Where Traditional Physical Therapy Fails the Athlete

Where Traditional Physical Therapy Fails the Athlete

When an athlete gets hurt, their first thought is rarely “how long until I can walk again?” - it is normally, “how long until I can play again?” If an athlete needs rehab, they are trusting their physical therapist to get them back to playing their sport. Physical therapists are supposed to be the best at this, right? Well unfortunately you need to make sure that you go to the right physical therapist at the right location if you want your needs as an athlete to be met. Just because a physical therapy clinic says “sports medicine” on their doors, does not mean that you are getting quality sports medicine care. Many of the larger physical therapy companies have huge amounts of overhead, and with insurance reimbursement declining for physical therapy, their clinicians are forced to treat more patients in order to keep the company afloat. This means less time with each patient. Also, these companies are big businesses that create business metrics disguised as patient care metrics. Example: If you care about your patients, you will get them in 3 days a week because if they come in more, they will get better faster, and while that sounds good in theory it does not hold up in reality.

To fully understand why this does not make any sense when applied within the world of insurance that we currently live in, it is first important to understand some basic time frames of soft tissue healing.

There are 4 stages of healing:

• Bleeding:
• Short, normally finished by 4-6 hours post injury.
• Inflammatory:
• Onset: shortly after injury
• Peak in activity: around 1-3 days post injury,
• Complete: Within a couple of weeks
• The inflammatory phase is an essential part of the healing process which is why many healthcare professionals suggest Tylenol / acetaminophen rather than an anti-inflammatory medication post injury.
• Proliferation: This is where the new scar tissue is laid down.
• Onset: 24-48 hours
• Peak in activity: 1-3 weeks (depending on vascularity of the tissue)
• Complete: 4-6 months post injury
• Tissue Maturation: When scar tissue is aligned into tissue that looks more like the native tissue prior to injury.
• Onset: 2-3 weeks post injury, maybe sooner
• Peak in activity: Not consistent
• Complete: Continues for 18 - 24 months after injury

If your physical therapist is urging you to get into therapy 3x/week for the duration of your care because it will get you better faster, run out of there. That therapist either does not understand how to provide you with the best value, does not understand tissue healing, or the most likely possibility, they under so much pressure from their superiors that they go against their better judgement to avoid being reprimanded for not seeing their patients frequently enough. Most insurances will reimburse for somewhere around 20-25 visits per calendar year, some more, some less, some have stipulations, but for arguments sake, let's say that you have pretty good insurance that will pay for 24 visits per year no questions asked. If your therapist pushes you to come in 3x/week because "it will get you better faster" you are probably going to believe them, they are the experts in tissue healing and rehab and if 3x/wk will get you on the field faster then you would be crazy not to.  The argument that 3x/wk is better is not completely wrong.  Coming in 3-7x/week throughout the course of your rehab will probably get you back on the field a little faster, you can progress exactly on the day that you are ready, little hiccups in your recovery can be addressed immediately, over-dosing or under-dosing of your exercises is under constant monitoring, if you are sore you can get all sorts of feel good massages and modalities to help with muscle recovery.  That is how it works in the collegiate and professional sports world which is amazing for those athletes and rehab professionals; however, they operate in a world different than the rest of us.

Physical therapy clinics unfortunately live in a world run by insurance companies that dictate how much a patient is allowed to be seen. So for a person with 24 visits / year, 3x/week allows for 8 weeks of physical therapy. 8 weeks sounds great, but going back to our tissue healing model, we see that our body isn’t even finished laying down scar tissue until 4-6 months post injury; and while most of the scar tissue is laid down by 2-3 months, there is still a lot of work to be done.  Unfortunately insurance companies do not see it this way.  When your pain has subsided and you have returned to your normal daily activities they often view that as a full recovery and deny paying for services.  These large companies know this and so to maximize their profit they make sure to get as much money as possible before the insurance company begins to deny payment since the patient / athlete has returned back to daily life.  Recovery to basic daily activities, will likely occur with or without rehab, returning to sport is where rehab becomes important in the athlete.

When we get injured we are limited by pain, often this pain persists for a while. Take a rotator cuff strain for example; this is an injury that will take anywhere from 6-12 weeks before you start feeling close to yourself. For an overhead athlete: baseball player, track and field thrower, swimmer, tennis player, ultimate Frisbee player, or a gymnast, this is a debilitating injury and effort needs to be made to restore strength and mobility to 100%. That being said, our body needs to go through the healing process and while that process is going on there will be pain with motion. Pain is not a bad thing, it is just part of the healing process and something that we have to deal with. Your early rehab exercises will be based around maintaining the strength of the tissues surrounding the injury and preserving as much range of motion as possible; couple this with some consistent pain free movement to encourage blood flow and you are setting yourself up for a good recovery. 

