Version May 2024
INTRODUCTION — This topic reviews the phases of musculoskeletal injury rehabilitation as they relate to the phases of healing, the transition from one phase to the next, the maintenance of cardiovascular fitness during rehabilitation, and the progression of goals that must be met before return to sports participation. The treatment principles and modalities are discussed separately. (See "Musculoskeletal injury in children and skeletally immature adolescents: Overview of treatment principles for nonoperative injuries".)
OVERVIEW — Proper prescription of physical therapy is vital to the completion of healing and a timely return to sports participation. The phases of rehabilitation correspond to the phases of healing:
●Inflammatory phase (0 to 72 hours after injury) (table 1)
●Reparative/fibroblastic phase (72 hours to 3 weeks after injury)
●Maturation/remodeling phase (3 weeks to 2 years after injury)
How and when a modality, manipulation, or exercise is deployed is guided by the type of injury and tissue response to physiologic demand and by the signs and symptoms of the stages of the healing process (table 2).
The discussion that follows assumes that fractures and joint instability have been excluded. The evaluation of musculoskeletal trauma and the management of fractures and unstable joints are discussed separately. (See appropriate topic reviews).
INFLAMMATORY PHASE — Management during the inflammatory phase (0 to 72 hours after injury) focuses on PRICE (table 1): Protection of the injured area, Relative rest, and decreasing swelling through Ice, Compression, and Elevation [1]. Some of these modalities also may be necessary during subsequent phases of rehabilitation, particularly if pain and swelling increase during therapeutic exercise.
Protection — Protection of the injured area prevents further tissue damage. Examples of protective modalities include crutches, padding, shock-absorbing insoles, and external supports (eg, air stirrup brace) [2-4]. In addition, protection includes a graduated return to play progression to help reduce the risk of reinjury due to tissue overload that exceeds the rate of tissue repair.
Relative rest — Relative, rather than complete, rest is prescribed during the inflammatory phase. Immobilization of the injured joint or musculotendinous unit should be local and for a short duration. Properly dosed exercise and activities of daily living can protect ligaments and joint soft tissues as long as the force is not too great and does not result in swelling or pain at the affected site. Pain and swelling are the body's response to overloading a tissue's ability to accommodate a particular load. Sudden return to high-level training without adequate proprioceptive training increases the likelihood of ligament injury [2].
Immobility is deleterious because it causes a net shift in ligament cell metabolism from homeostasis to a catabolic state. Immobilization results in bone resorption and focal weakening at the insertion sites of ligaments and tendons, with concomitant decreased strength and stiffness of connective tissue. After six to nine weeks of immobilization, the connective tissues lose one-half of their previous strength and stiffness [5]. Disuse of tendons leads to loss of tissue volume and formation of cross-links [6-9]. The resulting tissue is weak and fails at ≤60 percent of its previous strain-to-failure rate [9].
Cold therapy — Cold therapy is commonly used during the inflammatory and early reparative phase (ie, up to seven days after injury) to decrease swelling and pain. The benefits of cold therapy have been demonstrated with magnetic resonance imaging of the perfusion of muscle tissue and diffusion of water molecules following cryotherapy wherein tissue temperature and perfusion were both noted to be significantly reduced [10]. Cryotherapy has been demonstrated to have effects on acute injury including decreased pain, decreased swelling, and increased range of motion [1]. However, the early observational studies demonstrating the benefit of cryotherapy in patients with ankle sprain [11-13] were of limited methodological rigor and it remains unclear if cryotherapy improves functional outcomes significantly [1].
It is important to explain correct usage of cold therapy [14]. Ice application should begin immediately postinjury. Ice packs (crushed ice and water in a plastic bag) should be applied directly to the skin. Some experts suggest that ice be applied continuously for 20 minutes [15,16]; others suggest that it be applied in two 10-minute sessions separated by a 10-minute break [17]. Application of ice three to four times per day is considered sufficient, but cold therapy can be performed every hour; the more frequent the application, the greater the chance of effectively reducing the inflammatory process. (See "Musculoskeletal injury in children and skeletally immature adolescents: Overview of treatment principles for nonoperative injuries", section on 'Cold therapy'.)
