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Author of this guide: Dr. Dillon Caswell, PT, DPT, SCS

Doc Dillon is a Top-Selling Author, Speaker, Human Performance & Sports Doctor of Physical Therapy (a distinction held by less than 1% of PTs), and Adjunct Professor. Doc Dillon works with elite athletes, including military special ops, world-ranked strongman competitors, former NFL players, and D1 athletes, helping them perform at the highest level while spreading the message of hope to thousands worldwide. Learn more about Doc Dillon here.

Table of Contents

Introduction

After a decade of working with all levels of athletes we have learned the blessings and the curses of “Doctor Google.”

The Blessing: Quick access to information to better equip yourself with a gameplan.

The Curse: Often times the information gathered is misinformation providing false hope that doesn’t get you closer to returning back from injury AND ends up wasting the most precious resource you have: time.

We have found the curse is heavier than the blessing and more than ever athletes are being directed in the exact wrong direction.

In order to create some balance, we created this guide to point you in the right direction based on the best available science.

You will find the what to do’s and what not to waste your time on for the most common sports injuries. Feel free to jump to the section that is relevant to you, for a quick warmup we will take care of the most common questions and conversations we get related to sport related injuries.

The Most Common Topics & Questions

What causes injury?

Despite popular belief – incorrect form or mechanics are not the cause of injury. As more modern biomechanical research comes out we are learning biomechanics can be related to performance but NOT injury prevention.

Musculoskeletal injuries generally occur when:

  • The injured tissues take on a stressor that it has not built capacity for.
  • The injured tissues have taken on too much of the same stressor for too long without a period to rest and adapt.
  • The athlete’s internal load is high – meaning they are having trouble adapting to the work they are doing with the culprit being various psycho-social factors. Examples of psycho-social factors are sleep habits, previous experiences, societal norms, relationships, etc.

Can sport-related injuries be prevented?

Fully Prevented? No. There are too many variables to control for sports injuries to be 100 percent prevented, however the likelihood of injury can be reduced.

How?

Building up the capacity needed for the particular sport. For example, a game of basketball requires near miles of running with multiple change of directions and 50+ jumping efforts. If your pre-season program involved no running, jumping, change of direction training – you may be in trouble.

Should I use ice or heat?

It’s long been assumed after an injury using (Rest, Ice, Compress, Elevate) RICE principle, but did you know the origin story isn’t from a common injury? It came from a boy whose arm was severed and then re-attached.

From Top-Selling Book Hope Not Nope Pg. 95 “Following this success, Dr. Malt and his team travel around the world explaining the surgery. In a press conference a reporter asks “if we encounter a person with a severed arm, what should we do?” He replies, “Don’t panic, place the limb on ice, stop the bleeding by using a tourniquet, and elevate it above the heart.” This then becomes known respectively as rest, ice, compress, elevate.”

A physician named, Dr. Gabe Mirkin, then coined the term in 1978 and recently (if 2015 is recent which I think is generous to say but in any case) stated, “Coaches have used my ‘RICE’ guideline for decades, but now it appears that both ice and complete rest may delay healing, instead of helping.”

DESPITE him recanting the term he coined and our best efforts: athletes go to is RICE – a principle that may delay healing vs helping.

A new acronym has been proposed to replace RICE called the PEACE & LOVE principle (it’s much more up to date but harder to remember which each letter stands for because it’s longer)
Protection, Elevation, Avoid Anti-inflammatories, Compress, Elevate & Load, Optimism, Vascularization (blood flow to the area), Exercise.

What about heat?

It likely doesn’t help or hurt the healing process, it’s something you can do at home easily with a heating pad, so we will leave it at “no harm, no foul” for now.

Most of the time modalities are not truly helpful…

Modalities are things like electrical stimulation units, therapeutic ultrasound, low-level laser therapy, etc. These tend to be based on “tooth fairy science” and offer promises that they cannot deliver on. They may subjectively feel good but they don’t truly do anything for helping the healing process – at most they distract your brain as the regression to the mean takes place. What is that?

The body’s natural ability to heal on its own regardless of what treatment is sought.
This can make it look like a specific intervention “worked”, when in reality, the body was likely to improve regardless.

Example: If you hurt your back and seek treatment during the worst flare-up, there’s a good chance your pain will lessen soon after—even if the treatment had no real effect—just because symptoms tend to return toward normal levels.

So, regression to the mean reminds us to be cautious when attributing recovery solely to a treatment without proper evidence.

Coming up in the guide you’ll see for each common sports injuries where modalities fit (if at all).

What is Tooth Fairy Science?

“Tooth Fairy science” is a term used to describe research that investigates phenomena without first establishing that the phenomenon actually exists. It was popularized by skeptic Physician Harriet Hall and is often used to critique pseudoscientific or poorly grounded studies. The analogy comes from studying the habits of the Tooth Fairy—researchers might gather detailed data (like how much money is left or how often visits occur) without ever confirming that the Tooth Fairy is real in the first place.

In short, it means doing scientific-sounding work on something unproven or imaginary. For the science nerds out there (like myself) it means showing effectiveness without establishing efficacy.

Just because you see your favorite pro athlete getting a treatment does not mean you should invest your time in it as well…

We see popular athletes on Social, YouTube, or behind the scenes on a Netflix special getting a “specialized” treatment and immediately think, “I need that too!” We can promise you that the scene with the fancy treatment is less than 1% of the focus of where their Rehab plan truly is – it’s just what looks the best for TV.

Further, as you’ll learn throughout this guide – most modality based treatment shows to be no better than a placebo or sham treatment – meaning it’s a low value treatment not worth your time.

Beware of new trends and falling for the “there’s not much research on this yet”

This leads one into believing that they are receiving groundbreaking treatment and when the research “catches” up they will be able to say, “I told you so!” But here is the reality – there’s probably not research on it because it’s not worth researching!

Research costs money to conduct – if the theory or efficacy of how the treatment works is rubbish to begin with, researchers will not waste their resources to show what is already known.

Follow the money trail – if a company presents their product has been researched – who funded it? Was it the company selling the product? Hmm..wonder if there is a motive to fund your own research, use a weak research design and show a “positive effect” to help push sales.

The Misconceptions of Manual Therapy…

Including soft tissue work, active releases, myofascial releases, joint adjustments, scrapping, cupping, etc. Manual therapy is effective to decrease pain symptoms which is a good reason to utilize it as part of your rehab plan.

What it DOES NOT do:

  • Prevent injury
  • Change tissue properties. Example: To change the tissue property of the ITband you need 7,000+ newtons of force, how much is applied during deep tissue massage or foam rolling? A whooping 700 newtons, yeah, 6,300 newtons away from creating tissue resilience. For the same reason, the theory of spinal adjustments putting a “vertebrae” back in place is not valid. Again, an adjustment can feel good but what the science shows is that it is not “realigning” anything.
  • Get rid or reshape scar tissue (if it did, why would surgeons have to use a scalpel to remove it?)

Pain is an individualized experience, all the time, every time…

Two athletes can have the same exact injury but experience the pain much differently. Furthermore, two athletes can both have an irritated muscle or tendon and one has pain whereas the other doesn’t. Wait, what? Wouldn’t irritation always create pain? Simple answer, no – and we won’t get into the depths of pain science but we will provide this key concept:

  • Pain is an output from the brain 100% of the time.
    • This does not mean “pain is all in your head.” What it does mean is that the brain receives signals from the injured area, processes that signal as well as factors such as likelihood of survival, previous memories related to the current injury, metabolic health, and then determines the intensity or level of pain as an output.

Should I get imaging?

That is a complicated answer and a bit specific to each injury – we will leave that discussion for each common sports injury coming up!

What is the FIRST thing I should do after suffering an injury?

Don’t get mad with the response (and yes it’s super cliche), but TAKE A DEEP BREATH. It’s the phrase I and millions of other sports med staff have uttered to athletes on field/court/ice for good reason.

First, your brain works by prediction. When an injury occurs it tends to predict worse case scenarios (I cannot count the number of athletes who initially screamed, I heard a pop, ahhh it’s broken) – whom upon after taking the deep breath and allowing the on-field evaluation from the sports med staff is informed everything looks good – and they are back playing after a 1 play rest on the sideline.

Second, the deep breath allows you to practice the first pillar of hope: self-agency, you put you back in control and decrease the intensity of the situation.

Once the intensity is decreased: better evaluations and decisions can be made.

Side note: if you have belief in a higher power, coupling the deep breath with a prayer, exercises further self-agency and strengthens the ability to decrease the intensity of the situation.

Alright, warm up complete!

Let’s get into the Do’s and Don’ts for the most common sports injuries. You’ll also find an added category of “Won’t Hurt But Probably Doesn’t Help.”

To Do’s & To Don’ts Defined:

What qualifies as “Do’s”?

The “do’s” = high value solutions. It means it is worth putting your time & energy into because they yield a positive result shown repeatedly both in the lab and in the real world.

What qualifies as “Don’ts”?

The “don’t’s” = low value solutions that do not move you closer to return to sport and are harmful because they waste your time & energy when it could be spent on a “Do” or High-Value solution.

What qualifies as “Won’t Hurt But Probably Doesn’t Help”?

These are solutions in which the jury is still out. Either more research needs to be conducted to properly place it as a Do/Don’t OR it’s something athletes like doing but it doesn’t yield net positive results.

How was this guide developed & who made up these “Do’s” & “Don’ts” anyways?

This guide draws on the latest clinical practice guidelines, which provide comprehensive reviews to help clinicians follow the best practices based on current scientific evidence. We’ve distilled years of research and science into a more accessible format for athletes.

While we’ve aimed to minimize personal opinions, our decade-long experience working with some of the world’s top athletes has allowed us to offer valuable insights into what works—and what doesn’t.

The common pattern you’ll find throughout each common sports injury…

Each injury is unique and deserves its own attention but the similarities between them all is the Do’s (high value solutions) are related to:

Load Management:

It is not expected that after using this educational material that you have a full understanding of human kinetics, progressive overload, Acute:Chronic workload ratios, and graded exposure principles. It is expected that you are able to reflect and ask the simple questions:

  • Have I been doing too much of the same thing for too long?
    • Example: My shoulders are sore. I bench press 2-3x per week and barely ever mix in horizontal pulling.

  • Did I do too much of something too soon?
    • Example: I have not sprinted in a few months but my buddy challenged me to a race and I pulled my hamstring.
      • Mix in the, “I stretched before racing..” you’ll learn in the hamstring section stretching DOES NOT prevent injuries, being prepared to withstand the forces of the activity DOES.

 

Those questions help the initial brushstroke to develop the painting of why the injury may have occurred in the first place. Once injury has occurred the questions become:

  • What are the full demands of my sport and how much of it am I able to do?
    • All too often we see athletes cleared to return to sport WAY before they are truly ready which sets them up for re-injury.
      • Example: a basketball player typically jumps 50+ in one game. They are often cleared to return to games if they can balance on one leg AND maybe completion of a 6 meter hop test. The “return to sport test” commonly used significantly underestimates the demands of sport.

