You’re Not Fixing Your Patients

bobthebuilderPatients and therapists alike often joke about how their therapist fixed them, or they need fixing again. The term is commonplace and seems harmless at the surface. It’s an easy way to characterize the experience of physical therapy. Your knee hurts, you work with a physio, it gets better. Thus, you’re fixed. Makes sense to me. The only problem: that’s not how it works. The culture of “getting fixed” is harmful to both the patients and the profession of Physical Therapy as a whole.

“Fixing” implies that therapy is a passive experience. It leaves out the education, self efficacy, and empowerment that takes place during a physical therapy intervention. And it ignores the central point of therapy: therapists help people fix themselves. We aren’t magic voodoo healers, so let’s stop pretending to be.

Physical Therapy is active medicine

  • Most medicine is passive. People walk into a doctor’s office expecting to be fixed. Strep throat? Antibiotics. Fixed. Cavity? Filled. Fixed. Back pain? Cortisone shot. Fixed. The problem with this mindset is that physical therapy isn’t quite that easy. The therapeutic experience is multi-faceted. Patients are often asked to make lifestyle adjustments, do home exercise, and actively participate in their healing. This holistic understanding and subsequent adherence to physical therapy is a key determinant of success in both surgical and non-surgical patients (1).

Involve the patient in their treatment, help them fix themselves

  • Make treatment a collaborative effort. Ask the patient what they enjoy, give them a voice. Patient education and involvement in the decision-making process have been shown to be highly correlated with patient satisfaction and outcomes (2). The therapist should set clear expectations at the onset of therapy. Although the patient may not love every aspect of therapy, finding an agreeable treatment plan and having them enjoy part of it will go a long way towards recovery.


  • The therapeutic encounter between patients and therapists is complex and reflects the multidimensional nature of patient satisfaction (2). It’s not as simple as just removing the thigh bone, you have to smile while you’re removing it, therapy is a joint venture.
  • A good relationship where the patient and therapist can hold eachother accountable increases the probability of success. This is key as home exercise ramps up and patients want to return to full activity. Careful here. The reality is that even if all patients are compliant, up to 1/3 of them will perform their home exercises incorrectly (4). So keep the programs simple, increase volume over time, keep exercise selection low, and be realistic.
  • Tapering physical therapy before discharge can assist with self efficacy. Once a week, or even every 2 weeks at the end of treatment may be beneficial for long term self management. Tailored physical therapy has been shown to be superior to a standalone self management program on 3 month return to work rates and lifestyle exercise interventions (3,6).
  • Providing educational material about the importance of exercise has been shown to help with patient compliance and independence as well (5). In other words, hammer it home.

We aren’t Voodoo healers.

  • When I got into Physical Therapy I never anticipated there would be so much controversy. I had no idea how many therapists were choosing to ignore research in their treatment approach. Therapists making up their own secret manual therapies, patients getting their immune systems re-aligned by chiropractors, even bringing their dogs to chiropractors (its a real thing, I swear). There are just so many misconceptions out there about healing. Bottom line is don’t underestimate the power of placebo in manual therapy (9). If it seems too good to be true, it probably is.


  • The worst thing about all of this misinformation is it creates an overwhelming feeling of anxiety for the patient. It removes their control over the situation. Along with therapist’s affect, the ideas of backs being misaligned, pelvis’ slipping in and out, and scary sounding problems contribute to pre-treatment anxiety, a negative factor in treatment outcomes (7).
  • It’s important for a patient to understand that most injuries run their course. Even the dreaded slipped disc. Don’t let your patient be that guy still complaining about his “slipped disc” 20 years later. Educate your patients on the normal course for their injury. Instead of telling them you can’t fix their disc, tell them most people with disc herniations on MRI’s are walking around pain-free (10).
  • In addition to healing, educate your chronic patients about their pain. The reason as to why symptoms persist past the acute to sub-acute stage and become chronic is unclear, but likely results from complex interactions between structural injury, physical impairments, and psychological and psychosocial factors (8). They need to appreciate the interplay of factors in order to work on their pain.

In closing

detail on handyman manual worker, toolsbelt and red drill in his handsTherapy is active medicine. You’re not a handyman. You have skills, not tools. Your patient’s consistency and accountability is crucial to their success. Help them achieve this. Teach them that they’re “fixing” themselves, and not vice versa. Check your ego at the door. Don’t take all the credit. You’re not a voodoo healer. Sometimes people just get better.