Contraindications to cold therapy include [18]:
●Raynaud phenomenon (see "Clinical manifestations and diagnosis of Raynaud phenomenon")
●Peripheral vascular disease (eg, diabetes)
●Impaired sensation
●Cold allergy/hypersensitivity
●Severe cold-induced urticaria (see "Cold urticaria")
●Cryoglobulinemia (see "Overview of cryoglobulins and cryoglobulinemia")
●Paroxysmal cold hemoglobinuria (see "Paroxysmal cold hemoglobinuria")
Compression and elevation — Compression is traditionally paired with elevation to provide an increase in hydrostatic gradients and to promote venous return [18]. The addition of pain-free range of motion may increase lymphatic drainage 5 to 15 times the resting level, hastening restoration of fluid balance [18]. The combination of compression and ice is more effective in controlling edema than is compression alone [19,20].
The benefits of compression were demonstrated in a trial in which noninjured subjects were randomly assigned to use or not use an elbow sleeve after eccentric muscle exercise (exercise that opposes gravity and acts to lengthen muscles) [21]. Use of the compression sleeve was associated with reduced delayed-onset muscle soreness, decreased loss of strength, decreased swelling, improved resting joint angle, increased ability to perform daily tasks, decreased perception of soreness, and decreased levels of serum creatine kinase.
Therapies to avoid
Heat — We suggest that heat therapy be avoided during the inflammatory phase of rehabilitation. Heat increases local swelling, inflammation, vasodilation, and blood flow, all of which are detrimental in the inflammatory phase [11]. In observational studies of patients with ankle sprain, application of heat was associated with delayed recovery compared with application of cold [11,12].
Physical therapy prescription — When writing a prescription for physical therapy for a patient in the inflammatory phase, the prescription should reflect the principles described above (ie, protection of the injured area, properly dosed exercise, and application of various modalities to reduce edema) (table 2).
REPARATIVE PHASE — The reparative phase (approximately three days to three weeks after injury) of rehabilitation begins after inflammation is controlled, when swelling and spasms decrease or subside and the injured area can be moved with little to no pain [22].
An example of a patient in the reparative phase is a male child who presents one week after an ankle sprain and has mild discomfort, but whose overall pain is improved. The patient still has pain with activities of daily living, walks with a small limp, and, subjectively, cannot return to exercise or sports. The patient may recruit the muscles about the ankle but does so with a delay that does not protect the joint from injurious forces encountered during sports and does not permit cutting or pivoting.
Reparative goals — The goals of physical therapy during the reparative phase are:
●Continued protection of the injured structures (see 'Protection' above)
●Full range of motion of the affected joints and soft tissues
●Reestablished proprioception
●Progression from basic voluntary uniplanar muscular firing patterns to more complex, coordinated muscular strength, endurance, power, and functional tasks (table 3)
If pain and swelling increase during the reparative phase of therapy, it may be necessary to add the modalities used during the inflammatory phase (eg, ice and compression); reduction of the intensity and duration of therapeutic exercises is recommended.
Range of motion and flexibility — Flexibility and full range of motion must be restored to the injured muscles and joints in order to adequately distribute force inherent in daily activities and sports. In setting goals for physical therapy, it is useful to know the range of motion requirements for various activities. As an example, the knee range of motion requirements for walking, stairs, cycling, and jogging are as follows [18]:
●Walking without a limp – Flexion of 75 degrees
●Stair climbing and cycling – Flexion of 90 degrees
●Jogging or running – Flexion of 105 to 120 degrees
●Sprinting – Flexion of 140 degrees
It is necessary to have 5 to 10 more degrees of static flexion than listed above to achieve the smooth function of dynamic activity [18].
In patients with soft-tissue adhesions or contracture of muscles or joints, myofascial and/or joint manipulation is required to regain full range of motion, including osteokinematic (gross movements of bones at joints, such as flexion/extension) and arthrokinematic (movements of joint surfaces, such as gliding) motion. Arthrokinematics must be normalized before osteokinematics can be addressed.
Myofascial and joint manipulation (decreasing myofascial stiffness and joint accessory mobility) is an essential component of the reparative physical therapy regimen [23-25]. Restricted joint motion decreases the working surface area of the joint, increasing the force per unit area and contributing to greater wear and early fatigue failure of structures in and about the affected joint. Myofascial stiffness can be improved with muscular manipulation or stretching [26]. Muscular length can be increased with static or dynamic flexibility activities.
Static flexibility is the physical actual muscle length that allows range of motion about a joint assuming normal arthrokinematics. To achieve static flexibility, static stretching is conducted by placing the affected muscle-tendon unit in an anatomically lengthened position. Low-load, long-duration (30 to 60 second) stretches are preferred to shorter duration fast stretches for lengthening myofascial structures according to known tissue mechanical properties [22,27-31].