  • As my sport specific activity may decrease during rehabilitation, what things can I keep doing to keep my overall workload higher?
    • One of our “pet peeves” is when athletes get out of shape during rehabilitation – its honestly pure laziness on the rehab professional, athlete, or both. If your arm is hurt – there are plenty of leg exercises you can do to stay in shape. If your leg is hurt – there are plenty of arm exercises you can do to stay in shape. AND the cherry on top, working other muscle groups helps stimulate factors needed for healing injuries: growth hormone and IGF-1 (insulin-like growth factor.)
Strength & Conditioning for injury prevention / Exercise Therapy to return to sport:

One of the only methods that has been shown to prevent injury is a strength & conditioning program to prepare you for the demands of your sport.


One consistent “Do” or high value solution for every common sports injury is exercise therapy.


Spoiler alert: laying on a table and getting “worked on” may feel good and can even help decrease pain BUT it does not prevent injuries. It also cannot be deemed effective as a stand alone treatment to get you back to your sport. You know what does? What should get you excited as an athlete…movement!

Psychosocial Factors:

A fancy way of saying, “Hey, how are you doing?” while implying that as humans there are many more, let me emphasize that – MANY more factors – that lead to injury than biomechanics or the purely “physical” part of being an athlete.

  • Athletes, like every other human, have emotions, complicated relationships, societal norms picking at their beautiful brains, criticism, etc.
    • To put it simply, in 10+ years in high level sports performance I have never seen an athlete suffer a physical injury when everything else in the “psychosocial” domain was going well.
      • On the flip side, I have seen athletes that were physically prepped for their sport demands suffer an injury while they were dealing with increased psychosocial stressors: break-up, loss of a loved one, stress of getting the next contract, ability to provide for their family.

Needless to say for every common sports injury addressing the psychosocial domain is an absolute must. We do so by sitting down with the athlete, looking them in the eyes, and asking, “How are you doing?” OR our personal favorite “How is your spirit?”

  • We have found asking and nourishing the spirit has been a game changer in both preventing and recovering from injuries. So much so, we created a 8-session self-paced course for athletes to have the tools necessary to fuel their spirit.

For each of the common injuries athletes face coming up you will see in the Do’s: Load management, Strength & Conditioning for prevention/Exercise therapy for rehabilitation, and equally (if not more important) addressing psychosocial factors.

From there each injury has its own little nuance to it but we cannot stress this enough: take care of the high values “Do’s” explained above FIRST and then consider the nuance.

Alright the meat has been provided, enjoy the potatoes.

The Most Common Sports Injuries:

Plantar Fasciitis

A grueling heel and bottom of the foot pain making impacted related activity such as jumping, running, and walking difficult. The plantar fascia is a strong tissue that acts as a shock absorber in the arch of the foot. Plantar fascia irritation tends to happen from repetitive stress accumulated over time.

Load Management: Reflect on foot impact related activity and adjusting based on symptoms.

  • Step Count:
    • Your iPhone has a step tracker in it already located within the health app. You can use it to see how many steps are tolerated, when does pain spike, etc. You can use this as a marker of progress as well!
  • Running Mileage:
    • Similar to step count rationale above but we will add a few more tips here:
      • If you need to keep running because you have competition coming up you may look to switching to a more cushioned shoe. Why? This will transfer force away from the foot and bring it more to the knee and hip.
      • Look to run on a flat or downhill surface while avoiding uphill when symptoms are present. When going uphill, the toes go into extension, the ankle into dorsiflexion, which creates what is called “The Windlass Mechanism” or tightening on the Plantar Fascia.

Footwear:

  • Yes, minimalist footwear has become trendy and the idea that “barefoot” is better but we state a very simple question? Has any world record in running been set barefoot? No, because cushioned shoes provide more return energy helping to improve running economy. (learn more about running footwear in this podcast episode)
  • Aside from performance, you can use knowledge of different cushioned shoes to adjust where the forces of running are going to in your leg.
    • A more cushioned shoe will create decreased forces experienced by the foot and will increase force to the knee and hip. Vice versa – minimalist shoes will increase force in the foot and decrease force to the knee/ankle. In the best case scenario, you have both and use it for variability during regular training. While you are in pain and need to keep training, you can use the more cushioned shoe to keep mileage up while protecting the plantar fascia a bit more.

Strength & Conditioning for Prevention:

  • Calf (plantar flexor) strength: Strength and progressive overload is the factor that helps to reduce risk of injury, not stretching. You can continue to stretch if you enjoy it but again for prevention we need to look at strength and the force that is going to the plantar fascia.
    • Stretching the plantar fascia = ~0.2x Body Weight Force
    • Walking forces on the Plantar Fascia = ~ 1-2x Body Weight Force
    • Running forces on the Plantar Fascia = ~2-3x Body Weight Force
    • Takeaway: Stretching does NOT prep the capacity the tissue needs to develop for prevention or return to sport.
  • Other areas for strengthening:
    • Athletic movement is never isolated to one joint, muscle, or fascial tissue; it is a dynamic complex system that works together. It is crucial to look at other areas of the body and address any weaknesses that may be causing the Plantar Fascia to take on more force than it should. With our athletes we do a Phase 1 Assessment to find any contributing factors. For example, quad deconditioning on the non-injured side can lead to the injured side needing to use more calf to keep up. We need to look at the whole and take care of the whole, not just the “parts.”

Exercise Therapy for Rehabilitation:

  • Stretching can be helpful to decrease pain, but again, to get back to your sport, it’s not just about decreasing pain, it is making sure the tissue quality has been improved to accept the forces of running, jumping, cutting, etc.
  • Strengthening the Plantar Flexors
  • Strengthening muscle groups away from the injured site that may be contributing to the plantar fascia taken on more forces.
  • Neural Gliding: The sciatica nerve continues down the leg to branch off to the tibial nerve which then branches off in the bottom of the foot to the lateral and medial plantar nerve which then have their own branches. Gliding the full sciatic nerve (including the branches down in the foot) can have benefits of alleviating pain and improving neural mobility.

Manual Therapy:

  • Joint mobilization and soft tissue work can help to decrease pain, but again, to get back to your sport, exercise therapy is a must.
  • Do you need specialized manual therapy
    • Whether you want to roll your foot on a lacrosse ball or see a professional for soft tissue work the results are the same.
    • *** Note*** It does not matter the technique used, manual therapy does NOT change tissue quality. It is an input to the nervous system to change the output of the nervous system. There is benefit to that of alleviating symptoms, BUT for full return to sport exercise therapy is needed.

Psychosocial factors:

  • Research is showing those that have higher levels of stress, depression, or anxiety are more at risk of experiencing pain from an irritated plantar fascia and to have the initial pain turn to chronic pain. Does it have to follow that course? Nope, address the psychosocial factors and the path can change drastically.

Taping:

  • For this to fit in the To Do’s category, it MUST be coupled with exercise therapy.

Foot Orthoses:

  • Current research leads to the conclusion: “ …should not use orthoses, either prefabricated or custom fabricated/fitted, as an isolated treatment for short-term pain relief in individuals with plantar fasciitis.”
  • ***If coupled with exercise therapy maybe there is a place for it but there seems to be better ways to alleviate pain via manual therapy and taping vs foot orthotics

 

Therapeutic Ultrasound:

  • “It uses sound waves to creating vibration deep into the tissue allowing healing agents to come to the site of injury” blah blah blah, no it doesn’t! You can turn the machine on or leave it off during treatment and the same outcome can occur which has led to the statement in clinical practice guidelines, “Clinicians should not use ultrasound to enhance the benefits of stretching treatment in those with plantar fasciitis.”

 

Electrical Stimulation:

  • Iontophoresis: the idea that electrical current is driving a “medication” through the skin to the site of injury to decrease inflammation and alleviate pain. Yeah, not worth your time. The ONLY time this makes sense is if exercise therapy, manual therapy, and addressing psychosocial factors leads to no results (which is extremely rare that these would fail IF you are receiving a good framework and are putting in the work).
  • TENS/IFC (no medication patch, just electrodes but the same explanation as above, it should be an absolute last case scenario to use it).

 

Injections:

  • Platelet Rich Plasma (PRP): Saline injection will create the same effect (or lack thereof), Save your money on this one.
  • Cortizone: Creates a catabolic effect and can cause tissue to take longer to heal, not worth it when there are better strategies available to decrease pain.

Low-level laser therapy (LLT)

  • Risk of placebo is high, shows “effectiveness” but not “efficacy”, simply put – it’s “Tooth Fairy Science”

 

Dry Needling (acupuncture needle into a trigger point)

  • High risk of placebo-based effect and is not greater at alleviating pain better than manual therapy.

 

Shockwave

  • When research methodology is up to par (uses a true placebo in a double-blinded randomized controlled trial fashion) the results show no difference between sham shockwave and actual shockwave. Exercise therapy + manual therapy are superior; put your time and effort there. Note: Most research for Shockwave is also completed in participants that have had heel pain for greater than 3 months (plantar fasciopathy vs plantar fasciitis).
    • Furthermore, a meta-anlaysis looking at all potential placebo-based treatments of plantar fasciitis concluded, “The improvement of the placebo groups was higher in the extracorporeal shock wave therapy studies compared to the injection studies.”
      • So why is it in this category?
        • More research is being done and the harm is low as long this is not the only intervention being used.

Lateral Ankle Sprain

The common “twisting of the ankle” – causing discomfort on the outer part of the lower ankle. It is graded in severity of 1-3 and typically involves the lateral ligaments of the ankle (ATFL, CFL, PTFL with the ATFL being the most commonly injured).

Seek X-ray Imaging if the Ottawa Ankle Rules are Positive:

  • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR
  • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR
  • An inability to bear weight both immediately and in the emergency department for four steps

Bracing:

  • This one challenges our biases, but this is one of the very few conditions that ankle bracing can be helpful for those at risk of a lateral ankle sprain or for those who are currently dealing with one.
  • The type or brand does not matter comes down to athlete preference. Also this DOES NOT mean that athletes need to have a brace on the rest of their career. If the athlete feels like they don’t need it, they don’t need it, and shouldn’t have to feel reliant on it.

Exercise Therapy:

  • Build up tissue capacity and resilience needed for your sport. Although light intensity banded exercises laying on a table may be a starting point for severe ankle sprains, you should and need to progress to exercises on your feet.
  • Specific Propiocpetive/Balance training can be helpful to regain the motor control within the injured ankle. The focus doesn’t need to be balance on a BOSU Ball, the goal of balance training is for the brain to regain trust, knowledge, and fine tune movements performed by the ankle. Furthermore, being able to hold a single leg balance for 30 seconds does not = that you are ready to return to sport.
    • Example:
      • Single leg balance = less than 1x body weight force, minimal impact force.
      • Tuck jump = 2x body weight force to the ankle, moderate impact force.
      • Running = 3x body weight force to the ankle, moderate-high repetitive impact force
    • I’m not sure of any sports that have single leg balance holds for 30 seconds in them (maybe baseball, if you have a pitcher messing with a base runner but 30 seconds hold balance in the windup – no way). I am sure most field, court, and ice sports have impact forces. Therefore, your exercise therapy program needs to build up the forces you will face at game time.
      • Example:
        • Goal: Return to playing a full game of basketball
          • To play a full game, you need to be able to run ~2.8 miles with frequent changes of direction and ~50 different jump efforts.
            • Let’s work backwards to establish checkpoints:
              • Run 2.8 miles, 50 jumps
              • Run 1.4 miles, 25 jumps
              • Run .75 miles, 10 jumps
              • Complete 10 jumps without symptoms
              • Walking progression up to 2.8 miles
              • Restore full strength of my legs
              • Restore full range of motion.
        • The goal can seem far away, but the checkpoints help keep us on course!

