Parameters to Assess Return to Sports after Injury or Surgery

Dr. Amol Saxena, DPM
Palo Alto Foundation
Medical Group
Dept. of Sports Medicine
3rd Floor, Clark Building
795 El Camino Real
Palo Alto, CA 94301
Office: 650-853-2943
Fax: 650-853-6094
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Dr. Amol Saxena, DPM

Return to Sports After Injury

Parameters to Assess Return to Sports after Foot & Ankle Injuries and Surgery:
Amol Saxena, DPM & Marc Guillet, PT, ATC

Basic guidelines to return an athlete to running sports, includes assessment of pain level, range-of-motion and strength. Simplistically, the patient must have no pain with daily activities. Some initial onset of activity stiffness or soreness may be present for long periods post-injury, and this is not uncommon to persist for up to a year according to our clinical experience. However, the soreness or stiffness should get better with activity. There can be mild pain with palpation to either the Achilles tendon or the insertion. Ankle range-of-motion should be within 5° of the contra-lateral (opposite) limb’s ankle but adequate to perform the necessary activities. The circumference of the affected limb should be within a ¼” or 5 mm of the non-injured side. Strength assessment includes pain-free hopping and 20 single leg heel raises. Generally, 45 seconds of consistent activity repeated five times, is a good guideline for allowing a patient to return to sport.

Our typical regimen is to have the patient progress to being able to perform five sets of single-leg heel raises of 25 repetitions each as a barometer. We have found this parameter, along with having the range-of-motion within 5°, and calf circumference within 5mm to be statistically significant in getting people back successfully, at least when we evaluated 200 Achilles surgeries. Patients should be able to walk briskly for 40 minutes before trying to run. Standard Vertical Leap Testing, Single Leg Three Hop Test and a 20 Yard Lateral Shuttle Test should be assessed in the athletic population, especially those involved in lateral motion sports (see www.agilePT.com). Return to sport is not allowed unless all limitations are within 90% of the non-affected extremity.

A typical return to running program would be as follows: have the patient alternate walking and jogging for two minutes each, completing four cycles (16 minutes of total activity). Have them take a rest day and then re-assess two days later. If they felt challenged, have them repeat this every-other day for a week. If this was far too easy, then have the patient alternate three minutes jogging with one minute walking, again for four cycles. Again have the patient re-assess and repeat this every-other day for a week. Then the patient can begin with the following running schedule outlined in Table 1.

Table 1

	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
Wk 1	15 min	Rest	15 min	Rest	20 min	Rest	20 min
Wk 2	20 min	Rest	25 min	Rest	25 min	Rest	30 min
Wk 3	20 min	Rest	30 min	Rest	40 min	Rest	40 min
Wk 4	20 min	Rest	40 min	Rest	50 min	Rest	50 min
Wk 5	20 min	Rest	50 min	30 min	Rest	60 min	20 min

Anecdotally, we’ve found that patients with purely soft-tissue problems fare better with activity more often, versus those with bony involvement that may need to maintain an every-other day activity level for longer periods of time. We insist that the patients maintain their flexibility and strengthening regimen, along with any other therapy until they are up to their typical activity level, which again can take up to a year. We also encourage icing and compression (and even bracing with some injuries such as ankle sprains) up to a year post surgery/injury. Consistently patients say no matter which surgery or injury, that it takes a year to feel 100%, so be patient.

