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Rehabilitation considerations for sport injuries in school-aged patients

This is an excerpt from Therapeutic Exercise for Musculoskeletal Injuries, Third Edition, by Peggy A. Houglum, PhD, ATC, PT.

Just as surgeons must adapt their surgical techniques to accommodate growth and developmental stages, the rehabilitation clinician must make adjustments in the rehabilitation program. Not only do we have the physiological and physical immaturity issues to consider, but it also can be challenging to maintain a young patient’s interest in and focus on rehabilitation exercises. Young patients often do not realize the importance of performing exercises correctly; frequently they focus on completing the exercises as soon as possible rather than performing them correctly or conscientiously. With these patients, clinicians need to use their imaginations to make exercises fun while accomplishing the necessary goals of safe and sufficient recovery. Exercises must be carefully monitored for correct execution and proper compliance.

Proper care provided as soon as possible is a key factor in relation to the future and to injury outcome for young athletes. It is during this age that postural deviations are often discovered. Sometimes these deviations result in an athletic injury. The rehabilitation clinician should assess each young patient for possible postural deviations as part of a routine rehabilitation examination. Immediate care involves the use of modalities such as ice and electrical stimulation to relieve inflammation, pain, and edema. Range-of-motion exercises to restore flexibility follow reduction of pain and swelling. Strengthening exercises with primary emphasis on endurance activities are the next part of the progression. The final phase in a youngster’s rehabilitation program involves the restoration of proprioception, balance, and agility prior to sport-specific activities.

Preparation and planning for this rehabilitation program must account for the physical variations in younger patients compared to adults. Those factors have already been outlined; next we see how they need to be considered in relation to rehabilitation.

Bone and Articular Cartilage Factors. When we are dealing with injuries to bone, epiphysis, physis, or articular cartilage, the primary concern is preventing additional injury to these structures. Bone heals quickly in young patients; but if damage occurs to the growth regions of bone, one must be careful to avoid activities that cause pain, which is a key sign of excessive stress to these structures. Rehabilitation is gradual and progressive. Most epiphyseal injuries have good outcomes (Salter and Harris, 1963). Most are immobilized in either a cast or a splint. The site of common restriction following immobilization is the elbow joint. Although many fractures in children require little postinjury rehabilitation, elbow joint immobilization often necessitates postimmobilization treatment including joint mobilizations to restore full motion.

Following any immobilization, the clinician’s goals are to reduce inflammation and restore motion first. Active range-of-motion exercises are often sufficient for regaining motion. When necessary, assistive motion exercises and other types of activities to facilitate motion gains are used. If the joint is stable and demonstrates a capsular motion restriction, joint mobilization may also be used to restore full motion. Grade II joint mobilization is often used early in rehabilitation to assist in increasing joint fluid mobility and reducing pain.

Muscle and Tendon Factors. Athletes of any age benefit from strengthening exercises. It is important, however, that exercises for prepubescent athletes and young adolescents involve two factors, supervision and endurance. Rather than high weights, these age groups benefit more from high-repetition, low-resistance bouts. It is recommended that any youth below the Tanner stage V level begin with a resistance less than maximal. The number of repetitions should be eight at a minimum and should not lead to severe muscle fatigue. It is better to increase repetitions before increasing resistance when progressing in rehabilitation. My usual routine for preadolescent patients who are motivated is to have them perform sets up to 20 or even 30 repetitions before increasing resistance. A rest of 1 to 2 min between exercises should be incorporated into the program. The clinician must instruct the patient and explain cautions about proper execution of the exercises before having the patient perform any exercise with weights.

Manual resistance and resistance to the opposite extremity are both useful exercises for young injured athletes. There is evidence to demonstrate that exercising one extremity facilitates strength of the contralateral extremity (Hellebrandt and Waterland, 1962). Manual resistance is also an engaging activity for the young patient who may prefer to make a game out of the exercise, attempting to “conquer” the clinician and “win.”

Neurological and Thermoregulatory Factors. Recall that prepubescent patients will not increase their muscle bulk but will make strength gains. As these patients continue with repetitions, their accuracy also improves because the repetitions create an engram within the neuromuscular pathways (Kottke, 1982). This factor becomes important as the patient begins the last phase of the rehabilitation program, working on functional and sport-specific activities. Begin the sport-specific activities with exercises that the patient can do successfully in order to enable proper execution. As patients gain accuracy, the exercises become more challenging but they can still be successful.

Because of the thermoregulatory factors previously discussed, children often look red-faced after a workout. This is normal, but on days that are hot or are both hot and humid, extra caution must be taken to ensure more breaks and frequent water breaks. Because a young person’s thermal regulation is not as efficient as an adult’s, careful observation throughout an exercise program is warranted. Adolescent patients have a more efficient sweating mechanism than prepubescent patients, so the need for this caution is not as great with these youngsters.

Learn more about Therapeutic Exercise for Musculoskeletal Injuries, Third Edition.

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