How much, how soon?

Special to The Times

WHEN Alicia Di Rado Dingsdale tore her hip flexor muscle in a soccer game in 2004, she was determined not to let it hold her back.

A week later she ran a 5-kilometer race in Arcadia. "By the time I finished I was crawling," she says. She did physical therapy for a few months and eased back into running -- but not slowly enough.

"I had missed running so much I started doing too much," says the 36-year-old. Last summer, her doctor told her she'd aggravated the original muscle tear and probably compounded it with tendinitis.

The second time around, Dingsdale took a different approach to rehabilitation that included more cross-training and more gradual increases in the miles she ran. Now she says she's 100% pain-free and back to her usual 30 miles a week, running faster than before.

For many dedicated athletes, finding the fortitude to swim a few extra laps or play an overtime period is easier than finding the patience to sit on the sidelines. In recent years, their eagerness to return to play has been supported by a shift in medical opinion toward more aggressive rehab: Gone are the days when athletes were banned from working an injured limb for many weeks. But today, many sports medicine specialists think the pendulum has swung too far in some cases, raising the risk of further damage.

Playing injured, they add, is almost always a bad idea.

Compounding the confusion is the fact that even today, nobody really knows the right amount of activity. Each injury is unique, and there's surprisingly little rigorous research on sports injury rehabilitation. Many experts think that fine-tuning rehab has gone about as far as it can -- and that the biggest obstacle today to faster recovery is the biological healing process.

"We're about 90% there in terms of rehab, but only 10% there in terms of biological healing," says Dr. James P. Tasto, a professor of orthopedics at UC San Diego.

Researchers are working on strategies to speed up the biological healing process with drugs, stem cells and even gene therapy, but most of these treatments won't be available in the near future.

In the meantime, injured athletes will have to learn patience -- and seek the best physical therapist or athletic trainer they can afford.

There are few hard and fast rules on the best way to rehabilitate a particular injury and how to know when an injured athlete can safely return to play, says Dr. Thomas Best, chief of sports medicine at Ohio State University in Columbus. That's partly because the rigorous clinical trials used to evaluate drugs for cancer and other ailments are rarely done in this medical arena.

"Most of sports medicine is expert opinion," Best says, meaning a doctor just has a preferred way of doing things. Troubled by the lack of hard data, he co-wrote an editorial in the November issue of the Clinical Journal of Sports Medicine, urging more of this kind of research.

There is, at least, broad agreement on how to approach common and less serious sports injuries such as strains, sprains and stress fractures (see box). In general, activities that exercise the injured area without causing pain can speed recovery and can start almost immediately after an injury. Not so for activities that cause pain or increase swelling. These can slow healing and lead to worse problems.

Physical therapy can help immensely with rehab from injuries, but health insurance doesn't always cover as many sessions as doctors recommend. Many injured athletes end up paying for therapy out of pocket, or going to a few sessions to learn the exercises and then doing them on their own, at home or at a gym.

Amateur athletes shouldn't expect to bounce back from an injury as fast as professional athletes do, says Dr. Jonathan Chang, an assistant professor of orthopedic surgery at the University of Southern California.. Pros usually have access to the best care and facilities -- and no office job to take time away from rehab -- so they can get back twice as fast on average as someone who sees a physical therapist three times a week.

Pro athletes also have financial incentives and other pressures to recover quickly. That's not always a good thing. Many sports medicine doctors see a cautionary tale in the experience of Jerry Rice, the former star wide receiver for the San Francisco 49ers. In 1997, Rice had reconstructive knee surgery, and returned to play just 14 weeks later. During his first game back, he broke his left kneecap.

Common knee injury

REHABILITATION after knee surgery, particularly surgery to repair the anterior cruciate ligament (ACL), is possibly the most controversial area in sports injury rehab and return to play. ACL tears are common in sports that involve jumping or quick cuts and turns and are one of the most common ways that athletes find themselves in an operating room.

In the 1980s, orthopedic surgeon Dr. K. Donald Shelbourne discovered that his patients who cheated during rehab and exercised their knees sooner than they were supposed to recovered faster than those who dutifully followed a doctor's orders.

Shelbourne still advocates a fast return to activity at his clinic in Indianapolis, which specializes in ACL surgery and rehab. He characterizes it as an "ACL superstore" with surgeons and physical therapists working under one roof to coordinate the patients' care.

Coordination is key, Shelbourne says: If physical therapy is left entirely up to the patient and therapist -- as is more typical -- therapists are often afraid to push patients too hard, fearing that "if something goes wrong, the surgeon will blame them."

In the first week after surgery, the priority for Shelbourne's patients is to keep the swelling down. After that, they do physical therapy for an hour twice a day. Shelbourne says his patients usually return to play six weeks after surgery and are fully recovered within three to four months.

Other surgeons take a more conservative approach, typically advocating physical therapy three times a week after ACL surgery. They tell their patients, even professional athletes, to expect to be out for six to nine months.