  1. Gambhir RP, Valenti D, Rashid H. Compliance with Physical Therapy is a Key Determinant of Success of Thoracic Outlet Surgical Decompression. J Am Coll Surg. 2015 Sep;221(3):778
  2. Ali N, May S. A Qualitative Study into Egyptian Patients’ Satisfaction with Physiotherapy Management of Low Back Pain. Physiother Res Int. 2015 Aug 27. [Epub ahead of print]
  3. Andersen LN, Juul-Kristensen B, Sorensen TL. Efficacy of Tailored Physical Activity or Chronic Pain Self-Management Programme on return to work for sick-listed citizens: A 3-month randomised controlled trial. Scand J Public Health. 2015 Jun 25. [Epub ahead of print]
  4. Faber M, Andersen MH, Sevel C. The majority are not performing home-exercises correctly two weeks after their initial instruction-an assessor-blinded study. PeerJ. 2015 Jul 21;3. eCollection 2015.
  5. Van Waart H, Van Harten WH, Buffart LM. Why do patients choose (not) to participate in an exercise trial during adjuvant chemotherapy for breast cancer? Psychooncology. 2015 Aug 17. [Epub ahead of print]
  6. Andersen LN, Juul-Kristensen B, Roessler KK. Efficacy of ‘Tailored Physical Activity’ on reducing sickness absence among healthcare workers: A 3-months randomised controlled trial. Man Ther. 2015 May 2. [Epub ahead of print]
  7. Healy GM, Finn DP, O’Gorman DA. Pretreatment anxiety and pain acceptance are associated with response to trigger point injection therapy for chronic myofascial pain. Pain Med. 2015 Aug 26. [Epub ahead of print]
  8. Campbell L, Kenardy J, Andersen T. Trauma-focused cognitive behaviour therapy and exercise for chronic whiplash: protocol of a randomised, controlled trial. J Physiother. 2015 Aug 26.[Epub ahead of print]
  9. Chaibi A, Šaltytė Benth J, Bjørn Russell M. Validation of Placebo in a Manual Therapy Randomized Controlled Trial. Sci Rep. 2015 Jul 6;5:11774.
  10. Boden SD. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990. 72(3): 403-408.

Behavioral Change

The other day I got a text message from a friend I have helped many times with fitness advice and workout ideas over the years. The question he posed to me described an all too familiar scenario: an overweight person not knowing how to start exercising. He wanted to help his aunt improve her health, and she wanted to as well, but they didn’t know where to begin. Well my response was pretty boring.

aunt text

I went on to explain myself. Since he is a good friend I knew he could appreciate my advice without thinking I was being insincere or short with him. I told him the question he posed was one of behavior change. The first thing she needs to do to change her behavior is establish a routine. Secondly, she needs to begin her exercise with only a few basic movements to start. And third, she needs to learn the basics of exercise progression if she’s going to do this on her own. The goal of my advice was to make exercise easy for her, if that’s possible.


History of Pain Science

Functional movement is a topic that has been beat to death in the fitness and physical therapy industries. It’s become a word that people can understand and relate to. Hell, it’s in the definition of crossfit. And it makes sense- exercise should be functional!

(Crossfit definition, according to CrossFit is constantly varied functional movements performed at high intensity.)

Here’s the reality… ALL EXERCISE IS FUNCTIONAL. Everything you’re doing in a training or rehab protocol should and can be easily justified with a simple explanation. Sometimes exercise is as easy as strengthen what’s weak, stretch what’s tight.

To give credit where credit is due, Buddy Morris, an old mentor and now strength coach for the Arizona Cardinals is the first person I ever heard say “all exercise is functional.”

Let’s say you have a 75 year old man who tore his achilles trying to run after the ice cream truck. He had surgery 3 weeks ago and he is still in a boot holding him in plantarflexion. He can’t dorsiflex his foot past neutral per doctors orders for another 2 weeks. When he comes to PT he’s doing open chain, no resistance ankle pumps with his therapist guiding him closely. Is this functional? YES IT IS! It is a piece of the equation that is eventually contributing to his increased functionality. His achilles needs to scar down more and the surgery cannot be stressed at this point.

The point here is to not judge a book by it’s cover. I’m not saying ditch your squats for leg extensions and stop working on your balance and hip hinge patterns. I’m just saying don’t be so judgey when you see other modalities of exercise and you don’t know the whole story.



This topic has been covered by numerous other smart people and I have admittedly been influenced by their stance.


Functional Movement

Functional movement is a topic that has been beat to death in the fitness and physical therapy industries. It’s become a word that people can understand and relate to. Hell, it’s in the definition of crossfit. And it makes sense- exercise should be functional!

(Crossfit definition, according to CrossFit is constantly varied functional movements performed at high intensity.)

Here’s the reality… ALL EXERCISE IS FUNCTIONAL. Everything you’re doing in a training or rehab protocol should and can be easily justified with a simple explanation. Sometimes exercise is as easy as strengthen what’s weak, stretch what’s tight.

To give credit where credit is due, Buddy Morris, an old mentor and now strength coach for the Arizona Cardinals is the first person I ever heard say “all exercise is functional.”

