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INTRODUCTION

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Healing is a matter of time, but is sometimes also a matter of opportunity.

Hippocrates (c.460–370 BCE)

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This chapter is integrally linked to the following chapter on the principles of injury rehabilitation. While the terms treatment and rehabilitation are often used synonymously, we define treatment as specific interventions aimed at tissue pathology, impairments or symptoms. Examples of treatments include targeted tendon loading (therapeutic exercise), mobilisation of a cervical spine facet joint (manual therapy), extra-corporal shockwave therapy (electrotherapy) and non-steroidal anti-inflammatory drugs (therapeutic medications). In contrast, we define rehabilitation as a holistic process aimed at restoring the athlete to his or her pre-injury function—a part of which involves the application of the right treatments at the right time.

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This chapter provides essential background for the treatments detailed in Part B: Regional Problems. Evidence for treatment effectiveness is continually changing. However, remember that our craft remains as much art as science. Level 1 evidence is not always available (see box) and the decision to use (or not to use) certain treatments is also influenced by our experience, professional training and patient’s expectations (see ‘A cautionary tale’ below and Chapters 1 and 2). Nevertheless, clinicians should have a solid understanding of the theoretic rationale for the treatments they provide, as well as up-to-date knowledge of the evidence of their effectiveness.

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The effect of each treatment should be evaluated by objectively comparing symptoms and signs before and after the treatment, and at the next visit. Functional testing and patient-reported outcome measures (PROMs—Chapter 16) should also be used regularly throughout the course of treatment. This enables the clinician to choose the most appropriate mode of treatment for the specific injury and individual. In presentations that fail to improve, this also allows the clinician to change modalities or pursue further investigations.

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HIGH-LEVEL EVIDENCE IS NOT ALWAYS AVAILABLE

There are no randomised controlled studies to demonstrate that jumping out of a plane with a parachute leads to superior outcomes than jumping without one.1 The best evidence for the effectiveness of parachutes comes from retrospective case series (level 4 evidence; Fig. 17.1). Would this stop you from recommending their use?

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Figure 17.1

The level of research evidence supporting the use of parachutes is low

CORBIS

Graphic Jump Location
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A CAUTIONARY TALE

with KIERAN O’SULLIVAN

Before we launch into specific treatments and the evidence that underpins them, we need to share a cautionary tale. Just as Chad Cook (Chapter 14) alerted us that clinical assessment is not as accurate as the 1990s textbooks made out, treatment is not what a glitzy pharmaceutical video might suggest it is.

Unfortunately, several very important factors—that are unrelated to the pathology of a condition itself—can influence treatment outcomes. You have seen patients who are positive in their outlook and others ...

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