 

Manual Therapy:

  • Can be helpful with decreasing pain but needs to be performed in conjunction with exercise therapy for successful outcome to return to sport.

 

Psychosocial Factors:

  • For this specific injury with the mechanism being rolling the ankle, typically from landing on another player’s foot or awkwardly from a jump, this falls lower on the list but should never be discounted.

DO NOT expose yourself to unnecessary radiation if the Ottawa Ankle Rules are negative

 

Therapeutic Ultrasound:

  • “It uses sound waves to create vibration deep into the tissue allowing healing agents to come to the site of injury” blah blah blah, NO it doesn’t!
  • Copy and pasted from the Clinical practice guidelines, “Clinicians should NOT use ultrasound for the management of acute ankle sprains.”

 

Ice:

  • See common question (above) “Should I use Ice or Heat?”
    • Use PEACE & LOVE principle instead of RICE

Low-level laser therapy (LLT)

  • Risk of placebo is high, shows “effectiveness” but not “efficacy”, simply put – it’s “Tooth Fairy Science”

 

Kinesiotape for swelling:

  • May be somewhat helpful if there is significant swelling and the athlete is not able to elevate their foot throughout the day.

 

Dry Needling (acupuncture needle into a trigger point)

  • High risk of placebo-based effect and is not greater at alleviating pain better than manual therapy. 

Patellofemoral Pain (FPF / Jumper’s Knee)

More common in the younger athlete (15-30 years old) with an onset that includes symptoms just below the kneecap that can come gradually or suddenly. Pain is associated with worsening with lower limb loading activities in knee flexion – including squatting, prolonged sitting, up and down stairs, jumping, and running.

Load Management:

  • Sudden symptoms: Tends to happen from a large spike in workload for younger athletes. If so, take a few days off from running and jumping
  • Gradual symptoms: Tends to happen from doing too much of the same thing for too long or in other words. If so, especially, for athletes, learn about the long-term athletic development model and how harmful sports specialization can be for the developing athlete.
    • “…sports attrition rates are the highest during transitional years of adolescence and that by the age of 15, 70-80%of the youth will no longer participate in sports. Diamonds are formed under 725-825k pounds per square inch of pressure. It seems parents and coaches have applied the same mentality to their young athletes hoping they will make it pro one day. The results are typically not a diamond, but rather a resentful kid that now associates sports or movement with unbearable yelling and pressure.” p.6 from Top-Selling Book Hope Not Nope
  • To that point, if you (as a kiddo) or your kiddo wants to go pro, follow the model the pros did. The best players of all time did not specialize in their sport until college or after! (the only expectations are: tennis, gymnastics, diving, and ice skating). Variety is good for developing skill and using different parts of the body which helps to decrease overuse injuries.

 

Exercise Therapy:

  • Progressive overload of knee flexion dominant exercises:
    • A combo of hip and knee exercises to produce the optimal load for the individual to help in the healing process. If symptoms are high may need to hold on knee bent based exercises and slowly work towards them as the symptoms allow.
    • Example of progression:
      • Leg straight bridge → RDL→ Deadlift → Sumo Deadlift → Bent knee bridge → Partial Squats → Full depth squats → split squat or lunge progression → Single leg squat progression → Jump progression → Hop progression → Running/sprinting progression
  • If symptoms had a sudden onset, isometrics can be biased to help alleviate pain while not adding too much tendon stress.
  • If symptoms had a gradual onset, exercise therapy can be biased towards heavy slow loading for tendon adaptation stimulus.
  • Other areas for strengthening:
    • Athletic movement is never isolated to one joint, muscle, or fascial tissue, it is a dynamic complex system that works together. It is crucial to look at other areas of the body and address any weaknesses that may be causing the knee to take on more force than it should. With our athletes, we do a Phase 1 Assessment to find any contributing factors. We need to look at the whole and take care of the whole, not just the “parts.”

 

Psychosocial Factors:

  • This is key and, although appears after load management and exercise therapy, should be on the same line as them!
    • First, let’s look at the age range 15-30 year olds – not a lot of responsibilities BUT a lot of life changes happen in this time frame. All of these majors changes are a stressor to the system which can welcome the symptoms of Jumper’s Knee. Research has found that even with evidence of tendon changes/adaptation an athlete with jumper’s knee can still have pain if psychosocial factors are not addressed.
      • We need to make sure that athletes at this age know their identity, core values, and how to adapt to stressors. That’s exactly why we created Reclaimed Athlete.

Isolating the “VMO”

  • You can’t, nobody can, focus on getting the overall quad stronger

 

Dry Needling:

  • Clinicians should not use dry needling for the treatment of patients with PFP.

 

Manual Therapy:

  • Clinicians should not use manual therapy, including lumbar, knee, or patellofemoral manipulation/mobilization, in isolation for patients with PFP. If used in conjunction with exercise therapy, then it can be considered a “To Do” but again, the key factor is the combo – manual therapy on its own = a “To Don’t”.

 

Modalities:

  • What about that little machine that creates “buzzing around my knee” or other modalities?
    • The research is crystal clear:
      • “Clinicians should not use biophysical agents, including ultrasound, cryotherapy, phonophoresis, iontophoresis, electrical stimulation, and therapeutic laser, for the treatment of patients with PFP.”

 

Orthotics:

  • What does the research say about the patellar straps or braces?
    • “Clinicians should not prescribe patellofemoral knee orthoses, including braces, sleeves, or straps, for patients with PFP.”

Taping:

  • Kinesiotape or other methods: Let’s be honest- by the time you are through with warmups, the tape has either lost its integrity or is not even sticking to your skin anymore.
  • It’s a novel short-term sensory input at best.

 

Run Retraining:

  • We almost had to put this in the “To Don’ts” because of the slight harm of the cost and wasted time of doing a treadmill video analysis running assessment being cue to “forefoot strike” vs “rearfoot” strike.
    • Here is the reality: Get strong FIRST then have variety in your running. Running at a faster cadence or speed (when able to) will fix your running mechanics.
  • The reason it is here is because this would still be better than modalities!

IT Band Pain

The Iliotibial band (IT) or tract is a long, thick, fibrous connective tissue that runs from the outside of your hip to the outside part of your knee. It is the longest tendon in the human body and acts both as a tendon and ligament. It helps to connect a small hip muscle called the TFL (Tensor Fascia Latae) from the upper pelvis to the lower outer knee. Aside from connecting the TFL to its respective areas, the IT band has deep connections along the thigh bone and into the knee capsule. As it runs down the outer thigh, it also serves as attachments for some other muscles such as some fibers from the gluteus maximus (the major butt muscle).

IT band pain comes on when this tissue becomes irritated, usually with a gradual onset. To confirm it is true IT band pain the symptoms need to be located at the outer part of the knee. Anything in the front of the knee is not considered IT band pain. Likewise, anything in the hip is a different condition.

It is NOT a friction based syndrome, this has been ruled out yet remains the leading (now misinformed) thought. It is far more likely that it is a compression-based irritation at the lower knee. This is important because it debunks and puts a lot of IT band “lengthening” strategies in the “To Don’ts” category.

Load Management:

  • Usually caused by a big increase in running related volume but can also be in hiking and cycling volume.
    • Taking the volume down or resting from running and leaning into strengthening tends to be the best solution.
  • Decrease running/hiking/cycling mileage
    • Either you will or the discomfort will force you to.
  • Change pace: run shorter, faster
    • This condition is far more prevalent in distance runners. Adding variety and going short distances at a faster pace takes some stress away from the irritated area and also allows you to develop muscles of the posterior hip that are likely deconditioned.
  • Run uphill:
    • Symptoms are typically brought on when going downhill or down stairs so don’t poke the bear. Stay flat or go uphill. Similar to going faster, going uphill will allow you to develop your posterior chain which will be beneficial in the “long-run” for running performance and getting out of pain.

 

Exercise Therapy:

  • Applied in a progressive way to improve strength in areas that may be contributing to the ITband taking on increased forces when running. The most common areas for strengthening include the posterior chain (hamstrings, glutes, calves, etc).
  • The exercise therapy program should also take into account progressive overloading of impact forces to the ITband to build capacity for return to running.

 

Manual Therapy:

  • Soft tissue work can help to decrease pain, but again, to get back to your sport, exercise therapy is a must.
    • Do you need specialized manual therapy?
      • Whether you want to roll, scrape, or see a professional for soft tissue work the results are the same.
        • ***Note*** it does not matter the technique used, manual therapy does not change tissue quality. It is an input to the nervous system to change the output of the nervous system. There is benefit to that of alleviating symptoms BUT for full return to sport exercise therapy is needed.

 

Psychosocial Factors:

  • Research is showing those that have higher levels of stress, depression, or anxiety are more at risk of experiencing pain from an irritated IT Band and have the initial pain turn to chronic pain. Does it have to follow that course? Nope, address the psychosocial factors and the path can change drastically.
  • Also this injury is very common in distance runners – in which we have found that runners are either running for something or from something. When this is “taken away” due to injury, they have a lost a coping mechanism they relied on and their runner identity is challenged. We need to make sure that runners know their identity (in & out of sport), core values, and how to adapt to stressors. That’s exactly why we created Reclaimed Athlete.

Seek treatments that “loosen the IT Band”

  • You don’t need to stretch the ITband
  • Why not? Research from 2004 and on as debunk the myth of tight ITband causing pain:
    • In 2004, Michelle Devan and colleagues assessed runners and then followed them to see if tight ITband lead to running injury. What did they find? IT band was the most common injury in this running group and NOT ONE OF THEM had a tight ITband.
    • More research has shown that we are not even able to stretch the ITband.
  • Surgical treatment such as a fasciotomy to “lengthen the IT band”
    • If modern research shows a tightened IT band does not cause ITband pain and that it’s not a friction based condition, then why would the solution be going in to cut it and lengthen it? It doesn’t make sense, don’t waste your time and money on this.
  • Don’t hang your hat on the classic Ober’s Test
    • Willett et al.2016 assessed the Ober test: a test used orthopedically to assess length of the IT band. The findings were that it doesn’t even assess the ITband! Instead, it was measuring the “tightness of structures proximal to the hip joint, such as the gluteus medius and minimus muscles and the hip joint capsule.”
      Again, this is not an ITband length issue even if this test was accurate in measuring ITband pain, does it matter?

 

Pelvic Alignment:

  • The ol’ “this leg is shorter than the other due to your pelvis being out of alignment”. Just going to get to the point here: the pelvis is not out of alignment and leg length discrepancy is not related to or a risk factor for IT band pain.

“Scrapping the ITband”:

  • The tissue properties are not changing, at all, from scrapping, but it’s something you can do on your own and may help decrease the perception of pain.

 

IT Band Knee Soft Straps (bracing):

  • Provides an idea of “safety” to the pain, which decreases the output of pain. It does not actually change the forces at the IT band but it’s inexpensive and low risk.

 

Changing Running Surfaces:

  • Believe it or not there is actually no research showing that harder surfaces such as pavement is causative of IT band pain. With that being said, if you have less discomfort trail running, find yourself a nice path!

