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Orthopedic Injuries & Rehab Protocols

Anatomy Overview: What is the hamstring(s)?

The hamstring muscles are a collection of three different muscles that are located on the posterior (back) side of the thigh. These muscles are called the biceps femoris, semitendinosus, and semimembranosus. These muscles begin at the ischial tuberosity (bony part of your butt that you feel pressure on when sitting) and attach at the back of the knee along the tibia, or shin bone. These muscles act to flex (bend) the knee and extend the hip when the knee is straight.

A hamstring strain can occur through a few mechanisms, however it most commonly occurs during sprinting activities typically during deceleration (slowing down), however they can also occur from jumping activities as well. Athletes that are particularly susceptible include those that participate in track and field, football, baseball, basketball, rugby, and hockey. When a hamstring strain occurs, the muscle fibers are overstretched which then causes tearing along the fibers.

Diagnosis

Signs and symptoms of a hamstring strain include pain in the backside of the thigh, potential bruising depending on severity, and some people complain of hearing a "pop" during a more severe hamstring strain. Diagnosis is typically made through mechanism of injury, clinical findings upon evaluation, and MRI. Hamstring strains, like other injuries, are classified according to severity. A grade 1 is a mild strain, grade II is moderate, and grade III strain is severe. The severity of the strain determines the treatment protocol, which is listed below.

Rehab Protocol

Grade 1 strain. The most common and least severe. This is often referred to as a hamstring "pull" and the recovery timeline is approximately 1-3 weeks. After an initial rest period (a few days consisting of RICE (rest, ice, compression, and elevation)), where the individual is allowing the healing process to occur and applying ice to the painful area, rehab can begin. As with all hamstring strains, it is important to not overstretch the hamstring for about 3 weeks post-injury in order to minimize the risk of re-injury. Exercises for a grade 1 strain include stationary bike/cycling, 4-way straight leg raises, standing hamstring curls and treadmill walking, followed by walk/jog progressions. It is also imperative to educate the patient on dynamic warm-ups and a cool-down stretching program in order to reduce further risk of injury.

Grade 2 strain. More significant, but still an incomplete tear. Typical recovery timeline of 3-6 weeks. Rest ice compression and elevation (RICE) initially, and no heat application for the first 7-10 days after injury in order to control swelling. Then begin with active range of motion (ROM) exercises consisting of heel slides and stationary biking. Other suggested exercises include quad sets, standing or prone hip extensions and hamstring curls, and toe raises. After about 2-3 weeks of this, the individual may continue with phases 4 and on for their rehab (i.e. picking up with exercises in the grade 1 strain section).

Grade 3 strain. Complete tearing of the muscle-tendon unit. Can take many weeks up to months to fully heal. Sometimes surgical intervention is necessary. The rehabilitation program is similar to the grade 2 strain, however, it is imperative to ensure the individual is ready to progress to each subsequent phase in their rehabilitation program. If an athlete progresses too soon, a reinjury is highly likely.

Effectiveness Upon Return

Most athletes recover from a grade 1 or 2 hamstring strain without any long-term effects. An athlete may have longer-term effects after a grade 3 strain, especially if surgical intervention was necessary. After a severe strain, it is possible the athlete may lose a fraction of a second in regard to their speed and agility. This may not seem like much, and is a moot point for most of us “average Joe’s,” but in a high-level athlete, these fractions of a second are critical. New rehabilitation strategies are constantly evolving in order for athletes to return to their sport safely and effectively. Research indicates that a rehabilitation program consisting of neuromuscular control interventions, progressive agility and trunk stabilization interventions, and eccentric strength training optimize long-term outcomes for individuals post hamstring strain.

Additional Thoughts by Dr. Morse

Hamstring strains are probably the most common injury we see in the NFL. Especially earlier in the season, spanning from preseason until about Week 6. Transitioning from the offseason to the everyday grind of the NFL season causes a significant load on the hamstring tissues and tendons. In the offseason, the players are probably training at 50-60%, but when the season starts they ramp up to 100%. The tissue often isn’t quite ready and strains.

The primary issue with hamstrings is that they usually get injured at the myotendinous junction, which the body will try to ‘heal’ with scar tissue. Scar tissue is not as strong or as flexible as regular muscle/tendon tissue. Therefore it is weaker, and the first location that will likely reinjure if the tissue is stressed beyond the load it can handle. Similar to groin and calf muscles, all three tissues are notorious for re-injury. Players have to be smart when they attempt to return from these, if not the tissue will reinjure and the player will struggle for weeks/months.

Anatomy Overview: What is the AC joint?

The acromioclavicular (AC) joint is where the clavicle meets the highest point of the scapula/shoulder blade (acromion). An acromioclavicular (AC) joint sprain/separation occurs when an individual falls directly onto the shoulder when the arm is in an adducted position (close to the body). However, this injury can occur in other ways as well, such as a fall onto an abducted (away from the body) shoulder with an outstretched hand. AC joint injuries account for about 40-50% of all athletic shoulder injuries. This injury can range from minimal disruption and pain levels to more serious damage that requires surgical intervention. The greater the deformity, the longer it takes an individual to return to a pre-injury functional level. In short, A mild shoulder separation involves a sprain of the AC ligament that does not move the collarbone and looks normal on Xrays. A more serious injury tears the AC ligament and sprains or slightly tears the coracoclavicular (CC) ligament, putting the collarbone out of alignment to some extent. The most severe shoulder separation completely tears both the AC and CC ligaments and puts the AC joint noticeably out of position. Surgical intervention is often required for this type of AC joint injury.

Diagnosis

After a suspected AC joint injury, the athlete or individual is assessed by the sports medicine team. After the sports medicine team conducts various clinical tests, such as the AC shear test, passive cross-body adduction, and O’Brien’s Test, a radiograph (x-ray) is performed in order to determine the extent of the injury. The classification of AC injuries currently is numbered from I to VI and they are based on the direction and amount of displacement. Additionally, AC joint injuries are classified according to ligamentous injury rather than injury to the joint itself. Further explanation of the classification details of AC joint injuries as well as clinical findings can be seen in the table below.

Classification of AC Injury

Type I
Clinical Findings

Isolated sprain of AC ligaments

Coracoclavicular ligaments intact

Deltoid and trapezoid muscles intact

Tenderness and mild pain at the AC joint

High (160-180) degrees painful arc of motion

Resisted adduction often painful

Intervention is with transverse friction massage (TFM), ice, and pain-free active range of motion (AROM)

Type II
Clinical Findings

AC ligament is disrupted

Sprain of CC ligament

AC joint is wider & there may be a vertical separation when compared to the unaffected shoulder

CC interspace may be slightly increased

Deltoid and trapezoid muscles intact

Moderate to severe local pain

Tenderness in CC space

Passive range of motion (PROM) is all painful at the end range with horizontal adduction most painful

Resisted abduction and adduction often are painful

Intervention initiated with ice and pain-free AROM/PROM; with TFM beginning on day 4

Type III
Clinical Findings

AC ligament is disrupted

AC joint was dislocated and the shoulder complex was displaced inferiorly

CC interspace 25-100% greater than normal shoulder

CC ligament often disrupted

Deltoid and trapezoid muscles are usually detached from the distal end of the clavicle

Fracture of the clavicle is usually present in patients under 13 years old

Arm held in adducted position from patient

Obvious gap visible between the acromion and clavicle

AROM is all painful; PROM is painless if done slowly and carefully

Piano key phenomenon (clavicle springs back after being pushed inferiorly) present

