Rehabilitation procedures: progressive mobilisation, graduated exercise (stretching, conditioning, total body fitness), training, use of heat and cold; return-to-play indicators including pain-free, full range of motion, full strength, peak performance level, specific warm-up, sport-specific skills and tests

Rehabilitation is the bridge between acute injury and full return to sport. Done well it produces an athlete who is at least as resilient as before the injury; done badly it produces re-injury, chronic pain, and premature retirement. This dot point covers the rehabilitation phases and the return-to-play indicators the syllabus expects.

The phases of rehabilitation

The standard framework moves the athlete from acute management through progressive loading to full return.

Phase 1: Acute (0-72 hours)

RICER and no HARM, as covered in the injury management dot point. The focus is limiting secondary tissue damage and managing pain and swelling.

Phase 2: Sub-acute / progressive mobilisation (3 days to 2 weeks)

Once acute inflammation has settled, gentle, progressive movement begins. The principle is to restore function without overloading healing tissue.

Progressive mobilisation means starting with passive movement (the therapist moves the limb), progressing to active assisted movement (the athlete moves with help), then to active movement (athlete moves under their own power), then to resisted movement (against resistance).

For an ankle sprain, this looks like:

• Days 3-5. Gentle passive ankle circles, ABCs (tracing the alphabet with the foot).
• Days 5-10. Active flexion and extension against gravity only.
• Days 7-14. Progressively loaded resistance band exercises.
• Week 2 onwards. Single-leg balance, controlled hopping.

Phase 3: Graduated exercise (1-6 weeks depending on severity)

Progressive loading of the injured area through:

• Stretching. Restoring full range of motion at the joint.
• Conditioning. Building the strength and endurance of the injured area back to pre-injury levels.
• Total body fitness. Maintaining cardiovascular and strength fitness of the rest of the body (a runner with a hamstring strain can swim or cycle).

This phase is where most rehabilitation programs spend the bulk of their time. The challenge is progressing fast enough to maintain athlete motivation and full-body fitness, but slow enough to allow tissue healing.

Phase 4: Training and sport-specific work (2-12 weeks)

The injured athlete progresses from gym-based rehabilitation to sport-specific training.

• Sport-specific movement patterns at low intensity.
• Skill drills.
• Practice in non-contact or controlled environments.
• Progression to full training.

For an AFL footballer recovering from a hamstring strain, this might look like: jogging laps, then progressive running speeds, then change of direction work, then 1-on-1 marking drills, then full training without contact, then full training with contact, then a return-to-play match.

Phase 5: Return to competition

Full return to competition. Often staged - a return match at sub-elite level or a half-game at elite level before full participation.

Use of heat and cold

Heat and cold both have a place in rehabilitation, but in different phases.

Cold (cryotherapy)

Acute phase (first 72 hours)

Reduces swelling and pain through vasoconstriction and analgesic effect. Already covered in RICER.

Post-acute, post-training in rehabilitation

Used to manage inflammation after exercise sessions that load healing tissue. A 10-15 minute ice bath after a rehabilitation session can reduce soreness and inflammatory response.

Caution

Repeated cryotherapy during long-term adaptation can blunt some tissue remodelling signals. Use it for managing flare-ups, not after every session.

Heat

After the acute phase (72+ hours). Heat increases blood flow to the area, which supports healing, relaxes tissues, and reduces stiffness.

Methods:

• Heat packs (wheat bags, gel packs).
• Hot water immersion (hot bath, hot tub).
• Liniments and topical heat creams.
• Ultrasound and other diathermy. Therapeutic ultrasound delivers heat at depth.

Caution. Heat is contraindicated in the acute phase (it increases swelling) and in cases of active infection.

Contrast therapy

Alternating heat and cold (often 60 seconds each, 5-10 cycles). Used in some rehabilitation programs to promote circulation. Evidence is mixed but the practice is widespread, particularly post-training during heavy rehabilitation phases.

Return-to-play indicators

The decision to return an athlete to competition should not be based on a calendar. It should be based on whether the athlete meets specific criteria. The syllabus expects you to know these indicators.

Pain-free

The athlete should be pain-free during normal daily activity, during specific exercises, and at rest. Pain during sport-specific movement indicates the tissue is not ready. Some discomfort during the acute return is acceptable; sharp or worsening pain is not.

Full range of motion

The injured joint should have range of motion equivalent to the uninjured side. A knee that flexes to 130° on the uninjured side should flex to 130° (or within 5°) on the injured side. A 10-15° deficit is a return-to-play red flag.

Full strength

The injured area should have strength equivalent to the uninjured side (within 10%, ideally within 5%). Strength is measured with a handheld dynamometer, isokinetic testing, or functional tests (1-leg hop tests, etc.).

For a hamstring strain, the athlete should be able to:

• Perform isometric hamstring contractions with no pain at maximum effort.
• Hold the prone leg curl position symmetrically.
• Hit equivalent peak torque to the uninjured leg on isokinetic testing.

Peak performance level

The athlete should be performing at peak (pre-injury) level on sport-specific tests. A 100m sprinter should be running times within 5% of pre-injury best. A footballer should be hitting expected distance, intensity, and skill metrics.

Specific warm-up

The athlete should be able to complete a sport-specific warm-up at full intensity without any return of symptoms. The warm-up itself is the final stress test before competition.

Sport-specific skills and tests

Functional tests that mimic the demands of the sport. Examples:

• Single-leg hop tests (in 3 directions) for lower-limb injuries. Compared to the uninjured side.
• Y-balance test for proprioception and stability.
• Sport-specific functional tests. A return-to-play soccer test might include sprinting, change of direction, kicking with both feet, jumping, and tackling.

The athlete passes return-to-play when they meet all the criteria. Failing any of them means continuing rehabilitation, not returning.

Why return-to-play matters

Re-injury rates within the first month of return are substantial across many sports (the highest in hamstring injuries, around 20-30% re-injury within 6 weeks in amateur sport). The single largest driver of re-injury is returning too early.

The economic and personal cost of re-injury is substantial - longer time off, deeper rehabilitation, often surgical intervention for what would have been conservative management if the first injury had been managed properly.

Elite sport uses formal return-to-play protocols. Recreational and school sport often does not, which is why HSC PDHPE devotes significant attention to the indicators.

How to use this dot point in extended responses

A typical HSC question is "Describe the rehabilitation process for a specific sports injury and explain the return-to-play indicators". Strong responses:

1. Pick a specific injury (hamstring strain, ankle sprain, ACL reconstruction).
2. Walk through all five phases in order with timeframes.
3. Address heat and cold in the appropriate phases.
4. Cover all six return-to-play indicators.
5. Connect the indicators to the consequences of skipping them (re-injury rates).