Let’s say you have a 75 year old man who tore his achilles trying to run after the ice cream truck. He had surgery 3 weeks ago and he is still in a boot holding him in plantarflexion. He can’t dorsiflex his foot past neutral per doctors orders for another 2 weeks. When he comes to PT he’s doing open chain, no resistance ankle pumps with his therapist guiding him closely. Is this functional? YES IT IS! It is a piece of the equation that is eventually contributing to his increased functionality. His achilles needs to scar down more and the surgery cannot be stressed at this point.

The point here is to not judge a book by it’s cover. I’m not saying ditch your squats for leg extensions and stop working on your balance and hip hinge patterns. I’m just saying don’t be so judgey when you see other modalities of exercise and you don’t know the whole story.



This topic has been covered by numerous other smart people and I have admittedly been influenced by their stance.



Hamstring strains are one of those stubborn injuries that far too often become recurrent injuries or more chronic strains. Their high rate of recurrence is often times due to a lack of careful rehabilitation and training following the injury. If you are experiencing chronic hamstring strains, there is a specific and well understood way to begin to exercise the injured body part and progress back to full athletic participation.




The first step in rehabilitating insulted muscle tissue is to find ways to use this muscle without causing further injury. Isometric exercise is defined as a muscular contraction where the muscle length is not changing. In other words, the muscle is being flexed, but it is not creating any movement. An example of an isometric exercise is showing off your arm muscles or flexing your abs as hard as you can. Isometrics have been shown to help with pain and are an effective initial way to start exercising after injury. The bridge position is good place to start with isometric hamstring exercise.




Isometrics have numerous applications in strength training as well as rehab. They are an effective way to warm-up and prime muscles for movement as well as decrease sensitivity and pain after injury. Isometric contractions allow the athlete to recruit a maximal amount of muscle fibers and can help to optimize the nervous system for efficient muscular contraction. This process is often called “activating” muscles and is done prior to strenuous lifting. In addition to activation, isometric strength training develops strength that is extremely specific to the range of motion trained. This can be helpful in training weak points. For example, isometric holds in the bottom of a squat (pause squats), or isometric deadlift holds just above or below your sticking point can help bust plateaus.


In addition to the physiological benefits of pain relief, the increased neuromuscular recruitment efficiency, and the practical strength training application of isometrics, they can be extremely helpful in teaching exercise progression and introducing new movement. For example, in the bridge progression chart below, you must complete an isometric hold of each new challenging position before you do it for reps. During rehab, there might be a session where you do the dynamic movement of one position and the isometric holds from the next most challenging position. This is how you can slowly advance the difficulty of rehab. Isometrics allow us to “feel out” new ranges of motion. They’re helpful for teaching lifting for this same reason as for rehab. They are a useful method of self limiting progression to ensure we do not push ourselves too much and take a step back as well. Isometrics build the initial strength and comfort in each new range of motion.


Bridge Progression Chart


Phase 0: 2 feet on the box and flat ground → begin to experiment with single leg holds

Phase 1: single leg bridge marching and holds on the box and flat ground

Phase 2: begin to increase bridging distance. Bridge walk-outs start here. Moving the feet further away makes the bridge more hamstring intensive.

Phase 3: bridging on swiss ball, sliders, slide board, or sorinex roller, 2 feet

Phase 4: able to do all single leg slider bridges with no pain

video: bridge progressions


Start all new positions with isometric holds, then progress to reps and movement. Build from 2 sets x 5-8 reps to 3 x 10-12 before entering each new phase. Use pain and form as your guide for progression.


Modifying Bridges for Pain

video: bridge mods


If the phase 0 bridge is painful, there are a few ways to modify the exercise and experiment with finding pain free movement. Range of motion can be altered in order to reduce the strength of the contraction. Introducing extra isometric resistance in other planes of movement can help to recruit varied musculature and significantly alter pain sensation. Additionally there are pelvic and core positioning cues and considerations that can be used to find pain free movement. A posterior tilted pelvis and flexed spine positioning can effectively shorten the length of the hamstrings and increase contraction strength. This is one cue that can help to decrease sensitivity during the initial phase and also train the core to prepare for proper positioning under load later on.



One very common misconception is that tight feeling muscles need to be stretched. Muscles can feel tight for a variety of reasons, and it is not always necessary or even beneficial to stretch a muscle. Sometimes, it can even be detrimental to its recovery. During most muscle injuries, the fibers or microscopic cells are slightly torn. In extreme cases where bleeding is excessive, this can be seen in the form of bruising, swelling, and highly sensitized painful tissue. Insulted tissue responds much better to gentle exercise and movement than it does vigorous stretching. If this has been your method of relieving pain, you are in for a rude awakening.