Type IV
Clinical Findings

AC ligament disrupted

AC joint dislocated and the clavicle anatomically displaced posteriorly into or through the trapezius muscle

CC ligaments completely disrupted

CC interspace may be displaced but may appear normal

Deltoid and trapezoid muscles are detached from the distal end of the clavicle

Clavicle displaced posteriorly

Surgery indicated

Type V
Clinical Findings

AC ligaments disrupted

CC ligaments completely disrupted

AC joint dislocated and the gross disparity between the clavicle and scapula (300-500% greater than normal)

Deltoid and trapezoid muscles are detached from the distal end of clavicle

Tenderness over entire lateral half of the clavicle

Surgery indicated

Type VI
Clinical Findings

AC ligaments disrupted

CC ligaments completely disrupted

AC joint dislocated and clavicle anatomically displaced inferiorly to the clavicle or the coracoid process

CC interspace reversed with the clavicle being inferior to the acromion or the coracoid process

Deltoid and trapezoid muscles are detached from the distal end of the clavicle

The cranial aspect of the shoulder is flatter than the opposite side; often accompanied by clavicle or upper rib fracture and/or brachial plexus injury

Surgery indicated

Rehab Protocol

The intervention for AC joint sprain depends on the severity of the injury and the physical demands required of the athlete or individual in regard to their sport/work.

Types I and II AC Joint Sprain

Usually, recover full and painless function with conservative management

Ice, nonsteroidal anti-inflammatories (NSAIDs), and analgesics used as needed

A sling may be prescribed for 1-2 weeks

Gentle ROM exercises and functional rehabilitation started immediately after immobilization

Then isometric exercises for muscles with attachments to the clavicle

Then progress to progressive resistance exercises (PREs) for muscles that attach to the clavicle and scapula

Most athletes are back to full sports participation in 12 weeks' time, however, an individual can return sooner depending on individual healing

May use tape/orthotics when returning

Type III AC Joint Sprain

Initially attempt conservative management

Sling immobilization followed by supervised rehabilitation

Pendulum exercises post immobilization

PROM in the extremes of motion should be avoided for the first 7 days, but the goal should be for full PROM within 2-3 weeks

PREs introduced once AROM is full

Should emphasize strengthening of the deltoid and upper trapezius muscles and promote dynamic stabilization of the shoulder complex

Full return to sport expected by 6-12 weeks

If an individual is still functionally limited after more than 3 months, surgical intervention may be necessary

Types IV, V, VI AC Joint Sprain

All require surgical intervention

A most common procedure is the Mumford procedure in which there is a distal excision of the clavicle

Postsurgical progression involves gaining pain-free ROM prior to beginning exercises to regain strength, manual/hands-on techniques to normalize Arthrokinematics, and functional training to restore and improve neuromuscular control of the shoulder

Effectiveness Upon Return

Overall, many athletes return to their sport within a few months and have no long-term effects or reduced quality of performance. In a recent study published in the National Library of Medicine, about 94-100% of athletes return to their sport without long-term effects after sustaining a type I or II injury. This number decreases with a more severe injury. For example, in the same study, it was determined that 89.6% of athletes returned successfully after types III and IV AC joint sprain, and 86.2% for a type 5 injury. In short, outcomes are very good post-AC joint sprain, but there is an increased risk of a more severe injury.

Additional Thoughts by Dr. Morse

AC sprains are very common in the NFL given the nature of the way that the players are tackled and often ‘driven’ into the ground. What is fascinating is that these injuries continue to persist despite every player wearing shoulder pads. When I hear about an AC sprain, overall I’m not concerned. If it is a type one, the mildest of the forms, then the player likely will play through it and won’t even look injured. It’s the type of twos that get tricky. Often players miss a couple of weeks with these, and then when they return they are at very high risk for re-injury.

It is type III’s that start to significantly affect the player’s ability to use the shoulder. These struggle and many guys end up undergoing surgery. Thankfully they are not very common.

Overview: What is a Concussion?

A concussion is classified as a form of traumatic brain injury (TBI) that results from trauma to the head. The trauma and sudden movement can cause the brain to bounce around and twist within the skull. As the Centers for Disease Control and Prevention (CDC) states, “A concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head.” There are usually no findings on routine imaging with a concussion, which complicates the diagnosis. Concussions can occur in every avenue of life, however, they are more prevalent in collision and contact sports such as football, lacrosse, hockey, rugby, soccer, and basketball. It is estimated that 3.8 million concussions occur annually. Persistence of symptoms beyond the accepted time frame for recovery (usually 7-10 days) may indicate a prolonged concussion or the development of post-concussion syndrome (PCS). A concussion diagnosis makes an individual 1-2 times more likely to suffer a second concussion, especially within the first month after the initial injury.

Acute signs and symptoms of a concussion include

Confusion, loss of consciousness, post-traumatic amnesia, retrograde amnesia, balance deficits, dizziness, visual problems, personality changes, fatigue, sensitivity to light/noise, numbness, and vomiting

Chronic signs and symptoms of a concussion include

Cognitive deficits in attention or memory, and at least two or more of the following: dizziness, fatigue, headache, sleep disturbance, apathy, irritability, affective disturbance, or personality changes

An individual should be taken to the emergency department if they exhibit any of the following

A headache that worsens, drowsiness or the inability to be woken up, inability to recognize people or places, repeated vomiting, worsening confusion/irritability, seizures, hemiparesis/hemi sensory loss, unsteadiness, or slurred speech

Diagnosis

Diagnosis and management of concussions has evolved greatly over the last couple of decades and continues to evolve. Currently, there are a number of tests that exist to determine if a concussion is present, and how severe it is. Immediate testing (i.e. on the sidelines) is imperative in order to determine the severity of a possible concussion. This is typically performed under the supervision of a healthcare provider. Some diagnostic tests are included below.

Sport Concussion Assessment Tool-2 (SCAT-2)

Has been adopted by nearly every professional, and many collegiate teams https://cces.ca/sites/default/files/content/docs/pdf/scat21.pdf

Modified Maddocks Score

Used to assess orientation by asking the athlete about game events that day and the week before

Physical Examination

Assessment of concentration (stating the months of the year in reverse or counting backward from 100 in intervals of 3), memory (recall of 3 words after 5 minutes have passed), cervical spine (neck), gait, balance, cerebellar testing (finger to nose test to assess coordination), and an exam of the cranial nerves including ocular motion

Immediate Post-concussion Assessment and Cognitive Testing (ImPact)

Performed before the season and then baseline levels are compared to test results after suspected concussion https://impacttest.com/

Balance Error Scoring System (BESS)
Cantu Grading Scale

Helpful in assessing the severity of concussion and for making return-to-play decisions

Grade 1

Includes posttraumatic amnesia of less than 30 minutes and no loss of consciousness

Grade 2

Defined as loss of consciousness less than 5 minutes, or amnesia 30 minutes to 24 hours

Grade 3

Includes loss of consciousness greater than 5 minutes, or amnesia greater than 24 hours

Rehab Protocol

After an individual sustains a concussion, it is typically advisable to have them rest for a period of 24-48 hours. This includes avoiding strenuous activities, recreational drugs/alcohol, sleeping medication, and aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). After the initial rest period and no concussion symptoms are present, an individual may begin a return to sport protocol.

