Application and benefits during rehab. Blood flow restriction (BFR) training involves restricting the blood flow to working muscles during exercise, resulting in hypoxia in the muscle tissue. It can be applied to both resistance and aerobic exercise; however, the purpose of this blog is to have a look at the potential benefits of using BFR during resistance-based exercise in rehab. BFR resistance training has been shown to help increase muscle size and strength in young, old and load compromised populations (including post ACL replacement surgery and people suffering from OA). The greatest benefits of BFR training have been shown to occur during low-load resistance exercise, with some studies showing that muscle hypertrophy and strength adaptions using BFR are significantly greater than those achieved with low load resistance exercise alone. Benefits of BFR during rehab After sustaining an injury or having surgery, people will often struggle tolerating heavy loads through the affected area, which can cause an increase in pain during activity, reduce function and impact rehab and recovery timeframes. During rehab for any type of injury, it is important to load and strengthen the muscles around the injured or painful structure, however pain (and injury) can often prevent a person from being able to perform the required exercises (or tolerate the required load during exercise) to actually achieve this increase in strength, which can often lead to slow progression during rehab. This is where BFR training can be beneficial. BFR training can be used to get the most out of low-load resistance training for load compromised people who can’t tolerate heavy-load training during the early stages of rehab. Applying BFR training to rehab As mentioned above, BFR training can be a useful tool when trying to maximise the impact of low-load exercise during rehab. This can often be beneficial when pain/injury is impacting the ability to appropriately load the injured area in order to elicit a change in symptoms. A good example of this presentation in the clinic is during rehab following a patella dislocation or subluxation. The sensitivity and reduced capacity to load the patellofemoral joint after this type of injury can make it hard to perform quadriceps strengthening exercises with adequate load to elicit a meaningful change in strength, which can lead to the development of compensatory strategies and slow progression during rehab. BFR can be used to help overcome this hurdle. Have a look at our Instagram here to see an example of a rehab session using BFR for a client who suffered a patella dislocation. There are many other types of pain/injury that could benefit from the use of BFR at certain stages of rehab, such as managing OA pain and when recovering from ACL replacement surgery. Overall, BFR can be a useful tool to use during certain stages of rehab; but just like all aspects of rehab there is no ‘one size fits all’ approach, so get in contact in you would like to discuss if BFR could be useful for you. Reference for information Hughes L, Paton B, Rosenblatt B, Gissane C, Patterson SD. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Br J Sports Med. 2017 Jul;51(13):1003-1011. doi: 10.1136/bjsports-2016-097071. Epub 2017 Mar 4. PMID: 28259850.

Syndesmosis injuries, also known as high ankle sprains, are a type of injury that occurs in the ankle joint. Unlike traditional ankle sprains, which affect the ligaments on the outside of the ankle, syndesmosis injuries involve the ligaments that connect the tibia and fibula bones in the lower leg. These ligaments are known as the syndesmotic ligaments, and they help to stabilise the ankle joint during movement. Symptoms of syndesmosis injuries can include pain, swelling, and tenderness on the front of the ankle. The pain is often located above the ankle joint and can be severe, especially during weight-bearing activities. In more severe cases, the individual may experience difficulty bearing weight on the affected leg and may have limited mobility in the ankle joint. Syndesmosis injuries are often caused by a twisting or rolling motion of the ankle, which can occur during sports or other physical activities. They can also be caused by a fall or other trauma to the ankle joint. Individuals who participate in sports that involve jumping, cutting, or pivoting movements are at higher risk for syndesmosis injuries. Diagnosis of syndesmosis injuries usually involves a physical examination of the ankle joint, as well as imaging tests such as X-rays or MRI scans. The following is an example of a sports rehab program for an individual recovering from a syndesmosis injury: Phase 1: Acute Phase (1-2 weeks)  Rest, ice, compression, and elevation to manage pain and swelling Non-weight bearing with the use of crutches Gentle range of motion exercises such as ankle circles and ankle pumps Isometric exercises for ankle strengthening Phase 2: Sub-Acute Phase (2-4 weeks) Weight-bearing as tolerated Active range of motion exercises such as calf loading and calf raises Strengthening exercises such as calf raises, single leg balance exercises and posterior chain loading Manual therapy techniques such as soft tissue massage and joint mobilisation Sport-specific training Phase 3: Functional Phase (4-6 weeks) Plyometric exercises to improve power and agility Sport-specific drills to improve coordination and balance Proprioception and balance training Advanced strengthening exercises such as squats, lunges, and