Discussing The Return to Play Process with the LA Clippers Director of Rehabilitation
Let's talk about rehabilitation!
It’s been a while since I published an article to The Core, but suffice it to say that I have plans of writing here more frequently. While I’m working on future content, please enjoy my conversation with Dr. Maggie Bryant, a physical therapist and the Los Angeles Clippers’ Director of Rehabilitation, from a couple of summers ago. This article was originally published as the final component of a three-part series at AWolfAmongWolves.com and was approved for re-publication by Tim Faklis, the site’s Editor-in-Chief. (Full disclosure: I am the Managing Editor for AWAW.)
Return to play after an injury in professional sports is rarely discussed in depth. Conversations are often limited to discussing potential timelines and whether or not a player is “ahead of schedule” (my disdain for this phrase is probably worthy of a future article, but, for now, we’ll let the conversation end here).
So what, exactly, does the return to play process look like? Is it as simple as giving the injured structure time to heal, trying a few of the ever nebulous “basketball-related activities” during practice or before a game, and then heading back onto the court? Or is there more to it than that?
I spoke with Dr. Maggie Bryant, who is a physical therapist and the Director of Rehabilitation for the Los Angeles Clippers, to find out.
Let’s start with this basic question: What is “return to play”?
The question is simple enough, and while the answer may also seem straightforward, it does deserve to be laid out clearly. Return to play is strictly defined as the athlete resuming to participate consistently in their sport’s competition. This means that resuming play, in this case in the NBA, and then subsequently sustaining a re-injury or different injury would not qualify as a successful return to play; the player must be able to compete in games consistently, and ideally at their previous level of performance (i.e. their statistics pre- and post-injury are symmetrical).
The beginning stages of the return to play process often differ slightly depending on if the athlete suffered an injury that did or did not require surgery to correct.
If the injury did require surgery, such as an ACL or Achilles tendon rupture, the initial treatment modalities focus on addressing the athlete’s subsequent range of motion deficits, strength impairments, and swelling, while allowing for the repaired structure to heal. Various studies have demonstrated that the repaired tissue is weakest during the first six weeks or so post-op. However, that same window of time is critical for restoring range of motion and beginning to regain the strength that was lost during the operative process. But how exactly does one go about doing that?
According to Dr. Bryant, one treatment option often employed is personalized blood flow restriction therapy or BFR.
BFR therapy involves cutting off a majority of the arterial blood flow to the athlete’s injured extremity (up to 50% in the arm and 80% in the leg; 100% of the venous blood flow is restricted) and then completing various exercises at an intensity well below the athlete’s usual levels. To oversimplify the emerging science that is BFR therapy, the environment that is created within the athlete’s limb approximates anaerobic (i.e. without oxygen), which causes the athlete’s type 2 muscle fibers to be activated; these muscle fibers are usually recruited during high-intensity exercises and athletic movements such as squatting, jumping, or sprinting. In essence, personalized blood flow restriction therapy tricks the athlete’s body into believing that it is moving heavy loads, when, in actuality, the athlete is only lifting 20-30% of their one-repetition maximum.
Says Dr. Bryant, “A lot of the research shows that [personalized blood flow restriction therapy is] load-dependent, which is important if [the athlete] is early on post-op or with an injury [that requires that they don’t lift the] load they would if they were healthy; [in those situations I think BFR] is beneficial because it allows [the athletes to hit their] load threshold early, so you don’t necessarily have to [overload the recovering tissue] to still get the same benefit. You can still get the muscle to fatigue and the athlete’s body to respond like they’re giving max effort, but just with less load.”
This rehabilitation technique was adopted early by players such as former All-NBA center Dwight Howard and is currently utilized league-wide.
If the injury does not require surgical intervention, BFR may still be utilized, however, the research (as of now) seems to indicate that it isn’t as effective. Rather, early treatment modalities include stretching, massage, cryotherapy (i.e. ice or other cold substances/methods), manual therapy techniques, non-weight-bearing or low load aerobic conditioning (such as biking or jogging in a pool), and low-level strengthening.
