Runner’s knee and jumper’s knee are two common overuse injuries that can affect athletes, especially those who participate in sports that involve a lot of running or jumping. While both conditions can cause knee pain, there are some important differences between the two. Runner’s knee, also known as patellofemoral pain syndrome (PFPS), is a condition that causes pain around the kneecap (patella). It typically occurs when the kneecap doesn’t move properly, causing friction between the patella and the underlying femur bone. This can result in pain, stiffness, and a grinding or popping sensation in the knee. The causes of runner’s knee are not fully understood, but it is thought to be related to overuse and biomechanical issues such as muscle imbalances, poor running form, or weak hip muscles. Runners, as well as individuals who participate in other activities that involve a lot of knee bending, such as cycling or hiking, are at risk of developing runner’s knee. Jumper’s knee, also known as patellar tendinitis, is a condition that causes pain and inflammation in the patellar tendon, which connects the kneecap to the shinbone (tibia). Jumper’s knee is typically caused by repetitive stress on the patellar tendon, such as from jumping or landing from a jump. It is most common in sports that involve a lot of jumping, such as basketball or volleyball. Jumper’s knee can cause pain, tenderness, and swelling in the knee, as well as a feeling of stiffness or weakness in the affected leg. In severe cases, the tendon may even begin to tear or rupture. While both runner’s knee and jumper’s knee can cause knee pain, there are some key differences between the two conditions. Runner’s knee typically causes pain around the kneecap, while jumper’s knee causes pain in the patellar tendon, just below the kneecap. Additionally, runner’s knee is often associated with pain that is worse when going downhill, while jumper’s knee tends to be more painful when jumping or landing. Treatment for runner’s knee and jumper’s knee typically involves a combination of exercises to improve strength, mobility and flexibility in the affected structures. In some cases, bracing or taping may be recommended to support the knee during activity. In rare occasions if conservative treatments are not effective, surgery may be necessary to repair the damaged tissue.  In summary, while both runner’s knee and jumper’s knee are knee injuries caused by overuse, they differ in the location of pain and the activities that exacerbate the pain. It’s important to seek medical attention from a skilled physical therapist if you are experiencing knee pain, as early intervention can help prevent the condition from worsening and may even prevent the need for surgery.

It’s time we all face three facts: the first, if you are an athlete you should consider twice whether to use your insurance healthcare benefits to receive physical therapy at your neighborhood’s so-called “sports physical therapy” clinic. Second, we must face the reality that not all sports clinics can provide efficient and effective specialized care to athletes, whether amateur or professional. And third, we must accept that effective, efficient specialized care deserves to be recognized, paid for, and used on a regular basis in the sports performance world. Each player within our complex healthcare system in the United States, which includes insurance companies and big businesses among others, makes up the powerful and politically active special interest groups represented before lawmakers by high-priced lobbyists (14). Each player has a different economic interest, including physicians and physical therapists seeking to increase their reimbursement for services provided while insurance companies continue their effort to decrease their payment for providers, which inevitably leads to a major cost containment problem (6). This together with a system that is focused on acute care, uncoordinated, high cost, technology driven and offers unequal access and mixed outcomes (3,6,14). It is also not governed by one central agency and as a result is a very complex system to understand and change. While some athletes are covered for physical therapy services used directly through their team or organization, to a larger degree athletes pay a specific premium (financing) through their employer or self-pay based insurance plan to cover their healthcare services each year (6). These services include physical therapy services that are in most cases capped for a certain amount of time, sessions and treatment provided, chosen by the payer (insurance), in addition to additional continued increased costs via copayment per visit and/or yearly deductible (6). Some athletes will find themselves being treated in an outpatient physical therapy clinic (24). Currently there are about 18,000 outpatient physical therapy clinics (and increasing) in the United States, most of them are in-network (get reimbursed directly through the health insurance company), which are increasingly operated and owned by the big players in the market as they try to consolidate with other physical therapy businesses to increase overall financial revenue (17). This is no surprise as physical therapy has become more accessible and is used now more than ever before, to some extent due to the enactment of the Affordable Care Act and greater public awareness (3, 6, 7). This has