lateral movements Return to sport or activity with gradual progression and careful monitoring It is important to note that every individual's rehab program will be different and will depend on the severity of their injury, as well as their overall health and fitness level. It is recommended to work closely with a qualified physiotherapist to ensure a safe and effective rehab program that is tailored to your specific needs and goals. A systematic review published in the British Journal of Sports Medicine in 2019 found that early functional rehabilitation, which includes range of motion, strength, and proprioception exercises, can lead to better outcomes and faster return to sport for individuals with syndesmosis injuries compared to immobilization or surgery alone. Another study published in the Journal of Orthopaedic Surgery and Research in 2019 found that a structured rehabilitation program that included progressive weight-bearing, range of motion, and strength exercises resulted in significant improvements in pain, function, and ankle range of motion for individuals with syndesmosis injuries. In summary, syndesmosis injuries are a type of ankle injury that can be caused by a variety of factors. Prompt diagnosis and treatment are important for a successful recovery, and rehabilitation programs can help individuals return to their normal activities safely and effectively. By taking steps to prevent ankle injuries in general, individuals can reduce their risk of experiencing a syndesmosis injury and maintain good overall ankle health.

Injuring your ACL can be overwhelming, often you will be deliberating whether or not to get surgery while coming to terms with the long rehab process ahead. This blog will shed a bit of light on something that everyone should be doing after sustaining an ACL injury; Prehab. What is ACL Prehab? ACL Prehab is what is done between tearing your ACL and having surgery/performing rehab. It is the term used for the exercises and training that needs to be performed after sustaining an ACL injury and should be performed even if you are considering not having surgery. What does ACL Prehab involve? Prehab involves a block of supervised exercise sessions with a focus on lower body strengthening (particularly the quadriceps and hamstrings), knee mobility and stability/motor control. The timeframes and specific types of exercise will vary between different people, but the goal of prehab remains the same; maximise the chance of returning to your pre-injury level of activity and staying there. Why is Prehab so important? Performing a 5-week block of prehab training has been shown to increase the chance of returning to your pre-injury level of sport following an ACL replacement, it has also been shown to significantly improve knee function after ACL injury, regardless of whether you decide to have surgery or not (Eitzen et al, 2010). Prehab also provides a great opportunity to perform some strength and hop testing, which will be used later in rehab. This testing will provide a good comparison for leg strength and function prior to returning to sport, doing this has been shown to help reduce the risk of reinjury by up to 75% (Capin et al, 2019). The take home message. A short block of Prehab has been shown to have a great impact on knee function after ACL injury and will increase the chances of having a good recovery and returning to your chosen sport or activity, regardless of whether or not you require surgery. Everyone who suffers an ACL injury should perform some amount of Prehab; if you have recently injured your ACL and would like to have a chat about Prehab, then get in touch….

“You have torn your ACL”, the dreaded words that no sportsperson or weekend warrior wants to hear. The Anterior Cruciate Ligament (ACL) is the most important stabilising structure within the knee joint, most commonly injured through either a contact (eg being tackle) or non-contact (change of direction) mechanism. The classic symptoms are often reported to be hearing/feeling a pop in the knee joint, immediate swelling, and pain as well as feelings of instability. Typically, hands on clinical assessments are very good at diagnosing an ACL rupture, however, imaging such as MRI is often used to assess whether there are any secondary injuries to other structures within the knee which may impact management. We are so used to hearing about ACL injuries being season ending events reported within most sports media outlets, with many athletes going on to have around a 9–12-month rehabilitation before returning to sport. It was widely accepted at one time that there are only 2 options for rehabilitation when someone has torn their ACL, either to have surgical reconstruction of the ACL ligament, using either a hamstring or patella tendon graft, or conservatively managing without an intact ligament through strengthening the muscles around the knee to provide stability. However, there have been recent studies which have shown some spontaneous healing of ACLs on MRI imaging in patients who have undertaken conservative rehabilitation (Costa-Paz et al. 2012, Filbay et al. 2022) So, it begs the question, surgical or conservative management? Well, what if there was a 3rd option? The Cross Bracing Protocol Exciting new findings were presented by Dr Tom Cross, a local Sydney Sports Physician, during a lecture held by the Australian Physiotherapy Association exploring the utilisation of a novel bracing protocol to promote natural healing of the ACL. The