Currently, a six-step return-to-play protocol is used in order to determine an athlete’s ability to return to action. An athlete should only move to the next step in the protocol if they do not have any new symptoms at the current step. It is recommended to wait at least 24 hours before progressing to the next step. This means that if an individual is able to progress through each step without any setbacks, they are able to return to action in about 7 days. If symptoms return or the athlete gets new symptoms, this is a sign they are pushing too hard. If this occurs, then the previous step in the protocol is attempted again when symptoms subside (usually after 24 hours of rest). If symptoms continue to persist, all activities should be ceased and the medical provider should be contacted. The step-by-step progression for return to play is listed below.

StageActivityObjective
1 - Symptom-limited activityDaily activities that do not provoke symptomsGradual reintroduction of work/school activities
2 - SLight aerobic exerciseWalking or stationary bike at slow to medium pace. No resistance trainingIncrease heart rate
3 - Skating, running, plyometric drillsWalking or stationary bike at slow to medium pace. No resistance trainingAdd body movement while increasing heart rate
4 - Non-contact training drillsWalking or stationary bike at slow to medium pace. No resistance trainingAdd body movement while increasing heart rate
5 - Full contact practiceAFTER medical clearance. Participate in normal training activitiesRestore confidence and allow coaching staff to assess functional skills
6 - Return to playNormal game play 

Effectiveness Upon Return

As previously stated, an initial concussion increases an athlete's risk of future concussions, especially in the first month following the injury. Younger athletes, especially females, are more susceptible to additional concussions. Some possible explanations for this include: females have longer cervical spine segments and may not be as efficient at transmitting impact forces from their head into their torso, and females may be more likely to seek medical consultation after a possible concussion and truthfully report their symptoms. If an individual passes concussion protocol, a decrease in performance has not been definitively identified once they return to play. However, a truthful and honest progression through the rehab protocol is imperative. If an athlete has not cleared concussion protocol, then they are not ready to return to game action. A recent emphasis has been placed on ensuring that youth athletes have cleared concussion protocol before returning to their sport. Several states have enacted legislation in order to ensure athletes are safe and have passed this criterion. If an investigation determines that the athlete has not successfully passed protocol, then the coach and medical staff can be held liable with various punishments such as receiving a suspension, whether temporary or permanent.

Anatomy Overview: What is/are the Groin muscles?

The “groin” is the junctional area between the abdomen and the thigh on either side of the pubic bone. Collectively, this is also known as the medial compartment of the thigh. The groin muscles actually consist of three large groups of muscles that can be injured. These include the abdominals (rectus abdominis muscle, internal and external obliques); the iliopsoas (iliacus and psoas major) which is the only muscle that directly connects the spine to the lower limb; and the adductors (adductor longus, adductor magnus, adductor brevis, gracilis, obturator externus, and pectineus. Groin strains are common among athletes who compete in sports that involve repetitive twisting, turning, sprinting, and kicking such as football, ice hockey, soccer, and basketball. The exact incidence of these injuries is unknown because many individuals play through minor discomfort and pain.

Diagnosis

There are 3 primary mechanisms that can lead to a groin strain. First is direct blunt trauma. This is an acute and direct injury to the soft tissue structures resulting in a muscle hematoma. Second, a forceful contraction. This is the most common mechanism when it comes to sports. These occur after a quick reaction to a change in play, or a forceful contraction of the muscle. This can occur with change of direction, kicking, reaching, and jumping. As one would imagine, individuals that play a sport that requires frequent positional changes and sudden starts/stops can be more susceptible to a groin strain. A diagnosis is typically made with extensive clinical examination and possible diagnostic imaging such as an MRI. Similarly to other soft tissue injuries, there are different grades of injury (1, 2, and 3) with the higher number indicating more severe injury.

Grade 1

No loss of function or strength

A small area of focal disruption (<5% of total muscle volume)

Hematoma and perifascial fluid are fairly common on ultrasound (US) and MRI

Grade 2

Partial tear

Muscle fiber disruption > 5% but not affecting the whole muscle belly

Can have some intense pain in the groin area (knife-like in nature)

Localized tenderness with some swelling

Difficulty contracting the hip abductors

Grade 3

Complete muscle tear and full functional loss

Complete muscle tears with frayed margins and bunching/retraction of the torn muscle fibers

These often occur on the distal third of the muscle near the insertion site on the femur

Rehab Protocol

Most individuals are able to return to sport/activity anywhere from a couple of weeks post-injury up to 3+ months. Naturally, the more severe the injury, the longer timeline is expected for an individual to return to their sport effectively.

The primary goal of the treatment program is to minimize the effects of immobilization, regain full range of motion, and restore full muscle strength, endurance, and coordination. RICE (rest, ice, compression, and elevation) in combination with NSAIDs can be used initially. After this initial phase is complete, heat is a better alternative to use than ice. Early on, exercises should be performed in pain-free ROM and increased pain should not occur after activity. As rehabilitation progresses, there may be mild pain during exercise, but it should subside immediately after the training session.

Once full and pain-free ROM is achieved, the individual progresses through various strengthening exercises, trunk stabilization interventions, and neuromuscular control exercises of the lower extremity. Lastly, sport-specific activities are introduced in order to prepare for a return to activity. This last step can take anywhere from 3-6 months to complete. An example of a progressive rehabilitation program is listed below.

Muscle/MovementProgressionsProgressionsProgressions
Hip FlexorSupineSupported standingFree standing
Lateral hip controlSupported hip hitchedFree standing hip hitchStep Up
AbdominalsHook lying leg liftHook lying alternating leg dropPallof kneeling split lunge
Double leg squatHigh goblet squatLow goblet squatFront squat
Lateral hip strengthAbduction and external rotation in mini squatAbduction and external rotation in mini squat at wallBanded squat
DeadliftHip hinge½ rack deadliftFloor deadlift
LungeSplit lungeOverhead split lungeWeighted split lunge
PlyometricOn spot hoppingLine hoppingCone hopping
    

Running Progressions

LinearInstructions
Marching & skippingMarch skip on the spot with arms overhead, maintaining lumbopelvic and neutral and with aggressive ground contact
Barbell/Overhead RunningRun with dowel overhead or barbell across shoulders focusing on tall running posture and keeping stick still
Leg change drillIn single leg stand, focus on rapid leg change to drive alternating leg extension and swing leg recovery.
Complete 5-6 reps of 3-4 sets. Focus entirely on the quality of execution

Multidirectional Mechanics and Transitions

LinearInstructions
Lateral shuffleSide shuffle between 2 cones 8 meters apart arms locked overhead focusing on getting away from cones as quickly as possible. Progress to race to instruction or shadow opponent while shuffling
Zig zag cutting5 cones in zigzag formation, 5 meters apart from each other. Run and cut as quickly as possible around the cones. Add holding a med ball for increased resistance and higher center of mass. (CoM)
180-degree cone cutting5 cones in a semicircle, start in the middle and run at any cone and cut back straight to the starting point. Add holding a med ball for increased resistance and CoM. / > Complete 3-4 sets of 5-6 reps. Focus entirely on the quality of execution

Various other exercises that will be performed during rehabilitation include: bike, adductor stretching, squats, side lunges, pelvic tilts, ball squeezes, seated abduction and adduction machine, unilateral lunges with reciprocal arm movement, and various balance exercises. The goal is to have adduction strength in at least 80% of the hip abductors.

