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

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Rehab Milestones
Athletic patients are willing and actually prefer to set goals ranging anywhere from a one degree improvement in range of motion to the exact day they will be back playing.  This group of patients loves to “ be in control” of their rehab.  If the patient does not think you have a complete and logical plan of care that will fully and safely return them to their sport within the shortest period of time, they might just go off on their own.  Athletes need to feel like they are training, so if they are not playing their sport, then they are actively participating in their rehab.  The Athletic Rehabilitation Continuum (Chart 2) shows the relationships of the athletic rehabilitation process to guide the athletic physical therapist and establish a partnership with the patient.  Often, goals for the athletic patient group include “time off” and “rest”. 

Athletes need to be involved in their rehab.  It is called “buy in,” and if you can get an athlete to buy in to your particular rehab program, they will become actively involved and follow your rehab plan.  A partnership with an athletic patient is most important because the athlete knows better than anyone what they must do to optimize their own abilities.  It is not just enough to understand how an individual athlete can throw a fast ball exceeding 90+ mph.  In order to help the therapist and the athlete communicate, I divide the rehabilitation process into three stages.

The Power of Three
Sometimes the easiest explanation can make a big difference in helping the patient understand the rehab process.  Explain to the patient that their rehab will consist of three stages of an undetermined time.  The closer they follow your program, the faster they will progress to the next stage and eventually back to their sport.  The total duration of rehab can be as little as three treatments or as long as 6 months; the stages are not time dependent.  Rather, they serve as key milestones in a person’s recovery and serve the purpose of indicating progressions for treatment strategies.  Each case is different, but a general rule of thumb applies to all patients that enter the clinic: I call it the Power of Three.

Stage 1
The first third consists of anti-inflammatory or tissue healing treatments using mostly manual skills and modalities to create a healing environment for the injured tissue.  Phase I and II exercises are low load, controlled speed, limited duration and frequency, and performed in a supported, controlled, and isolated manner.  The therapist and patient must take care to avoid going above the irritability threshold by controlling all or most of the causative factors.

Stage 2
The second third consists of a continuation of manual therapy techniques, a decrease in the use of modalities, and a change in Phase III therapeutic exercise.  Phase III exercises are multi-jointed, complex movement patterns with a medium load, speed, duration, and intensity.  Aggressive manual therapy for tissue remodeling and neuromuscular integration is appropriate.  Patients and therapists have a tendency to progress too quickly through this stage.  This leads to an increase incidence of exacerbation and creates only a partial foundation for the most demanding stage ahead.

Stage 3
The final third consists of a discontinuation of modalities and limited manual therapy.  Fully loaded Phase IV and V athletic functional exercises are performed with increased speed designed to simulate sport-specific conditions and prepare the athlete for competition.  These exercises consist of significant aggregate force and speed and should be performed only by those patients who are preparing for a competitive return to sport.