protocol is described as 4 weeks in a Range of Motion brace locked at 90 degrees of knee bend, with the next 8 weeks the brace slowly being let out to full knee extension. The reason for this is that by placing the knee in that position, it allows for the greatest chance for the two torn ends of the ACL to be aligned as closely as possible and hopefully lead to healing. Dr Cross’ preliminary work has shown that by following this protocol, 82 out of 84 patients demonstrated a healed ACL at 6 months post injury. Whilst there are many factors that go into which patients are offered the protocol and which have the greatest chance of healing, this case series demonstrates that there is an ability for the ACL to be able to heal on its own. This would allow for patients to be able to avoid possible risks of surgery, such as infection, whilst also having an intact ACL which would arguably allow them to return to sport in a quicker time frame. If you currently have an ACL injury or any knee injury which requires rehabilitation, you can book online via the website or chat to our friendly staff on 9194 1800 to book a detailed initial assessment and management plan to get you back to doing the things you love! References: Costa-Paz, Ayerza, M. A., Tanoira, I., Astoul, J., & Muscolo, D. L. (2011). Spontaneous Healing in Complete ACL Ruptures: A Clinical and MRI Study. Clinical Orthopaedics and Related Research, 470(4), 979–985. https://doi.org/10.1007/s11999-011-1933-8 Filbay, Roemer, F., Lohmander, S., Turkiewicz, A., Roos, E. M., Frobell, R., & Englund, M. (2022). 32 Spontaneous healing of the ruptured anterior cruciate ligament: observations from the KANON trial. BMJ Open Sport & Exercise Medicine, 8(Suppl 1), A3–A3. https://doi.org/10.1136/bmjsem-2022-sportskongres.

With the start of the sporting season upon us, it’s not surprising to see more people out and about, going for a jog around Sydney Park or beginning their community sporting endeavours with the local soccer or footy club. Unlike professional sports stars however, much of the general population who like to play organised sport don’t have the luxury of having a preseason and an ability to reintroduce the body to the loads that they will be experiencing during the season. Due to this, many people may begin to experience niggling injuries in the hamstrings and calves, knees, ankles and groins when they begin their training. If ignored, these may turn into a more serious or chronic injury during the season and prevent you from playing the sport you love! Can niggles prevent me playing my chosen sport? To demonstrate this point further, a recent study published in 2020, which looked at whether injuries that do not result in time away from sport (i.e. niggles) increase the risk of someone suffering a time-loss injury where they are unable to complete their sport for a period of time. The study looked at 218 semi-professional football players in NSW, all participating in at least 3 football-based sessions per week (for example 2 trainings and 1 game). They completed screening questionnaires at every training session and game day over a 35-week period, which was designed to pick up on time-loss and non-time loss injuries respectively. So, what did they find? Over the 35-week observation period, the researchers found that within the test subjects, time-loss injury risk was 3-6x higher when a non-time loss injury (niggle) was reported in the past 7 days. As well as this, 33% of participants reported some kind of injury, whether it was a time-loss or non-time loss injury, each week. What does this mean? The most important message from this study is to listen to your body! Think of a niggle as an early warning sign from the body telling you that you are potentially at risk of having a bigger injury. Our advice – Nip it in the bud! What should I do if I get a “niggle”? Come and see us! Our friendly team at Alexandria Physiotherapy and Sports Injury are here to help! Our physiotherapists will listen to your story as well as perform a comprehensive physical assessment to diagnose your injury. Following this, we will work with you to design a tailored rehabilitation program to get you back to doing what you love better than ever! Reference: Matthew Whalan, Ric Lovell & John A Sampson (2020) Do Niggles Matter? – Increased injury risk following physical complaints in football (soccer), Science and Medicine in Football, 4:3, 216-224, DOI: 10.1080/24733938.2019.1705996

1. Back and neck pain is more present than ever As Physiotherapists, we often see clients who present with back and neck complaints, however in the last 18 months it has been rife. Most Physiotherapists would agree that neck and back issues have been the common trend during the pandemic, with many clients attributing their symptoms to changes to their working environment. Most of these complaints are musculoskeletal in nature and we’ve learnt that there is several variables that are attributing to such increases. You’ve been working in an office job for several years without issues and are now experiencing more pain than ever – why is that? Is it because you are working from home without an ergonomic office chair or sit-stand desk, or is it more complicated than that? My take away message – keep reading! 