resulted in physical therapy services being reimbursed with lower pay to meet the high demand, which on the flip side results in a more work for less money scenario for business owners. This in turn leads to increased patient caseload per therapist in the outpatient clinic setting and high turnover rates (5, 16, 18, 20). Nowadays, the standard in-network clinics hire physical therapy assistants, physical therapy aids and trainers to meet the high demand for services so as to share patient care and withstand the higher caseload per day. These same outpatient clinics largely operate on a uniform basis, in that all physical therapists treat any patient that comes in through their door, from an elder after a traumatic brain injury to a wheelchair bound adult after a spinal cord injury sustained in a motor vehicle accident, to an elite athlete recovering from an ACL reconstructive procedure. The newly graduated doctors of physical therapy who are hired to work in these clinics are undoubtedly highly educated and motivated professionals that underwent extensive studies to treat a wide variety of conditions including musculoskeletal, cardiopulmonary, neuromuscular, integumentary and developmental, and as well as the aforementioned conditions I mentioned, but with two big caveats: lacking advanced practical knowledge and advanced theoretical knowledge (9, 25). And it is here that one may raise the question on whether the current physical therapy educational program was solely designed for the therapist to seamlessly integrate with the healthcare system and meet the demands of the big players in this system. The ongoing increase in sought for treatment by people who suffer from sports, musculoskeletal and orthopedic conditions as they relate to movement dysfunction, pain and disabilities brought clinics to an understanding that specifically naming and marketing their practices as “sports physical therapy” will lead them to an increased patient caseload. From a business perspective this is clearly a good marketing strategy, but from the physical therapist’s perspective this could be viewed as an ethical and professional issue that may lead to healthcare fraud and abuse. According to the Code of Ethics for the Physical Therapist (1) therapists “shall demonstrate independent and objective professional judgment in the patient’s or client’s best interest”, while the Standards of Practice for Physical Therapy (2) call for therapists to “ensure that the level of expertise within the service is appropriate to the needs of the patients and clients served”. Both of these statements are undermined in reality as professional judgment and level of expertise is clearly lacking in these clinics. Caring for the athlete through on-going physical therapy, regardless of injury status, will help in mitigating injury risk both in the short and long-term, promote physical and mental wellbeing, as well as maintain and/or increase performance during both the in-season and off-season (11, 19, 22). Moreover, caring for the professional athlete becomes highlighted in the case of injury as the financial tolls, as well as mental to some degree, are high to all people surrounding the athlete, including the athlete’s family, medical and support staff, and other stakeholders including investors (15, 21, 23). This individualized specialized care is time consuming and requires a therapist to be sufficiently educated and experienced, collaborate with the athlete and other healthcare providers, as well as to be highly motivated and willing to invest to maintain continued professional development and standards (8, 10, 12). An in-network clinic will simply not be able to provide this level of care to an athlete because of time restrictions, insurance limitations, equipment and space restrictions, lack of incentives to provide high quality care and high caseloads of patients per therapist. While some benefit from this standard care, simply put, the specific subgroup of athletes who are treated in an in-network outpatient clinic are likely to withstand increased costs and poor outcomes due to ineffective and wasteful care that can also impact athletes safety (4, 13). The good news for athletes is that more and more specialized privately owned sports performance practices have been opening their doors to offer high quality care. These practices are unique, customizing their comprehensive quality services to fit athletes’ needs individually, and are run by highly specialized therapists (and not big corporations) who, needless to say, do not base their treatment and care decisions solely on insurance companies’ decisions on plan of care, and reimbursement revenue. Some of the most brilliant minds in the sports performance world in physical therapy work in these practices. Their dedication to the profession is uncanny, spending most of their time, money and effort to make this possible. The athletes among us should start making these same informed decisions relating to their minds and bodies rather than the insurance companies and big “sports physical therapy” mills, and embrace these advantageous high quality services while investing their money doing so, understanding they are closer now than ever before to reaching their performance goals. References American Physical Therapy Association. (2020, August 12). Code of ethics for the physical therapist. https://www.apta.org/siteassets/pdfs/policies/codeofethicshods06-20-28-25.pdf American Physical Therapy Association. (2020, August 12). Standards of practice for physical therapy. https://www.apta.org/apta-and-you/leadership-and governance/policies/standards-of-practice-pt American Physical Therapy Association (2021, February 26). Levels of patient access to physical therapist services in the u.s. https://www.choosept.com/globalassets/choosept/assets/pdf-downloadables/direct-access by-state-map.pdf Babatunde, F., MacDermid, J., & MacIntyre, N. (2017). Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature. BMC health services research, 17(1), 375. https://doi.org/10.1186/s12913-017- 2311-3 Balogun, J. A., Titiloye, V., Balogun, A., Oyeyemi, A., & Katz, J. (2002). Prevalence and determinants of burnout among physical and occupational therapists. Journal of allied health, 31(3), 131–139. Bodenheimer T., & Grumbach K. (2020). Understanding Health Policy: A Clinical Approach, 8e. [eBook edition]. McGraw Hill. https://accessphysiotherapy-mhmedical-com.akin.css.edu/content.aspx?bookid=2853§ionid=241739104 Center for Health Workforce Studies: University of Washington. (2020, November 23). The physical therapist workforce in the u.s. https://familymedicine.uw.edu/chws/wp-content/uploads/sites/5/2020/11/PT_PB_Nov_23_2020.pdf Charmant, W. M., van der Wees, P. J., Staal, J. B., van Cingel, R., Sieben, J. M., & de Bie, R. A. (2021). A framework exploring the therapeutic alliance between elite athletes and physiotherapists: a qualitative study. BMC sports science, medicine & rehabilitation, 13(1), 122. https://doi.org/10.1186/s13102-021-00348-3 Childs, J. D., Whitman, J. M., Sizer, P. S., Pugia, M. L., Flynn, T. W., & Delitto, A. (2005). A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC musculoskeletal disorders, 6, 32. https://doi.org/10.1186/1471-2474-6-32 Delaney, H., McKenna, J., & Phillips, S. (2002). Physiotherapists’ lived experience of rehabilitating elite athletes. Physical Therapy in Sport, 3(2), 66-78. https://doi.org/10.1054/ptsp.2001.0092 Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K. M., Latimer, J., & Adams, R. D. (2013). The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical therapy, 93(4), 470–478. https://doi.org/10.2522/ptj.20120137 Hall, A. M., Ferreira, P. H., Maher, C. G., Latimer, J., & Ferreira, M. L. (2010). The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical therapy, 90(8), 1099–1110. https://doi.org/10.2522/ptj.20090245 Hush, J. M., Cameron, K., & Mackey, M. (2011). Patient satisfaction with musculoskeletal physical therapy care: a systematic review. Physical therapy, 91(1), 25–36. https://doi.org/10.2522/ptj.20100061 Johnson, J., Stoskopf, C. and Shi,L. (2018). Comparative Health Systems: A Global Perspective, 2e. [eBook edition]. Jones and Bartlett Learning. https://eds-s-ebscohost-com.akin.css.edu/eds/ebookviewer/ebook/bmxlYmtfXzEyMjkzOTZfX0FO0?sid=32245208-cdc2-4605-a1bb-2da8274645ba@redis&vid=1&format=EB&rid=1 Leeds M., & Allmen V. (2005). The Economics of Sports. 2e. Pearson Addison Wesley. Linzer M. (2018). Clinician Burnout and the Quality of Care. JAMA internal medicine, 178(10), 1331–1332. https://doi.org/10.1001/jamainternmed.2018.3708 Lo, D., Pine, D., & Janiga, N. (2020, April 10). 2020 outlook: Physical therapy clinics and centers. https://healthcareappraisers.com/2020-outlook-physical-therapy-clinics-centers/ Manske, R. C., & Lehecka, B. J. (2012). Evidence – based medicine/practice in sports physical therapy. International journal of sports physical therapy, 7(5), 461–473. Mendonça, L. D., Schuermans, J., Wezenbeek, E., & Witvrouw, E. (2021). Worldwide Sports Injury Prevention. International journal of sports physical therapy, 16(1), 285–287. https://doi.org/10.26603/001c.18700 Rogan, S., Verhavert, Y., Zinzen, E., Rey, F., Scherer, A., & Luijckx, E. (2019). Risk factor and symptoms of burnout in physiotherapists in the canton of Bern. Archives of physiotherapy, 9, 19. https://doi.org/10.1186/s40945-019-0072-5 Rosen, P., Heijne, A., Frohm, A., Fridén, C., & Kottorp, A. (2018). High Injury Burden in Elite Adolescent Athletes: A 52-Week Prospective Study. Journal of athletic training, 53(3), 262–270. https://doi.org/10.4085/1062-6050-251-16 Saragiotto, B. T., Di Pierro, C., & Lopes, A. D. (2014). Risk factors and injury prevention in elite athletes: a descriptive study of the opinions of physical therapists, doctors and trainers. Brazilian journal of physical therapy, 18(2), 137–143. https://doi.org/10.1590/s1413-35552012005000147 Shuer, M. L., & Dietrich, M. S. (1997). Psychological effects of chronic injury in elite athletes. The Western journal of medicine, 166(2), 104–109. Strack, D. S., MacDonald, C. W., Valencia, E. B., & Davison, M. (2019). Case for the specialized sports physical therapist to be an essential part of professional athlete care: letter from America no. 1. British journal of sports medicine, 53(10), 587–588. https://doi.org/10.1136/bjsports-2017-097575 Swisher L. L. (2010). Moral reasoning among physical therapists: results of the Defining Issues Test. Physiotherapy research international : the journal for researchers and clinicians in physical therapy, 15(2), 69–79. https://doi.org/10.1002/pri.482