Stretching a muscle can create a temporary inhibitory effect on its fibers, causing the tone of the muscle to relax and thus allowing for more range of motion. Muscle length is a fluid and dynamic quality that changes based on the status of the nervous system and muscle fibers themselves. For example, if your hamstrings are extremely stiff after a killer deadlift workout, their fibers and cells are highly sensitive and do not want to be tugged on and stretched. Therefore, your nervous system knows this and disallows intense stretching. Your muscles did not physically shorten over night, and if worked back into range of motion properly, they will return to a comfortable resting length once the soreness is resolved.


After a hamstring injury, there are some gentle stretching and mobility techniques for the hamstrings and posterior chain that can be helpful. Some gentle mobility is OK, but this should not be a rehab focus until basic movements like lunges, squats, and bridges are pain free and mobility is seen as a limiting factor. For many, a properly performed lunge or single leg deadlift is a mobility movement by itself. Make single leg strength training the priority, not just stretching.


Here is a video of some gentle stretching techniques that can be used. Incorporating hip rotation into stretches will ensure the entire hamstring group is stretched equally.

video: stretching w/hip IR




Hamstring rehabilitation involves feedback and monitoring of pain and feeling in the hamstring. The more in tune you are with your body, the better your recovery and rehabilitation will go. It is important to be honest with yourself and be disciplined here, as it is human and athletic instinct to want to constantly push yourself. Testing limits is OK and necessary. It just needs to be done correctly with the proper thinking and feedback mechanisms.


The goal is to continually add progressions and challenges to the exercises while being able to distinguish between good pain, working muscles, stretch vs. pull, and bad pain. Good pain during a hamstring rehab is a slight stretch, or a very small pulling feeling that improves throughout the exercise or set. Good pain is muscular soreness afterwards. Bad pain is a strong or painful pull, a tug, and any strength of contraction that would not be able to be tolerated for a 5-10 second hold. If you are working with a patient, come up with some mutually shared ways to communicate about stretch vs. pain vs. pull, good vs. bad pain, etc.




Athletes require more advanced ways to increase the strength of their hamstrings and move beyond the basic bridge and isometric progressions. Unilateral exercises can teach body stiffness, core control, balance, and controlled eccentric lengthening along with reciprocal hip movement. They can be beneficial for all athletes including barbell lifters. Developing single leg strength is markedly different than lifting with both your feet on the ground, it will make you stronger and more resilient. These exercises are sure to challenge even the healthiest of hamstrings.


Single Leg Deadlift


The single leg deadlift should be in everyone’s training program. It’s a key move for combining hamstring mobility and strength into one movement. All of these exercises can be progressed with speed as well as weight. Hamstrings are called up on to contract quickly and need to be rehabbed accordingly.

video: SLDL progression


Standing Band Pulldown


The band pulldown recreates the cyclical motion of gait with the swing leg. It can hard very quickly with ample band tension. This exercise also challenges the core and pelvis in a more generalized way to stay level and not get torqued by the band.

video: hamstring band pulldown


Slider Lunges and Fall Outs


Lunges involve much more hamstring activity when they’re done with sliders. Like all of these exercises, increasing the speed makes this significantly more challenging to the hamstrings.

video: slider hamstring exercises




Exercise 1: Nordic Hamstring Curl

video: nordic hamstring curl


Exercise 2: Glute Ham

video: glute ham raise


Exercise 3: Romanian Deadlifts (RDLs)

video: barbell RDL


At this point, the athlete should be able to resume normal lifting that does not stress the hamstrings. This exercise list includes more shallow range of motion squats with forward knee bend, think of a front squat or goblet squat. Pushing a sled can also be great during this time. The concentric work of a marching sled push can be a very effective way to tax the hamstrings. The hamstrings require a high amount of stiffness in order to propel the body against a sled pushing forward. This can also serve as an ongoing assessment tool for physical readiness. The sled should be taxing but tolerable for hamstrings. Any sort of deadlifting or posterior chain dominant work should be progressed under the previously stated rules as well: gradually increasing range of motion, load and speed.



Hip Extension


If we want to explore the “WHY?” question as to hamstring injuries, we might want to look at two different areas: the opposite hip flexor and the same side glute. During gait or running, as the hamstring is lengthened, so is the contralateral hip flexor. If you are having recurrent hamstring issues, you might want to look at opposite anterior chain. Poor hip extension on one hip can make hip flexion of the opposite hip more difficult, thus affecting the hamstring.


Here is an example of an active thomas test that you can do yourself to asses hip flexor mobility and control as well. Use a box or raised bench if you don’t have access to a table.

video: active thomas test


Glute Strength


The glutes and hamstrings play synergistic roles as powerful extensors of the hip. It would stand to reason that if one glute was weak, for whatever reason, that side hamstring might have to take on more load. Training hip extension with both glute and hamstring dominant movements is just as important as training knee flexion in the rehab process.