Attending therapy 3x/wk is not always bad. If you have a tricky presentation and your therapist felt that there are still a few things that they want to look at or see how you respond after the initial evaluation, coming back 3x that first week can be beneficial. This high frequency of visits helps you and your therapist work to find the best program for you to get started with your rehab. Once that plan is established, the most important part of rehab is making appropriate progressions to that plan which commonly happen every 1-2 weeks. 

Remember, the healing phases take weeks to months and almost every injury will require at least 8-12 weeks before you start to feel even close to normal. Around 8-12 weeks, the pain has likely subsided a substantial amount if not completely; but there are commonly significant strength deficits and potentially losses in flexibility and mobility that can impair your performance and put you at greater risk of re-injury. This is where a physical therapist with appropriate knowledge of athletic injuries can really help with the rehab process. However if you started rehab 1-2 weeks after your initial injury and you were seen 3x/wk for 8 weeks, you have completely exhausted your insurance benefits by 9-10 weeks post-injury. At this point, the body is still laying down scar tissue and in many cases there is still some pain with certain movements or activities; and you likely spent almost all of your time in rehab doing similar exercises to what you could easily do at home or at the gym.

Now you are faced with a choice: ditch PT and run through the program that your PT gave you and hope that it is good enough to get you back to where you need; or continue to go to PT and pay cash for services at rates commonly more than $100 / session for cookie cutter exercises from a therapist that is spread thin among 2 or 3 other patients.

This situation may sound extreme but it is not uncommon. Going to a larger physical therapy company has some benefits. You are commonly getting new grad clinicians, fresh out of school and hungry to work and apply the latest science to you, and trust me, you would rather have a young fresh mind than someone who has been working 20 years and is coming to work to clock in, do the same basic exercises they have been doing for the past 10 years, and clock out. Don’t get me wrong, doing that basic stuff is often plenty to get your pain to go away, but remember our bodies are awesome at healing and your pain would have likely gone away anyway. The benefit of rehab comes by restoring you back to your sport quickly and safely. 

Let's go back to our rotator cuff strain example and say that this person has pain reaching overhead. Initial goals during early rehab are to find ways that this person can get further overhead with less pain. If there is a postural component, the therapist can address posture; if there is an issue with scapular strength and mobility, then that can be addressed; and if there is a potential issue with the function of the other rotator cuff muscles, that can also be addressed. In none of these instances is there anything that a therapist can do that is miraculously different than what you can do at home with some simple exercises using a theraband or simple equipment at your gym. There are some thrust mobilization / manipulation techniques as well as some targeted glenohumeral (the true shoulder joint) and scapular mobilization techniques that can be used, these are often unnecessary in the athlete, or can be supplemented with exercises to accomplish the same goals. They may feel good in the moment, but likely do not provide much benefit to the healing tissue beyond what exercise can provide.

Moving forward to 12 weeks post rotator cuff strain, the patient / athlete has exhausted their insurance benefits but still feels they are a few weeks from getting back to playing at full intensity due to end range pain during their throwing motion, with tumbling, with getting into streamline with swimming, or with serving a tennis ball as well as a measurable strength deficit on their involved side. Instead of really working on targeted return to sport activities in rehab, the patient / athlete is faced with a decision to continue with a home program and hope for the best, or continue to come to PT but have to pay $100 or more / visit.

3 months later, that same athlete is playing pickup basketball with his or her friends and lands on another player's foot and rolls their ankle. Now they go back to physical therapy with exhausted insurance benefits and a headache trying to justify the need for their care, they have to pay more co-pays or cash for their rehab and total extra cost and time to this patient / athlete ends up being in the thousands of dollars.

This situation happens every day but can be easily avoided with proper understanding of healing time frames and how to apply that to an athlete returning to sport. The strength of a physical therapist when rehabbing an athlete is not in the ability of getting that patient to basic function, the body will do that on its own; but it is the ability to return the athlete to a high level of function with as little risk of re-injury as possible which is accomplished in the later stages of rehab. 

Building a strong foundation during early rehab is incredibly important, rehab will need to be performed consistently, but most days this can be done in the comfort of your own home or at your gym. Your therapist is there to guide you with: exercise; education; and some hands on techniques; to augment the miraculous healing process that our body is able to perform, not to heal your body exponentially faster. 

Look for a therapist that wants to provide you with value based care throughout the course of your rehab all the way until you are back playing your sport the way you want and keep a little bit of money in your time and money in the process.


For more information on me, visit reevespt.com