It’s a situation no athlete ever wants to experience: injured and unable to play. No one wants to be injured, but when your career must be put on hold due to injury, rehabilitation takes on a new dimension of importance. Often athletes will feel significant pressure to recover and return to competition as quickly as possible.
THE RETURN TO PLAY CONTINUUM
It’s understandable that athletes will want to return to competition as quickly as possible. However, without a systematic approach to both the rehab process and the transition back to competition, you run the risk of reinjury or sustaining a new injury – forcing you to take more time off from competition as the vicious cycle continues to spiral. The return to sport process should be viewed as a continuum, one that measures and balances all aspects of recovery with sport specific needs to ensure that the whole athlete is ready to return to competition.
PUT ME IN, COACH
You’ve taken time off, rested, and participated in skilled rehab, now you’re ready and eager to get back on the court. BUT WAIT! How do you ensure that your injury is completely healed and ready to withstand the rigors of professional sport? Research shows that following return to sport, up to 44% of athletes will have a recurrence of Achilles tendinopathy, and up to 20% of surgically repaired ACLs will be re-torn. Additionally, in a study following shoulder injuries of major league baseball pitchers, researchers found that after returning to competition, almost 50% of players missed more time later in the season and there was a significant decline in performance when they returned to play.
So, how do you know that you’re ready to compete again at the highest level with minimal risk of reinjury?
“My body could stand the crutches, but my mind couldn’t stand the sideline.”
-Michael Jordan (Professional Basketball Hall of Famer)
A GRADED PROGRESSION
Working with a physical therapist to complete an individualized rehab exercise program is a crucial first step toward returning to tennis, however, it is only part of the process. Too often athletes will “feel great” during a training session and then increase volume and intensity of loading too much, too quickly, leading to reinjury and prolonging time away from competition. As you progress through rehab and improve it is important to go through a graded return to play progression (RTPP). A graded RTPP will:
- Systematically introduce and gradually increase tennis loads from session to session
- Allow the body to adapt to the new challenges without excessive overload
- Monitor acute to chronic loading ratios by comparing training workloads from the last week (acute) to those over the past 4 weeks (chronic) to ensure you aren’t increasing training too quickly, thus increasing risk of reinjury. Speak with a WTA PHCP to learn how to calculate the acute to chronic workload ratio.
ENERGY SYSTEMS AND MATCH FITNESS
Not only must you treat and rehabilitate the injured tissue, you must restore functional strength and endurance as well as train your energy systems to withstand the return to competition. In the early stages of rehabilitation, this may be in the form of endurance training to maintain cardiovascular fitness. As you progress through the rehabilitation process, training should become more tennis specific, mimicking the intensity, duration, and work to rest ratios required for matches.
- Early phase: Cross train for fitness and endurance (bike, elliptical, swim). Begin psychological skills program.
- Intermediate phase: Increase tennis specificity of cardiovascular training by using 1:2 to 1:5 work to rest ratios
- For example, do a 30 second bike sprint followed by 60 seconds of slow riding to recover
- These ratios mimic the work to rest ratios of a typical tennis point and help prepare your body to return to practice and matches
- Continue psychological skills training, emphasize the skills needed to manage competitive stress and self-applied expectations
- Late phase: Practice sets, progressing to practice matches
- Practice matches are the best way to train energy systems for return to competition
- Play on consecutive days, 3-sets, at match intensity
- Apply psychological skills under match conditions. Use incentives of value for successes specific to emotional/mental reactions on court.
It is recommended to play two or more 3-set practice matches at 100% intensity prior to return to competition.
Following completion of an appropriate and individualized rehab program and graded RTPP, you should undergo functional testing to ensure adequate fitness and readiness for return to match activity. Functional tests are chosen based on the injury diagnosis and location, they are used to assess functional strength, speed, power, and agility. Results are compared to either your pre-injury test values or norms established within a similar population. Research shows there is no single test able to determine readiness to return to play, rather a grouping of tests should be chosen to evaluate all components of fitness and sport activity. Your treating physical therapist will help to select an appropriate grouping of functional tests to assess your readiness to return to play.
“It is hard to beat a person who never gives up.”
-Babe Ruth (American Baseball Legend)
OTHER ASPECTS TO CONSIDER
- Equipment: After an injury, it is important to evaluate any possible causative factors, including equipment. Changing your shoes, racquet, grip, etc. may be necessary to ensure a successful return to sport. Be sure that you have adequately trained using this new equipment!
- Sport Psychology and Mental Preparation: Elite athletes and champions persevere despite losses, injuries, and other personal or professional setbacks. Sport psychology strategies and mental training tactics enable an athlete to embed and strengthen her mental thought patterns, which makes it possible for the athlete to repeat her successes after experiencing setbacks.
- Mental components addressed when returning to play include:
- Visualization and mental rehearsal drills
- Restoration of confidence and motivation, and when necessary, addressing fear of reinjury
- Strengthening of concentration and focus
- Developing positive self-talk and mindfulness strategies
- Resiliency training
- Sport psychology is an important rehabilitation component and guides a player to embrace, nurture and manage her own comeback.
- Speak with a psychologist to learn and practice these essential skills
- Mental components addressed when returning to play include:
- Schedule: Once you return, it is important for you and your team to plan a schedule that allows for adequate rest,
recovery, and training blocks to help minimize the risk of reinjury.
PUTTING IT ALL TOGETHER FOR A SUCCESSFUL RETURN TO SPORT AND PERFORMANCE
Several factors will determine when an athlete is ready to return to competition including:
- Completion of rehab program followed by a normal, asymptomatic functional physical exam and return to play
testing with an orthopedic or sports physical therapist
- Completion of a graded return to sport progression
- Completion of energy systems training, culminating with ability to play consecutive practice matches at 100% intensity without symptoms
- Mental focus, concentration and confidence to play with the sustained physical and emotional intensity required for matches.
While it may be enticing to return to competition prior to achieving these milestones, returning before your body and mind is 100% puts you at risk for re-injury, may result in more time off and decrease your ability to achieve your performance goals. It’s not only important for your injury to be fully healed, you must be conditioned for a successful return to sport!
The information provided within this Physically Speaking topic is for informational purposes only and should not be treated as medical, psychiatric, psychological, health care or health management advice. If you have any health or related questions or concerns, please consult your physician or other qualified health care professional.
A special thanks to the author, WTA PHCP, Lindsey Elizondo, DPT, ATC, LMT, CSCS