2. Your posture may not be the main cause Have you been spending more time working from the couch or the kitchen bench and noticing that you’re slumping more than ever? Is this the reason for your pain? What if I told you that it isn’t about the posture, but more about the fact that you’re spending too long in that static position. The longer you spend in that posture, the less time you’re moving. I’ve never been and will never be a Physio to promote the ‘perfect posture’ of sitting up tall with your shoulders and neck back. What I do promote however is an ‘ever-changing posture’ – one that promotes lots of breaks, differences in movement patterns and avoiding long static positions. If I sat for 8+ hours a day hunched over my desk and didn’t change my position, of course I’d have aches and pain. However, if I sat for 8+ hours, upright and my shoulders and neck back in the ‘perfect posture’ and didn’t change my position, I’d still have aches and pains. My take away message – it is fine to have ‘poor posture’ just as much as it is to have ‘perfect posture’, but as long as you aren’t spending too long in either position. 3. A lack of incidental exercise is the main problem With our exercise routines taking a shake up in the last 18 months, we’ve had to come up with new ways to keep active. All you have to do is look at your local park or walking track to see more people running, walking their dogs or performing 1 on 1 PT sessions. Despite this, the incidental exercise that we’d normally complete in our day to day lives have been greatly impacted. The walk or ride to the train station, the walk to get your local cafe or browsing shops in your lunch break – all of which have become a distant memory for most throughout lockdown. It is this type of movement that increases your daily exercise volume and promotes constant movement. My take away message – movement is medicine & this is the best way to prevent a several aches and pains! 4. Slow and steady wins the race With the closure of gyms, a lot of us have taken up running. But for many, running is a new form of exercise that we don’t have much experience doing. We’ve seen a large proportion of clients go from running very little to running high weekly volumes in a short period of time. Four to six weeks later, I’m seeing the presentation of lots of knee and heel pain and people are wondering why? Similar to an increases in neck and back pain, tendon overload issues (i.e. tendinopathies) have also increased. This is an overuse injury that occurs when the load placed on the tendon exceeds the capacity it can withstand. In short – you haven’t prepared your muscle to be able to cope with the amount of running volume in such a short period of time. My take away message – don’t listen to Drake and go “ 0 to 100 real quick”. 5. It’s a different world we live in! We are living in an unprecedented situation and going forward, the world will be a very different place. We must adapt, learn and move forward as better versions of ourselves. Never under-estimate the impact that mental health has on our physical health. The last 18 months have been a challenging time psychologically and many have experienced immense amounts of pressure and grief. My take away message – remember to check in on the wellbeing of family and friends and we will get through this together!

The hip adductors, commonly referred to as your Groin muscles, are a group of muscles which lie on the inside of your femur (leg bone) and move your leg inwards across your body. They originate from your pubic bone then migrate along the inside of your leg inserting at various point along your inner thigh and leg. There can be numerous causes of groin pain from musculotendinous , neurological and internal bony and cartilage structures in the pelvic region. This can make differentiating between diagnoses extremely difficult due to the overlapping nature of various pathologies. Groin pain pathologies can include adductor tendinopathies, osteitis pubis (pelvic overload syndrome), sports or inguinal hernia, iliopsoas bursitis, stress fracture, avulsion fracture, nerve compression, snapping hip syndrome, and others. What is known however, is that adductor related pain or injuries are one of the most common cause of injury in team sports such as football, with one of the main risk factors being low strength levels of the associated musculature. Muscle synergy and balance around the pelvic region is also extremely important as evidenced by one study which found athletes were 17 times more likely to sustain an adductor muscle strain if their adductor strength was less than 80% of their abductor (gluteus medius, gluteus minimus, and tensor fasciae latae) strength. TENDINOPATHY: One of the common adductor pathologies that is prevalent in athletes and weekend warriors alike is adductor tendinopathy. As with any other tendinopathy, it is non-inflammatory damage to a muscle tendon resulting from a failure to adapt to loading – primarily due to a rapid increase in intensity, frequency or duration of training with insufficient time to recover. This leads to a reduction in the load bearing capacity of the tendon and result in pain and weakness with movements around the hip. Due to the diverse nature of intrinsic, extrinsic and environmental factors that can lead to a tendinopathy of the adductors, different treatment interventions are required that take into account the specific mechanisms of injury. PHYSIOTHERAPY MANAGEMENT With Adductor Tendinopathies, passive treatments such as stretching, massage, mobilisations and cryotherapy may alleviate symptoms in the short term, but they do little to rectify the problem or safeguard against further damage or degeneration. The