The ever expanding scientific research in the field provides athletes and their coaches with the best available principles and concepts to use to maximize sports performance, and of course – to win – something that can be worth billions of dollars in professional sports. Cutting-edge equipment and technology is continually studied and iterated upon, with the aim of improving practice and performance in sports. Currently in the sports performance world, the main topic that is being discussed, studied and implemented is monitoring technologies that provide a wide array of data regarding a player’s fitness, workloads and fatigue status, to inform decisions regarding training and recovery options for minimizing injury risk and optimizing performance. Workload monitoring tools like microtechnology, including microsensors and accelerometers, have become popular and measure the physical demands placed on athletes during training and competition, such as accelerations and decelerations. Fatigue monitoring tools, such as testing devices that measure workload and monitor physiological responses to competition demands (such as blood lactate and heart rate), provide coaches, medical staff, sports performance staff and scientists with a better understanding of how the athlete is responding to training load, competition demands and non-training stressors.  Fatigue and workload monitoring tools are already changing the sports world – and will likely continue to change it – for example, by perhaps reducing the number of games in a professional basketball season, to help athletes avoid fatigue and enable them to perform at the highest level with low risk of injury, to the benefit – socially and financially – of all of the sports industry.

Every physical therapist has a unique personal story about why they decided to become a physical therapist. This is my story. For as long as I can remember I have always been involved in sports. My parents (especially my dad) signed both my brother and I up for many sports classes starting from a very young age. Tennis, karate, and judo were just a few of them. However, it was swimming that my dad decided I was perfect for. I began taking swimming classes at the age of 4 and started competing in swimming around the age of 6. My dad was invested in my brother and I to becoming the best possible swimmers. There wasn’t anything fun or glamorous about this time honestly, as most days were spent in school and at the swimming pool. In my teenage years we traveled all around Israel for local and regional leagues and competitions. My brother and I did really well and I even became the top two in the nation in the backstroke at the age of 15. From the age of 16 on, my interest in swimming dropped significantly as my love for basketball started to outweigh my love for swimming. Soon after I stopped swimming. This part of my competitive swimming life was over. Around the time I stopped swimming, I started playing basketball on one of the local teams. To be honest I wasn’t very good – I spent most of the time on the bench and fairly quickly understood that my basketball talent would not take me far. At the same time my curiosity toward bodybuilding grew stronger as I had also started gaining weight from inactivity and poor diet. This is when I discovered the sport of bodybuilding. I was very invested in learning about everything related to bodybuilding, from nutrition to exercise, that I spent a lot of time reading books on the topic. It was around this time I joined the gym that was located in the country club where I had swam in the past. Luckily enough soon after I started working out, I met a former bodybuilding competitor and coach.  The amount of knowledge I gained from him has not been exceeded by anything else I have learned to this day. It was an exciting time for me. Without knowing it, this was my first introduction to physical therapy. My coach encouraged me to read and so I read many books and magazines in English. I even remember being one of the first Israeli customers to buy a bodybuilding book on Amazon. Eventually I ended up studying computer software engineering before I joined the Israeli Air Force. I also spent many hours in the gym and hoped to keep developing my body throughout my service. I also kept playing basketball and football during my time off. And that is when my injuries started. The first injury I sustained happened while I was playing football – flag football – while playing as a receiver I turned to receive the ball and heard a “pop”. The knee was so painful I couldn’t move. I had no idea what was going on until I made it to the doctor, who diagnosed me with a torn ACL and torn meniscus. At that time I had no idea what physical therapy was and what therapists did. But after this injury I certainly did – I had two surgeries on my left knee and I was treated by therapists before and after my surgeries (I have since also had two more surgeries on my knees). This experience led me to start thinking about the medical field as my go to field to study after I finished my military service. During my last year in the Air Force, like most people in the Israeli Defense Force, I started to explore different career paths. Computer science wasn’t interesting to me anymore. I had grown bored of it, mostly I think because of how hard it seemed to directly connect and help other people in this field. Nursing was my initial thought – my mom has been a nurse in Israel for over forty years now – and I believed at the time that nursing would fit me well, as my interest in helping others grew stronger during this period. My decision was not met with a lot of excitement from my parents and they suggested physical therapy instead. Eventually my mom introduced me to the son of someone she worked with, a therapist who had graduated from a physical therapy program in the Czech Republic. Long story short, this conversation and later on, many more, made me realize that physical therapy is what I always wanted to do. My mind was set. I was going to be a physical therapist. A profession that is closely related to sports, that I love and have experienced. A profession that helps others to rehabilitate and overcome injuries, like I had experienced myself. A profession that cares about the people around, as I believe I always have.