Dynamic flexibility is the ability to use the full range of motion of a joint by overcoming resistance during performance of an activity [5]. Dynamic flexibility may be gained with dynamic drills in addition to static stretching methods [29]. Some evidence exists that passive stretching is more effective in creating long term change [31].
Improvement in flexibility can be gained through a progressive velocity flexibility program (PVFP). PVFP facilitates motor learning response as the muscle stretches at higher velocities over time, simulating movement and integrating functional activities. Days or weeks of PVFP may be necessary to achieve the desired freedom of motion [5].
A PVFP consists of:
●Static stretching
●Slow short-end range stretching
●Slow full-range stretching
●Fast short-end range stretching
●Fast full-range stretching
Adjunctive therapies — Heat therapy and cold therapy may be used as adjuncts to stretching exercises. Warming the muscles before stretching (eg, with warm-up exercises or passive heating modalities) enhances the beneficial effects of stretching exercises [22,32]. Applying ice to a tissue in a lengthened position results in lengthened tissue and increased range of motion [18,33].
Proprioception — Return to sports activity requires proprioception, as well as range of motion and flexibility [5]. Injury disrupts the proprioceptive feedback loop when the nerve ending is stretched or torn [5,34]. The goal of therapy is to reduce the time between the neural stimulus and the desired muscular response, thus reducing stress on the injured joint [35]. Proprioceptive drills can be progressed from weight-bearing exercises on two limbs, to one limb, and finally, on compliant surfaces such as mini-trampolines and balance boards [5]. Physical therapy treatment of a joint with a ligament sprain improves proprioception, function, pain, and disability scores [2,35-38].
Retraining methods to improve proprioception of the affected segment include [39]:
●Taping or bracing to aid joint alignment and increase sensory input
●Progressive static balance exercises moving from a firm surface to a compliant surface
●Increasing difficulty by increasing the speed of the task or performing the task without looking at the affected limb
The use of an elastic bandage (or neoprene sleeve) improves proprioception during open-chain activities (eg, those in which the distal extremity is free to move, such as knee extension in the seated position) in uninjured knees; the greater the initial impairment in proprioception, the more wrapping improved performance [40,41]. In contrast, the use of an elastic bandage (or neoprene sleeve) does not appear to objectively improve proprioception during closed-chain (eg, those in which the distal extremity is fixed, such as squats) activities, perhaps because of the inherent increased proprioceptive input at the plantar surface, ankle, and hop during closed-chain tasks [41].
Physical therapy prescription — Prescriptions for physical therapy during the reparative phase should request a program emphasizing normalizing range of motion, flexibility, functional stability, and proprioception (table 2) [2,35-38].
TRANSITION TO MATURATION PHASE — When the athlete begins the transition from the reparative to the maturation phase, it is important to establish clinical and functional rehabilitation goals that must be met before the athlete can return to sports activity. This planning spans the reparative and maturation phases [5].
A goal-oriented approach allows the athlete to return to play when they are ready. The physical therapy regimen should establish step-by-step goals so progress can be evaluated. When setting goals, it is important to involve the athlete so that they are invested in the process, and to provide objective measures of goal attainment.
Clinical goals should be established for flexibility, proprioception, voluntary muscle firing patterns, strength, endurance, and cardiovascular fitness. Functional goals should be established for power, speed, agility, and sport-specific skills [5,18]. Each of these areas is discussed in greater detail below. (See 'Maturation phase' below.)
As an example, sequential goals for a running athlete with knee pain would include:
●Normal range of motion about the knee
●Ability to activate the quadriceps correctly in isolation
●Ability to activate the quadriceps during concentric phase contraction
●Single-limb, load-bearing balance with the concentric phase contraction
●Eccentric phase step-down with control of speed, angles, and balance
●Dynamic drills such as hopping, figure-of-eights, shuttle runs, or cutting drills, depending upon the athlete's sport, to further load the knee
With such a program, the athlete progresses from easier to harder skills and from lesser to greater demand. Interval return to sports programs can be used to advance the throwing athlete, golfer, tennis, or running athlete from the injury rehabilitation phase to sports-ready condition [5].