 

Changing Running Shoes

  • Research has shown how this changes where forces go during running. For example, a minimalist shoe has greater impact force to the foot/ankle which can help decrease the forces going up to the knee and ITband. Although this has been studied it has not been validated in research that a minimalist shoe decreases risk of or is a first line treatment for ITband pain.

ACL Injury

It seems like EVERY knee injury that happens we hear someone automatically assume it’s the dreaded ACL tear. Before assuming, let’s cover some basics.

The Anterior Cruciate Ligament (ACL) is an intracapsular ligament in the knee connecting the femur and knee. Its role is to prevent the tibia (shin) from translating forward in relation to the femur (thigh).

Traditionally, from cadaver research, it was thought the ACL is the primary restraint preventing the translation of the tibia on the femur. This makes sense when you take out consideration of the neuromuscular system and only have a dissected section of the thigh, shin, and ACL. When we add the layers that make you human, including the neuromuscular system, we learn the ACL tears after a failure of the feedforward mechanism.

What is the feedforward mechanism?

The feedforward mechanism in the human body is a predictive motor control process where the brain anticipates movement demands and activates muscles before the movement or impact happens. It’s crucial for stability, especially in high-speed or high-impact activities.

If the muscles activate too late or too weakly, the knee is unprepared for the forces.

This delay leads to poor neuromuscular control, increasing strain on the ACL.

As a result, the ACL may absorb forces it’s not designed to handle, leading to tears or ruptures, especially during sudden deceleration, pivoting, or awkward landings.

In short (which is typically only used after something has been long and probably should have come first): a failed feedforward response = delayed muscle activation = increased ACL injury risk.

We no longer should consider the ACL to be the primary restraint to stopping the translation of the tibia on the femur, it is the secondary restraint. The primary restraint is the feedforward mechanism, which is improved with strength & conditioning and with decreasing psychosocial factors! Increased stressors mixed with doubts, fear, confusion, etc create a delay in neurological signaling. We can combat that by addressing psychosocial factors on the offense side. We have helped thousands of athletes do so, which led to the creation of Reclaimed Athlete.

To save reading time, other common ACL myths are covered in the below To Do’s/To Don’ts:

For Prevention:

  • Strength and conditioning focused on quad strength and preparing for sport specific demands.
    • Note: Research has shown knee valgus is likely not the cause of ACL tearing, rather it is a result from an already torn ACL. The takeaway being ACL prevention does NOT have to be focused on knee valgus prevention. It should be focused on overall strength and building capacity.
    • Current recommendation on frequency: “…should involve training multiple times per week, training sessions that last longer than 20 minutes, and training volumes that are longer than 30 minutes per week.” Also, “Clinicians, coaches, parents, and athletes should start exercise-based knee injury prevention programs in the preseason and continue performing the program through the regular season.”
  • Psychosocial Factors:
    • All injuries are complex but ACL may take the cake. Do not wait to address psychosocial factors after injury occurs. Get on the offensive side, improve the feedforward mechanism by strengthening the body AND the spirit. Learn how in our self-paced online Reclaimed Athlete Series.

For Tears:

  • Exercise Therapy:
    • Identify if you are a coper or non-coper.
      • What is a coper vs non-coper?
        • A coper is an athlete that is able to return to high level activity without an ACL reconstruction after tearing. This is shocking to read because the old school thought was everyone that tears an ACL NEEDS surgery, but that is not the case anymore.
          • “We are also learning that people can function at high levels without an intact ACL, like really high levels; John Elway, Mickey Mantle, Joe Namath, Thurman Thomas, DeJuan Blair, Hines Ward to name a few. Research is showing in a larger proportion of the population that almost half can be a coper, meaning they return to pre-injury level without an ACL reconstruction.” p. 68 from Top-Selling book Hope Not Nope
        • A non-coper is an athlete that tears their ACL and needs surgery because the knee buckles and they are not able to return to sport without ACL surgery.
    • How to determine if you are a coper vs non-coper:
      • Snyder-Mackler and her team developed a screening protocol to distinguish copers from non-copers based on performance and symptom response after ACL rupture. The key criteria include:
        • Number of Giving-Way Episodes:
          • Copers: Fewer than 1 episode of the knee “giving way” since injury.
          • Non-Copers: Multiple episodes of instability during daily or sports activities.
        • Knee Outcome Survey (KOS) Score:
          • Measures perceived knee function in daily living.
          • Copers generally score ≥80% on the Activities of Daily Living Scale.
        • Global Rating of Knee Function:
          • Self-reported score (0–100 scale).
          • Copers typically rate their knee at ≥60% of pre-injury function.
        • Timed Hop Test:
          • Tests functional symmetry of the lower limbs.
          • Copers must achieve ≥80% symmetry between legs.
    • ***Screening typically takes place 4 weeks after the injury. If determined a non-coper, time is not lost as PT prior to reconstruction is very beneficial. Furthermore, it meets the surgeon guidelines of reconstruction being completed within the first 3 months of the injury.
    • Interesting facts:
      • Some individuals are long-term copers and can return to high-level activity without surgery.
        • A prospective study involving 271 athletes with acute ACL injuries examined the impact of a 10-session neuromuscular and strength training (NMST) program. Approximately 50% of those initially classified as non-copers transitioned to potential copers post-training (p < 0.001). At the 2-year follow-up, 64% of the ACL reconstruction (ACLR) group and 74% of the non-operative group met success criteria, which included achieving knee function levels comparable to pre-injury status and experiencing no more than one episode of knee instability. Athletes who were potential copers after NMST had 2.7 to 2.9 times higher odds of success, regardless of their treatment choice, compared to non-copers
      • Others may cope only temporarily; they might initially adapt well but eventually develop instability.
      • Studies suggest that successful copers can function for years without reconstructive surgery, especially with proper neuromuscular training and rehabilitation

  • If surgery is needed:
    • Non-coper & needs reconstruction:
      • Pre-op Rehab:
        • Regaining full knee extension decreases the chance of post-op complications.
        • Regain Quad Strength: a 20% or more deficit predicts significant strength deficit until 2 years after surgery.
      • Surgery Type:
        • Autograph (from your body) over allograft (from a cadaver)
          • Autographs are superior, allograft has a higher failure rate.
          • Your surgeon may recommend Bone Patellar Tendon Bone graft, Hamstring graft, or quad tendon graft. Pros and cons of each should be discussed.
      • Repair vs Reconstruction:
        • From The American Academy of Orthopaedic Surgeons “ACL tears indicated for surgery should be treated with ACL reconstruction rather than repair because of the lower risk of revision surgery.”
      • Post-Op Rehabilitation:
        • Focus on exercise therapy:
          • Progressive overload of the quad is crucial. Do not fear quad extensions, they just need to be done at the proper dose and range of motion. Those specifics are out of the scope of this resource and should be discussed with your Rehabilitation provider (physical therapist, physio, athletic trainer).
          • Blood Flow restriction therapy:
            • “Low load blood flow restriction training might be used in addition to standard care in the early phase of rehabilitation to improve quadriceps and hamstring strength, particularly when patients have increased knee pain or cannot tolerate high knee joint loads. However, clinicians should be aware of the contraindications (eg, cardiovascular disease, extensive swelling, skin irritation, etc)”
        • Early use of Neuromuscular Electrical Stimulation (NMES):
          • “We recommend the use of neuromuscular electrical stimulation (NMES) in the very early phase after surgery to stimulate muscle activation or minimise the expected disuse atrophy. At the early phase, NMES might be used during functional activities to further facilitate strength gains.”
        • Manual Therapy:
          • Can be helpful with decreasing pain but needs to be performed in conjunction with exercise therapy for successful outcome to return to sport.
      • Return to sport:
        • An extensive test battery should be used for return to sport. This test battery should include limb symmetry strength and hop assessments. Further, the athlete should build up to sport specific demands and be able to perform confidently for return to sport.
        • Return to sport should not occur before 9 months.
          • A study published in the Journal of Orthopaedic & Sports Physical Therapy found that athletes who returned to knee-strenuous sports before 9 months had a 7-fold higher rate of sustaining a new ACL injury compared to those who waited until 9 months or later. This increased risk persisted even when accounting for factors like muscle function and symmetry.
          • Similarly, a study following 530 male athletes over 2 years post-ACL reconstruction showed no increased risk of new knee or ACL injuries for those who returned to sport after 9 months, provided they met rehabilitation criteria. In contrast, athletes who returned earlier without meeting these criteria had a higher risk of re-injury
    • Psychosocial Factors:
      • ​High risk of kinesiophobia (fear related to movement) after an ACL tear. It is an ABSOLUTE MUST to address this fear and have strategies to combat the fear or doubt of injury again. If this does not address the feedforward mechanism we discussed earlier is impacted and the athlete is at risk for reinjury. Our athletes do not get the green light to return to competition until they have completed a vigorous test battery specific to their sport AND both show and report confidence.

Bracing:

  • Prevention:
    • Does not significantly decrease risk of injury, strength and conditioning does.
    • The American Academy of Orthopaedic Surgeons state, “Prophylactic bracing is not a preferred option to prevent ACL injury.”
  • Return to sport post-op:
    • The American Academy of Orthopaedic Surgeons state, “Functional knee braces are not recommended for routine use in patients who have received isolated primary ACL reconstruction, as they confer no clinical benefit.”

 

Dry needling:

  • “We do not recommend the use of vastus medialis trigger point dry needling in the very early rehabilitation phase due to increased risk of haemorrhage.”

 

Whole body vibration:

  • “Whole-body vibration might be used as an additional intervention to improve quadriceps strength and static balance but cannot replace conventional rehabilitation. Given the additional cost, and the reported complications (pain or swelling) when using this intervention, we suggest not including this in the rehabilitation protocol.”

 

Continuous Passive Range of Motion Machine:

  • “There is no additional benefit for pain, range of motion or swelling in using continuous passive motion compared with active motion exercises. We recommend against using it in the rehabilitation protocol as it is time-consuming and costly.”

Icing/Cryotherapy:

  • Post surgery with excessive swelling:
    • Woah!!!! I thought you said to not ice because it can delay the healing process! Correct but we are making an exception here specifically for post-surgical ACL reconstruction, Why?
      • It’s effective for decreasing pain, it is not effective for decreasing swelling or improving range of motion.
        • So why is it here again? It’s safer than pain medication!

 

Playing Surfaces:

  • This topic is full of confirmation bias and natural fallacy – “grass is natural, therefore safer”, “we didn’t have turf when I grew up and let’s just say we didn’t have all these ACL injuries”, but that doesn’t downgrade the research that has been completed on it. The tricky part is the research is not consistent across different levels of play (high school, D1-D3, and professionals) nor is it consistent across sports.
    • It is a topic to keep our eye on as more research is completed but there are many other major factors to address prior to worrying about playing surface.

 

Low-Level Laser Therapy:

  • To prevent scar tissue build up:
    • The research showing this was completed on a population who had Open surgery (rarely done) vs Arthroscopic (commonly done). The majority of ACL reconstructions are done arthroscopically which creates much less scar tissue. If you fall into the arthroscopic category don’t waste time with laser therapy.
  • Photo biomodulation to increase healing time of the ACL:
    • Based on tooth fairy science and with high risk for placebo.