1. Not referring patients to others when necessary Yes, I consider myself to be well educated and experienced in the field of physical therapy. But does that mean I know everything? Definitely not. Many therapists only come to this realization over time as they gain experience in the field. There are several key reasons why I might refer an athlete who has come to me for treatment to someone else. Inability to specify the injured structure – although some clinical manual examinations can provide insight into what is going on structurally, it is impossible to detect the structure involved. In most cases the correct imaging studies will rule in one condition and rule out others with the correct clinical examination. Examples of this are wrist and foot fractures. Different expertise needed – some physical conditions that mimic orthopedic or sports related conditions are ignored and missed by therapists. A good example is the uncommon case of treating someone who has a systemic infection resulting in low back pain with the standard protocol to relieve lower back pain. This can be avoided completely by correctly taking the patient history and referring him/her to a specialist accordingly. Although I am a strength and conditioning coach myself, connecting with the athlete’s strength and conditioning coaches and sports performance professionals is an integral part of my success treating athletes. Doing so gives me more information about the athlete and the condition, training protocols that will be used in the future with the athlete that are essential to learn and test before the athlete resumes full activity, and overall good communication that will lead to trust between the athlete, coaches and therapist. 2. Not spending enough time questioning the client Unfortunately, in some clinical settings engaging in long conversations during history taking is practically impossible. The most important element of an initial visit is history taking, which must include a conversation between two human beings. This does take a lot of time, but it enables me as a therapist to form a hypothetical diagnosis, which I’ll be able to confirm later on. Even better, it enables me to better understand and get to know the athlete so I can help him/her in the long term by being able to pinpoint difficulties that may mask another potential condition or high injury risk activities. One thing I always remind myself is that the difference between a good clinician and an average one is the ability to get as much useful information about the patient as possible. And that takes time. Don’t have enough time? Then you can expect errors, such as misdiagnosis that will lead to a negative treatment outcome in treatment. 3. Not being creative Unfortunately, many therapists start and end their careers in a clinical sitting where they treat as many as 40 patients a day. This means that most of their treatments are based on the same techniques and approaches to save time and money, especially as it relates to working with health insurance companies. I experienced this as well but quickly changed my approach by starting my own business to help athletes on an individual basis. This initially took sacrifice – but I quickly saw that this is the approach that results in the best outcomes. Although evidence-based practice necessitates following the scientific basis, this doesn’t necessarily mean one way of doing things at work. As I view it, physical therapists should be limited only by their imagination. This is because physical therapy depends on many variables, especially in the sports performance world, and therefore creativity should be taught to reach the athlete’s specific goals as plans and protocols don’t always follow direct guidelines. 4. Not adhering to exercise science I have been an athlete for as long as I can remember. I began swimming competitively at an early age. This experience led me to remain active as I grew up, to take part in several sports and to understand athletes’ minds and actions generally better than those who have never been involved in sports. The combination of coming from an athletic background and being a strength and conditioning coach, understanding all the key concepts of training, is vital. Exercise and training in combination with the correct education must stressed more with athletes compared to the average Joe who comes for treatment.  Correctly applying exercise science in practice as it relates to athletes’ specific training protocols and progressions, and the ability to relate to their efforts will lead therapists not only to better outcomes but also to promoting longevity in their respective sports.

