Physiotherapy for Muscle and Ligament Tears

Understanding the Injuries

Phase 1 — Acute (Days 0–3): POLICE/PEACE & LOVE Protocol

• Protect — offload and restrict movement for 1–3 days
• Elevate — raise limb above heart level to reduce swelling
• Avoid anti-inflammatories — early inflammation is necessary for healing
• Compress — elastic bandage to limit swelling
• Educate — set realistic expectations, avoid passive treatments

• Load — progressive mechanical loading as pain allows
• Optimism — positive mindset improves outcomes
• Vascularisation — pain-free aerobic exercise (cycling, swimming)
• Exercise — restore mobility, strength, proprioception

• TENS or interferential therapy for pain control
• Gentle range-of-motion (ROM) exercises within pain limits
• Manual lymphatic drainage if significant swelling

Phase 2 — Subacute (Weeks 1–6): Tissue Repair

• Joint mobilization (for ligament injuries limiting ROM)
• Soft tissue massage / myofascial release
• Instrument-assisted soft tissue mobilization (IASTM/Graston)

• Isometric exercises → progress to isotonic (concentric then eccentric)
• Eccentric loading is especially important for muscle healing (e.g., Nordic hamstring curls for hamstring tears)
• Open-chain then closed-chain exercises

• Ultrasound therapy (promotes collagen synthesis)
• Low-level laser therapy (LLLT)
• Kinesio taping for proprioceptive feedback and edema control

Phase 3 — Remodeling/Functional (Weeks 4–12+): Strength & Proprioception

• Progressive resistance training (theraband → free weights → functional loads)
• Emphasis on eccentric and plyometric exercises in later stages
• Kinetic chain exercises (e.g., single-leg press, step-downs)

• Balance board / wobble board training (critical for ligament injuries — the mechanoreceptors in ligaments are destroyed with tearing)
• Single-leg stance progressions
• Perturbation training

• Agility ladders, cone drills
• Sport-specific movement patterns

Phase 4 — Return to Sport/Activity

• Limb symmetry index ≥90% for strength (isokinetic testing)
• Full pain-free ROM
• Hop tests (single-leg, triple hop, crossover hop)
• Psychological readiness (ACL-RSI scale for knee injuries)
• No joint effusion

Site-Specific Highlights

Ankle Ligament Sprain (most common)

• Early weight-bearing with support (brace/tape)
• Priority: peroneal strengthening + balance training
• Risk of chronic instability if proprioception rehab is skipped

Hamstring Strain

• Eccentric exercise (Nordic curls) is the gold standard for both rehab and prevention
• Aggressive early return = high re-injury risk
• Criteria: >90% symmetry, pain-free sprint, maximal elongation test negative

ACL / Knee Ligament

• Usually surgical (Grade III); post-op PT is extensive (9–12 months)
• Quad/hamstring co-contraction, neuromuscular training critical
• Return to sport: minimum 9 months + hop tests

Rotator Cuff (shoulder)

• Grade I–II: conservative PT is first-line
• Scapular stabilization, rotator cuff strengthening in pain-free range
• Posterior capsule stretching (sleeper stretch) for flexibility

Key Physiotherapy Principles

1. Pain should guide loading — some discomfort is acceptable (≤3–4/10), sharp pain is not
2. Progressive overload — tissue heals stronger when loaded appropriately
3. Biological healing cannot be rushed — collagen remodeling takes months
4. Address contributing factors — muscle imbalances, biomechanics, footwear, training errors
5. Patient education reduces re-injury rates significantly

Cardiac Physiotherapy (Cardiac Rehabilitation)

Figure 22-1. The five core components of cardiac rehabilitation — Fuster and Hurst's The Heart, 15th Ed., p.715

Indications

• Acute myocardial infarction (MI)
• Coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI)
• Stable angina pectoris
• Heart failure (HFrEF) — Class I recommendation by both ESC and ACC/AHA guidelines
• Cardiac valve surgery
• Heart transplantation

Contraindications

Program Structure & Phases

Phase 1 — Inpatient (Hospital)

• Begins during the hospital stay post-MI or post-surgery
• Goals: progressive ambulation, patient education ("teachable moment"), smoking cessation counseling, bridge to outpatient rehab
• Now shorter in duration due to reduced hospital stays

Phase 2 — Outpatient (Supervised)

• 2–3 sessions/week × 36 sessions (standard in US/Canada)
• ECG-monitored throughout
• Each session structure:
  • Warm-up: 5–10 min of stretching and light calisthenics
  • Exercise training: treadmills, stationary bicycles, ellipticals (cross-training)
  • Resistance training: upper and lower body strengthening for all ages
  • Cooldown: 5–10 min monitoring for recovery
• Medical director + nurses + exercise physiologists form the team

Phase 3 — Maintenance (Optional)

• Long-term exercise maintenance program
• May or may not be medically supervised or ECG-monitored
• Varies widely by facility

Exercise Prescription

• Baseline symptom-limited or modified exercise tolerance test (while on usual medications)
• Identifies inducible ischemia, arrhythmia, and determines target training heart rate (THR)
• If no exercise test: start at resting HR + 20 bpm

• Moderate intensity — equivalent to brisk walking
• THR maintained at 70–85% of maximum HR (adjusted across 36 sessions)
• Borg Perceived Exertion Scale used to guide effort (moderate level)
• High-intensity interval training (HIIT) vs. moderate-intensity continuous training (MICT) — both used in practice, with HIIT showing comparable or superior VO₂ max gains in meta-analyses

• Aerobic: treadmill, cycling, elliptical
• Resistance: free weights, resistance bands, weight machines
• Breathing exercises (especially in heart failure and post-CABG)

Clinical Benefits

Home-Based vs. Centre-Based CR

Barriers to Participation

• Lack of physician referral or program awareness
• Transportation and geographic distance
• Cost-sharing (copays) — each $10 increase → 1.5 fewer sessions attended
• Work/home responsibilities
• Depression or low motivation
• Low health literacy or language barriers

Key Takeaways

1. CR is a Class I intervention for post-MI, post-revascularization, and heart failure patients
2. Exercise training is the cornerstone, but CR is multidisciplinary
3. 36 supervised sessions is the standard — the more sessions completed, the greater the benefit
4. Exercise intensity should be guided by testing and the Borg scale
5. Both aerobic AND resistance training are essential
6. CR is underutilized globally — referral and access remain major challenges