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

...continue from page 1

Controlling the Irritability Threshold 

There are five irritability factors with many possible combinations that contribute to the irritability of a tissue that need to be understood and controlled.  If the therapist correctly identifies the causative factors and the athlete modifies those activities that correlate with crossing over the irritability threshold, the athlete and therapist should anticipate a successful rehabilitation (Chart 1).  Sport activities or treatment techniques that exceed the irritability threshold will perpetuate the inflammatory cycle, create athletic dysfunction, and prolong rehabilitation.  All five factors can contribute to recovery in various proportions and at different stages throughout the rehab process.  Reproduction of symptoms or the development or exacerbation of impairments during or up to 24 hours after treatment or sport activity should be interpreted as crossing above the irritability threshold.  One or all of the time, force, and position factors must be corrected until the injured tissue is not provoked. 



Total Time
Time can be broken down into three subsets: duration, frequency, and speed.  Measure and observe the response to the duration, frequency, and relative speed of a dose of treatment or sport activity to determine the causative relationship with irritability.  Remember that it is easier to speed up a treatment program than slow it down once started.  Err on the side of caution until you are certain of the ensuing treatment result.

Aggregate Forces
The aggregate force through a tissue has to do with the repetitions, sets, and load being applied and transferred through the target tissue.  You must apply the appropriate force during a treatment in order to stimulate the healing response but avoid going over the irritability threshold.  The literature can tell you how to strengthen a fast twitch muscle fiber or when a nerve achieves chemical neuromuscular fatigue, but only the therapist can interpret all the necessary information to determine how the athlete is progressing.

Position
Even if you have the proper aggregate force with optimal timing, the proper alignment must be maintained or you risk crossing the irritability threshold.  During treatment, the athletic therapist must pay close attention to proper sport-specific alignment to unsure maximum potential and minimal irritability.  Athletes often perform at the extreme limits of anatomical and structural ability.  Therefore, the athlete must be trained into full anatomical positions as well.  The athletic therapist must place sport-specific torque at the end of range of motion in order for the athlete to be prepared for their return to sport.  Most patients do not require such attention, nor do they request it, but an athlete must be completely restored prior to discharge and return to full competition.