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Solving the Athletic Patient Puzzle
Stephen Clark, PT, DPT, MHS, OCS, MBA

In order to be successful in sports rehab, therapists must adjust their methods.

Is there really a difference between rehabbing a competitive athlete and a sedentary patient?  Do weekend warriors and professional and Olympic athletes really require a different approach than your average worker or orthopedic patient?  The answer is a resounding “Yes,” and to become a successful athletic physical therapist and sports medicine specialist, you must understand what makes the athletic patient different from the rest.

Reducing a patient’s activity level is sometimes challenging, but try telling a weekend warrior or professional athlete that they need to rest and you had better have track shoes on ready to catch them as they run out of your clinic.  The last thing a competitive athlete wants to hear is that they cannot participate in their sport.  Sometimes they will lie, cheat, and steal just to keep playing.  A good sports medicine physical therapist or athletic trainer sympathizes with this behavior and tries every possible way to keep the athlete playing.  Part of it is a negotiation between you and the patient, eg, “In order to allow your back to recover, I’ll let you throw the ball but absolutely no swinging the bat.”  If an athlete know you are working with them, they are more likely to follow your program.  However, it cannot just stop with good negotiation techniques.  Athletic therapists must have additional tools to make a difference for this demanding patient group.  For an athletic patient to maintain their highest possible level of participation while injured, the athletic therapist must understand and master the Irritability Threshold Matrix (ITM).

Irritability Threshold Matrix

The Irritability Threshold Matrix is a tool used by the athletic physical therapist or athletic trainer during rehabilitation to allow the athlete to continue to participate in their sport at their highest possible level while simultaneously maximizing their recovery potential.  In order for an athlete to recover and become less symptomatic, the therapist and the athlete must work together to keep the specifically injured tissue under the irritability threshold (Chart 3).  The irritability threshold is a variable point in time during the athletic rehab continuum when a subjective reproduction of symptoms occurs and/or the objective assessment of impairments is measured indicating that the injured tissue is unable to meet the demands necessary for requested athletic activities.  A patient develops athletic dysfunction when they cross over the irritability threshold.  A careful and continuous assessment of symptoms and impairments will determine if an athlete is recovering (under the irritability threshold) or regressing (under the irritability threshold).  Obvious reproductions of symptoms and impairments can include increased pain, edema, palpable tenderness, lost range of motion, and weakness.  Frequently, and more difficult to determine, are episodes of irritability, which result in a decrease in sport performance, accelerated fatigue, uncharacteristic weakness, and/or compensatory movement pattern.  It takes frequent and close communication with the athletic patient to know what a normal performance should be in order to decide whether the athlete has crossed over the irritability threshold or simply performed page

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