Pulled Hamstring

The most common sports injury! (Although most would think ACL because it’s on TV and social media all the time – the stats don’t lie). As well as it being the most common, it’s also one of the more complex injuries and the management is crucial!

There are 3 types of injury (myofascial, muscle–tendon junction, and intratendinous) with 3 levels of severity for each (grade 1, 2, 3). Each has their own return to play time and individualized hamstring program. Let’s make that clear:

  • For injury prevention a general hamstring program works great!
  • For a hamstring injury a “general” hamstring program will prolong your rehab.
    • Example:
      • A grade 1 myofascial injury can be aggressively loaded early with running and return to sport can happen in 2-3 weeks. A general hamstring program will prolong the rehab process by underloading the injured area.
      • A grade 2 intratendinous injury cannot be aggressively loaded. If a “general hamstring rehab” program loads too soon this can increase the severity of the injury.

To add even further to it, there is another category that has a gradual onset vs sudden onset called a hamstring tendinopathy. Rehabilitation will share some similarities but will be loaded more and even may be instructed to lean into discomfort for a gradual onset tendinopathy, whereas a sudden onset hamstring injury the instruction would be opposite to not worsen the initial tear.

We will not get into the specifics of how to do load management and exercise therapy for each injury here but we are working on resources that will. Stay tuned for those.

Prevention:

  • Strength & Conditioning:
    • If your sport has sprinting in it, sprinting needs to be part of your prevention program – no rules, no exceptions, it is a must. Why? The best hamstring exercise (nordic hamstring curls) only elicits 66% activation compared to sprinting. If you fail to prepare for the demands of your sport, your hamstrings will fail you. If you prepare for the demands your hamstrings will lift you to new levels of performance.
      • Furthermore, strengthening tends to bias the medial hamstrings (semitendinsoussemitendinosus semimembranisous) whereas most sprinting related injuries happen to the lateral hamstrings (the bicep femoris). A strength + sprint program with optimal load will address the entirety of the hamstrings.
    • Do not focus on stretching:
      Stretching does not change muscle or tendon tissue properties meaning it has no ability to prevent injuries. Instead focus on getting strong first, utilizing eccentrics to strengthen and lengthen, and as stated above, sprints.
  • Load management:
    • This example is TOO easy. Think of all the dads that “blow their hamstring” racing their kids after not sprinting for 5 years. Load management: prepare to perform instead of instantly spiking workload.
    • The other example is not as easy and more related to gradual onset hamstring tendinopathies but you need variety. Too much of the same thing for too long leads to overuse. Small changes in variety go a long way. For example, changing long steady state runs to interval running mixed with the longer steady state runs.
  • Psychosocial Factors:
    • High life stressors creating poor metabolic health can increase risk of injury.

 

After Strain/Injury:

  • Exercise Therapy:
    • Specific to the type of hamstring injury you have.
      • Include groin strengthening in conjunction with hamstring. The adductor magnus is an important teammate for the hamstrings.
  • Manual Therapy:
    • Use to decrease pain but needs to be done in conjunction with exercise therapy for successful return to sport.
  • Psychosocial Factors:
    • High life stressors can impact recovery, take care of these to decrease metabolic stress and improve recovery efforts. Learn how you can take care of your spirit and improve your adaptability to stressors in Reclaimed Athlete.

Prevention:

  • Stretching, “I stretched rigorously but pulled my hamstring. Help…”
    • Stretching does not prevent injury, at most it provides sensory enrichment which may be enough of a reason to do it but it should not be the focus.

 

After Injury:

  • If you’re following a general hamstring program, the likely outcome is that you will be significantly underloaded and away from your sport whereas a program specific for the hamstring injury you had will get you back faster.

 

Modalities (e-stim, laser therapy, etc.):

  • Don’t waste your time with these. Manual therapy can be more effective at alleviating pain symptoms, but the research is very clear: exercise therapy is the best for rehab.

Pelvic position/lower ab muscle control:

  • The prevailing thought is that an anterior pelvic tilt puts more strain on the proximal hamstring tendon and by having stronger lower abs you can counteract this position, thereby decreasing risk of injury. This is known as “lower crossed syndrome.” An interesting theory that has been…debunked.
    • At the same time developing more strength in other areas is never a bad idea so feel free to do so just don’t lose focus on the bigger factors.

 

Run Retraining (changing running form):

  • We almost had to put this in the “To Don’ts” because of the slight harm of the cost and wasted time of doing a treadmill video analysis running assessment being cue to “forefoot strike” vs “rearfoot” strike.
    • Here is the reality, get strong first then have variety in your running. Running at a faster cadence or speed (when able to) will fix your running mechanics.
  • The reason it is here is because this would still be better than modalities!

Pulled Groin

Let’s start with..the groin is the most underrated muscle group in the body. Athletes will focus on strengthening the glutes, hamstrings, quads AND neglect one of the most important muscles for performance: the adductors.

This muscle group does not just squeeze the thigh muscles together. The adductors help with sprinting, jumping, and create 50% of the torque needed to get out of the bottom of a deep squat (that’s right! Squatting is an adductor dominant exercise!)

Last quick point while nerding out about the adductor: the scary knee valgus that is always talked about…research has shown its not from weak glutes (medius, minimus). The smaller glute muscles actually become hip internal rotators vs external rotators and abductors as the hip moves into flexion. So what can create valgus? Weak Adductors! Aside from that paradigm shift in sports rehab and performance there are MANY other reasons to train this muscle group.

For Prevention:

  • Strength & Conditioning:
    • Add to Abd ratio: has emerged as a risk factor for a groin injury, specifically if the ratio is more than 90 percent being representative of full-strength recovery and less than 80 percent being predictive of future adductor strain (Thorborg et al 2011, Tyler et al 2001). Furthermore, Tyler et al 2001 showed in hockey that a player was 17 times more likely to sustain an adductor muscle strain if adductor strength was less than 80% of abductor strength!
    • Copenhagen progressions for adductor strengthening has become the “nordic curl for hamstrings”
    • Ensure total hip rotation range for both hips:
      • Note: in most sports the pivoting occurs with the pelvis rotating on the femur, therefore, its beneficial to develop the rotation via closed chain vs open chain or femur rotating on the pelvis. See example of an exercise here.
    • Load Management:
      • To prevent sudden onset/pulled groin: Build up to the demands your sport requires to avoid spikes in workload especially with running, cutting/pivoting, and jumping.
      • To prevent gradual onset/adductor tendinopathy: ensure variety in training program to not have too much of the same thing for too long.
  • Psychosocial Factors:
    • High stress levels can cause chronic tension in this muscle group as a way to protect a very valuable area of the human body. To decrease tension in this area, yes exercise will help, but we can do better. The key is to change the signal the brain is sending to this muscle group to “protect” by allowing the athlete to feel safe, confident, and thriving vs surviving. These skills can be gained in our Reclaimed Athlete course.

 

After Injury:

  • Rule out inguinal hernia:
    • This can be done with a simple physical examination looking for a bulge in the groin area, pain with activity (lifting, coughing, etc), or mechanism of injury
      • If there’s no bulge, no tenderness, and negative cough impulse a hernia becomes unlikely but not 100% ruled out.
        • Note: A sports hernia and inguinal hernia are two different things. The research in groin management is relatively newer and musculoskeletal injuries to this area have taken on different names through the years: sports hernia, athletic pubalgia, and gilmore’s groin – which are all synonymous with each other but not related to an inguinal hernia.
  • After ruling out inguinal hernia the conversation becomes similar to the hamstring convo above – it’s a bit more complicated and a general groin strengthening program is at risk of underloading and extending your time to return to play or overloading too soon and creating a higher severity of injury. We will not get into the extreme specifics here as it is a complex area, but we will provide as much value as we can below.
    • Exercise Therapy:
      • There can be a sudden onset (pulled groin while sprinting or pivoting) or gradual onset (adductor tendinopathy). Rehabilitation will share some similarities, but will be loaded more and even may be instructed to lean into discomfort for a gradual onset tendinopathy, whereas a sudden onset groin injury the instruction would be opposite to not worsen the initial tear.
        • Exercise Therapy should start with optimal loading (likely isometrics) progressing to concentric/eccentrics and then should include return to jumping, sprinting, and agility progression.
        • Include hip flexor and abdominal strengthening if symptoms are near the front of the hip.
        • Include hamstring strengthening if symptoms are near the back up of the hip.
        • To the previous 2 points we raise the question: Why not include both hip flexor, ab, and hamstring strengthening? We would, the benefits far outweigh the risk.
        • Restore total hip rotation:
          • Note: Pivoting and cutting in sports involve the pelvis rotating on the femur, not the femur rotating on the pelvis. Due to symptom severity total hip rotation restoration may start with Femur moving on pelvis rotation (open chain exercises, think of a clamshell exercise or figure 4 movement) but should progress to closed chain pivoting aka pelvis on femur rotation. See this video for an example:
    • Manual Therapy can be used to decrease pain symptoms but should not be a stand alone treatment – Exercise Therapy is needed for return to sport.
      • This can be more painful muscle strain because of the location. The adductor longus tends to be strained the most as it has the length of the tendon compared to the muscle is small. Also in the area are a lot of sensitive nerves, which makes sense as it’s located near the private areas.
      • Neural pain can be decreased with gentle nerve gliding of the obturator and sciatic nerve
        • Note: Due to the nerve sensitivity in this area a compression wrap may help decrease symptoms throughout the day. It’s not going to be the thing that gets you back to sport but it may help decrease some discomfort.
    • Psychosocial Factors:
      • Higher stress levels with poorer metabolic health can create long standing groin pain after a simple strain. Don’t let that happen – address these factors early. That is why we created Reclaimed Athlete for athletes to have tools to take care of these factors and not go on to have chronic discomfort.

The need for surgery is unlikely and does not improve return to sport time:

  • “a recent systematic review has indicated that nonsurgical and surgical interventions have similar return-to-play times.”

 

Injections:

  • Platelet Rich Plasma (PRP):
    • Saline injection will create the same effect (or lack thereof). Save your money on this one.
  • Cortizone
    • Creates a catabolic effect and can cause tissue to take longer to heal, not worth it when there are better strategies available to decrease pain

 

Intra-tissue percutaneous electrolysis (EPI) – acupuncture needle into the site of injury with a galvanic electrical stimulation:

  • Difficulty area to access and with the evidence currently being low quality the benefit of this treatment does not outweigh the risk.

Shockwave:

  • The research on this topic currently is biased due to low quality methodology. It’s been claimed that it gets athletes to return to play faster, however we suspect as higher quality studies are done they will find this is due to other factors.

Low Back Pain

We have to clear the air here…a bad back is not genetics, it’s environmental. Over 90% of low back injuries heal on their own with no intervention whatsoever.

And while we have your attention, it’s worth noting: an initial back injury may have been caused by playing a sport, but if symptoms are still present 20 years later, it’s not the original injury itself—it’s likely high stress and poor metabolic health that are allowing the symptoms to persist.

Now that the air has been purified, we will acknowledge that low back pain is complex, multifactorial, and a bit different for each person. To be precise in this resource, we will focus on only two categories of back injury: disc herniation and lumbar hyperextension injuries (spondylolysis and spondylolisthesis).

Disc Herniation

“A slipped disc” which is a funny name because discs don’t actually slip.

