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In this article I am going to discuss my experiences of rehabbing athletes and talk about some common trends with the pain/ injuries they present with. Again I am aiming this article at people with knowledge of exercise/ training but less knowledge when it comes to rehabilitation topics.
The general trend of injuries among lifters and athletes
We have all seen the videos of horrific traumatic injuries that occur on the field, track or platform, you know the ones where you see a leg snapped backwards during a tackle in all its ligament tearing glory or a fracture in someones radius when armwrestling, a concussion in NFL or even a patella detachment when squatting in a powerlifting competition.
In my experience these types of traumatic injuries are far less common among athletes and lifters with pain/ issues affecting their performance. Generally if someone has a big traumatic injury and their femur is sticking out of their quadricep or their achilles tendon has snapped and they can no longer walk, people have a tendency to know something is seriously wrong and seek medical attention. For these sort of orthopedic injuries it really doesn’t matter if you are an athlete or don’t exercise as far as your management is concerned at least initially, the medical management whether you have surgery or conservitive management (i.e put in a cast for several weeks) tends to have pretty clear guidelines of what you can and cannot do for a set period. Generally the care you receive (from medics, nurses and physios who dont even lift) at this stage will be exactly what you need, at least until you get to the return to sport phase anyway, then seeking out a rehab professional who deals with sports injuries would probably be better than generic rehab professionals with no sporting experience.
Anyway,
The biggest type of injuries I have a tendency to see among athletes, lifters and active people are the non-traumatic type. So this is the type of pain that gradually comes on when you didn’t really do anything obvious, you were just in the gym one day and your knee started to hurt and it got worse over the next few weeks.
There is a general trend among these types of injuries- they are all overload type issues and they tend to occur for similar reasons-
- Poor load management- this includes things like a whackass programme, increasing load too quickly, a ridiculous amount of volume with no recovery.
- Poor conditioning- Many athletes simply do not condition themselves properly for their sports/ the demands they place on themselves, many do not do much if any strength and conditioning at all and those that do tend to have holes in their conditioning.
- Side note- poor technique- I do feel that poor technique- particularly in lifting, can be a factor in why people can get issues but not necessarily the main cause. The body adapts to stresses placed upon it and gets stronger in response to these stresses. The body will adapt and get stronger despite crappy technique, however as we all know crappy technique is not optimal and if done badly enough will place more stress on particular areas of the body, this in turn makes it far easier to develop load management issues- especially if you are pushing the boat out a bit. However developing better technique will reduce the chance of load management issues and most of all will probably help you lift more anyway so although not necessarily the main cause of injuries, it should not be ignored and is no excuse for poor technique.
A proper strength and conditioning programme is vital to reduce injury risk in all athletes and active people. Research has repeatedly shown that only one thing can reduce injury risk in athletes- strengthening, despite this there is a significant amount of lets say “gurus” out there that suggest stretching, rolling on bits of plastic or getting a massage will reduce injury risk. Well sorry to say all the high-quality research suggests otherwise and these things do literally nothing to reduce injury risk. Now i’m not suggesting that there are never any instances where stretching can be useful, if you are new to a sport that requires end joint ranges and you can’t hit these, stretching can be PART of a plan to get you there. But generally speaking if you are an athlete who does a sport week in and week out, thus putting your body through the required range of motion for said sport week in week out you do not magically get “tight” and start losing range of motion particularly when as said your putting your body through the required ROM for your sport week in week out.
Now i’m not going to go into this too much during this article as I don’t want to derail the narrative but- A small phrase from some world class sport physios made me totally re-evaluate and properly assess the situation when the countless athletes i meet tell me they “feel tight”- “weak muscles feel tight”, a simplistic way of thinking about it is- weak muscles tighten to protect themselves from stresses they cannot handle, stretching will do literally nothing to prepare a muscle to handle more stress. You can also test this- if an athlete states they feel tight at a joint- test the range of motion and perform muscle length tests at the joint. In my experience most of the time it’s totally fine which tells me it’s a conditioning issue. I have had some athletes where stretching has been required but generally it’s more a lack of conditioning and they need strengthened or conditioned better, and yes that includes strength athletes.
With many athletes I see, it has to be said particularly in the normie sports such as running, tennis and golf most of the time these athletes/ active people do no strength and conditioning work at all. Most of the time they come to me when they increase their practice or as they start to get a little older and have started to weaken as a part of age as they are doing nothing to stay strong, and have subsequently developed an overload issue. In essence these people are not fit enough for the demands of what they do. These people do not need a physio they need a strength and conditioning coach, for whatever reason many have a resistance to seeking out S&C coaches but will happily see a physio, literally all i do is strength and conditioning coaching while reassuring them and they get better. Usually after they get better I educate them about the need for ongoing S&C and tell them that’s all they have been doing with me. After this most have a tendency to seek out proper coaching.
For lifters and those athletes that do take part in regular strength and conditioning, for me, this is usually more of a fun challenge, you have to really break them down and dig into their training to discover the areas of conditioning that they lack. For lifters there is a tendency to just do the big 3 lifts as many lifters think their conditioning and their sport are the same thing, they are not. When was the last time you did single leg work, when have you worked on your rotator cuffs, hips and knees in something other than the big 3?. A Lot of these exercises although they won’t directly improve your PBs, they will reduce your injury risk while chasing them.
And this leads me nicely into the last part of this article-
Most of the time the rehab athletes receive is frankly shite
For those athletes I spoke about above, the ones in a back to sport phase of rehab or they take part in a high level of training, a regular physiotherapy appointment is frankly useless a lot of the time.
