Back in the game...
From surgery, to the pinnacle of South African schoolboy rugby all in the space of a month - narrated by "the physio".
This was a first for me. Despite more than 10 years of clinical sports physiotherapy, I still get nervous / excited for cases like this*. It proves to me that I still care, and care enough to break out the whiteboard pens and start thinking on a blank canvas.
Allow me to share this case with you (with permission). Not to toot my own horn, but to give insights into what exactly a sports physiotherapist does when an athlete gets injured. We often mistakenly imagine them “massaging” a knee from injury all the way till performance, but it’s so much more than that - and instead of bemoaning the misconception, let me highlight some of the considerations in a very unique and interesting case.
All the credit for the outcome here needs to go to the athlete, and to the orthopedic surgeon. It’s a truly team effort, and this is just the view through my lens as the physio…
The athlete is an 18 year old rugby player, and it would be fair to say that his presence in the team is pivotal. Like his presence in the team, I take my role in this case extremely seriously. I’m going with the mantra - full responsibility, fully accountable. If we don’t meet the timeframe or if there is a recurrence of injury along the way, I’ll take the blame, but this is the only way I see this case working. I need to plan every single detail of this moonshot (with my athlete, of course).
How is it possible to go from injury, to surgery, then through rehab and return to 1st XV and Craven Week rugby - all within the space of a month? Here’s some of the factors I feel are vital and although “its only school sport” it's the same framework I use with an athlete in a competition like the SA20 or any elite athlete for that matter.
If you’ve ever wondered how physiotherapists assist in taking athletes from injury back to competition, hopefully this give you some insight…
Diagnosis: Symptoms were reported immediately post match, and physical assessment was done at the side of the field. Monitoring of those symptoms over 24h with a reassessment at 48h post injury. There was an immediate suspicion based on the mechanism of injury and behavior of symptoms as to what might be wrong.
Contacts: Enough rapport with an orthopedic knee specialist to phone them and arrange an appointment within 24h, explaining the gravity of the case. Sending supporting documents such as the clip from the match highlighting the mechanism of injury. I often think that this is more crucial than having good physical testing for injured structures, as the “how” it happened is more revealing than how the knee is presenting on the physio table.
Favors: With much communication between parents, patient, ortho and myself, and everyone calling in favors, an MRI is arranged on the same day as the orthopedic consult and within two days of the consult - surgery is happening! This is a difficult decision, as the considerations on conservative management vs operative are often mixed in the literature - but in this case, if there is any chance of resuming participation during the season, then this is the only way. Surgery goes well and after a long call with the orthopod, I’ve got a good idea of what exactly happened during the surgery. What structures were damaged, to what extent and how they were repaired.
Now the planning can begin! Challenge accepted: 3 weeks till the start of return to competition (partial exposure), 4 weeks till the big season finale derby (full match?) and 6 weeks until the provincial week(3 matches on alternating days) - which for many boys at this level can be a significant opportunity for their careers in rugby.
Structure: Reverse engineering is the name of the game here, how many days till the first return to competition and what is expected at this date. Here are some of the big questions from the whiteboard:
When do we need to have full tackle contact?
When do we need to be sprinting?
How much running volume needs to be accumulated?
When to introduce plyometrics?
How long till we can assume the knee is completely recovered from the surgical procedure, stitches etc.
What were his pre-injury training loads?
How often will I have access to the athlete? What are the financial implications here?
Measurable’s: How can we measure or assess in real-time whether we are on track, ahead, or even behind on these goals? Here are some of the tools to measure and stratify risk:
Swelling response to rehab / running or return to play, tape measure and visual analogue scale.
IKDC knee questionnaire - an objective knee questionnaire completed via an app.
Force Plate testing
Handheld dynamometry
Single leg bridge
Single leg hop tests, lateral hop tests
Field tests of agility and running fitness
GPS data during return to training compared to match loads
The kicker here is knowing when to measure and these and what we are hoping to find out from these tests. Simply doing them to tick a box just wont suffice.
Lessons from this case:
The more you know, the more you realize you don’t know. Having an environment where I can have exposure to these cases regularly, certainly helps me to grow, but it also hinges on whether I take them head-on with the right mindset. Always willing to learn, adapt and overcome.
A physio needs the ability to think critically, plan meticulously and have the organizational skills to communicate their plan to all stakeholders. The athlete needs to be at the center of this. If theres no trust between the clinician and athlete through this process, it doesn’t work. It is certainly two-way street, but as the professional, I feel that the burden of leading the relationship is on us. To earn this trust comes with years of congruent character, developing rapport and showing integrity.
Stratification of risk. Not every case needs this level of detail. But you need to know all the ways that you can measure progress to make the best decisions for the patient and their goal. The devil is in the detail and the ability to go deep when necessary is core skill in this instance.
My philosophy remains that we must create our own vision of what “world class” should look like and strive towards that in our current settings. If we wait and hope to land in a world class setting and then develop these skills - our stay there is likely to be short lived.
Nick Pereira
MSc. Sports and Exercise Physiotherapist
*For those who don’t know me from a bar of soap, I am a sports physiotherapist who has worked with adolescent sports, and elite team sports for the last 10 years.
My current professional settings include lecturing post graduate physiotherapy students and presenting “continuous professional development” modules to other health professionals. Managing physiotherapy practices at two of the oldest boys high schools in Kwa-Zulu Natal. I am also currently the lead physiotherapist and medical coordinator for the IPL franchise “Delhi Capitals” in the SA20 league (Pretoria Capitals). The array of athletes I attend to yearly ranges from adolescents to elite World Cup winning cricketers and Olympic / Paralympic athletes.