Sample Rehab: Warning- do not attempt without permission from your medical professional, coach etc
Grade II Ankle Sprain
Exercise	%BW	Time post injury	Comment
Heel Raises/Balancing	60-70%	Immediate	Tape or Brace
Running	60-70%	2-14 days
Grade III & High Ankle Sprain
Exercise	%BW	Time post injury	Comment
Heel Raises/Balancing	60-70%	2-3 wks	Tape or Brace
Running	60-70%	4-8 wks
Distal Lesser Metatarsal Stress Fracture
Heel Raises	60-70%	1 wk	Insert w cutout
Running	60-70%	1-3 wks
Jones Fracture, Prox Met Str Frx, Sesamoiditis
Heel Raises	60-70%	3-4 wk	Insert w cutout
Running	60-70%	4-6 wks
Achilles Tendinosis, Plantar Fasciitis, Tibial Str Frx & Calf Strain	60-70%	1 wk	Use insert or orthoses PRN
Heel Raises	60-70%	Immediate
Running	60-70%	1-3 wks
Post Foot & Ankle Surgery
Heel Raises	60-70%	Procedure dependent eg: bunion & Achilles surgery 6-10 wks
Running	60-70%	When bone stable or tendon healing occurs
Note: Initiation & progression should be surpervised by a licensed medical professional
Initial experience with approximately 200 patients has shown that patients should adjust BW to be painfree, and that outdoor running is allowed once patients can achieve 85-90% BW on the G-trainer

	Outside running		Alter-G time	Alter-G body weight
week 1			30-->40min	70-->85%
week 2			30-->60min	75-->90%
week 3	20 min qod 3days		40-60min	75-90%		1 day off
week 4	30-40min qod 3 days		60-75min	75-90%		1 day off
week 5	40-50 min qod 3-4 days		60-90min	75-90%		1 day off
week 6	50-60min 4 days	strides on grass	60-90min	75-90%		1 day off
week 7	60+min 4 days	strides on grass	60-90min	75-90%	tempo/speed on alter-g	1 day off
week 8	60+min 4 days	strides on grass	60-90min	75-90%	tempo/speed on alter-g	1 day off
week 9	Gradual ->Full Training

qod=everyotherday

Check list Return to Run Program

Commence running upon successful completion of the following;

Steps 1-9 should be carried out IN ORDER (steps are progressive)
Ideally there should be NO pain. If pain is felt record the movement and inform your medical professional
Steps/levels may be progressed with caution under advice of medical professional with minimal discomfort (<3/10 pain-scale)

Walk

Flat ground
Up stairs
Down stairs

Air Squats x10
Alternating lunge x10
Double Leg Heel Raise x20
Single Leg Heel Raise x10
Run on spot 10 seconds (knee to hip height)
Double Leg Hop

X20 up and down
X20 swivel
X20 side to side

Single Leg Hop

X10 up and down
X10 swivel
X10 side to side

Run drills

Ankling x20m x2
A Skip x20m x2
B Skip x20m x2
Straight Leg x20m x
Stride 40m x3

Return to Run Program

If no pain progress
If pain stop and speak to a medical professional
Pace should be comfortable “conversation pace”
May progress with minimal pain (<3/10) if cleared/advised by a medical professional
Patience is key to facilitate physiological adaptation
RTR should incorporate strengthening/technical drill program (RTR programs are specifically designed to allow time for corrective exercises to address deficits and asymmetries) “Window of Opportunity”
Each run should be proceeded by muscle activations for maximum effectiveness
After successful completion of level 8 the athlete has “earned the right” to commence a running program

Day
Level 1

2x2mins (1min)
Rest

Level 2

3x2mins (1min)
4x 2mins (1min)
Rest

Level 3

3x3mins (1min)
5x2mins (1min)
4x3mins (1min)
Rest

Level 4

3x4mins (1min)
5x3mins(1min)
4x4mins(1min)
3x6mins(1min)
Rest

Level 5

2x9mins(1min)
2x10mins(1min)
3x7mins(1min)
5x5mins(1min)
4x6mins(1min)
Rest

Level 6

20mins
3x9mins(1min)
25mins
3x10mins(1min)
25mins
3x11mins(1min)
Rest

Level 7

30mins
3x12mins(1min)
35mins
3x9mins(1min)
35 mins
3x10mins
Rest

Level 8

40mins
25mins
40mins
30mins
25min
45mins
Rest

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