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Injuries can be scary, so let's talk about them and understand them.
As we went over in Part 1, US elite gymnast Emily Lee suffered an Achille's tendon rupture during her floor routine at the Olympic trials. In that post we talk about what this injury is, how it happens, risk factors, and a brief overview of what rehab will look like.
Here in Part 2, we're talking about the role of the athletic therapist or athletic trainer in this injury, from when it happens and into return to sport. Take a look at the video, or scroll down for text!
Just a little disclaimer here, we cannot say for sure whether it was ATs who helped Emily at the time of injury (it could have also been a paramedic, or sport physiotherapist), or if it will be ATs who she works with during her rehab process, but we are talking in this post about what we saw happen, and what an AT would theoretically do. Let's get into it:
What Do We Do When the Injury First Happens?
After Emily fell, she was able to stand up, walk to the side of floor, and sit down, where she was attended to by a medical professional, who we will refer to as the AT.
One of the first things we see happen is the AT holds onto to her injured ankle.
At that point, especially with such a high force mechanism like this, we also want to determine if there is a threat to the limb, and this is done by assessing 3 things:
if there is a pulse (dorsal pedal artery, tibial artery),
if there is a loss of or change in sensation, indicating a compromised nerve,
and if they are any motor deficits, i.e. not being able to move the toes
Without one or more of these things, it is possible that important structures, such as a blood vessel or a nerve, are either injured themselves or being compromised by an injury, (e.g. being pressed on by a bone). This can therefore threaten the integrity of the limb.
Then we move onto our HOPS, meaning History, Observation, Palpation, and Special Tests. These can happen somewhat concurrently with the previous mentioned steps, and with each other.
History includes the mechanism of injury, how did it happen, when did you feel it happen, etc. In Emily's case this is super important because it would be easy to assume that she hurt herself on the
landing, when it actually happened on the take off of her movement.
Other clues we look for in the history are if there were any specific sounds or sensations at the time of injury, such as snaps, cracks or pops; and we will also ask about pain characteristics, including the time of onset, what provokes or mitigates pain, the severity of pain, is the pain radiating or static, and the pain quality (e.g. sharp, dull, achy, stabby, throbbing, tingling, etc.)
This is all important in determining what the injury may be and how therefore how to properly manage it.
In Observation and Palpation, we are looking for any obvious deformity, swelling, bruising or other discoloration, skin quality, and crepitus ( a crackly feeling in the area of injury). This would be done through the whole ankle and foot.
The AT is likely asking at this point about what Emily felt happen, and the quality of the current pain she is experiencing and that she experienced at the time of injury. This is to help get an idea of what the injury may or may not be and therefore how to handle it.
The last component, Special Tests, we didn't really see a ton of in the management of Emily's injury, but we will still go over for this post. We use special tests to determine the integrity of the bones, connective tissue, and muscles.
We could kind of see at one the way the AT had her hands on Emily's leg, she may
have been doing a squeeze test. In a squeeze test, pressure is applied inward on the calf from both sides. If we have a break in either the tibia or fibula, or if there is disruption in the ligaments that hold them together, depending on where pressure is
applied, we can see splayage of the bones and/or there may be an increase in pain.
Other fracture tests that may have been done later but that we didn't see include a vibration test, where a tuning fork is applied to a superficial aspect of the suspected fractured bone, and away from the suspected fracture site. If there is a break or a disruption in the bone, the applied vibration from the tuning fork will cause an increase in pain.
As well, there are the Ottawa Ankle Rules to determine whether someone needs to be sent for imaging as there is likely to be a fracture:
Based on the information gathered with our HOPS, then a transport decision must be made:
EMS
Splint in position found and go for further care, whether to emergency care or to other medical professional
Move off floor for further assessment and management.
We know there wasn't any obvious threat to life or limb as EMS wasn't called. We cannot know for sure if there were any positive fracture tests, in which case Emily would ideally have ideally been put in an immobilizing splint on the floor. However, it is also possible that a decision was made to move her first even if there was a positive test for the sake of her privacy and dignity.
If we suspect an Achille's rupture, then we would want to splint the athlete in plantar flexion, i.e. in the position of a pointed foot, and refer the patient to a sports medicine physician for surgeon referral.
What Does the AT do After Surgery?
After surgery, and in most cases surgery will happen relatively quickly after an Achille's rupture, the AT comes back in and has a role to play in the athlete's rehabilitation.
The goals in the first few days and weeks after surgery are mostly to manage pain, inflammation, and swelling, and to promote healing. This can include:
ice application
massage to surrounding structures to decrease muscle tension and promote blood flow
Like we talked about in Part 1, we then move on to regaining range of motion, strength, balance, proprioception, and power. The details and timelimes of those can be found in the first post, and all of it can be overseen by an AT.
As we move further along in the rehab process, closer to the 8-12 week range as strength training gets more intense and we start to reintroduce plyometrics, rehab may start to include other members of the athlete's coaching team, such as the strength coach or coach, or it can continue with the AT. This is very variable to a given team, their resources, and team dynamics.
What is the Role of the AT Once the Athlete Returns to Training
Even once the athlete is back into play, the AT still has a big role to play. They are there to support the athlete in managing their injury in many different ways including:
Taping to support the Achilles during practice and competition
Post practice or competition recovery, e.g. icing, stretching,
Clinic appointments to promote optimal biomechanics through not just the ankle, but also the foot, knee and hip to decrease risk for injury a second time.
Lastly, load management; this may be done by the AT or another member of the coaching staff depending on the team resources/dynamics.
Load management refers to making sure that there is a gradual return to full play and full practice volume only as the healing tendon can handle safely. This decreases risk for reinjury and promotes a more successful return to previous levels of play.
ATs are important at all stages of injury and healing. If you have any questions leave a comment below or contact me here!
Wishing Emily an easy and speedy recovery <3
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