The spinal disc or intervertebral disc is comprised of two main parts the outer annulus fibrosis and the inner nucleus pulposus. A disc herniation occurs when the nucleus pulposus begins to push (lower severity) or escapes (higher severity) the nucleus pulposus. This causes a compression of the spinal nerves leading to numbness, tingling, burning, etc along the nerve root (typically down the back of the leg) and back pain.

The 4 types of disc herniation from least to most severe include bulging, protrusion, extrusion, and sequestration. Interestingly and somewhat counterintuitive, the most severe disc injury has shown to have the greatest ability to heal itself.

“The human body is much more robust, adaptable, creative, and has amazing healing capabilities making it overall a fun mystery with twists, turns, head-scratching, and unknowns. For example, in the case of disc herniations where research has found the rate of spontaneous regression or healing to be 96% for disc sequestration, 70% for disc extrusion, 41% for disc protrusion, and 13% for disc bulging.” p. 67 from Top-Selling Book Hope Not Nope

Another counterintuitive point we want to add in is that disc herniations are not abnormal and actually become more normal as we get older.

“Every single day, people, likely you, are being fed the idea that you are broken or not enough! You are being fed these lies about the human body or not being told the entire story. Ready for the truth? The prevalence of disc herniation increased from 30% in 20 year olds to 84% in 80 year olds, again with no pain or dysfunction.” p. 46 Hope Not Nope

Prevention:

  • Load Management:
    • If you haven’t done one deadlift in 6 months and then you go into pre-season workouts that have deadlifts 2x per week at a moderate load – your risk for injury is higher. Not because of the deadlift, because of your lack of preparation.
      • To be clear: Movements do not cause injury, the lack of preparation for the movement causes injury.
        • ***Note: A common injury pattern we have been seeing is athletes having low back pain because in attempts to prevent “rounding of the spine” they overarch into spinal extension. In doing so, they irritate the facet joints and often are misdiagnosed with a disc herniation.
    • There’s being underprepared from not building tissue capacity and then there is being underprepared from overpreparing and not given your body the time it needs to recover. Optimal loading and recovery is key.
  • Strength & Conditioning:
    • Fun fact: Like other tissues in our body, spinal discs adapt and become stronger to the stressors placed upon them. Whether it be compressive forces from running or shear forces from hip hinging, the annulus fibrosis can become more resilient and help prevent and bulging of the nucleus pulposus.

 

After Injury:

  • Medical Imaging (X-ray, MRI):
    • If there is a reason to suspect fracture (fall from a tall height, car accident, high impact contact compression injury, etc) and if there are changes in reflexes, bowel & bladder behavior, and sensation changes in the saddle area seek imaging.
  • Exercise Therapy:
    • Directional preference: Don’t go right to “McKenzie Extension exercises” or an Extension based protocol. Instead, undergo a directional preference exam to learn what direction helps to centralize symptoms (Centralization means pain moves toward the spine, a good sign of improvement) and which direction peripheralizes your symptoms (while peripheralization means pain spreads outward, often indicating worsening nerve irritation).
    • It’s long been thought that spine extension (press-ups, cobras, etc) push the disc away from the nerve roots. That science was from cadavers and is now outdated.
      • Modern research has shown flexion (rounding the spine) can push the disc away from the nerve roots, whereas extension can push them towards the nerve roots.
        • The takeaway being, undergo a directional preference exam and initially move in the direction that centralizes symptoms. Once symptoms have decreased, improve core strength, and the ability to move in all spinal positions without fear.
    • Exercise therapy/conservative management should be conducted for a 3 month period prior to seeking surgery. The only exception is if there are other complications described above in the medical imaging section.
  • Manual Therapy:
    • Manual Therapy can be used to decrease pain symptoms but should not be a stand alone treatment – exercise therapy is needed for return to sport.

 

Psychosocial Factors

  • Higher stress levels with poorer metabolic health can create long-standing back pain. Don’t let that happen; address these factors early. Furthermore, misinformation from outdated research can cause fear and doubts that impact the person’s ability to move the way they were created to. That is why we created Reclaimed Athlete for athletes to have tools to take care of these factors and not go on to have chronic discomfort.

Avoid imaging if:

  • There is no reason to suspect fracture and no changes in: reflexes, bowel & bladder behavior, sensation in the saddle area.

 

“Lean into the discomfort”

  • The goal of exercise therapy is to “centralize” the symptoms meaning no longer having the neural symptoms through your leg. Even if back pain becomes slightly increased but symptoms are no longer traveling down your leg – this is a great sign!

 

Corticosteroid injections:

  • “No articles with high evidence levels comparing the usefulness of epidural corticosteroid injection therapy with that of other therapeutic methods are available.” Our opinion is the risk is higher than the benefit until more research is available.

Modalities including electrical stimulation, massage, acupuncture, ultrasound, and traction:

  • “It is not advised to use non-invasive therapies including heat/cold therapy, traction, massage, acupuncture, bed rest, or therapeutic ultrasound.”

 

Body Mechanics:

  • High-risk of confirmation bias and an industry that makes millions of dollars – the body mechanics industry preaching on “proper lifting technique.”
    • Research has debunked that rounding the back is the clear mechanism of disc injury and ruled in the factor that matters more: load management.
      • With that being said, body position and having the body control to execute lifts in various fashions can be helpful for injury prevention and to work around symptoms if injury is present.
        • To paint this picture clearly: We worked in the CrossFit space for years and can attest that people can lift with very sloppy form, but if they have built up weight using that sloppy form, they don’t get hurt. Their performance does become limited though, due to inefficiency.

Lumbar Hyperextension based injury (Spondylolysis & Spondylolisthesis)

Simply stated, the mechanism of injury for spondys is much clearer than that of disc herniations. Spondylolysis & Spondylolisthesis injuries are a result of repetitive over-arching or extension of the lower back. The force combination of repetitive over-arching, compression, and slight rotation creates a fracture to the vertebral bodies facet joint.

The term spondylolysis = a fracture of the facet joint. Spondylolisthesis = a fracture of the facet joint with forward motion of the vertebral body.

The spine is strong with thick supporting ligaments (layers of ligaments, fascial tissue, and muscle) to protect it. This helps us to understand this injury is common only in a few sports, ones that have repetitive forceful extension – gymnastics and wrestling. What else do these sports have in common?

Cutting weight by restricting calories. In gymnastics to try to achieve the impossible “perfect body” and for wrestling to make your weight class. The result of cutting calories consistently with overtraining leads to REDS (relative energy deficiency syndrome). One of the many effects of REDS is decreased bone health and increased risk for fracture.

Prevention:

  • Metabolic Health:
    • Consume the amount of calories that you need to perform, recover, and frankly to be a human. Yes, some sacrifice is needed at some points but living in a caloric deficit is NOT healthy for anyone!
    • Take care of psychosocial factors:
      • The idea of being “perfect” in gymnastics takes a toll on a young athlete’s spirit. Ensure you know your identity, core values, and how to strengthen your spirit. We show you how to do exactly that in our Reclaimed Athlete online course.
  • Load Management:
    • For athletes at risk monitor intensity and reps of repetitive high force spine extension based movements.
  • Strength and Conditioning:
    • Building core and leg strength can add a layer of protection. If the athlete is worried about “losing flexibility” as a result of getting stronger, focus on an eccentric based program to both strengthen and lengthen.

 

After Injury:

  • Medical Imaging (X-ray, MRI):
    • If there is a reason to suspect fracture (fall from a tall height, car accident, high impact contact compression injury, etc) and if there are changes in reflexes, bowel & bladder behavior, and sensation changes in the saddle area seek imaging.
  • Exercise Therapy:
    • Directional preference: with this being an extension based injury its typically recommended that spinal extension or hyperextension be avoided for a period of time to allow the irritated facets joints to become less or not at all irritated.
      • The focus should be on developing spinal flexion mobility and strength as well as core and hamstring strength.
    • Once symptoms have calmed down or been abolished the athlete should go through a specific return to sport program to ensure they are able to tolerate the stressors (especially the compression forces in landing from high heights in gymnastics).
  • Psychosocial Factors:
    • Athletes tend to not do great overall when they are not able to train and compete in a sport they love. When this happens we can help the athlete strengthen their recovery efforts by giving them the tools to build up their spirit. That’s exactly why we made Reclaimed Athlete.
  • Bracing:
    • Pending on the severity can be helpful to decrease initial symptoms but the athlete should not become reliant on the brace long term.
  • Surgery***
    • MAY be appropriate pending results from imaging + symptoms of what is presented in the above medical imaging section. If the symptoms are not that of reflexes, bowel & bladder behavior, and sensation changes in the saddle area, conservative management has been shown to be as effective as surgical management.

Press-up or spinal extension + rotation based exercises:

  • Don’t poke the bear, let the irritated facet joints be at peace and heal.

 

Traction:

  • From a clinical practice guideline: “Lumbar traction is contraindicated.” From us: The risk is higher than the benefit, not worth doing.

 

Spinal Adjustments (high velocity thrust):

  • The area is fractured, please don’t add more stress to an area that is trying to heal! Low level (grade 1) mobilization may be used AWAY from the injured area to decrease the output of pain, BUT again do not let someone “adjust” your low back if you have a spondy.

Modalities (electrical stimulation via TENS, therapeutic ultrasound, etc):

  • May help decrease pain but high-risk of placebo. Manual therapy + exercise therapy are better solutions to seek.

Shoulder Impingement Syndrome / Rotator Cuff Pain

Shoulder impingement syndrome is a misnomer at worst and an umbrella term at best. Whichever way it falls, it can be agreed upon that the shoulder is the most commonly injured area of the upper extremity in a wide variety of sports. We will not cover every single type of injury that this area of the body can encounter, but will focus on a couple by demonstrating what the umbrella term “shoulder impingement syndrome” covers.

Primary Shoulder Impingement

Mechanical compression of the rotator cuff tendons or subacromial bursa beneath the acromion, often due to structural abnormalities like bone spurs or a hooked acromion.
This concept from 1972 has been challenged in recent years for great reasons. The acromion process extends from the shoulder blade and meets the clavicle creating the acromioclavicular joint. A common surgery used to treat primary shoulder impingement is a clavicular decompression which involves shaving down the end of the clavicle to get the shoulder “more room to move.” But here’s the challenge to that theory:

“Another classically held belief is the clavicle plays a significant role in shoulder discomfort requiring it to be shaved down in the case of shoulder impingement. Researchers, Paavola et al 2020 completed a shoulder decompression surgery in one group and sham surgery in another one. The outcomes were no different both at 2 and 5 years!” p. 26 Hope Not Nope

To further challenge the traditional theory, multiple studies have concluded the same thing: It’s not about the space – it’s about the tendon – the rotator cuff tendons.

A 2021 study found that individuals with symptomatic subacromial impingement syndrome actually had larger acromiohumeral head distances, meaning more space.

Another finding was greater thickening of the supraspinatus tendon compared to people without symptomatic shoulder pain suggesting that the symptoms associated with subacromial impingement syndrome were related to the tendon itself rather than the subacromial space!

In light of traditional concepts being challenged and frankly debunked, modern day management of the Athlete’s shoulder has drastically improved and a new umbrella term has been introduced.