Physical therapy prescription — The prescription for physical therapy during this transition should include activities starting in the reparative phase and progressing through the end of the maturation phase, allowing the physical therapist to select the best phase-dependent choice for neuromotor recovery (table 2).
MATURATION PHASE — During the maturation/remodeling phase (approximately three weeks to two years after injury), new collagen and bone matrix fibers that were deposited during the reparative phase increase their strength and organization. The application of excessive force during this phase will disrupt the immature tissue. On the other hand, if insufficient force is applied, the tissue will not organize along lines of stress and will fail during the application of strong force as the athlete returns to sports activity.
Properly dosed exercise can protect ligaments and joint soft tissues as long as the force is not too great and does not result in swelling or pain at the affected site. Low, cyclic loads increase collagen proliferation and material remodeling, making the tissue stronger and stiffer [5,18,28]. The challenge for the physical therapist is to use sufficient motion to stimulate maturation without exceeding the tissue's load tolerance. (See 'Load tolerance' below.)
Maturation goals — Clinical and functional goals that begin during the reparative phase and continue into the maturation phase relate to [5]:
●Flexibility
●Proprioception
●Progression from basic voluntary muscular firing patterns to muscular strength, endurance, and power (table 3)
●Cardiovascular endurance
●Power
●Speed
●Agility
●Sport-specific skills
Flexibility and proprioception are discussed above. (See 'Range of motion and flexibility' above and 'Proprioception' above.)
During the maturation phase, there should be little need for physical modalities, but protection (eg, braces, taping, protective equipment) may still be necessary [22]. Flexibility and joint motion should be normal, but ongoing maintenance is necessary to retain earlier gains. Therapeutic exercise may focus on higher speeds of contraction, enhancing power and endurance, and restoration of proprioception.
Load tolerance — A major goal of therapy during the maturation phase is to identify the load tolerance of the maturing tissue and apply sufficient force to allow the tissue to get stronger without exceeding its threshold; cyclic loading has been demonstrated to alter collagen in a manner consistent with the goals of physical therapy for improving collagen synthesis and resistance to loading [42]. The load must match the strain tolerance of healing collagen without disrupting the immature fiber matrix. Pain is a sign that the load is excessive and must be reduced.
In a patient with a partial thickness tear of the Achilles' tendon, for example, if pain occurs with single-limb load-bearing exercise, double-limb load-bearing exercise can be used. If there is pain on two legs, the load can be reduced through a variable inclined plane or aquatic exercise. These adaptations enable the patient to exercise at as little as 3 percent of body weight up to ≥70 percent of body weight. Over the course of weeks, the plantar flexion load is progressively increased until the activity demand is met by the healing tissue, permitting a pain-free return to sports activity.
Identification of appropriate load is accomplished by selecting exercises that are specific to the injured muscle tendon unit and allowing the patient to reach fatigue between 20 and 30 repetitions of the exercise without pain provocation. Each phase of the progression adds a degree of challenge to the maturing tissue when it has met the previous stage's goal.
Progressive loading can be done by increasing the percentage of body weight for which the patient is responsible, increasing the resistance applied, or speeding up the movement [5]. As an example, an athlete who begins at a load tolerance of 50 percent of his body weight before provocation of familiar pain may be progressed to 60 percent when sets of 30 or more repetitions can be performed at 50 percent of body weight without pain.
Strength — The development of strength is a primary step in rehabilitation. Strengthening exercises should be as functional or sport-specific as possible and should be progressed from general strength to specific strength [5]. However, to achieve the premorbid sports level, core strengthening of the lumbo-pelvic muscular stabilizers also may be necessary.
In the progression of strengthening exercises, it is important to involve concentric and eccentric strengthening, isometrics, isotonics, proprioceptive neuromuscular facilitation, and stretch-shortening cycle activities (table 4) [5]. Closed-chain exercises are an excellent way to include all these phases of strengthening. Closed-chain exercises are performed with the distal segment of an extremity fixed and with motion occurring at the proximal segments. Examples of closed-chain exercises for the lower extremity include partial squats, leg presses, single leg load bearing balance with or without perturbation, step-ups, lunges, stair climbers, lateral slide boards, treadmills, the use of a biomechanical ankle platform system (BAPS) board, mini-trampolines, and Dyna Discs.
Working in closed-chain contexts provides functional deceleration training for large lower-extremity muscle groups and enhances speed, balance, and coordination. Closed-chain exercises increase joint stability through a larger range of motion and enhanced muscle action around the joint. However, closed kinetic chain exercises should be augmented by open chain exercises where deemed appropriate by the treating therapist because the addition of open kinetic chain exercise to a closed kinetic chain regimen improves outcomes [43].