"I've used a certain protocol, and pushed it, and beyond that it's counterproductive," Chang says. He adds that recent research suggests that recovery from surgery to repair the rotator cuff, the complex structure of muscles, tendons and fibrous material that stabilizes the shoulder joint, can also be slowed by coming back too quickly.

It all adds up to a slight shift in medical strategy.

"In the last 10 to 15 years, there's been an attempt to stress rapid rehab," says Tasto. "In some cases that's been successful and in some cases we feel we've pushed the envelope a bit too far and seen recurrent injuries.... If we are returning people to play before the biological process has taken place, then the patient is at risk."

Improved healing

ONE day doctors may be able to give the biological healing process a boost.

"The key is going to be to change the biological environment to promote healing," says Dr. Kurt Spindler, a professor of orthopedics and director of the Sports Medicine Center at Vanderbilt University in Nashville, Tenn.

The tendons, ligaments and cartilage that tend to get frayed in active athletes aren't very good at healing themselves, Spindler explains. It might be possible, however, to encourage damaged tissue to regenerate using natural chemicals called growth factors.

Researchers have already identified several compounds that promote bone growth. These might, Spindler says, be useful for treating stress fractures -- tiny cracks in bone that result from repeated pounding, like the abuse taken by the feet of runners. But no one has tested this idea.

Researchers have also found growth factors for soft tissues such as tendons, ligaments and cartilage. These connective tissues are crucial for holding joints together and keeping them in working order, but in adults, their cells are relatively inactive. When an injury happens, they don't make the collagen and other materials needed to make repairs.

Growth factors might spur them to action and improve healing, says Dr. David McAllister, an associate professor of orthopedic surgery at UCLA. One possibility would be to use engineered viruses that carry the genetic instructions for growth factors, collagen or other compounds to shuttle these substances into the injured joint.

Researchers have had some preliminary success in animal studies, delivering growth factor genes that stimulate healing of injured cartilage in rabbit knee joints, for example. But such treatments are a long ways from leaving the lab.

Another approach that may be closer to reality involves coaxing stem cells to form replacement cells for the injured tissue.

A trial getting underway at USC is the first attempt to use stem cells to repair injured knee cartilage.

Gil Solomon, a 53-year-old triathlete in West Hills, is participating in the trial, which uses stem cells extracted from the bone marrow of adult volunteers.

Solomon says he started having knee pain last February. A physician himself, he suspected the problem was tendinitis. "I knew it would take time [to heal], and for the most part I was good, but there were times when I became frustrated and tried to see if it was ready," he says. So he'd run a little more than his trainer told him to.

"Sure enough, I was worse for a period of time afterward.... Unfortunately, the athlete mentality is to push though the pain, which is often the wrong thing to do," he says.

On Dec. 9, Solomon had surgery to repair what turned out to be a torn meniscus, the pad of cartilage that sits between the thigh and shin bones. A week after that, he got an injection of either stem cells or a placebo.

He says he hopes he got the stem cells, but he won't find out for two years.

In the meantime, he's planning to train for the Los Angeles Triathlon in September. He has participated in the event every year since its inception in 2000 and says he's not going to let his knee problems get in the way of doing it again.

"I decided I'm going to do it even if I have to walk the run part," he says.

If the stem cells kick in, maybe he won't have to.



When to get back in the game

Deciding when to return to play depends on the type and severity of the injury, the patient's history, the sport involved and other factors that vary from case to case. It's a decision every athlete should make with a doctor or physical therapist, ideally one with a good reputation for treating that type of injury.

Severe injuries require immediate medical attention and may require surgery. For less severe injuries such as the ones below, players usually are ready to return when they can move the injured limb or joint through its full range of motion, have recovered full strength and can do the motions of their sport normally and without pain.

Here are some general guidelines for the two main classes of injuries -- acute injuries to muscles and ligaments and chronic injuries such as tendinitis.


-- Greg Miller

Rehab for acute injuries

Muscle strains (when muscle fibers are stretched or torn by sudden movement) and sprains (sudden tears of ligaments, the fibrous bands that connect bone to bone in joints) are among the most common sports injuries.

Follow the old acronym RICE -- rest, ice, compression, elevation. Avoid painful movements of the injured area and reduce swelling with ice, a compression bandage and by keeping the affected area above the heart. Keeping swelling down can shorten the recovery period.

Nonsteroidal anti-inflammatory drugs (NSAIDs) help reduce pain and swelling.

Moving the affected part within the range of motion that doesn't cause pain can speed healing, and can begin almost immediately after the injury.

With time, gentle stretching and strengthening exercises can be added. Activities that increase pain or swelling will make the injury worse.

Rehab for chronic injuries

Repeated exercise can wear down joints and bones, causing damage that accumulates over time. Common examples among athletes are tendinitis (swelling and irritation of tendons that connect muscle to bone) and stress fractures (tiny cracks in bone). Rest is the key to both.

Too much activity on a stress fracture can cause a more serious fracture. Any activity that causes pain or swelling should be stopped immediately. Scale back activity to avoid pain during or immediately after exercise, then increase in small, gradual steps to return to normal.

For more information

The following Web sites can lead you to many useful articles on sports injury prevention and recovery.






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