Effectiveness Upon Return

Most athletes will return to sports with no pain and normal function with appropriate rehabilitation and rarely will there be a need for surgery. Active training rehabilitation was found to be very effective in managing groin strains.

Subsequent groin strains may occur, resulting in a recurrent problem. Hence primary and secondary prevention is equally important. To identify the athlete at risk and possibly correct the predisposing factor(s), the intrinsic and extrinsic risk factors for the injury type must be known. Previous groin injuries, reduced hip adduction strength, higher level of play, and lower levels of sports-specific training are associated with an increased risk of new groin injuries.

Anatomy Overview: What is a knee sprain?

A knee sprain is a broad term that can be used to describe an injury to the various ligaments of the knee. For this rehabilitation protocol, we will discuss a fairly common injury, a medial collateral ligament (MCL) sprain. The MCL is considered to be an extra-articular ligament. The MCL develops as a thickening of the medial joint capsule and can be divided into a superficial and deep band. The anterior fibers of the MCL are taut in flexion and can be palpated easily in this position. The posterior fibers, on the other hand, are taut in extension. However, they blend with the capsule with the medial border of the medial meniscus, which makes them difficult to palpate.

The MCL is the primary stabilizer of the medial side of the knee against valgus forces, and external rotation of the tibia, especially when the knee is flexed. A recent study published by Grood et al. determined that the MCL was the primary restraint providing 57% and 78% of the total restraining moment against valgus force at 5 and 25 degrees of flexion.

After reading all of that, you may be wondering, “what the heck is a valgus force?” In short, a valgus force is when direct contact is made to the outer portion of the knee, and stress is placed on the medial structures of the knee, like getting tackled on the outside of your knee, causing the energy to stress the MCL. An injury that comes to the forefront of my mind was Le’Veon Bell a few years back, while a member of the Pittsburgh Steelers. This injury pretty much ruined my fantasy football season, so it has naturally stuck with me for a while. A closer look at this injury can be found on YouTube here:
https://www.youtube.com/watch?v=uehFeg8zlgY

Diagnosis

Clinical diagnosis of medial knee injuries is primarily achieved using the application of valgus stress in full extension and at 30 degrees of knee flexion. Additionally, the dial test can also be performed, which examines the amount of anteromedial tibial rotation at 90 degrees of knee flexion. These tests are positive when there is a reproduction of pain, or there is increased laxity when compared to the opposite side. Valgus stress radiographs (and ultrasounds) are also useful in order to determine the amount of medial compartment gapping.

Rehab Protocol

Most MCL injuries heal nonoperatively, however, there are instances where a severe MCL injury will require an anatomic medial knee reconstruction with grafts. Non-operative rehabilitation programs focus on controlling edema, regaining ROM, and avoiding any significant valgus stress on the healing ligaments.

Healing timelines vary with an MCL sprain, but typically, the timelines are as follows:

. 1-2 weeks for a grade 1 MCL sprain

. 2-4 weeks for a grade 2 MCL sprain

. 4-8 weeks for a grade 3 MCL sprain*

. *This is for an MCL sprain only. If an additional ligamentous injury occurs (such as the ACL), healing timelines will be greater

A sample rehabilitation program/protocol can be seen below.

Crutches/reduced weight bearing (WB) with a hinged knee brace may be utilized after an MCL sprain. It is important to avoid pivoting/twisting on the knee due to ligamentous injury and possible instability of the injured knee. It is also important to ice and elevates the knee for the first few days after an acute injury. Once pain and swelling begin to subside, the rehab program can begin.

Initial exercises:

  • Stationary bicycle
  • Quad sets (for improved quadriceps strength)
  • Heel prop (for improved knee extension)
  • Heel slides (for improved knee flexion)
  • Straight Leg Raises
  • Short arc quads
  • Standing hamstring curls
  • Heel Raises
  • Standing hip abduction
  • Wall slides
  • Mini Squats

Once full ROM is achieved the next progression of exercises will include:

  • Hamstring, quad, and calf stretching
  • Knee flexion & extension machines
  • Leg Press
  • Hip abductor/adductor machine
  • Single leg strengthening exercises
  • Single leg balance
  • Single-leg wall slide
  • Lateral step downs
  • Single leg squats

It is important to continue to focus on aerobic activities during this time as well as to maintain adequate endurance. This can include stationary cycling, rowing, elliptical, and treadmill walking. Once the physician and physical therapist determine it is safe, the athlete will then be progressed to sport-specific interventions. When progressing the athlete through the rehab program, it is important to keep in mind the precautions, listed below.

  • Avoid pain at the patellar tendon site
  • Also, avoid crepitus at this site
  • Build up resistance and repetitions gradually
  • Perform exercises slowly avoiding quick directional changes and impact loading
  • Strength training should be done 2-3 times a week
  • Be consistent with the schedule

Effectiveness Upon Return

While it may take an athlete a few weeks to a couple of months to return to game action after sustaining an MCL injury, there are usually no long-term effects or a reduction in performance.

Additional Thoughts by Dr. Morse

Knee sprains are a very general term, and are usually used to describe everything from a hyperextension injury to a minor MCL or LCL sprain, and sometimes even a minor injury to the meniscus. The majority of the time, an MCL injury should come to mind for an NFL player given the way that players are usually tackled, on the outside of their knee.

Each sport and even position is unique in terms of return to play, even for the same degree of injury. For instance, offensive lineman play with big bulky knee braces and play all the time with grade-one MCL sprains. On the other hand, RBs will likely be shut down for 2-3 weeks even for a minor grade one. The offensive players hate wearing knee braces and won’t return to the field until they are confident in their knees, especially with cutting, again.

Returning too quickly from certain knee sprains, especially MCL sprains, can be detrimental. The MCL is a protective ligament for the ACL. Returning too quickly from an MCL sprain will put the ACL at increased risk for rupture. My suspicion is this is exactly what happened to Cooper Kupp a couple of years ago.

Anatomy Overview: What is a high ankle sprain?

The ankle is a complex joint. It is made up of three bones: the tibia, the fibula, and the talus. In addition to these bones, the ankle joint consists of several ligaments that help stabilize the joint. When an ankle sprain occurs, the ligament that is involved is "overstretched" resulting in pain, inflammation, tenderness, and reduced functionality. When a high ankle sprain occurs, the individual damages the ligaments that are superior (higher) to the ankle joint, also known as the ankle mortise. These ligaments include the interosseous ligament, the posterior inferior tibiofibular ligament (PITFL), and the anterior inferior tibiofibular ligament (AITFL).

In most cases, an ankle sprain occurs with excessive inversion. This is often referred to as an individual "rolling" their ankle. However, a high ankle sprain has a slightly different mechanism of injury. Damage to these ligaments, collectively known as the syndesmosis/syndesmotic ligaments, occurs usually when an individual has their foot planted on the ground combined with rotation. This mechanism results in shearing forces between the tibia and fibula, which then damages these ligaments. High ankle sprains account for about 15% of all ankle sprains.