focus of treatment should be on load management, strengthening and behaviour management. Recovery can vary greatly between individuals depending on the level or stage of degeneration in the tendon. In recent years, glute exercises have been given all the attention when it comes to athletic development and rehabilitation. Little attention however is paid to the adductors beyond the old “stretch your groin” advice. Adductor strengthening is an essential component of athletic performance and developing single leg control/ stability. The added benefit of adductor exercises is injury prevention for the groin, especially when the sport involves sprinting, cutting or changing direction quickly. A Copenhagen Side Plank like the one below can help reduce the risk of groin strains. The aim of rehabilitation should be to restore muscle and tendon properties. Strength training is proven to be beneficial to the tendon matrix structure, muscle properties and limb biomechanics. There is some disagreement on the most appropriate type of strength training in rehabilitation with respect to isometric, eccentric and isotonic loadings. Previously, evidence has suggested that an eccentric (loading whilst lengthening the muscle) based exercise programme is the most effective exercise for improving both pain and function in the tendon. More recently however, heavy isometrics (resisting load, but without movement) are showing to be more effective in the early stages of degeneration or in the acute injury stage. What is certain however, is that tailoring the type of exercise to the athlete’s specific sport and training load based on their relative pain tolerance is extremely effective in the rehabilitation of tendinopathies.  Consult our fantastic team at Alexandria Physio for a detailed assessment and a tailored tendon rehabilitation program. IMPORTANT POINTS TO NOTE: Complete rest may alleviate symptoms but will not rectify the tendon issue. Relative rest in the form of load management is the most appropriate intervention with a guide of no more than 3/10 pain for activity which is achieved through altering speed, distance, intensity and frequency of training. Strengthening abdominal core muscles is also recommended to support the adductors during activity as well as hip flexor exercises. In acute cases, a return to a normal function can be within in a few weeks, but in more chronic cases, rehabilitation can take a number of months before returning to normal, pain free, activities. To prevent the development of adductor tendinopathy, an athlete should ideally engage in a strength and conditioning programme to work on the factors mentioned, such as improving strength and coordination of the muscles, but allowing sufficient periods of recovery and adaptation in between training sessions, i.e. not too much training too soon. When all else fails, and despite your best attempts to rehabilitate the injury , surgery may be the appropriate course of action if symptoms persist or deteriorate, and for those for those who are prone to recurrent tears. Keep your eye out for our upcoming blog on surgery and rehabilitation for chronic adductor tendinopathy.

A question we are often asked is whether you should get a scan on your knee. Despite there being numerous times where a knee scan can be beneficial to assist with further investigation – is it always required? An interesting article was published in 2020 which looked at identifying how common it is to display abnormalities in individuals without knee pain. The results are interesting and can help provide some great insight into how/why a scan does not always correlate to pain. In the study, 230 knees of 115 uninjured and asymptomatic sedentary adults were scanned using a high powered MRI machine. Of this cohort, there were 51 males and 64 females, with a median age of 44 years. All participants had both knees scanned. Two senior musculoskeletal radiologists assessed the scans and graded all intraarticular knee structures using validated scoring systems. The Results 97% of the knees scanned displayed abnormalities!! (227 of the 230 knees) This was broken down into the following abnormalities: 33% – Meniscal Tears (Horizontal 23%, Complex 3%, Vertical 2% & Bucket Handle 1%) 57% – Cartilage abnormalities at the patellofemoral joint 48% – Bone Marrow Abnormalities at the patellofemoral joint 19% – Moderate Cartilage lesions and bone marrow oedema 31% – Severe Cartilage lesions and bone marrow oedema 21% – Tendon Lesions (Patella Tendonitis accounted for 11%) 3% – Partial Ligament Tears (ACL Partial Tears accounted for 2%) So, what does this mean? You are not your scan! A scan does not always correlate to the pain you are experiencing, and the results have been mirrored in other parts of the body across numerous other research articles. As Physiotherapists , we always aim to listen to your story and your history, assess your biomechanics and functional assessment before we look at your scans. And even though you will likely have some changes on your scan, this doesn’t mean that you can’t return to full, pain-free function. If you are unsure of your scan findings, have knee pain or need some further advice – be sure to get in contact with our team at Alexandria Physiotherapy. Reference: Horga, L. M., Hirschmann, A. C., Henckel, J., Fotiadou, A., Di Laura, A., Torlasco, C., D’Silva, A., Sharma, S., Moon, J. C., & Hart, A. J. (2020). Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal radiology, 49(7), 1099–1107.

