally adapt to physiological changes and compensate for deficiencies. When functioning normally, muscles contract and relax during movement to provide stability to joint structures. But when an injury occurs, causing immobilization, muscle deterioration becomes inevitable, and the body sometimes compensates in un-natural ways. Regaining stability requires not just a rebuilding of the tissue, but also a retraining of the kinetic memory. (2)
If you bypass this critical step, you will not only delay your full recovery but also put yourself a far greater risk of subsequent injury, because your body is relying on sub-standard support. Only once normal mobility and stability have been reached, should you begin performing strenuous activity and strength training. (3)
One symptom you may begin to notice during this period is the development of a bone callus that may appear around the fracture site. This calcium deposit encases the fracture to protect it and assist the healing process. A side effect of this is that it may apply pressure to surrounding tissue and may produce tingly sensations that lead to restlessness in your leg. These are normal and should in no way inhibit your regimen. However, if you begin to experience consistent pain at the break site, ease back and talk with your surgeon or physical therapist. (4)
Restoring muscular strength
I had monthly check-ins with my surgeon so he could monitor the progression of my healing and mobility. He would order another round of x-rays to ensure that my bones were fusing well and by my 3rd month’s assessment, he was astounded by my progress and said that he had never seen someone heal as quickly. He gave me complete clearance to not only begin strenuous strength training but also running as soon as I felt able. This was great news because our first match was fast approaching in just six short weeks and I was committed to running out on the field before the end of the 2016 season.
I began going to the gym 2-3 times a week. I started on the elliptical machine to minimize the impact on my leg while providing support to my ankle, which was still fairly stiff. After about 20 minutes I shifted to weights where I could focus specifically on building muscle back in my right leg. During every gym session I would do isolated right legwork on various machines: Leg Press, Leg Extensions, Leg Curls, Calf Raises, and Single-Leg Romanian Dead Lifts, Etc.
After roughly 3 weeks of rebuilding work, I felt ready and confident to begin jogging on the treadmill. Despite my walking gimp resolving after about a month off the crutches, it returned in full force when I attempted to run. So I had my wife take my iPhone and record video of my jogging gait from behind and from the side so I could assess my mechanics and isolate the areas I needed to retrain for symmetry.
This is an area where you can really see a lot of progress being made and understand how all the rehab components work together. Injury related gait issues are primarily caused by muscle imbalances at the break site or within the kinetic chain associated with the break. Hyper-irritable points or Trigger Points are made up of knots of tight fiber in the muscle or fascia that impact the nervous system function, thus altering gait. So the myofascial therapy, strength training, and renewed muscle memory formation must be employed to achieve the desired result. (5)
When you stick to the process, improvement can begin to happen fast as the recovery milestones start to snowball. Recovery can be exhilarating. As your doubts dissipate, goals seem more attainable than they did before mobilization and your expectations become focused. Pushing yourself is critical even to attempt the feat of returning to rugby, but you must know your staggered limitations and pace accordingly.
Setting the mobilization pace
The final goal of the mobilization phase is the recovery of running at full pace. And this is where you have to be very calculated.
There are four principles to keep in mind:
- Work below your "break point."
- Allow a rest day between each run and rehab day
- Add 1 element at a time
- Only progress when you are comfortable to do so
You will first need to establish a baseline. To do this use a treadmill and after a 5-minute walking warm-up, increase the speed to a pace where you can still talk. Go for as long as you can remaining pain-free. When you are finished record your distance, time, and pace. You should already know from your pre-injury fitness level what a reasonable goal should be. For me, it was a sub 24 min 5K. It is important that for the first couple of weeks, you do not increase the pace of your workout from the baseline rate, only increase the distance. Once you can run 75% of your distance goal at baseline pace, then begin to make incremental speed adjustments. This is the recommended method to minimize any subsequent injury. You will also want to regularly monitor your gait mechanics by recording your sessions to ensure you are maintaining proper form. (6)
Overcoming mobilization obstacles
Momentum is critical when you're working through the mobilization phase since witnessing physical improvement is a real motivator. But truth be told, it's almost inevitable that any rehab process will involve at least one setback. Typically resulting from an overextension or pushing too hard or too long, and your body simply says ENOUGH! Because the healing tissue around the injury site is mostly made up of immature collagen, it simply isn't as strong as healthy tissue and when overloaded, will tear. This is called microtrauma and causes pain, inflammation, and stiffness. (7)
This can be a demoralizing experience. Because the days or potentially week(s) of rest can make it feel like the previous effort is just wasting away. This where you have to keep your blue head. Take care of your body with rest, ice, compression, and elevation as needed, but maintain an "intensity attitude" if you can using a strict routine to recalibrate your focus.
The good news is that microtrauma heals quickly, especially if you manage it correctly. Naturally, you can't expect to just jump back in at the workload where you left off. In fact, it may even be beneficial to establish a new baseline and work from there.
Show your face at rugby
As soon as you can get yourself to training. Your presence will be a real boost to the club and begin to lay the expectation for a full return. Regardless of your personality, take advantage of the opportunity to be an inspirational motivator for your squad. Encourage your mates to keep working hard and allow them to encourage you to do the same. As I shared in the first article, for the amateur athlete, the willpower to return to the pitch is found in the camaraderie of the club. You do it for your mates.
For myself, I was also given the opportunity to join the coaching staff having just completed my Level 200 Coaches Certification. So despite not yet being physically ready to compete, I was in a position to still contribute. And with the season fast approaching the anticipation of strapping up was beginning to burst inside me.
1. Soft tissue contractures http://staff.aub.edu.lb/~ss15/soft-tissue_contractures.htm
2. Explicit and Implicit Memory: Intuition Training Basics https://www.psychologytoday.com/blog/ambigamy/201011/explicit-and-implicit-memory-intuition-training-basics
3. Sports Injury Rehab Basics - http://www.sports-injury-info.com/sports-injury-rehab.html
4. Hallam, Liam Getting Back to Running after a Broken Leg - https://healdove.com/injuries/Getting-Back-to-Running-After-a-Broken-Leg
5. Gangemi, Steve How to Use Manual Therapy to Restore Essential Gait Mechanics - https://breakingmuscle.com/learn/how-to-use-manual-therapy-to-restore-essential-gait-mechanics
6. Goom, Tom Returning to running after injury - http://www.running-physio.com/returnafterinjury/
7. Micro-trauma http://www.summitmedicalgroup.com/news/fitness/Overuse-Injuries/