I’d usually be hesitant to make such a bold statement, but as someone who has been in the physical therapy profession for over a decade I know I’m going to say it sooner or later – and it might as well be now. Most physical therapy clinics suck. The profession of physical therapy has changed significantly over the past few decades. After changes such as new regulations allowing patients to see therapists without a prescription from a doctor, to offering specialization in different fields, physical therapists are now highly regarded as important clinicians in the medical community. However, these changes don’t necessarily mean that all physical therapists are created equal or that all clinics provide good outcomes, particularly in the case of athletes. In this blog post I’ll share 3 points on why my approach to physical therapy is unique compared to most physical therapy clinics. 1.Generally speaking, most physical therapists just help their athlete patients get better after an injury, whether that means decreasing pain or returning to regular activities such as walking. In contrast, I not only try to get athletes back to their sport after an injury with enhanced performance, but also always consider the following: Facilitating athlete’s recovery in-season via manual therapy and other modalities. Assisting athletic staff in program design/training to optimize performance. Guiding and assisting both athlete and staff in safely preparing for high levels of performance. Assessing and adjusting the athlete’s mechanics and biomechanics to decrease the risk of injury. Educating both athlete and staff on various matters related to health, fitness and wellness 2. Unfortunately, in most clinics therapists are stuck treating up to 40 patients a day, seeing each patient for about 15-20 minutes and then handing off the treatment portion of the session to an assistant or aide. In my experience, too many clinics are focused on trying to see the patient as many times possible so that health insurance will pay as much money as possible, even when treating a condition that doesn’t necessarily need that many treatment sessions. This is for good reason (for the clinics): insurance companies don’t pay very much per visit for treatment and the amount they pay has only been decreasing over the past decade. With me, things are very different. I see a maximum of 4 athletes a day. This means that I can spend 60-90 minutes with each athlete. This not only gives me enough time for treatment but also to learn more about the athlete. The fact that I see this few athletes per day may mean I’m less profitable than a 40 patient per therapist clinic, but it also means that I see much better outcomes with the athletes I work with. 3. In physical therapy and sports performance, there is just no substitute for education and exercise over the long term. But it comes at a cost. In a typical physical therapy clinic an athlete is treated to resolve the acute injury without really gaining an understanding of why the injury occurred in the first place. The fact is that most injuries are unlikely to resolve or may even get worse in the long term if the correct exercises and training programs are not given. Taking the time to progress through a rehabilitation program, as well as to educate the athlete on their condition is time and energy consuming. Therefore most clinics simply skip this crucial stage of physical therapy.  As an athlete and a strength and conditioning coach myself I know exactly how difficult it is to be an injured athlete. That’s why I go above and beyond – to spend more time with the athletes, to invest in my professional expertise and growth, to connect with and learn from other professionals. This approach has consistently lead to the success of my athletes and to my own growth as a sports performance physical therapist.

