It’s so important to have one. Even if it’s just the age-old phrase that I love and hate, “it depends”. Because it always depends, but I also feel like you need to be able to give somewhat of a straight answer, knowing full well that there is going to be nuance. Other clinicians will hopefully latch onto that nuance, and with your patients you’ll just need to explain that a little bit more. That tangent aside, having a rehab philosophy gives you a framework to start with so you’re not scrambling and struggling.
There are a few things that I focus on:
- Movement is medicine.
- Freedom in movement.
- Meet your patients where they are.
- Keep it simple, stupid! (K.I.S.S.)
Before I get into anything…as I work mostly with athletes, I will discuss athletes, and I may use that term — I’m not trying to be exclusive, I just don’t have much experience with other populations so I’ll keep my mouth shut there, even if things are similar.
Key words in my philosophy: humility, patience, self-efficacy, simplicity.
So when we look at athletes, I like to look at it in terms of “supply and demand” — this was introduced to me by a former team doctor I worked with, and it was a great new way to simplify things in my head. If their sport is demanding x amount of physical and mental effort, but their body/mind can only supply y amount (x > y in this case), then something is going to fall through. This is my starting point for nearly every case I see, and I often explain it to them, hoping that it frames the injury in a more positive light (usually not for contact injuries like a teammate or opponent stepping on them, of course). But it also allows me to leave room for the potential that decreasing load can improve the situation.
Additionally, thinking of “supply and demand” allows you to think more critically about the demand of the sport. For example, overhead athletes — but even then, each overhead sport is different! Volleyball, baseball, softball, water polo. Field athletes vs. court athletes. Implement wielding athletes (field hockey, lacrosse). Indoor vs. outdoor. Men versus women (decently different rules in lacrosse!). Water sport athletes. Powerlifters. Weightlifters. Bodybuilders. Parkour. Okay, at this point I’m just listing random things for pure shock value, but we absolutely have to think of the sport demand when it comes to rehab! I had to get a little deeper into the baseball pitching motion & understand that the lats often take over, and the serratus anterior muscle could always use some help. I also had to consider the eccentric demands of a LOT of muscles in a pitch.
The phrase “movement is medicine” comes with some caveats, because we have to be specific about the type of movement. Athletes are constantly moving in practices, so why do we need more movement? We need movement in different ranges of motion — it is true that in some field sports, no one is ever in a squat position close to parallel. However, I believe we need to build up movement outside of that range because they may randomly reach that position in sport, and squatting to parallel is generally best (I’m going to use parallel as my basic requirement because even that is really tough for some athletes who are relatively untrained). Plus, going into those deeper motions improves or at least maintains joint mobility.
So in terms of movement, I look at a few things. First, end-ranges — we need to be sure that we are training the muscles in their shortened, “at rest”, and lengthened positions. Second, contraction type — while eccentric exercise is touted as the end-all be-all for tendon issues, studies show that isometric and heavy/slow concentric movements are good too. So it is good to vary it up, but you’ve also got to think of sport demands. Also, you have to think — isometrics are great for learning to build up tension and reach maximal contraction, whereas eccentrics are actually an excellent tool in creating more “functional flexibility” (sidenote, the word “functional” is vomit-inducing in my head. I think it’s over-used so that when it actually applies, it somewhat loses its value to me) or mobility.
We also need loaded movement because adding load changes speed and intention of an exercise. Tendons love load, for example! Generally, the heavier you load, it’s more strength-based, but the lighter you go, it is more velocity/power based. To be honest, it gets a little fuzzy in this area because first, athletic trainers don’t always have access to resources like these aforementioned heavy weights, but second, when it comes to working with untrained athletes, any load or movement that they need is going to help. More on this later in number 3.
What do I mean by freedom in movement? I try to stay away from the term “corrective exercises” because I want to let people know that there’s not necessarily anything inherently wrong with them. I’m not saying to let all “dysfunctions” go, but many baseball players, and especially pitchers, will have winged scapula because of the way the scapula glides along their ribcage during a pitch. Instead of focusing so heavily on “decreasing the winging”, focus on exercises that you know are not generally strengthened in practices or lifts, for example — target the serratus, the mid/low traps, etc.
I believe that giving people some freedom in movement allows them to love exercise, not fear movement, and take charge of their own body. I also believe that educating the patient on this concept is key! Improving self-efficacy is almost always on my mind for multiple reasons — it’s really good for them, but it’s also helpful when you don’t have that many hands but people have a lot of needs! And of course this doesn’t always apply since we have a duty to give our patients what they need, sometimes they really do need someone else to rely on for a little bit.