Hip Flexion


Lastly, one important test to help look at proper hip function and screen out for future hamstring issues is the standing hip flexion hurdle test. The hurdle test is part of a movement screen that can be helpful for bringing to light hip pathology or movement deficits in active flexion that might impact gait and running mechanics.


The video below shows 3 common compensations: trunk sidebending, hip hiking, and then hip rotation compensations. One thing to notice with the hip rotation deficits is the concomitant compensations with foot eversion and inversion.

video: hip flexion deviations



Returning to jogging after a hamstring injury usually isn’t too bad. It’s the sprinting and high velocity work that is both challenging and daunting. This can be especially true for athletes who injured their hamstrings running at full speed.


Modify Gait for High Effort Running (Sprinting)


There are two ways that I like to modify the running gait during rehab. Running up a hill effectively shortens the stride length and is a safe way to progress to a 100% effort sprint. I always recommend starting max effort running on an incline. The second option is to do sprints while dragging a light sled. Start around 20% body-weight and work your way down. Decreasing weight is a progression for sled sprints. With increasing speed, the hamstring will be contracting faster and moving with a greater range of motion.

video: sled drag sprints


Both of these methods reduce stride length, and maximum velocity for sprinting. They can also be helpful for reviewing and teaching sprinting mechanics. An example of how a sled drag progression might look is to gradually decrease the weight over 3-4 weeks to return unweighted sprints. With hill sprints, the hill volume can gradually subbed in for flat ground sprinting until the sprinting volume is all on flat ground.

video: hill runs


Re-condition with Tempo Runs and Cross-Training


Proper conditioning is critical when returning from hamstring injuries. A fatigued hamstring is a weak one, and this can make it susceptible to re-injury. Conditioning of the muscle itself is just as important as the cardiovascular system The hamstring needs be repeatedly conditioned for max velocity running gait. A significant part of rehab for high level athletes is getting back the endurance to maintain a high level of performance over the duration of a game or practice. It is for this reason that cardiovascular conditioning should be maintained as much as possible during rehab.


Tempo running and a gradual return to running and practice drills are helpful. Oftentimes athletes want to re-condition by jogging, they’ll go out and run 4 miles in 30 minutes and think they’re helping their hamstring. Jogging is not sufficient. That’s an 8mph pace. During a competitive event, most high level athletes (men & women) will be achieving speeds between 14 and 18 mph. Hamstring injuries happen during higher velocity running and these conditions must be re-created in rehabilitation in order to fully prepare the athlete.


During a tempo run the athlete should be briefly hitting 10-12 mph and should strive for a full cycling range of motion similar to max velocity running. By the time the athlete is returning to practice and movement they should be well conditioned, extremely in touch with their body, and constantly self monitoring to avoid extreme fatigue and scenarios that can potentially cause a re-injury. Returning from a muscle pull or tear requires self limiting behavior and discipline: pain is subjective and the athlete is the only one that knows how they feel.


One nice way to do tempo runs is on a woodway curve. The curve gives you a speed reading and allows you to run as fast as you like and easily accelerate to 10 or 12 mph. If you don’t have access to this kind of equipment, any field or open area will do. A normal belt powered treadmill is not ideal for tempo runs. Using a radar gun to gauge the athlete’s speed and assign objective numbers is a helpful way to control tempo runs on the field.

video: woodway running




This is the hardest part, and it’s where the most injury recurrences and mistakes happen. Conditioning is extremely important, this non-negotiable. One session with a few 100% effort sprints at the end does not equate to being physically ready for full game play. This 100% effort must be sustained for longer and longer each session. Film and slo-mo video can be helpful here to analyze running form. Pick one thing to analyze each time you watch and compare side to side. Look at front-side mechanics: how’s the knee drive? Back-side mechanics: where does each heel end up, are they getting full extension? This video analysis is an objective way to look at the athlete’s physical readiness.


There are some other locomotive ways to challenge the hamstring in the last part of rehab. Bounding running, galloping, and running downhill or overspeed running will increase the stretch on the hamstring and potentially expose the injured area. During this last phase of rehab you need to expose the injury in order to ensure it’s strong enough for return to sport.


This concept of exposing and protecting the injury is what the entire rehabilitation process is based on. At first we protect while the injury heals, we then expose by strengthening the insulted tissue. In later rehab, we expose by increase running speeds and introducing new stimuli, while we simultaneously protect through modifications like sled drags and hill running. Expose vs. Protect, that is the continuum that all rehabilitation is based on.