Physical therapists play an important role in today’s society. Therapists have different specialities and work in many different settings, from helping people rehabilitate after devastating injuries like spinal cord injuries, encouraging healthy lifestyles to helping athletes perform at the highest levels of sport. Although I’ve already picked my path in the profession, working specifically with athletes, I believe that physical therapist working in all settings share some common characteristics. In this post I will share my thoughts on what I believe are the most important principles of any successful physical therapist and how I myself have approached them. I absolutely believe in periodically checking in on them to ensure that I’m on the right path to successfully help athletes perform at the highest possible level. Question yourself Strength and conditioning, sports performance and sports rehabilitation are all fairly new fields in the research and literature. The amount of information available on these subjects is vast and constantly changing. As a result, being fixated on just one philosophy is for me, a therapist working in these fields, very dangerous to say the least. Using subpart treatment and concepts will result in subpar outcomes. Questioning myself before, during and after treatment has always been one of my core principles. Asking questions, looking for the best available answers and then implementing them in real practice leads to the best outcomes. Optimize manual skills Physical therapy evaluations, assessments and treatments all revolve around the ability of the therapist to use his/her hands properly. My ability to sense what is underneath my hands provides me with the information I need during all aspects of treatment. Far too often therapists forget the importance of manual skills, especially as they relate to manual therapy treatment. The hands are a powerful tool especially in sports performance, as they are able to influence multiple systems in athletes, such as the musculoskeletal, immune and psychological systems. They also therefore influence recovery after injury, and before and after an intense activity like a basketball game. Think outside the box As I mentioned above, the field of sports and sports performance physical therapy is in a constant process of change. No one type of treatment modality in the field or evidence of a best practice leads to good outcomes. It’s a combination of thoughts, evidence seeking and application that leads to the best outcome. The need for creativity is huge. As I see it, physical therapy is a form of art, an art that makes you think outside the box and engage with other like minded people not only in the fields of medicine and sports but also in other professions. For example, I can learn more about teaching and coaching from observing how a musician applies different concepts of learning in his/her teaching and then apply these lessons to my work as a physical therapist. Communicate The ability to communicate, coach and lead by example is very underrated. As a therapist and coach you are engaged with an athlete throughout treatment. Being able to educate him/her on the specific condition, coach certain movements, or apply certain physical modalities in your treatment depends on your ability to communicate this information to the athlete. This leads to a more trusting relationship with the athlete, which will help you be better able to understand their condition and help them in the best way possible. Walk the walk It is absolutely essential for the therapist to understand what athletes go through both in-season and off-season. Personally speaking, I have had the opportunity to work in the strength and conditioning world at several universities, which I believe has made me well rounded therapist as it relates to sports. A therapist that engages in a healthy lifestyle and engages in training just like an athlete will be able to gain more trust from the athlete to ultimately lead to better outcomes. In addition, experiencing the return to sport process as an athlete myself, returning to sport after each of my four knee injuries, has also helped me to relate better to an injured athlete, motivate them to return to sport and treat them with this understanding in mind. Compassion and empathy Athletes are human beings who come from a variety of cultures, religions, ethnicities and backgrounds. Respecting the differences between myself and others is a necessity to build trust. That being said, elite athletes’ jobs depend on their ability to perform in their sport — an injured elite athlete can experience a real risk to his/her job security. Imagining being in the position of losing my job as a coach and a therapist is devastating. Psychologically, the pain and suffering is only intensified after a sports injury. My role as a therapist here is to encourage a gradual return to sport and in order to do so I have to be compassionate and emphasize with the athlete to be trustworthy. This will lead to less suffering, less pain and most importantly a faster and safer return to sport under my guidance.  I am by no means the best physical therapist out there. I do my best to honor all of my core principles with every client I met and treat, and this gets me one step closer to being the best physical therapist I can be.

The Role of Training Errors in Sports Injuries: A Focus on Running Sports injuries and the factors that increase the risk of sports injury can be very complication. However, one thing that has been consistently identified in scientific study is that training errors directly increase the risk of injury. While this post will mostly focus on running injuries, the training principles it discusses are relevant to any athlete, coach or clinician such as a physical therapist who works with athletes. Sports injuries can be divided into two main types: traumatic injuries and so-called overuse injuries. Traumatic injuries are the result of tissue failure after a single application of force, such as a sprain, strain or fracture; while overuse injuries are the result of repetitive force placed on tissues over time without allowing for recovery Unfortunately, it is a commonly believed (especially by physical therapists and trainers) that abnormal posture may lead to running injuries, particularly “overuse injuries”. Although this may seem like common sense, body anatomy varies greatly between people and there