Muscular endurance — Muscular endurance is the capacity of muscle to perform repetitive contractions against a load [5]. Endurance is compromised after injury and immobilization because there is a preferential loss of type I muscle fibers (also known as slow-twitch, red, or oxidative endurance-biased muscle fibers) [44]. During rehabilitation, it takes longer to regain muscular endurance than muscular strength.
Endurance can be obtained via high-repetition, low-load exercises. A level of muscular discomfort but not familiar pain should be reached at 20 repetitions of the assigned weight. The speed of movement or the load should be decreased if muscular discomfort is felt before 20 repetitions. The speed or load should be increased if the muscle is not fatigued within 30 repetitions in one set.
Exercises should be performed daily with progression until symptoms are gone and full load-bearing is achieved with sport-specific weights. As the resistance increases, a greater stress is placed on the tissues and recovery from training efforts may take longer than 24 hours [45]. This increase in recovery time may require a decrease in training frequency to three days per week [46]. It may take 2 to 16 weeks to achieve the goal of increased endurance (average six weeks). Reasons for failure or delay include incorrect diagnosis, insufficient energy availability, non-adherence, or improperly paced progression.
Cardiovascular endurance — The athlete's cardiovascular fitness should be maintained during rehabilitation [5]. Maintaining cardiovascular endurance helps to minimize the time away from sport. The athlete may return to sports without delay when the rehabilitation goals for the injured tissue have been met if cardiovascular endurance is maintained during rehabilitation.
Cardiovascular endurance can be maintained via cross-training (eg, aqua jogging, upper-extremity bikes, gait-unloading devices). Runners can maintain maximum oxygen consumption (VO2 max) and two-mile run performance similar to that achieved with running through cycling or aqua jogging [47].
Power — Power is the ability of muscle to exert a large amount of force at a fast rate [5,48,49]. Increased power requires increased strength or rate of muscle shortening.
To improve power with training, exercise should occur at 30 to 60 percent of maximum voluntary contraction (MVC). Training at 30 to 60 percent MVC increases both force and velocity (and thus power), whereas training at 100 percent MVC improves force, but not velocity [5].
Plyometric activities, which use the stretch-shortening cycle to get a greater force of contraction, increase power by requiring the muscle to change from eccentric to concentric action quickly [48-50]. They also may help develop reciprocal reflexes to help prevent injuries. A plyometric program should be performed two to three times per week to allow for soft-tissue repair but should be discontinued if pain or swelling occurs.
Practical examples of plyometric activities for lower- and upper-extremity injuries include:
●Lower-extremity injuries – Pilates machine (supine rebounder), mini-trampoline, platform-floor-platform jumping (4-inch platform increased 2 to 4 inches per week, up to 10 inches)
●Upper-extremity injuries – Plyoballs or medicine balls
The training consists of three to five sets of 15 to 20 repetitions. The intensity may be increased by turning 90 to 180 degrees in the air, including a slant board, or both.
Speed — The well-designed physical therapy regimen includes a progression of strength and endurance superimposed on a progression of speed. Speed is important for return to sports; it is one of the elements that compose agility. Muscular recruitment is specific by angle and speed, so training that occurs in a rehabilitation gym at 30 to 60 degrees/s will not fully prepare an athlete who performs sport-specific movements at ≥300 degrees/second [51]. Performing drills to regain coordination and muscle recruitment at sport-specific speeds should be included [5].
Agility — Agility is the ability to change directions of the body and its parts quickly [5]. It is a combination of reaction time, speed, coordination, power, and strength. Agility allows the athlete to avoid obstacles or contact with other players and thus to avoid injury.
Agility can be trained using figure-eight running, zigzag running, shuttle runs (repetitions of running back and forth between markers), carioca (running sideways with the legs crossing each other), retro-running (running backwards), and cross-over cutting. It is possible to progress the degree of difficulty by going from half speed to full speed and increasing the cutting angle from 45 to 90 degrees.
Sport-specific activities — Progression to sport-specific activities requires the athlete to possess power, speed, and agility [5,48,49]. The goal is to reacquire sport-specific motor memory patterns learned by thousands of repetitions. The regimen of sport-specific activities uses all the skills the athlete has gained in physical therapy to make the transition from clinical wellness to game readiness.
