Considerations and Guidelines for Return to Sport for the Postpartum Athlete (Part 2)

Considerations and Guidelines for Return to Sport for the Postpartum Athlete (Part 2)

by Kelby Howell, SPT

April 12, 2024

Returning to Sport

 

        With high impact sports that require running, jumping, leaping or hopping, postpartum athletes may have difficulty returning to sport without symptoms of pelvic floor dysfunction. It’s important to consider that these symptoms may not resolve on their own, and if you are experiencing these issues to consider medical care.


Reminders for the Rehab Team When Working With Athletes

  • Athletes are highly motivated and generally want to get back to sport as quickly as possible & may disregard their symptoms – be on the lookout for warning signs of pelvic floor dysfunction.
  • Athletes are competitive & may compare themselves to other postpartum athletes
  • Lack of sports participation may increase symptoms of postpartum depression

Risk Factors for Return to Sport

  • Mindset of the athlete– are they ready to return to sport?
  • Tissue healing time– are their incisions or wounds fully healed?
  • Postpartum athletes are at an increased risk for stress fractures after returning to
    high-volume training
  • Breastfeeding can impact the recovery process and bone integrity
  • Relative Energy Deficiency in Sport (RED-S) and mental health
    • RED-S: Relative Energy Deficiency in Sport is caused by a lack of sufficient
      caloric intake as compared to one’s energy expenditure. RED-S can result in
      impaired metabolic rate, impaired menstruation, deficits in bone integrity and
      immunity, impaired protein synthesis and impaired cardiovascular health.
      Postpartum athletes should consult with their primary care provider and
      registered dietitian or nutritionist for how to best avoid developing RED-S during
      training.

Assessment for Return to Sport
When determining if a postpartum athlete is ready to return to sport, this successive testing can be implemented to help with the assessment. Can the athlete:

  • Walk for 30 mins
  • SL balance for 10 seconds
  • 10 reps of a SL squat on each leg
  • Jog in place for 1 minute
  • Forward bounds for 10 reps
  • Single leg hop in place for 10 reps

Without an increase in pelvic floor dysfunction symptoms? If she can pass through these
without an increase in symptoms, then the workload can progressively be increased until she is ready to go back to her sport.


Below is a general protocol recommended by Selman et al. for the postpartum athlete
immediately following delivery through the fourth trimester. It is crucial to remember that
protocols are guidelines and are not rules.

 

General Protocol For Return to Sport Per Selman et al.

TimeframeGoals & Example Criterion
Weeks 0-2 Postpartum
  • Body mechanics education,
  • Anterior/posterior tilting,
  • Diaphragmatic breathing,
  • Light open kinetic chain movements to mimic walking
Weeks 3-4 Postpartum
  • Short duration walking (<15 mins) that can progress as tolerated
  • Transverse Abdominis sets 20x 5 secs in supine, side lying and quadruped
  • Double leg bridges 30x 5 secs
  • Contract relax kegels for 5 secs
Weeks 5-6 Postpartum
  • Increase walking program duration (<30 mins) symptom-free
  • Muscular endurance tasks (15-30 reps) with <10# resistance
  • Contract relax kegels for 10 secs
  • Long hold kegels for 10 secs
  • Clamshells, reverse clamshells, standing march/hip abduction/hip extension, quadruped fire hydrants/donkey kicks, sit to stand, double leg calf raises, 4 way SLR
Weeks 7-12 Postpartum
  • Muscular strength tasks (8-12 reps) with weights as tolerated
  • Squats, single leg sit to stand, mountain climbers (to table) single leg calf raise, step ups
  • *potentially include impact exercise at 8-10 weeks*
Weeks 13+ Postpartum
  • Exercises performed with a metronome consistent with athlete’s desired cadence
  • 60 secs of symptom free performance– single leg calf raise, single leg hop down from step, single leg hopping, jump in place, wall sit, plank hold

 

 

        When determining the training volume and training intensity for postpartum athletes, you should consider the patient’s current ability to perform the workload they are currently assigned. As recommended in the course I took, exercise intensity or exercise volume should only be increased if the athlete can perform the exercises without an increase in signs or symptoms of pelvic floor dysfunction. Secondarily, increases in exercise volume, or repetitions, should be increased prior to increasing resistance with exercises. If the athlete starts to exhibit signs of overloading (see below), exercises should be regressed and the athlete should be allowed time to adjust to the new workload before progressing again.


Signs and Symptoms of Overloading

  • Inability to maintain current workload
  • Decreased weight without increase in workload or without decrease in caloric intake
  • Exhaustion
  • Mood Changes
  • Changes in immune function/Frequent illness


        To wrap all of this up, postpartum return to sport is a topic that should be discussed
more freely and commonly amongst healthcare providers with their patients. Postpartum
athletes require personalized plans of care with proper exercise dosage to ensure they are
adequately healed prior to resuming high impact activities to decrease their likelihood of
developing pelvic floor dysfunction.


References

  • Selman R, Early K, Battles B, Seidenburg M, Wendel E, Westerlund S. Maximizing
    Recovery in the Postpartum Period: A Timeline for Rehabilitation from Pregnancy
    through Return to Sport. Int J Sports Phys Ther. 2022;17(6):1170-1183. Published 2022
    Oct 1. doi:10.26603/001c.37863
  • The postpartum athlete: Guidelines for returning to Sport. MedBridge. Accessed
    February 18, 2024. https://www.medbridge.com/courses/details/the-postpartum-athlete-guidelines-for-returning-to-sport-catherine-cram.