Dr. Teddy Willsey is a sports medicine physical therapist and performance coach at Healthy Baller Speed & Performance Center. Healthy Baller is the premier strength and conditioning and rehabilitation sports medicine center in the Washington D.C. metro area. As a former high level powerlifter and strength coach himself, Teddy specializes in bringing strength & conditioning principles to the rehabilitation world and filling the void that often exists between therapy and training.

Injured athletes don’t need to rest, they need to train!!

This article will highlight some of the deleterious effects of immobilization through a quick research review summary and then provide some videos of training and work that I did with a patient who was non-weight bearing in an ankle cast and for 6 weeks following ankle ligament reconstruction.


On Disuse Atrophy: Muscle wasting begin almost immediately once an athlete goes into a cast or has a joint immobilized. When a joint can’t move, the muscles that cross it literally turn off and begin to shrink in size.


Research has consistently shown significant losses in muscle mass over relatively short periods of immobilization. In one recent study, five days of immobilization led to 3.5% reduction in quadriceps CSA (cross-sectional area) and 9% muscle strength. In the same study, there was a 8% decrease in muscle CSA and a 23% reduction in quadriceps strength after 14 days of immobilization. There multiple factors at play during disuse atrophy including central nervous system changes as well as muscle physiology.


The process of muscle atrophy is highly regulated and results in reduced protein content, reduced force production, increased fatigability and decreased insulin sensitivity, decreased capillary density of both fiber types and disruption of the 3-dimensional architecture of skeletal muscle. Skeletal muscle also undergoes a shift in contractile capacity of the fibers toward fast glycolytic phenotypes. For example, the soleus muscle which is predominantly composed of slow twitch fibers is a postural muscle and highly susceptible to disuse and fiber type switching.


Take Home Point


Rehab for the high level athlete should start the day they are injured. In addition to considering the injury site itself, I contend it is the job of the physical preparation staff (physical therapist, athletic trainer, strength coach, etc.) to find creative ways to support the athlete and their individual needs.


In addition to rehabilitating and protecting the injury itself, the ideal approach should expose the rest of the body to basic strength training and cardiovascular exercise. The goal is to preserve as much muscle mass and cardiovascular conditioning as possible. Why don’t we do this enough? Injured athletes don’t need to rest, they need to stay fit. This helps to ensure a safe return to sports and reduce the learning curve of “getting back into shape” after an injury.


In addition to the reduction in maladaptations, helping injured athletes continue to exercise can have an positive psychological effect. The link between season ending or catastrophic injury and depression is real. Keeping athletes active and motivated may help them not lose their identity as an athlete.


Here is a case study and series of videos I took working with a high school basketball player last year. She had ankle ligament reconstruction following a traumatic ankle sprain that ended her season early. Once she got out of her cast and then boot, it was incredible. This particular athlete recovered as fast as I’ve seen for a lower extremity injury that was non-weight bearing / immobilized. As you will see in the videos, she worked her tail off. She came in twice per week and did a ton of home exercises as well. She was back on the court playing basketball (not full contact yet!) 6 months after her surgery.




Exercises for the injured leg


Standing Band Kick Backs



Standing Band Press Downs



I typically use the band kickdown in a cyclical motion to mimic frontside sprint mechanics and emphasize the hamstring / posterior chain lengthening. If done with greater than 90 degrees knee flexion and a pistoning motion, it turns into a more quad and glute dominant movement.


Standing Band Single Leg Knee Drive



Standing Band Single Leg Knee Drive (foot elevated on box)



Sidelying Hip Abduction w/Ankle Weight


Form notes on this exercise: she has her toe pointed slightly down to ensure maximal glute activation and not hip flexor activation. She also is going below parallel and into relative hip adduction. Hip adduction increases the stretch on the hip abductors and external rotators while giving some glute max extension fibers an abduction moment arm. This is a sweet glute exercise.


Exercises for the non-injured leg


Box Pistol Squat



This is an exercise you can do to take advantage of the crossover effect and train the non-injured limb. This athlete is currently non-weight bearing on her surgical leg status post ankle ligament reconstruction.


Core Exercises


It’s important to note that core exercises are working the injured and non-injured leg. During a plank the quadriceps and hip flexors are being used as prime movers to isometrically drive anti-knee extension and anti-hip flexion. The glutes, adductors, and other hip muscles are being recruited at a lower level as well.


Plank + Body Saw on Foam Roller



This exercise should be done in later weeks of recovery (weeks 3-6 after surgery) as I prefer to not load the ankle in any way early on in recovery. It should be progressed with holds for small periods of time at first to watch for any post exercise surgical site soreness.


Ab Roll Outs (with range of motion block)



Cardiovascular Exercise





I have the rower resistance turned all the way down because this athlete is not accustomed to rowing. She has her cast in a cloth slideboard booty and surgical leg on a slide board. There is no pressure on the surgical leg: it’s just along for the ride. I recognize her form is not ideal, but we found this to be the absolute best way for her to boost her heart rate. Remember, inefficient exercise can elicit a large cardiovascular tax.