Diagnosis

Athletes who participate in pivoting/cutting sports are at the greatest risk of sustaining a high ankle sprain. After a suspected ankle sprain, the individual will be assessed by the sports medicine team. Swelling is not always present, but activities such as walking, active dorsiflexion (flexing the foot upward), and rotation of the foot can be fairly painful

A couple of clinical tests that the sports medicine team can implement to begin formulating a possible diagnosis include Kleiger's Test and the Squeeze Test. Personally, I implement Kleiner's Test fairly frequently when a patient with an ankle injury is referred to me. It helps differentiate between a common lateral ankle sprain and a high ankle sprain. A short video on how to perform this test can be found here: https://www.youtube.com/watch?v=AXPxMmChQj0. Other diagnostic imaging includes X-rays, MRI, CT scans, and ultrasound.

Rehab Protocol

In short, the typical timelines of recovery and rehabilitation are as follows for various ankle sprains. Grade 1 lateral ankle sprain 1-2 weeks. Grade 2 lateral ankle sprain 2-4 weeks. Grade 3 lateral ankle sprain 8-10 weeks. A high ankle sprain, in contrast, can take up to 12-16 weeks in order to return to full functional activity without pain. A sample rehab protocol can be seen below.

PhaseGoalsPrecautionsExercises
Acute (0-2 weeks)Control pain and swelling; restore pain free ROM; protect healing structures with a brace/splintUsually non weight bearing at first with progression to CAM boot; avoid painful dorsiflexion and eversionAnkle pumps, ankle circles, toe curls,
Subacute (2-5 weeks)Maintain ROM and improve flexibility; progressing WBing and normalizing gait mechanics; improve strength and begin double-limb balance activitiesMay need to continue use of crutches and CAM boot for WBingBicycle; gastroc and soleus stretching; seated wobble board for ROM; seated heel raises; seated toe raises; ankle 4 way with theraband; body weight squats; standing hip isotonics; double limb balance activities progressing to foam surfaces
Advanced strengthening (4-8 weeks)Maximize strength and initiate CKC exercises; maximize neuromuscular control and initiate single leg balance activities; begin treadmill walkingFull WBing, but can use brace for protectionGastroc/soleus wall stretch; standing wobble board; bike, elliptical or treadmill; increase resistance with ankle 4 way with theraband; heel raises progressing from double to single limb; forward and lateral lunges; hip abduction side stepping; planks and side planks; single leg bridging; single leg ball toss progressing to uneven surfaces; Y balance
Return to Sport/Performance (6-10 weeks)Continue dynamic strengthening and proprioceptive exercises; initiate jog to run progressions; cutting, pivoting, sport specific drillsAttain physician clearance before returning to sportContinue gastroc and soleus stretching; jogging at progressive speeds; continue advanced strengthening exercises; single leg squats and deadlifts; single leg balance exercises with perturbations; wall jumps; vertical jumps; bosu lateral step overs; skater hops; agility ladder; sport specific tasks

Effectiveness Upon Return

While an athlete may have reduced performance initially when returning from a high ankle sprain, this is usually short-lived. Once they progress through a rehab program and pass their physical performance/sports testing (with scores > 90%) they will be cleared to return to action. They may return with a brace for added protection. The goal is to prevent an additional ankle sprain from reoccurring, and various balance/proprioception exercises are vital in order to minimize the future risk of ankle sprains.

Additional Thoughts by Dr. Morse

High-ankle sprains are awful. While not very common in other sports, they are unfortunately way too common in football, especially for running backs. Once you hear the term ‘high-ankle sprain’ in association with a player’s name, especially one that is required to run repetitively, you should immediately get concerned about their effectiveness over the next 3-8 weeks.

Almost every one of your favorite running backs have sustained this injury at one point or another. Christian McCaffrey (2020), Alvin Kamara (2019), Dalvin Cook (2021), Joe Mixon (2021), Austin Ekeler (2021) and the list literally goes on and on. Every player that I have spoken to about what their high-ankle sprain did to them was ‘zap their explosiveness.’ It also messes with what we call proprioception, knowing where your foot is placed/planted without having to actually look down at it.

In the early stages after the injury, even putting your foot on the ground can be very painful, so often guys use a ‘wheeled scooter’ and have a cam-walker boot on. Alvin Kamara was once quoted saying that it took over 6 months after his injury to finally feel 100% again. Just because they return to the field doesn’t mean they are 100%, remember that when you’re making judgments about their effectiveness post-injury.

Anatomy Overview: What is a lateral ankle sprain?

The ankle is a complex joint. It is made up of three bones: the tibia, the fibula, and the talus. In addition to these bones, the ankle joint consists of several ligaments that help stabilize the joint. When an ankle sprain occurs, the ligament that is involved is "overstretched" resulting in pain, inflammation, tenderness, and reduced functionality.

In most cases, an ankle sprain occurs with excessive inversion. This is often referred to as an individual "rolling" their ankle. A lateral ankle sprain is one of the most common orthopedic injuries. In general, a lateral ankle sprain damages the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and/or the posterior talofibular ligament (PTFL).

Diagnosis

An MRI may be performed in order to determine the severity of the damage to the affected ligaments, but clinical findings can also be helpful in determining the diagnosis and differentiating between a lateral ankle sprain and a high ankle sprain. Patients will complain of pain on the outside of their ankle, swelling, bruising and difficulty bearing weight on the foot. Usually, those who have sprained their ankle are still able to bear some weight compared to patients who have suffered an ankle fracture which makes weight-bearing extremely difficult or impossible.

Ankle sprains are usually classified as mild, moderate, or severe. A mild injury is also known as a grade 1 injury. A grade 1 sprain usually involves only the ATFL and the recovery timeline is around 5-14 days. A grade 2 sprain involves the ATFL and some of the CFL and can take about 2-4 weeks to recover, but often up to 8 weeks. A grade 3 sprain involves the ATFL, CFL, and PTFL and can take anywhere from 8-10+ weeks in order for the individual to recover.

Rehab Protocol

As with all soft tissue/ligament injuries, an initial RICE period (rest, ice, compression, elevation) is recommended before beginning a rehab program. An individual may be weight-bearing as tolerated with an ankle brace as well for added support/protection.
A sample rehab protocol for a lateral ankle sprain can be seen below.

PhaseWeight BearingGoalsExercisesPrecautions
Acute phasePartial WB with a braceControl pain and swelling; restore pain free ROM; normalize gaitRICE & ESTIM; pain free active ROM all planes; towel curl and marble pick up; isometric ankle strengthening; open chain hip strengtheningMinimize joint effusion and edema; avoid forceful DF and rotation to protect healing structures
Sub-acute and strengthening phaseWB as tolerated with possible braceFull AROM; normal gait at higher speedsBicycle without resistance; ankle 4 way with theraband; seated heel and toe raises; body weight squat; double limb balance; standing hip isotonicsMinimal pain with activity; minimal swelling; pain free AROM and normal gait at higher speeds
Functional strengthening & return to activityFull WBPain free functional WB; advance strengthening; initiate sport specific activityContinue lower extremity strengthening; begin plyometrics; progress balance to single limb; running and functional/sport specific tasksEducation on prevention of subsequent ankle sprains

Effectiveness Upon Return

While an athlete may have reduced performance initially when returning from a lateral ankle sprain, this is usually short-lived. Once they progress through a rehab program and pass their physical performance/sports testing (with scores > 90%) they will be cleared to return to action. They may return with a brace for added protection. The goal is to prevent an additional ankle sprain from reoccurring, and various balance/proprioception exercises are vital in order to minimize the future risk of ankle sprains.

Anatomy Overview: What is the ACL?