The criteria for the sport-specific activities phase include:
●Subjective assessment from therapist or trainer that the athlete can use the injured extremity well without symptoms.
●Athlete's demonstration of self-confidence to participate fully in sport-specific activities without experiencing pain, swelling, or giving way.
●Sport-specific movements of the affected region without mechanical deviations, substitutions, or compensations.
Specific tests can be used to assess the quality of performance including systematic screens such as functional movement screen [52], or individual functional tests including a single leg squat [53], jump-and-land movement [54], or hop tests [55] for lower extremity injuries. For upper extremity injuries throwing tests or dynamic push up tests can be used [56,57], the former for open chain athletes and the latter for closed kinetic chain athletes.
Sport-specific drills — The final phase of an athlete's physical therapy in order to return to sports is performance of sport-specific drills. These drills are akin to a practice regimen. There are several specific programs available for certain sports, such as throwing, tennis, and golf [18]. At this point in the rehabilitation, the athlete makes a return to unrestricted activities that should follow as a natural progression from functional rehabilitation, with the final step mimicking competition or performance conditions [5].
DISCHARGE CRITERIA — Before discharge from the functional rehabilitation physical therapy program, the athlete must meet certain criteria, including:
●Complete resolution of acute signs and symptoms related to injury. The strength and motion of the injured extremity must be within normative values for active age-matched individuals [58] or, where normative values are not available, equal to the uninvolved side extremity [22]
●Full, dynamic range of motion of all joints, with adequate strength and proprioception to perform expected skills successfully.
●No alteration of the normal sport-specific movement mechanics and free of known risk factors [54,59], which might otherwise predispose the athlete to subsequent injury.
●Performance of sport-specific activities at or above pre-injury level.
Post-rehabilitation goals — When the athlete has met the criteria for each phase, has met the discharge criteria, and is formally discharged from care, the treating practitioner should define the specifics of the sports program, such as number of exercise bouts per day or week, intensity level, repetitions/distance, and amount of rest. With the completion of a comprehensive, phase-dependent physical therapy regimen, the athlete can return to sports with confidence and yield excellent performance with minimal chance for reinjury.
SUMMARY AND RECOMMENDATIONS
●Phases of rehabilitation – Proper prescription of physical therapy is vital to the completion of healing and a timely return to sports participation without second injury. The phases of rehabilitation correspond to the phases of healing (see 'Overview' above):
•Inflammatory (0 to 72 hours after injury)
•Reparative (72 hours to 3 weeks after injury)
•Maturation (3 weeks to 2 years after injury)
●Inflammatory phase therapy – Management during the inflammatory phase focuses on PRICE (table 1) (see 'Inflammatory phase' above):
•Protection of the injured area
•Relative rest
•Decreasing swelling through Ice, Compression, and Elevation
We suggest cold therapy during the inflammatory phase of sports injuries (Grade 2C). Ice application should begin immediately postinjury. Ice packs (1 kg of ice and water in a plastic bag) should be applied directly to the skin for 20 minutes (either continuously or in two 10-minute sessions separated by a 10-minute break) at least three times per day. (See 'Cold therapy' above.)
We suggest not applying heat to injuries during the inflammatory phase of sports injury (Grade 2C). (See 'Heat' above.)
●Reparative phase therapy – The goals of physical therapy during the reparative phase are continued protection of the injured structures, full range of motion of the affected joints and soft tissues, Normal proprioception, and progression from basic muscular strength, to endurance, and finally power (table 3). (See 'Reparative phase' above.)
●Transition to maturation phase – During transition from the reparative phase to the maturation phase, it is important to meet clinical and functional testing criteria. Return to play decision-making should be an evaluative process that is based on objective criteria. (See 'Transition to maturation phase' above.)
Clinical and functional testing criteria for progression from the reparative phase to the maturation phase include adequate flexibility; proprioception; progression from basic muscular strength to muscular endurance, power, speed, and agility. The patient should also demonstrate performance of sport-specific skills without mechanical risk factors. (See 'Maturation goals' above.)
●Discharge criteria – Criteria for discharge from functional rehabilitation include all of the following (see 'Discharge criteria' above):
•Normal clinical exam, with normative strength values, and adequate dynamic proprioception to perform the sports-specific expected skills successfully
•Absence of known risk factors
•Performance of sport-specific activities at or above pre-injury level
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