Immediate Management of Soft Tissue Injuries- PEACE and LOVE Common and well-known principles of soft tissue injury management include principles such as RICE and POLICE , but there is so much more complexity to the management and rehabilitation of soft tissue injuries. These well-known methods focus on the acute management of soft tissue injuries and do not really provide any information on the sub-acute and chronic stages of soft tissue healing . However, the British Journal of Sports Medicine has spent much time studying the literature and they now suggest the use of these two new acronyms to optimise recovery. P.E.A.C.E. for initial injury management and L.O.V.E. for subsequent management. PEACE PROTECT Unload or restrict movement in the area for 1 to 3 days. This may require the use of crutches for a leg injury, or a sling for the arm. this reduces bleeding minimises further damage reduces risk of aggravating injury Let pain guide removal of protection and gradual reloading ELEVATE Elevate the injured area above the level of your heart to reduce swelling. this promotes fluid flow out of the injured tissue although poor evidence for it – it still is recommended as there is a low risk-benefit ratio AVOID ANTI INFLAMMATORIES During the acute phase anti-inflammatories can inhibit tissue repair. Simple analgesics like paracetamol can be used for pain relief. Optimal soft tissue regeneration is supported by the various phases of the inflammatory process. Making use of medications to inhibit the inflammatory process could impair the healing process AVOID ICE use of ice is mostly analgesic although it is widely accepted as an intervention there is very little high quality evidence that supports the use of ice in the treatment of soft tissue injuries COMPRESS External mechanical compression with a brace, bandage or taping can reduce local swelling and prevent further bleeding within the injured tissues. EDUCATION Speak with your physical therapist about the injury and get a guideline for recovery and a therapy plan. Set goals about recovery times and expectations. Understand that restrictions for loading the injured area is only a temporary protective measure for the first 2 to 3 days. There are many benefits of an active approach to recovery instead of a passive approach Patients need to have a better understanding of their condition. This is achieved through consultation with your physiotherapist to set realistic expectations and recovery times LOVE “After the first days have passed, soft tissues need LOVE” LOAD An active approach, with movement and exercise, benefits most injuries. Loading or stressing the joint or muscle (essentially making it work) within the limits of pain early on, actually promotes healing and stimulates tissue repair. Optimal loading without increasing pain promotes repair and remodelling builds tissue tolerance and capacity of tendons, muscles and ligaments OPTIMISM The brain plays a significant part in rehabilitation interventions. Science has shown that depression, fear and catastrophising about an injury and the recovery, can actually result in worse outcomes and a worse prognosis. Stay realistic but optimistic to improve the chances of optimal recovery. VASCULARISATION This is a fancy word for improved blood supply to an area. Better blood flow means more oxygen and nutrients to the injured tissue which ensures good healing. Moving and working the joint or muscle and exercising the tissues around the area will increase blood flow to the injured site Pain free cardiovascular activity is a motivation booster and it increases blood flow to injured structures Benefits of early mobilisation and aerobic exercise in people with musculoskeletal disorders include: improvement in function improvement in work status reduces the need for pain medication EXERCISE Controlled exercise, within pain limits, is key from the beginning of your recovery. Restoring mobility and building strength will speed up your recovery and help prevent a recurrent injury Evidence supports the use of exercise therapy in the treatment of ankle sprains and it reduces the risk of a recurring injury Benefits of exercise: restores mobility restores strength restores proprioception, early after an injury Avoid pain to promote optimal repair in the subacute phase Use pain as a guide to progress exercises gradually to increased levels of difficulty The management of soft tissue injuries , whether it is a hamstring strain or an ankle sprain, should not just focus on short-term damage control. Rehabilitation should also focus on long-term outcomes and management.