The Anterior Cruciate Ligament (ACL) is one of the four main ligaments that stabilize the knee. Its function includes preventing excessive anterior (forward) translation of the tibia on the femur; stabilizing the knee during activities in which rotational forces are exhibited on the knee such as pivoting and cutting; and preventing knee hyperextension.

Diagnosis

ACL injuries are usually from non-contact occurrences, however they can occur during contact as well. Oftentimes, the player attempts to plant/cut, pivot, land from a jump, and the anterior shear force exhibited on the ACL is too much for the ligament to withstand, and it tears. This usually results in the knee buckling, and the player may report hearing/feeling a “pop” from the knee. ACL injuries are quite painful and result in swelling at the knee, which makes it difficult for the individual to flex (bend) or extend (straighten) their knee, as well as walk.

A magnetic resonance imaging (MRI) is the gold standard for diagnosing ACL injuries. However, the sports medicine team generally has a fairly confident potential diagnosis prior to imaging. There are a number of tests the physicians, physical therapists, athletic trainers, etc. can implement in order to rule in/out a possible ACL injury. These include: Lachman’s test and the anterior drawer test to assess laxity, and the pivot shift test to assess rotational stability.

Rehab Protocol

After undergoing an ACL reconstruction, the athlete may begin their rehabilitation post-op day 1. The rehabilitation is a multi step process that will take several months to fully complete. Currently, return to sport/play timelines vary from 9-12+ months post-op, however some individuals are now returning to sport as soon as 8 months post surgery. A closer look at a sample rehabilitation program is listed below.

TimelineGoalsExercisesProgression Criteria
0-6 weeksProtect graft, minimize pain, improve mobility, minimize gait abnormalities, control inflammationAnkle pumps Heel slides Prone Hang Heel Prop Calf stretching Straight leg raises x 4 Calf Raises BikeDisplay full knee extension (0 degrees) Ability to contract quadriceps with good patellar mobility Straight leg raises without lag 90 degrees knee flexion
6-8 weeksInitiate closed kinetic chain (standing) activities, protect graft, normalize gait/walking patternWall Slides Mini squat 4-way hip Calf Raises Hamstring Curls Terminal knee extension (TKE) with resistance band Single leg stance balance Bike Hamstring & calf stretchingFull range of motion in flexion and extension Minimal pain Normal gait Ability to actively contract and maintain quadriceps contraction
8 weeks to 6 monthsFull range of motion, return to functional activities, do not overstress graftLeg Press Squats and mini squats progressing to single leg Step Ups Single leg balance interventions with slide board or perturbations Walk & jog progressionsFull pain free range of motion Strength approximately 60-70% of uninvolved side Physician clearance
6-12 monthsAdequate strength, range of motion, endurance, proprioception for safe and effective return to sport or workCutting & jumping activities Continued strengthening > 90-95% strength of uninvolved side Continued running progressions & plyometrics Sport specific activitiesNo patellofemoral joint pain or soft tissue complaints during activity Clearance from medical team

Effectiveness Upon Return

As recently as 40 years ago, ACL injuries were considered career-ending injuries. However, due to the advancements made in medicine since then, an athlete can return to their sport anywhere from 8-12 months post surgery. The biggest question many athletes and individuals ask is, “How effective will I be when I return? Will I be the same?” For most, the answer is yes. However, not everyone recovers and heals the same, so individual time frames can vary greatly. It’s not unheard of for some individuals to take 12-15+ months to return from an ACL injury. Rushing back too soon from an ACL tear risks not only a rerupture of the ACL graft, but a tear of the contralateral (opposite) ACL.

A recent systematic review published in the British Journal of Sports Medicine found that 83% of elite athletes returned to their preinjury sport level of performance post ACL reconstruction. The graft rupture rate was 5.2%, and the average return to sport timeline was 6-13 months.

Anatomy Overview: What is the labrum in the shoulder?

The shoulder joint involves three bones: the scapula (shoulder blade), the clavicle (collarbone), and the humerus (upper arm bone). The humeral head rests in a shallow socket on the scapula called the glenoid. Because the head of the humerus is much larger than the glenoid, a soft fibrous tissue labrum called the labrum surrounds the glenoid to help deepen and stabilize the joint. The labrum deepens the glenoid by up to 50 percent so that the head of the humerus fits better. In addition, it serves as an attachment site for several ligaments.

A good way to visualize the glenohumeral joint is to picture a golf ball sitting on a tee. In this scenario, the glenoid is the “tee,” and the head of the humerus is the “ball” that sits on the tee. Due to the anatomical position/orientation of this joint, one can appreciate how the glenoid labrum serves to help stabilize the joint.

Diagnosis

Injuries to the labrum can occur via an acute traumatic incident, or with repetitive shoulder motion. Examples of acute traumatic injury occur by falling on an outstretched arm, a direct blow to the shoulder, a sudden pull such as when lifting a heavy object, and forceful overhead motions.

A labral tear can be located either above (superior) or below (inferior) the middle of the glenoid. A SLAP lesion (superior labrum, anterior [front] to posterior [back]) is a tear of the labrum above the middle of the glenoid that may also involve the biceps tendon. A tear of the labrum below the middle of the glenoid socket that also involves the inferior glenohumeral ligament is called a Bankart lesion. Tears of the glenoid labrum often occur with other shoulder injuries, such as a dislocated shoulder (full or partial dislocation).

Labral injuries can be difficult to diagnose due to overlapping signs and symptoms with other shoulder pathologies. Some symptoms include pain with overhead activity; catching, locking, popping, or grinding; night pain or pain with functional activities; feeling of instability in the shoulder; decreased ROM; decreased strength.

There are various clinical tests that can be used to determine a possible diagnosis, however, undergoing an MRI is the gold standard in order to diagnose a labral tear. Depending on the severity of the injury, a nonoperative approach may be used first. This will consist of rest, anti-inflammatory medications, and rehab exercises to strengthen the shoulder/rotator cuff. However, if a nonoperative approach is unsuccessful, then an arthroscopic labral repair may be necessary.

During the surgery, the doctor will examine the labrum and the biceps tendon. If the labrum is detached, then it will be repaired with sutures. If there is an injury to the labrum without detachment, then the loose piece can be removed instead of being re-attached. The labrum connects to the biceps tendon as well. Oftentimes if this connection is not stable, the biceps is surgically cut from the connection and reattached to a more stable place in the humerus (biceps tenodesis).

Rehab Protocol

After surgery, the individual will need to keep their shoulder in a sling for about four weeks. The surgeon will also prescribe gentle, passive range-of-motion exercises. When the sling is removed, the athlete/individual will need to do motion and flexibility exercises and eventually start strengthening. Athletes can usually begin doing sports-specific exercises after twelve weeks, although it will be about six months before the shoulder is fully healed. A sample rehabilitation program can be seen below. The recovery can vary based on the degree of injury and the nature of the surgery.