Freedom in movement also means that we need to make sure that our different joints and body parts are moving like a well oiled machine. I’m going to give the example of the scapulae again — in movements such as scaption, overhead presses, pull-ups, the scapulae have to move on the ribcage. When I teach scaption, Y/T exercises, or shrugs, I make sure that their scaps move up and around as needed. Another way to work towards moving our joints smoothly is CARs — controlled articular rotations. I stepped away from these for a bit with my female athletes because many of them had decent mobility, and a little too much — but it’s very helpful for my baseball players right now because it gives them greater command of their bodies. It improves the mind-muscle connection!
When I say to meet your patients where they are — you have to think of their training history, current training regimen, injury history. I have some athletes who have never strength trained in their lives — I can afford to utilize some relatively low load exercises to strengthen them (see the next paragraph for an important exception). On the other hand, I have some athletes who love to lift and are very strong — it technically makes my job a little bit easier! First, I make sure that their lifting routine is up to snuff. Then, I think about what they might be missing and supplement it. For upper body, this includes rotator cuff (though most baseball players do enough of it on their own), serratus, all the trap muscles, levator scap, neck. For lower body, it might include glute med, adductor, hip rotation, lower leg/ankle/foot exercises.
Essentially, low-threshold rehab activities are not necessarily effective enough for some stronger athletes. It’s good to challenge them a little! I believe that it’s important because it keeps them engaged and helps it be an effective exercise. It shouldn’t be so hard that they can barely do it, though — they should be able to improve the movement. Plus, some athletes are naturally curious and like to explore movement and learn alongside you — cherish them and teach them every bit you can. The only caveat to this is that the athletes who could benefit from some low-load rehabilitation exercises — could actually benefit more from strength training.
I’ll give you an example of “meeting them where they are” — one of my biggest passions is foot/ankle function. I had an athlete who rolled his ankle and didn’t feel 100%. He began to mention how he has no calves, and how he has very flat feet. So the first day I gave him some simple rehab exercises just for the ankle and taught toe yoga. The third day, I noticed that he was frustrated with knee valgus during a one leg squat movement. I began to look at ways to explain a hip hike, and how to use the stance hip to lift the other hip. This was difficult because he would lean backwards in an effort to squeeze the glutes. Finally, I realized that some good ol’ hip hinge-ing would help a lot. And I think it did!
So finally I narrowed things down — toe yoga is going to be a staple for him, but so are posterior tibialis exercises. Luckily I would say his “dysfunction” with post tib is minimal and it may be because of poor understanding of calf raises (and my own poor understanding that I had to look at). The 3rd thing will be a lot more body awareness, balance, and strength building in glutes and hamstrings. I had to remember that I wasn’t necessarily wrong the first day, I was just slightly misguided, so I adjusted and continued. Though I did want to jump more into higher-level movement patterns…I have to wait. And it’s going to be okay, and it’s much better this way.
Keep it simple…stupid — depending on your level of involvement or the amount of time you can give, of course (ex. 1 team at a D1 level versus 2+ teams at a D3 level, both of which I have experienced). Quite honestly I enjoy working with multiple teams because it forces me to keep it simple. I’ve developed a general arm care routine for baseball after pitching, for example. I tend to do similar things for athletes with hip mobility issues, those with patellar tendon issues, or low back “tightness”. First, doing these exercises and receiving feedback from athletes allows me to develop a more individualized routine for them, but it gives me a simple starting point and it’s been helpful.
Some key, more concrete items: glutes, hamstring and back — these are staples for athleticism. Hamstrings are special because there’s a lot of concentric/eccentric demand, sometimes both at the same time! Make sure athletes aren’t using their upper traps to do all their shoulder/scap movements. Trap shrugs can actually help “tight” traps feel better. Pinchy hip flexors? Work end-range active hip flexion. Always check hip rotation, but don’t panic about it. “Too much” mobility? Emphasize strength in narrower ranges of motion. A lot of core exercises should emphasize anti-movement: anti-rotation/extension. Spinal mobility is just as important as “core stability”. The soleus muscle is very important for the lower leg! Eccentric calf raises go a long way for shin pain. Toe yoga isn’t just a foot exercise — it’s also a brain exercise!
Lastly — humility as a clinician is very important. I am struggling with a lot of cases right now that I can’t quite figure out, or it’s just very slow going. It is okay to admit even to your athlete that you’re not 100% sure on something, that you have to think about it and give them a better answer. I think it’s good to ask questions and be questioned! It helps us improve our standard and philosophy of care, and allows us to form a network with other clinicians who are similarly interested in these things. Conversely, we need to be skeptics about the information that’s out there.
I think I’ve written a few similar things previously. First — Things I’ve Learned About Rehab from July 2018. Then, Movement is Medicine from September 2018. It’s definitely interesting to watch how things have changed! So, if you made it this far — what things are part of your rehab philosophy?