Rotator Cuff-Related Shoulder Pain (RCRSP)

An overarching term that encompasses a spectrum of shoulder conditions including; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, and symptomatic partial and full thickness rotator cuff tears. The common presentation is discomfort with overhead movement.

The most common patterns we have found in the athlete with RCRSP is this:

  • Too much overhead motion without enough dynamic stability from the rotator cuff and other musculature.
    • The shoulder has the greatest range of motion which means the cuff has a large responsibility – not as a rotator – but as its main role: a dynamic stabilizer.
  • Not enough functional motion for the demands of their sport causing irritation from working at available end ranges.
    • Not to simplify it but too hands down oversimplify it – ensure you have the required motion needed to complete the movements your sport demands.
  • Error in load management (most common)
    • Covered in more detail below
  • Shoulder overcompensating for deconditioned or underdeveloped areas
    • Typically, Olympic weightlifters and functional Fitness Athletes although other sports can fit into this category as well.
      • Lifting Example:
        • A squat snatch is a complex lift involving the entire movement system. If an athlete is limited in ankle mobility or stability they will shift their trunk forward (hips back, chest forward) as a counter balance. The counter to this counter balance of the weight being overhead is the shoulders shifting the barbell further back into shoulder flexion. In this scenario to help the shoulders, help the ankles.
      • Throwing Example:
        • Throwing power is generated from the hips. If the rotational power of the hips is lacking a pitcher may rely on further torque development from the shoulder. The higher acceleration of the shoulder to make up for the hips, the higher the deceleration demands on the rotator cuff. So you can keep doing banded cuff exercises and wondering why your shoulder remains sore OR you can add in lower body/core rotational development based exercises complemented with cuff conditioning and enjoy your time on the mound.

Prevention:

  • Load Management:
    • Throwing Athletes: Follow the Pitch Smart guidelines.
      • Side note: most youth pitchers, once done pitching, are moved to shortstop or third because of their arm strength. Consider 2nd base as a shorter throwing distance to protect the arm in the same game once their pitching outing has concluded.
        • If playing on multiple teams at the same time, the pitch guidelines should not be independent to that team and should be dependent on OVERALL total pitches.
        • You can cheat the system but the data is clear – you’ll cheat yourself out of future opportunities on the field and create a lot of time spent in sports rehab.
    • Weight Lifting:
      • Ensure you have the required pre-reqs to complete the movements in your training.
        • Movements do not create injury – not being prepared for movements does.
          • Example: If you have not built the capacity to front squat, let’s not add a squat clean on top of a shaky foundation.
    • Other:
      • General load management principles apply. Don’t spike your volume or intensity too much too soon OR do too much of the same thing for too long.
        • Let’s directly hit it: Bench press and push-ups
          • Most athletes (male more than female) will tell us they Bench 3x per week and do push ups nearly every day. Great, we get it, a big chest aesthetically looks good but how does it help perform? Especially, if there is a massive imbalance between the anterior shoulder vs posterior shoulder? We strive for balance with horizontal pushing vs pulling in our programs for long term shoulder health while still honoring aesthetic goals. Take a peek at your program and ensure some balance between pushing and pulling (specifically horizontally: rowing, face pulls, etc)
            • Why Horizontal pull and not vertical pulling?
              • We get the: “Well I also do a lot of pull-ups”. This is a vertical pull focused on the lats which attach from the sacrum up to the shoulder blade and then to the FRONT of the shoulder. Although it is a pulling movement it adds to more shoulder imbalance due to its attachment point.
  • Strength & Conditioning:
    • The best way to prevent RCRSP – prepare your movement system for the demands your sport requires.
      • To ensure you have the motion needed for your sport, focus on eccentric strengthening.
        • Stretching does not change muscle or tendon tissue properties meaning it has no ability to prevent injuries. Instead focus on getting strong first, utilizing eccentrics to strengthen and lengthen
          • Example: DB Lat Pull Over
      • Athletic movement is never isolated to one joint, muscle, or fascial tissue; it is a dynamic complex system that works together. It is crucial to look at other areas of the body and address any weaknesses that may be causing the Plantar Fascia to take on more force than it should. With our athletes, we do a Phase 1 Assessment to find any contributing factors. We need to look at the whole and take care of the whole, not just the “parts.
  • Psychosocial Factors:
    • Research is showing those that have higher levels of stress, depression, anxiety are more at risk of experiencing pain from an irritated tendon and to have the initial pain turn to chronic pain. Does it have to follow that course? Nope, address the psychosocial factors and the path can change drastically.
    • Also with high levels of stress, the brain signals the body to “protect.” How does it protect and what does it want to protect? Or another way to ask: If the shoulder is sore what position does it instinctively go to? Across the chest while the shoulder blade shrugs up towards your ear. This protects vulnerable “kill areas” of the neck, in doing so the resultant muscle tension can create further irritation. How do we change it? Change the signal from “I’m in danger, I need to protect” to “I’m safe.” How do you do that? Check out the tools in Reclaimed Athlete.

 

After Injury:

  • Exercise Therapy:
    • Focused on building the capacity needed to return back to your sport from available range of motion, dynamic stability related movements of the shoulder, and overall shoulder strength + power.
      • The program should be progressive and when ready should include power based movements: med ball slams are a great bridge between strength and return to throwing protocols.
  • Manual Therapy:
    • Joint mobilization and soft tissue work can help to decrease pain but again to get back to your sport exercise therapy is a must.
      • Do you need specialized manual therapy?
        • Note*** it does not matter the technique used, manual therapy does not change tissue quality. It is an input to the nervous system to change the output of the nervous system. There is benefit to that of alleviating symptoms BUT for full return to sport exercise therapy is needed.
  • Psychosocial Factors:
    • Athletes tend to not do great overall when they are not able to train and compete in a sport they love. When this happens we can help the athlete strengthen their recovery efforts by giving them the tools to build up their spirit. That’s exactly why we made Reclaimed Athlete.
  • Is surgery needed for rotator cuff tears?
    • Depends on the type of tear and symptoms. In most cases conservative therapy should be utilized first.
      • Many athletes show rotator cuff tearing on imaging but have no symptoms or dysfunction associated with it.
      • Furthermore, research has shown a successful outcome after a surgery is NOT dependent on if the cuff stays intact.
    • If surgery is required, what about biological patches?
      • What are they?
        • Biologic patches (e.g. bovine-derived, porcine, human dermal allografts) are scaffolds placed over or within the repair site.
          • The theory: they provide mechanical support, promote tissue regeneration, and reduce re-tear risk.
      • Do they work?
        • The research via randomized controlled trials and meta-analyses (e.g., Bailey et al., 2020, and others) show little to no consistent improvement.
          • Many studies are small, underpowered, industry-funded, or have high bias risk.
      • Placebo effect or patch hype?
        • Improvements seen in some studies are often similar to placebo or standard care.
        • Imaging follow-ups often show no structural or healing advantage long-term.
        • When improvements are seen, it’s often not statistically or clinically significant.
      • Real Concerns of biological patches:
        • Cost: These patches are expensive, often not covered by insurance.
        • Risk: Some have been associated with inflammatory reactions, graft rejection, or infection.
        • Regulation: Many are cleared via 510(k) process, meaning no need to prove clinical effectiveness, just similarity to existing devices.
      • Bottom Line:
        • Biopatches — especially bovine and other xenografts — are currently more marketing than medicine. They might have some promise in the lab, but real-world evidence doesn’t justify the hype or the cost.
        • Until we have large, independent RCTs showing meaningful patient benefit, these patches are glorified cow band-aids.

Rely on imaging results (X-ray, MRI):

  • “Research using ultrasound imaging has found that 96% of people without shoulder pain or dysfunction showed “abnormalities”, MRI has found that 90% of professional pitchers in the MLB showed cartilage dysfunction and 87% showed abnormal rotator cuff tendons and guess what? They had no pain and were able to complete one of the most impressive but violent motions the shoulder experiences via pitching at high levels! Imaging and a 2-minute conversation is not enough, to quote worldwide orthopedic surgeon, Dr. James Andrews, “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI.” p. 47 from Hope Not Nope

 

Injections:

  • Platelet Rich Plasma (PRP):
    • Saline injection will create the same effect (or lack thereof). Save your money on this one.
  • Cortizone
    • Creates a catabolic effect and can cause tissue to take longer to heal, not worth it when there are better strategies available to decrease pain.

 

Clavicular decompression surgery:

  • See intro of this section: research has shown no difference between this surgery vs placebo vs conservative management – this surgery is unnecessary.

 

Shockwave Therapy:

  • From clinical practice guidelines: “Clinicians should not use or recommend extracorporeal shock wave therapy to reduce pain…”

Taping (Kinesiotape or rigid taping)

  • Sensory input that can alter the symptoms or output. It is not too costly and does NOT need to be applied in a specific way – making it easy, do it yourself or have someone slap it on (gently) for you.

 

Electrical Stimulation:

  • The ol buzzy machine with pads placed on your shoulder also known as TENS unit
  • May decrease symptoms short-term but there are more effective ways available.

 

Low-level laser therapy (LLT)

  • Risk of placebo is high, shows “effectiveness” but not “efficacy.” Simply put, it’s “Tooth Fairy Science”

 

Dry Needling:

  • Research is conflicting – it may be good to decrease symptoms short-term that are highly irritable. At the same time, the research is newer and has high-risk of placebo effects.

Elbow Pain (Golfer’s Elbow / Tennis Elbow)

A nagging annoyance felt on the outer elbow (tennis elbow) or inner elbow (golfer’s elbow) typically caused by chronic overuse OR a sudden increase in workload of the wrist extensors (tennis elbow) and wrist flexors (golfer’s elbow).

The following “To Do’s/To Don’ts” will group these together but point out the small nuances of each.

Prevention:

  • Load Management:
    • Most golfers and tennis players spend the winter not swinging a club or racquet. Then, the sun peaks out from behind the grey, snow melts, and they go from 0 swings per week to 150+. Having a ramp-up plan that allows your elbow tendons to adapt to the stressor of gripping and swinging can prevent this injury.
    • Although more common in golf and tennis, hence the names “golfers elbow” and “tennis elbow” they are not exclusive to these sports. We have seen an increase in weightlifters and functional fitness athletes that have a sudden spike in grip related exercises (carriers, deadlifts, pull-ups, etc). The strategy for prevention doesn’t change – ramp it up to prevent!
  • Strength & Conditioning:
    • Developing layers of elbow strength helps the area to become more resilient to stressors of your sport.
    • Strengthening areas throughout the body ensure that the elbow is not taking on unnecessary force.
      • For example, a tennis player with limited or deconditioned rotational strength may compensate by using more of their shoulder putting more stress on the elbow.
  • Psychosocial Factors:
    • Some can get away with a big increase in workload while others don’t? Why does that happen? Different metabolic health and ability to adapt to stressors. We recommend athletes get on the offensive and address metabolic health by strengthening their spirit. That’s exactly why we made Reclaimed Athlete.