Acute/Protected Motion Phase (Day 1 - 6 weeks)

Goals: protect the repair; prevent and minimize secondary effects of immobilization; promote dynamic stability; reduce pain and inflammation

Post-op day 1 to 2 weeks post-op

  • Sling for 4 weeks, with the patient sleeping in a sling as well
  • Wrist and hand active and active assisted ROM exercises (AROM/AAROM)
  • Hand gripping exercises
  •  
  • Gentle passive range of motion (PROM) & AAROM
  • No AROM in ER, extension, or abduction
  • Submaximal isometrics for all periscapular, rotator cuff, and shoulder muscles
  • No elbow flexion
  • Ice and modalities as needed

Week 4

  • Discontinue use of sling at 4 weeks
  • Continue gentle PROM/AAROM exercises (Rate of progression based on patient’s tolerance)
  • No AROM ER, extension, or elevation
  • Initiate rhythmic stabilization drills within the above ROM
  • Initiate proprioceptive training within the above ROM
  • Progress isometrics as above

Week 6

  • Begin AROM of the shoulder (all planes, gravity eliminated positions then gravity resisted position once adequate mechanics)
  • Gradually improve PROM and AROM to tolerance
  • Gentle Proprioceptive Neuromuscular Facilitation (PNF) manual resistance
  • Initiate a prone exercise program for periscapular musculature i.e. prone rowing, prone extension, prone scaption, prone horizontal abduction
  • Begin AROM elbow flexion and extension

Phase 2: Intermediate Phase and Moderate Protection (weeks 7-14)

Goals: gradually restore full AROM & PROM by week 10; preserve the integrity of repair; restore muscle strength and balance/symmetry

Weeks 7-9

  • Gradually progress PROM/AROM
  • Begin isotonic rotator cuff, periscapular, and shoulder strengthening program
  • Continue PNF strengthening
  • Initiate "Thrower's Ten" program except resisted biceps exercise

Weeks 10-12

  • Progress to the thrower's motion
  •  
  • Progress shoulder isotonic strengthening exercises as above
  • Continue all stretching exercises as needed to maintain ROM
  • Progress ROM to functional demands (i.e., overhead athlete)

Criteria for progression to phase 3: full and non-painful ROM; good stability; muscle strength ⅘ or better with MMT; no pain or tenderness

Minimal Protection Phase (weeks 14-20)

Goals: establish and maintain full ROM; improve muscle strength, power, and endurance; gradually begin functional activities

Weeks 14-16

  • Endurance training
  • Initiate a light plyometric program
  • Restricted sports activities (light swimming, half golf swings)

Weeks 16-20

  • Begin throwing program

Phase 4: Advanced Strengthening Phase (Weeks 20-26)

Goals: enhanced muscle strength, power, and endurance; progress functional activities; maintained shoulder stability during activity

Weeks 20-26

  • Plyometric strengthening
  • Progress interval sports programs

Phase 5: Return to Activity Phase (months 6-9+)

Goals: gradually progress sports activities to unrestricted participation; continue with stretching and strengthening exercises

Effectiveness Upon Return

In short, effectiveness upon return after labral repair is dependent on the type of injury, and the demands of the athlete/sport in which they play. For example, an athlete that is required to throw overhead frequently (quarterback/pitcher) will have greater difficulty returning to their sport effectively compared to an athlete who is not required to throw overhead.

For example, a recent article published in the American Journal of Sports Medicine studied labral injuries in professional baseball players.

Among the sixty-eight athletes that were identified with SLAP lesions, twenty-one pitchers successfully completed the nonsurgical algorithm and attempted a return.
Their RTP rate was 40%, and their RPP rate was 22%.

The RTP rate for 27 pitchers who underwent 30 procedures was 48%, and the RPP rate was 7%. For 10 position players treated non-surgically, the RTP rate was 39%, and the RPP rate was 26%.
The RTP rate for 13 position players who underwent 15 procedures was 85%, with an RPP rate of 54%.

Additional Thoughts by Dr. Morse

Labrum injuries are very common in the NFL. Most players will have some damage to their shoulder labrums on at least one side if not both. The severity of the tear will determine how much it impacts them. If it is ‘only’ 5-10%, then that’s a small manageable tear. Something like 50-70% is a huge injury and they will undergo season-ending surgery (I think this is what happened with Juju Smith-Schuster).

The player most commonly associated with recurrent shoulder dislocations leading to torn labrums is Dalvin Cook. He’s had surgery on each shoulder at least once, and probably dislocated each shoulder 3-4x. This is what derailed Baker Mayfield’s season, even though it was on his non-throwing shoulder, so the pain and immobility/instability can be significant.

While surgically repairing these is the gold standard, I personally have had fantastic results with non-surgical approaches, specifically from ‘stem cell injection’ (bone marrow). I could see more and more players starting to take this approach as the return to play is significantly faster (3-4 weeks as opposed to 4 months).

Anatomy Overview: What is the Achilles tendon?

The Achilles tendon is the thickest, strongest tendon in the body. This tendon comes from the posterior calf muscles, then courses distally to attach approximately three-quarters of an inch below the superior portion of the os calcis, on the medial aspect of the calcaneus. The fibers of this tendon spiral 90 degrees instead of vertically, which allows for increased potential elongation and energy production. In fact, the Achilles tendon can stretch up to 4% before microscopic damage occurs; and macroscopic rupture occurs at strain levels greater than 8%.
Although it is the strongest tendon in the body, it is also the tendon most commonly torn or ruptured. Typical mechanisms of injury include:

  • Pushing off on the forefoot while extending the knee Also known as plantarflexion, such as when performing a vertical jump
  • Sudden dorsiflexion with full weight bearing (WB) as might occur with a slip and fall
  • Aggressive dorsiflexion such as that occurs when jumping or falling from a height and landing on a plantarflexed foot

Most tendon ruptures occur in sports that involve running, cutting, and changing direction. These injuries are more common in males, with the highest incidence among those aged 30-40 years old. Other risk factors for Achilles tendon rupture include previous history of gastrocnemius/soleus injury, use of Fluoroquinolone antibiotics, and direct steroid injections into the tendon.

Diagnosis

The diagnosis of an Achilles tendon rupture is based almost solely on the history and physical findings. Classic history includes reports of sudden pain in the calf area, often associated with an audible snap, followed by difficulty stepping off on the foot. Physical examination reveals swelling of the calf as well as a palpable defect in the tendon, as well as ecchymosis (bruising) around the malleoli. Additionally, a positive result on the Thompson squeeze test is another indication of an Achilles tendon rupture. Due to these tests and clinical findings, the sports medicine team usually has a confident diagnosis prior to additional diagnostic imaging (MRI, ultrasound) that can confirm the injury/diagnosis. While an ultrasound is near confirmatory, the gold standard is an MRI to confirm the diagnosis.

Treatment options for an Achilles tendon rupture include surgical repair and conservative non-surgical rehabilitation. Decision-making is based on age, past medical history, and desired level of functional return. Conservative non-surgical treatment includes immediate placement of the ankle in a plantarflexed (toes down) position and rehabilitation with initial immobilization followed by a gentle range of motion and progressive strengthening to regain function. Most surgical procedures to repair a torn Achilles tendon include an open longitudinal incision medial to the Achilles tendon, however mini-open repairs with an internal brace are becoming more common, especially among athletes (e.g. Cam Akers of the Los Angeles Rams).

Rehab Protocol

Rehabilitation following Achilles tendon repair is vital in regaining motion, strength, and function. Initially, a walking boot is used for the first 4–5 weeks. Gradually more weight bearing and mobility are allowed to prevent stiffness post-operatively. The rehabilitation progresses slowly into strengthening, gait, and balancing activities. Rehabilitation guidelines are presented in a criterion-based progression. General time frames refer to the usual pace of rehabilitation. Individual patients will progress at different rates depending on their age, associated injuries, pre-injury health status, rehab compliance, tissue quality, and injury severity. Specific time frames, restrictions, and precautions may also be given to enhance wound healing and to protect the surgical repair/ reconstruction. A sample rehabilitation program can be seen below.