The goal here is to provide quick bursts of cardiovascular effort that are helping her to maintain an aerobic base as well as her alactic and anaerobic energy system base.


Why Exercise Feels Good

After years of powerlifting training I started to learn that no matter what aches or pains I had, I would ALWAYS feel better when I left the gym. If you talk to guys who are still training hard, runners, or any exercise nut in their 40’s and 50’s they’ll tell you the best they feel all day is when they’re at the gym. For runners, they call it the runner high. These are exemplary of the short term “feel good” benefits of exercise.

What we don’t know as much about is the long term effect of exercise. Researchers recently set out to better understand the long term effect of exercise on pain control, exercise-induced analgesia. I put together a quick review on this article and offer a unique scientific look at why exercising helps with pain. Warning- some of this gets a little sciencey!READ MORE

Crossfit – Not So Bad

There is a lot of conflicting information in the rehab and strength and conditioning world. Look no further than the message boards on any popular blog or facebook page and you will see disagreement. Sometimes it’s even hard to find conclusive information in the research. And for people who don’t spend their lives immersed in this field, it’s downright confusing. I’m here to tell that if you’ve ever given advice to someone, you were probably wrong.

While the healthy debate of ideas in our field is essential to growth, problems arise when conflicting information leaves people confused. It doesn’t help us reach a larger audience, get more people exercising, and positively influence our clients, athletes, and patients. I’m sick and tired of hearing people say “but my trainer said you *have* to do this…”


Corrective Exercise

Remember when the term “corrective exercise” came into vogue? It was the smart man’s way to exercise. Trainers were energized by the wave of new information and everyone started looking for flaws that needed correcting. Although corrective exercise has it’s place, I’m going to look at the problems with a widespread focus on corrective exercise and use 17 articles to back my claims.

ALL exercise is corrective. When exercise is done correctly it causes positive adaptations.

Most everyday aches and pains respond well to non-specific exercise. We don’t always need complex corrective exercise plans based on biomechanic assumptions.

Cases that require actual corrective means should be referred to an injury specialist. While corrective exercise may be beneficial here, there may be potential deformities or pain that would benefit from manual therapy, medication, bracing, orthoses, or even surgery.

Don’t forget the KISS principle (keep it simple stupid!). Because sometimes exercise is as simple as strength, activation, and blood flow. All well programmed exercise is corrective. ALL OF IT!

For some populations, an exercise as simple as step-ups is “corrective” and helps to attenuate age related atrophy. Research on males 70 y/o has shown that increasing daily step frequency by adding in a high repetition low load unilateral resistance training program causes increases in muscle protein synthesis (1).

Now I’m not a big fan of the leg press, we don’t have one in our clinic. But for post-ACL patients, adding it to their program has been shown to be corrective. During ACL rehab, adding a functional squat machine from weeks 4-15 has been shown to increase week 15 measurements of quadriceps, hamstrings strength and increased score on functional measures such as single leg distance and vertical jump (2). To clarify, the functional squat machine does not qualify as a squat in my eyes.

Everyday movements and basic exercises are corrective when they are applied correctly. You don’t need to be Gray Cook to use corrective exercise.

Many aches and pains respond just as well to non-specific exercise programs. A recent study showed that rock climbing was an effective exercise to help reduce chronic back pain (4). I wonder if that ever occurred to the low back pain corrective exercise specialists? (drops mic and walks out…)

Research on low back pain has demonstrated previous lifestyle, exercise, and confidence in treatment to be large predictors of disability and function (5).

Although there are some well substantiated directional preference treatment approaches for low back pain, these fall under the category of rehabilitative or therapeutic exercise (3).
This is where the ever blurring distinction between therapy and training starts to come into play.

  • The greatest predictor of non-specific chronic low back pain is exercise, and it’s not specific to core exercise (6). For sedentary workers, a 1-year walking program was shown to be a protective factor for reducing neck pain (7).
  • So when you’re addressing pain, don’t always assume something structural needs correcting, sometimes you just need to get it moving.

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An example when correcting is actually necessary: chronic ankle instability.

  • Chronic ankle instability is associated with neuromuscular changes and poor postural stability (10). Postural control exercises have shown benefit in the treatment of chronic ankle instability (9). Although this is a perfect case for corrective exercise, this athlete will likely benefit from other interventions beyond the scope of a trainer as well. And by the way, kinesiotape doesn’t help chronic ankle instability (13).
  • For ankle instability as an example, a comprehensive approach to increasing ankle stability would be most beneficial. Prefabricated ankle orthoses can correct ankle dynamic stability and lead to a decrease in ankle sprains (8).
  • Take a runner with pes planus (flat feet), he has a structural deformity. Now he might suffer from posterior tib pain at some point in his life. And although there are postural control exercises for addressing PTT, more severe cases may benefit orthotics and sometimes even surgery (11,12). All the corrective exercise in the world can’t correct his anatomy.