 

After Injury:

  • Exercise Therapy:
    • For sudden onset: Decrease load on the irritated structure.
      • Golfer’s elbow: Take some time to work on your short game and then when symptoms are gone start reintroducing the longer shots and driving.
      • Tennis elbow: Allow symptoms to calm down, keep working on footwork, core, and shoulder strength while overall swing volume is decreased. Once symptoms are gone gradually build back up swing volume. Note: backhand swings are likely the most provocative, add this in once other swings can be completed symptom free.
      • For weightlifting/functional fitness athletes: Decrease load of grip related exercises and then build back up once symptoms have decreased.
    • For gradual onset (chronic overuse): Tennis and Golfer Elbow:
      • Now we are in the territory of a tendinopathy, in which the treatment may be an increase in loading the specific muscle groups to microdose the inflammatory process to help the stubborn tendon adapt.
  • Manual Therapy:
    • Can be used to decrease symptoms, but to return to sport Exercise Therapy is needed.
    • Do you need specialized Manual Therapy?
      • Whether you want to roll your elbow on a lacrosse ball or see a professional for soft tissue work the results are the same.
  • Counter-Force Bracing (elbow strap) or Rigid Taping Techniques:
    • Research has shown it is good to alleviate pain and improve elbow function in the short-term but it should not become relied upon. Again for long term results load management principles + exercise therapy are the golden ticket.
  • Specific for Golfer’s Elbow:
    • See a clinician to rule out UCL injury of the elbow, Ulnar nerve compression, and that it’s not a neck related issue showing itself as a medial elbow discomfort (cervical radiculopathy). There are similarities in treatment strategy but also slight differences. We believe in being precise and a Rehabilitation specialist (Physical therapy, physio, athletic trainer) will help you create a precise plan while ruling out other factors.
  • Specific for Tennis Elbow:
    • There is less to rule out in this area but still worthwhile to ensure it’s not a neck related issue showing itself as lateral elbow discomfort (cervical radiculopathy). There are similarities in treatment strategy but also slight differences. We believe in being precise and a Rehabilitation specialist (Physical therapy, physio, athletic trainer) will help you create a precise plan while ruling out other factors.
  • How can you tell the difference between cervical radiculopathy vs true elbow symptoms?
    • If it’s the elbow:
      • Pain is localized to the tendon (medial or lateral elbow)
      • Pain increases with gripping, wrist extension or flexion under load
      • No neck involvement or nerve symptoms
    • If it’s from the neck (cervical radiculopathy):
      • Pain may travel from the neck or shoulder down the arm
      • Numbness, tingling, or weakness may be present
      • Neck movements (like turning or extending) reproduce, worsen, or alleviate symptoms
      • Positive Spurling’s test, and possible symptom relief with neck traction
    • A trained clinician can differentiate between true tendon irritation and nerve root referral with a thorough assessment.
  • Psychosocial Factors:
    • If your symptoms are feeling like they are drawn out longer than they should, it’s a sign that your metabolic health could use some help in better adapting to stressors you face. We recommend doing that by taking care of your spirit. How would you do such a thing? Check out Reclaimed Athlete.

Injections:

  • Platelet Rich Plasma (PRP):
    • Saline injection will create the same effect (or lack thereof), Save your money on this one.
  • Cortizone:
    • Creates a catabolic effect and can cause tissue to take longer to heal, not worth it when there are better strategies available to decrease pain.

 

Phonophoresis (ultrasound using medicated topical gel):

  • Low to no effectiveness. From the clinical practice guidelines: “Clinicians should not use phonophoresis with 10% hydrocortisone gel, topical prednisolone (2 mg/d), or 1% diclofenac sodium gel.”

Low-level laser therapy (LLT)

  • Risk of placebo is high, shows “effectiveness” but not “efficacy.” Simply put, it’s “Tooth Fairy Science”

 

Dry Needling:

  • Research is conflicting – it may be good to decrease symptoms short-term that are highly irritable. At the same time the research is newer and has high risk of placebo effects.

Tension & Cervicogenic Headaches

Just the name sounds terrible, right? Nobody enjoys a headache.

Thankfully, there are solutions.

A tension headache is described typically as a mild to moderate, dull, aching pain that feels like a tight band around the head. It’s often bilateral (both sides), and is brought on by the combo of high stress and low ability to adapt to the stressors.

The other type of headache experienced by athletes is not tension type headaches, but cervicogenic headaches. This presentation includes one side pain irradiating from the neck and sometimes feel like something is “locked.” Symptoms may be precipitated by pressure over trigger spots in the cervical/nuchal areas or sustained awkward neck positions.

The strategies for both are similar but also have their own nuance.

Address Psychosocial Factors:

  • In a stress response, the muscles of the neck (upper trap, scalenes, etc) get the message to protect. How do they protect? They contract. What happens when they contract for a prolonged period of time? It changes the nerves abilities to glide and receive nutrients. When this happens they become irritated and let you know by creating the headache that ranges from the back of your neck and raps around the head in a “Ram’s Horn” distribution.
  • The goal is to not GET RID of stress that CANNOT BE DONE. What the successful approach is to improve your adaptability to stress by having the tools to do so. Learn how in our Reclaimed Athlete online course.

 

Exercise Therapy:

  • Exercise can help decrease sympathetic tone (fight or flight) part of the nervous system in a positive way the improve overall metabolic health. A combo of aerobic and strength training should be used.
  • Relaxation techniques: deep breathing and progressive neuromuscular techniques can help to decrease sympathetic tone as well.

 

Manual Therapy:

  • For Cervicogenic headache:
    • Cervical Manipulation should be considered to alleviate discomfort and “locking” sensation.
      • Screening should be done to ensure they are a candidate to safely receive a cervical manipulation
  • For tension-type headache:
    • A combo of manual therapy (techniques for relaxation over adjustments) and exercise therapy has shown positive benefit in allevaiting tension type headaches.
  • Reliance on any modality (therapeutic ultrasound, electrical stimulation – TENS, traction, low-level laser therapy, dry needling, etc) on its own.

  • Imaging without red flags: Routine imaging isn’t necessary unless serious pathology is suspected.

Self-SNAG techniques: basically using a towel to apply pressure to the back of your head.

  • The research is mixed on this as far as how much benefit it creates, BUT it can be done easily at home independently, so it may be worth trying out.

 

Low-level laser therapy (LLT)

  • Risk of placebo is high, shows “effectiveness” but not “efficacy.” Simply put, it’s “Tooth Fairy Science”

 

Dry Needling:

  • Research is conflicting – it may be good to decrease symptoms short term that are highly irritating. At the same time, the research is newer and has high risk of placebo effects.

Sport-Related Concussions

A sports-related concussion is a mild traumatic brain injury caused by a blow to the head or body, creating movement of the head that results in a rapid, short-lived disruption of brain function. It doesn’t have to involve a loss of consciousness, but it can leave athletes feeling like their brain got tossed in a blender — temporarily dizzy, foggy, slow, or just not quite “right.”

It affects how the brain functions — not how it looks on a scan.

Recovery Stats (a bit of good news):

  • 80–90% of athletes recover from an acute concussion within 7–14 days (a bit longer in younger athletes).
  • Only about 10–20% develop persistent symptoms, known as post-concussion syndrome (PCS).
  • Even among those, most do improve with proper care over time.

 

So, while concussions are no joke, most athletes bounce back fully — especially with early rest, gradual return to activity, and avoiding the classic mistake of “playing through it.”

Prevention:

  • Guardian Caps:
    • They DO NOT prevent concussions and have never claimed to.
      • From their website directly:
        • “No helmet, headgear, or chinstrap can prevent or eliminate the risk of concussions or other serious head injuries while playing sports or otherwise. Researchers have not reached an agreement on how the results of impact attenuation tests relate to concussions or other injuries. No conclusions about a reduction of risk or severity of concussive injury or other injury risk should be drawn from impact attenuation tests.”
          Even the data on softening impact forces is weak at this point. Yes, the NFL has mandated them in pre-season but that doesn’t mean everyone needs to follow suit. Especially when the data is extremely weak yet looks good on media for “player safety.”
  • Rule changes – the thing that HAS made a difference in play
    • Concussion rates dropped significantly following key rule changes, especially:
      • 2013: Ban on crown-of-helmet hits
      • 2016: Expanded definition of defenseless player
      • 2018: “Lowering the head to initiate contact” rule
        • A 2021 study in The American Journal of Sports Medicine found:
          • A 23% decrease in concussion incidence after the 2018 helmet-lowering rule.
    • Kickoffs, once a concussion hotspot, saw notable reductions in injuries after formation changes limited high-speed collisions.
  • Address Psychosocial Factors:
    • Some type of impact is needed as a mechanism for injury but there is more to it than just impact.
      • “A player can score a touchdown and celebrate with teammates with multiple headbutts, yet everyone walks away with no concussion. Now, a defenseless player going up for a ball across the middle getting hit is a completely different story, even with the same amount of impact as the player getting head-butted by his teammates in celebration. What are the differences? Being in control of the situation vs unknowingly being attacked. The person headbutting teammates in celebration knows the headbutt is coming but also knows that in football this is a social bonding construct. The defenseless player on the other day does not know the hit is coming, cannot prepare for it, and the social construct surrounding this situation is harm. One leads to a celebration, one leads to the blue tent being popped up for further evaluation.” from Hope Not Nope

 

After Injury:

  • Rule out higher-level brain injuries: should be done by a healthcare provider who will rule in need for imaging and higher-level care based on cranial nerve changes, presence of cerebrospinal fluid, and other symptoms.
  • Exercise Therapy:
    • Follow symptom-based guidelines for return to sport. Don’t rush it and follow the guidelines to a T. Example here.
  • Load Management:
    • Relative rest for 24 hours, reducing but not complete bed rest, and avoidance of cognitive strain (screens, reading). The optimal load will be whatever amount does not make symptoms worse.
  • Sleep Management:
    • Sleep is extremely helpful in the brain’s healing. If you struggle with sleep, download our sleep guide, which will give you tips to improve your sleep performance.
  • Address Psychosocial Factors:
    • Athletes tend to not do great overall when they are not able to train and compete in a sport they love. When this happens, we can help the athlete strengthen their recovery efforts by giving them the tools to build up their spirit. That’s exactly why we made Reclaimed Athlete.
  • It is NO longer recommended to stay in a dark room for 24 hours after a concussion injury. Instead, relative rest is recommended, where the goal is to decrease cognitive and physical strain versus getting rid of it completely.


  • Increase caffeine dose or start using caffeine for the first time while symptomatic.

ICE YOUR HEAD:

  • It sounds silly but I have seen too many coaches throw an ice pack on a concussed players skull at this point.

 

Supplements:

  • They are in this category because the research is mostly:
    • On animal vs human studies
      • Been completed in neurodegenerative conditions versus concussion
      • Some benefits but more research needs to be done for full understanding and recommendations
    • Nonetheless, here is a list of the many supplements that fall into this category:
      • Omega 3’s – Anti-inflammatory, neuroprotective
      • Creatine – thought to help restore ATP in the brain but taken at high dosages 10-20 g/day. (note: that is a lot of creatine!)
      • Zinc – neuronal repair and neurotransmission
      • Magnesium – Helps regulate NMDA receptors and neuron excitability
      • N-Acetylcysteine (NAC)
      • Resveratrol – May help reduce oxidative damage and protect the blood-brain barrier
      • Vitamin D – Neuroprotective, anti-inflammatory, supports neuroplasticity
*The reference list for the data provided in this resource is exhaustive, but available upon request. Also, if you type in (name of sports injury) clinical practice guideline to read them for yourself – most are open access*

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