The main goals of the early return to play process, whether non-op or post-op, is to normalize range of motion, decrease the athlete’s pain and swelling, and not cause further injury.
Once these goals have been accomplished, the aforementioned “basketball-related activities” begin. (Quick note: if the injury required surgery, the athlete is cleared to begin simpler activities such as light jogging, running, hopping, etc. prior to progressing to basketball-related activities). Basketball-specific activities can involve shooting hoops, completing defensive drills, performing lay-ups/dunks, and everything in between.
“What we do is…try to introduce them to basketball or to specific movements,” says Dr. Bryant. “[For example], you start with a lateral lunge; and then [you progress to] a lateral hop; and then you go into lateral hop repetition; and then you go to the court and you do some lateral movements; and then you do some change of direction; and then you do a high-speed change of direction; then you do one-on-one [drills] where you have the athlete on offense first so that they know, proactively, which way they’re going to move; and then you get them on defense where there are no other opponents, they’re just reacting to the one person; then you do three-on-three, so that there’s some movement with other people and, again, that’s offense-first defense second. So, you can kind of systematically [progress the player]…Get [the athlete] in specific movements and see what they can tolerate…You don’t really need specific tests as long as you’ve introduced them to whatever they need for that sport. You introduce them to whatever test or exercise is going to load that injury and you see their tolerance.”
If the player tolerates the progression well, they are often fully cleared to return to play. If they do not, they return to the steps prior to the activity that is giving them trouble and begin the cycle again.
It is important to mention that clearance to return to play involves input from a variety of sources and isn’t determined solely by the athletic training staff, medical staff, coach, or player. Dr. Bryant emphasized that appropriate communication between the player, coach, and medical staff is key and that the decision to clear a player for return to play is based on the opinions and viewpoints of all parties involved.
The tools available to the medical staff go a long way in helping to determine when a player is healthy enough and return to play is appropriate. Luckily for Dr. Bryant and rehabilitation specialists across the NBA, resources are rarely an issue.
“We use a lot of graph monitoring of load…Where I used to work we used ConnexOn, which is a GPS unit you put in the players’ shorts or jersey and then you can monitor the change of direction, acceleration-deceleration, and vertical displacement. You can also get intensity through that, so that’s pretty helpful. We also use IMU (inertial measurement units), which you can put on [the players’] shins and that can be more specific to some bone loads for, like, stress [injuries] or fracture. [The IMU] can tell you how many displacements are on that specific leg and if there are any asymmetries during practice or during their workout. You can get high, moderate, or low intensity with that as well…We use a lot of force plates. We’ll do preseason force plate assessments, we’ll do mid-season assessments. You can get a lot of different measures on that. You can get some hop testing, rate of force development, torque, and then you can [monitor those measurements] throughout their rehab. Other than that we use the standard exercise and manual [therapy]. We have an AlterG treadmill, we have a HydroWorx underground treadmill, a running treadmill. We are lucky in that we pretty much have whatever we need at our fingertips. Whatever we don’t have, we can either argue to buy or just find it elsewhere. But I don’t think you need all that to [provide quality rehabilitation]. I mean, a handheld dynamometer you can use for strength [monitoring]; you can use that early on to get an [isometric strength measure], you can use that for concentric/eccentric [strength measurements], a bunch of different things. So, you don’t necessarily need the really, really high technology, but it is helpful.”
In summary, the return to play process is systematic and involves input from a number of sources, including the athlete. No one person is in charge of determining when an athlete is appropriate for return to play, rather it is based on objective data gathered throughout the process as well as viewpoints from the player, athletic training, medical, and coaching staffs.
Putting it succinctly, Dr. Bryant described the return to play process as such, “As long as you know the injury, you know the [deficits that need to be addressed]…The return to sport phase should be dictated by what you’ve been doing the last however many months or weeks. Rehab should be the return to sport. Everything you do should be to return them [to sport].”