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  • Keep it simple, stupid. Because not all of your pre-conceived notions are correct.
  • Some “corrective exercise” is a waste of time. For those who do not have proprioceptive deficits, unstable surface training does not allow enough progressive load to elicit optimal training effect (17).
  • When addressing pain, not every exercise needs to be dynamic with a range of motion goal. You don’t always need to fix their perceived deficits. Isometric exercises can help with pain. A dose response relationship has been shown with the proposed effect of activation of high threshold motor-units involved in exercise-induced analgesia (14).
  • Push-ups may be the best shoulder corrective exercise that exists. Upper extremity weight bearing exercises have advantages in providing increased joint proprioception, cuff co-contraction as well as reducing joint shearing forces (15,16).

In closing, don’t overthink corrective exercise. Everyday movements and basic exercise are corrective when applied correctly. And if problems arise that need actual correcting, refer them appropriately so that they can get the most beneficial treatments.

I have been positively influenced on this topic by Mike Reinold, Adam Meakins, Nick Tumminello, Greg Lehman, and many others.




  1. Devries MC, Breen L, Von Allmen M. Low-load resistance training during step-reduction attenuates declines in muscle mass and strength and enhances anabolic sensitivity in older men. Physiol Rep. 2015 Aug;3(8).
  2. Kınıklı GI, Yüksel I, Baltacı G. The effect of progressive eccentric and concentric training on functional performance after autogenous hamstring anterior cruciate ligament reconstruction: a randomized controlled study. Acta Orthop Traumatol Turc. 2014;48(3):283-9.
  3. Surkitt LD, et al. Efficacy of directional preference management for low back pain: a systematic review. Physical Therapy. 2012; 92(5): 652-663.
  4. Schinhan M, Neubauer B, Pieber K.Climbing Has a Positive Impact on Low Back Pain: A Prospective Randomized Controlled Trial. Clin J Sport Med. 2015 Aug 4. [Epub ahead of print]
  5. Cecchi F, et al. Predictors of response to exercise therapy for chronic low back pain: result of a prospective study with one year follow-up. Eur J Phys Rehabil Med. 2014; 50:1-9.
  6. Slade SC, et al. What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain?: A systematic review of qualitative studies. Clin J Pain. 2014; 30(11):995-1005
  7. Sitthipornvorakul E, Janwantanakul P, Lohsoonthorn V. The effect of daily walking steps on preventing neck and low back pain in sedentary workers: a 1-year prospective cohort study. Eur Spine J. 2015 Mar;24(3):417-24.
  8. Faraji E, Daneshmandi H, Atri AE. Effects of prefabricated ankle orthoses on postural stability in basketball players with chronic ankle instability. Asian J Sports Med. 2012 Dec;3(4):274-8.
  9. Pourkazemi F, Hiller CE, Raymond J. Predictors of chronic ankle instability after an index lateral ankle sprain: a systematic review. J Sci Med Sport. 2014 Nov;17(6):568-73.
  10. Hadadi M1 Ebrahimi I2 Mousavi ME. The effect of combined mechanism ankle support on postural control of patients with chronic ankle instability. Prosthet Orthot Int. 2015 Aug 13. [Epub ahead of print]
  11. Madhav RT, Kampa RJ, Singh D. Cobb procedure and Rose calcaneal osteotomy for the treatment of tibialis posterior tendon dysfunction. Acta Orthop Belg. 2009 Feb;75(1):64-9.
  12. Noll KH. The use of orthotic devices in adult acquired flatfoot deformity. Foot Ankle Clin. 2001 Mar;6(1):25-36.
  13. Kodesh E, Dar G. The effect of kinesiotape on dynamic balance following muscle fatigue in individuals with chronic ankle instability. Res Sports Med. 2015 Aug 17:1-12. [Epub ahead of print]
  14. Hoeger Bement MK, Dicapo J, Rasiarmos R. Dose response of isometric contractions on pain perception in healthy adults. Med Sci Sports Exerc. 2008 Nov;40(11):1880-9.
  15. Meakins, A. My top 5 shoulder rehab exercises. Accessible at
  16. Uhl TL, Carver TJ, Mattacola CG. Shoulder musculature activation during upper extremity weight-bearing exercise. J Orthop Sports Phys Ther. 2003 Mar;33(3):109-17.
  17. Mate-Munoz JL, et al. Effects of instability training versus traditional resistance training on strength, power, and velocity in untrained men. J Sport Sci Med. 2014; 13:460-468
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