Phase 1: Immediate Post-Op (0-3 weeks after surgery)

Goals: protect repair; maintain strength of hip, knee, and core; manage swelling

Weight Bearing (WB)ExercisesCriteria to Progress
Non-WB with crutches and in splint or bootPassive hamstring stretch; strengthening (with boot on) consisting of: quad sets; straight leg raise; abdominal bracing; hip abduction; sidelying clamshells; prone hip extension; prone hamstring curlsPain < 5/10

Phase 2: Intermediate Post-Op Phase (4-6 weeks after surgery)

Goals: Continue to protect repair; avoid over-elongation of Achilles; reduce pain and minimize swelling; improve scar mobility when the incision has healed; restore ankle plantarflexion, inversion, and eversion; dorsiflexion to neutral; normalize gait in the boot (may need to use shoe leveler on the uninvolved side to prevent secondary musculoskeletal complaints/deficits)

Weight bearingExercisesCriteria to Progress
Week 4: begin partial progressive WB (about 25% increase each week until full WB is achieved with no pain) on crutches in Achilles boot with 3 wedges each about 1 inch in height Week 5: wean 1 heel wedge leaving 2 in boot Week 6: wean 2nd heel wedge leaving wedge in bootInitiate PROM, AAROM, AROM but DO NOT DORSIFLEX BEYOND NEUTRAL (0 degrees); ankle pumps, ankle circles, ankle inversion/eversion, seated heel slides; foot ankle ankle mobilizations performed by PT as well as great toe stretching; gentle scar mobilization (BUT NO instrument assisted soft tissue mobilization (IASTM) directly on tendon until 16 weeks post op; arm bike (UBE); continue proximal lower extremity strengthening from phase 1; planks; seated heel raises and talar doming; joint position retrainingPain < 3/10; minimal swelling; full ROM in plantarflexion, eversion and inversion; dorsiflexion to neutral/0 degrees; optimal gait in Achilles boot with 1 wedge & crutches and shoe leveler on uninvolved side

Phase 3: Late Post-Op Phase (7-8 weeks post-surgery)

Goals: Continue to protect repair; avoid over-elongation of Achilles (NO OVER STRETCHING); normalize gait in the boot; restore full ROM including DF; safely progress strengthening; promote proper moving patterns; avoid post-exercise pain/swelling; FWB in the boot without wedges, without crutches, with good tolerance and normalized gait by week 8

WBExercisesCriteria to Progress
Week 7: remove final heel wedge from boot; WBAT/FWB with one crutch or no crutches as needed Week 8: full WB in boot with no wedges or crutchesDF NO LONGER RESTRICTED but continue to progress slowly; toe stretching; stretching of quads, hamstrings, hip flexors, piriformis; ankle mobilizations (foot too); stationary bike in boot; 4 way ankle with theraband; bridging on physioball (with progressions); hip abductor and adductor machine; hip extension machineNo swelling/pain after exercise; normal gait in boot without wedges or crutches; ROM equal to opposite side; joint position sense symmetrical

Phase 4: Transitional (9-10 weeks post-op)

Goals: maintain full ROM; normalize gait in a supportive sneaker with 1cm heel lift; avoid over-elongation of Achilles; safely progress strengthening; promote proper movement patterns; avoid post-exercise pain/swelling

WBExercisesCriteria to Progress
Transition to sneaker with 1cm heel lift (full WB)Continue with exercises from phase 1-3; progress to standing DF stretching on step; stationary bike and swimming/flutter kicking and pool jogging when incision is fully healed; bilateral standing heel raises with progressions; seated hamstring curl and knee extension machine; leg press; double limb balance progressing to uneven surface/wobble board; single limb balance with progressing to uneven surfaces & perturbationsNo swelling/pain after exercise; normal gait in supportive sneaker with 1 cm heel lift

Phase 5: Transitional (11-12 weeks post-op)

Goals: maintain full ROM; normalize gait in supportive sneaker WITHOUT HEEL LIFT; avoid over elongation of Achilles; safely progress strengthening; promote proper movement patterns; avoid post-exercise pain/swelling

WBExercisesCriteria to Progress
Wean heel lift from sneaker; normalize gait patternContinue with exercises from phase 1-4 and progress as appropriateNo swelling/pain after exercise; full ROM during bilateral concentric heel raise with equal WB through both legs; normal gait in supportive sneakers

Phase 6: Advanced Post-op Phase (3-6 months after surgery)

Goals: avoid over-elongation of Achilles; safely progress strengthening; promote proper movement patterns; avoid post-exercise pain/swelling; good tolerance with progression to plyometrics and agility training

Exercises: standing ankle DF mobilization on step; gentle IASTM to Achilles (if indicated AFTER 16 weeks post-op); elliptical and stair climber; progress to eccentric heel raises and then unilateral heel raises; seated calf machine; forward and lateral lunges; bilateral squats progressing to unilateral; bilateral hopping in place with progression to unilateral hopping in place

Criteria to Progress: no swelling/pain after exercise; standing heel-rise test > 90% of uninvolved side; no swelling/pain with 30 minutes of fast-paced walking; good tolerance and performance of beginner-level plyometrics

Phase 7: Early to Unrestricted Return to Sport (6+ months post-op)

Goals: continue strengthening and proprioceptive exercises; safely initiate sport-specific training program; symmetrical performance with sport-specific drills; safely progress to full sport

Exercises: continue with phase 3-6 interventions; can begin GENTLE standing gastroc and soleus stretching at 6 months post-op; interval walk/jog program with progressing to returning to running program; continue to progress agility and plyometric activities

Criteria to Progress: clearance from MD and ALL milestones have been achieved; completion of both phases of return to running program without pain/swelling; sufficient functional assessment; lower extremity functional tests should be > 90% compared to the opposite side for various unilateral tests

Effectiveness Upon Return

Many different factors influence the post-operative Achilles tendon rehabilitation outcomes, including the type and location of the Achilles tear and repair. Consider taking a more conservative approach to a range of motion, weight-bearing, and rehab progression with tendon augmentation, re-rupture after non-surgical management, revision, chronic tendinosis, and co-morbidities, for example, obesity, older age, and steroid use. It is recommended that clinicians collaborate closely with the referring physician regarding intra-operative findings and satisfaction with the strength of the repair.

A recent systematic review with meta-analysis, published in the British Journal of Sports Medicine, found that the average return to play among all participants was approximately 80%. Nowadays, athletes can return to sports post Achilles tendon repair, however, it is possible that they may have lingering deficits such as reduced speed/power and agility. Although these deficits may be minor, a fraction of a second is crucial in professional athletes.

Additional Thoughts by Dr. Morse

Achilles tears have been more and more common in the NFL over the past decade. These athletes have become bigger, faster, and stronger but in my opinion, the body’s ligaments and tendons have struggled to tolerate the increases in force, as a result often tearing. The two positions that struggle the most with Achilles repairs are RBs and LBs, both positions require explosiveness and require a fast ‘recoil’ of the Achilles, which after repair it may struggle to do repeatedly.

An emerging technology that is being used by some high-level programs for rehab (LA Rams, Alabama Crimson Tide) is GPS-guided technology. The players wear devices that track tons of data including route taken, energy used, force, and speed, that they use to compare before and after the injury to determine what exact % the player is back to 100%.