For example, if you are a 250kg squatter and you are getting knee pain every time you squat over 180kg, although you are getting pain, you are still extremely strong and still performing at a high level generally speaking, even if for you this is only 72% of your 1RM. A basic physiotherapy screen in my experience tends not to pick up much, you need to take the physiotherapy principles and apply them to a higher level of testing because after all- the athlete is still performing to a higher level despite pain. Too many physios I have worked beside, although brilliant physios with general populations, don’t have any sporting knowledge. With sporting populations they don’t know how to apply their knowledge up into situations where the athlete is still functioning highly but still has pain and weakness. I have heard far too many athletes being told they need to take it easier because the therapist does not know how to condition the athlete for the demands of what they do properly, that is not to say that there are never instances where athletes need to take it easier for a while however. A simple way to tell if you are in the right place in these situations- are you being assessed in a gym or when you are doing sport specific tasks? Or are you in some crap clinic with a pink dumbbell rack upto 5kg with a half bosu ball and skeleton model in the corner?
A chart that displays what I am talking about well, which can be seen below- this chart was used in a journal article talking about the rehabilitation of military personnel.
As you can see, the further on a person gets into their rehab journey the more and more you need to apply mainstream strength and conditioning principles and less and less rehab principles. So let me ask you, why would you listen to a rehab professional that sure, does a good job with rehab concepts but does not have a clue about S&C concepts if you are an athlete looking to get back to sport?.
There is again more discussion coming out in rehabilitative circles among experts that many musculoskeletal conditions are massively UNDERLOADED during rehabilitation. When I first began as a student and in my early days of practicing, I tended to do the monkey see monkey do approach with my rehab- I copied the clinicians around me. You know the usual do this one bodyweight exercise and stretch once 3x per day for 10, – utter garbage. Yeah sure it works sometimes for generic populations who literally do nothing and giving them literally ANY exercise works. But for active people and athletes this does not work, you massively underload them by doing this so they don’t make the adaptations they need to get stronger/ better in best case and make them weaken even more and worsen in worst case.
The principles of exercise are the same whether it is for rehabilitation or performance, so how has my practice changed for rehabbing people and athletes- i give them strength and conditioning WORKOUTS and ensure the key factor is followed- progressive overload, not just a random exercise to do 3x per day with no progression. My rehab programmes look similar to regular programming- sets and reps, 3-4x per week, progressions etc. This works much better, and you know what for most people, even normies, prefer it to work harder 3x per week and have their rest times rather than doing some sloppy crap 3x per day from a time management perspective, it also works better this way and you get faster results as the musculoskeletal condition is not being underloaded.
A final point is many athletes look to things such as manual therapy- massage, manipulations etc for their rehab and unfortunately many therapists over sell this, the research on these things is that they have no specific effects and all it does is give you a short term pain relief effect, it does not decrease injury risk or even help rehabilitate an injury. I am not saying there cannot be benefits to short term pain relief but the benefits of this sort of therapy are hugely over exaggerated/ bordering on total lies. I hope to go into this topic more in a future article. But there is not a strong evidence base for this form of therapy and some of the major downsides tend to be a loss of self efficacy as patients start to rely on constant short term pain relief rather than getting to the route of their problem.
Far too many therapists- particularly in the private sector over sell these non evidence based modalities or methods of rehabilitation. Unfortunately there has been research that shows that 43% of physiotherapists do not follow evidence based treatments and only 54% do. And this is only in physiotherapy, never mind sports-therapy, osteopathy, chiropractic and other types of therapists. I may offend some people here but physiotherapy is the best regulated out of all the rehabilitation branches- there is a reason only physios work in the NHS. This is not to say there are not brilliant sports-therapists, osteopaths etc- I know some people who do these professions and are brilliant evidence based therapists who do a fantastic job, even better than by the looks of things, 43% of physios. But if the best regulated profession only has a rate of 54% following the evidence base, it does not give a good impression of what happens in the rehab industry on the whole.
Summary
Perhaps now it is becoming clear why I titled this blog series from powerlifter to physio and back again, many of the strength and conditioning principles that I learned through my experiences performing and studying sport and training are highly relevant and a cornerstone in the rehab world. The rehab world is full of brilliance and nonsense in equal measure, and the more I travel forwards in my rehabilitative journey the more I return to my roots in exercise and strength and conditioning. I go forward with the vision of being the fusion of a strength and conditioning coach and physio which, at least in my mind, makes me a specialist strength and conditioning coach who also has a specialization in rehabilitation.
References
Nuzzo, J. (2020). The Case for Retiring Flexibility as a Major Component of Physical Fitness. Sports Medicine. May, Issue 50, No 5. PP 853-870
Lauersen, J. Bertelsen, D. Andersen, L. (2013). The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine. August, Vol 48, no 11. Pp 1-6
Afonso, J. Campillo, R. Moscao, J. Rocha, T. Zacca, R. Martins, A. Milheiro, A. Ferreira, J. Sarmento, H. Clemente, F. (2021). Strength training is as effective as stretching for improving range of motion: A systematic review and meta-analysis.
Lauersen, J. Bertelesen, D. Andersen, L. (2014). The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine. June, vol 48, no 11, pp 871-877
Ladlow, P. Conway, D. Hayhurst, D. Suffield, C, Cassidy, R. Coppack, R. (2020). Integration of strength training into UK Defence Rehabilitation practice: current trends and future challenges. British Medical Journal Military Health. October, vol 2, no 1
Zandro, J. O’Keeffe, M. Maher, C. (2019). Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review. British medical journal. Vol, 9, no 10.
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