is actually no evidence that abnormal posture leads to overuse injuries, even among elite athletes. In addition, other factors such as the use of orthotics in the shoes, decreased range of motion, warm-up exercises, muscular imbalances, skill level and running frequency have not been found to have a direct correlation with injuries. The Importance of Training Errors in Injury Prevention In the running world, about 70% of all injuries have been shown to be associated with training error. The training error most closely tied to overuse injuries is underestimating the principle of recovery and adaptation. If in fact all overuse injuries were correctly classified as such, then all runners (and all athletes more generally) would be injured at the same point in training. Therefore, the assessment and treatment of athletes for “overuse injuries” must be re-examined. It is necessary to understand both the training program and the mechanical factors that led to the injury, as well as the biomechanics that contributed. This way sports performance professionals can help athletes rehabilitate well and return to sports safely. Physiologically, a stimulus applied to tissues (such as a muscle, tendon, etc.) will initiate a response at the cellular level, resulting over time (with sufficient recovery) in an adaptation.The adaptation will lead to an increase in tissue strength and response. Here is a simple example: if a basketball player jumps 20 times on Monday, applying mechanical loading to the calf muscles, in an effort to return from an ankle sprain, and then rests for two days (adaptation and recovery), by Thursday the basketball player will be able to jump more than 20 times, as his/her calf musculature will have adapted to the stimulus received on Monday.  As these types of under-recovery injuries are caused by stimulus during training, training is also their solution. But it must be training that takes into account balance between stimulus and adaptation (and recovery). This balance must be determined wisely (depending on the sport) to promote healing and increase the demands of the sport. Ignoring this balance will result in injury, as the stimulus will exceed the rate of adaptation. In summary, the tissues in the human body are able to respond to stresses placed on them in sports by recovering and adapting amazingly well.

Functional Training and Sport-Specific Assessments: A Key Component of Injury Recovery Functional training, or as I like to call it, sport specific training, involves training and stressing different body tissues in the way they are stressed in the athlete’s specific sport. Returning to activity, or for athletes returning to sport, after an injury is an important topic in sports performance and rehabilitation. It is a topic that has been studied since athletes first sustained injuries in modern sports and is unlikely to stop being studied anytime soon. This is because there is currently no universally accepted valid and reliable sport specific test used by clinicians in rehabilitation. In this blog post I will expand on the topic of important general activities that should be trained and tested before returning to sport and highlight the need to also test sport specific activities before returning to sport. Sport specific activities are important to stress before returning to sport and must be trained, specifically after lower extremity injuries, to safely return to sport, to avoid re-injury, delayed return to sport, or other complications. In most cases, performance based training and testing can begin after the initial stages of rehabilitation are successfully completed. This means that lower level activities can be tolerated at this stage without swelling, pain, or discomfort before, during and after exercise. Key Categories of Functional Performance Tests for Athletes The following functional performance test categories are used by clinicians to evaluate the athlete’s readiness to return safely to sport, as well as to assess lower extremity function. Furthermore these testing categories can give us insight into which skills the athlete needs to correct and improve upon: Strength and joint stability: Most often activities that test single leg based skills, such as squatting, to asses general strength and joint stability. Joint stability: Dynamic joint stability activities that stress two systems, the proprioception system and the balance system. Proprioception is the ability of a joint to determine position in space and the ability to detect fine movement, while balance is the ability to preserve the center of gravity over the base of support. In most sports, deficiencies in one or both of these systems will result in an injury as unwanted movement will occur. Speed, agility and coordination: These are activities that stress the athlete’s ability to develop complex movement patterns in a short period of time, to quickly change direction and cut, and for the athlete’s nervous system and musculoskeletal system to work together to prevent injury while cutting, jumping or pivoting. Plyometric: These are activities that stress the athlete’s ability to load, jump and land. They include quick and powerful movements and are used to improve lower extremity dynamic control. In addition, these activities will prepare the neuromuscular system to deal with rapid changes in movement and increased joint forces as needed in various sports. Running: Each sport may demand different types of running, sprinting and cutting, therefore the athlete’s running mechanics should be assessed and normalized as needed. In some sports, such as football and lacrosse, activities such as running with several starts and stops should be stressed to mimic the sport’s specific running needs. Training progressively to achieve harmony between these categories is needed starting with general activities and ending with sport specific activities under fatiguing conditions to account for the demands of the sport. The Advanced Lower Extremity Sports Assessment (ALESA) is one of the tools that I and many other professionals use to target functional deficits in athletes who want to return to sport after lower extremity injuries. Rather than using this tool as a standard protocol to guide me, I use this assessment tool to gain further insight into the athlete’s quality of movement as it relates to the specific needs of the sport, taking into account all of the aforementioned test categories.