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Making Strides in Rehabilitation

Comprehensive Sports Medicine Care Soldiers On

Patricia D. Mees


Returning injured World War II soldiers to battle-ready status helped establish physiatry as a specialty. The parallel of returning an athlete to activity underscores a close relationship between sports medicine and physiatry. In addition, the musculoskeletal focus of physiatry has always complemented sports medicine. Frank Krusen, MD, who coined the term "physiatrist" in 1938, was also a team physician for Temple University.

Chain Links

Physiatry treats the whole person, not just the injured structure. Stan Herring, MD, team physician for the Seattle Seahawks, says, "The injured joint is the victim, not the culprit." The real problem is a weak link somewhere else in the kinetic chain. An elbow injury may be caused by an imbalance in the shoulder, spine, hip, knee, or even the foot. Every break in the chain needs to be addressed before the patient can successfully return to activity. Finding and addressing the root cause facilitates healing and will help prevent reinjury.

A case in point is Arizona Diamondback's pitcher Randy Johnson. Following surgery for a herniated disk in 1996 and a year of rehabilitation, Johnson won the National League Cy Young award four years in a row (1999 to 2021).1 The key to his successful return to preinjury performance levels, according to Herring, was that "rehabilitation addressed core strength, core flexibility, leg strength, and total body conditioning. All of the weak links in his kinetic chain were addressed during recovery and rehab to restore functionality and prevent future injury."

Rehabilitation once meant little more than passively resting the injury until it no longer hurt, then returning the patient to sports. Herring says that "rehab is not rest—it's active care." Both Herring and Edward Laskowski, MD, at the Mayo Clinic in Rochester, Minnesota, believe that one of the most important milestones in injury rehabilitation has been the emphasis on evaluation and treatment of the entire kinetic chain. Laskowski says, "The focus on rehabilitation of a movement system rather than just the area of injury is a cornerstone element of functional rehabilitation now, and it will also be important in the future."

Katherine L. Dec, MD, a physiatrist in Richmond, Virginia, says "Attention to the factors of activities of daily life, work, and sport are important, because addressing the recurring mechanism of strain is important in all the patient's activities." Overuse injuries may be traced to improper technique that puts too much stress somewhere in the kinetic chain. She adds, "A progression to more challenging rehabilitation principles—such as strengthening muscles that act across the joint and proprioception of the joint in movement and in static posture—will be important."

Michael Fredericson, MD, in the Department of Orthopedic Surgery and Sports Medicine at Stanford University, says that advances in core stabilization training are an important milestone in functional rehabilitation. The hip, pelvis, spine, and abdominal muscles work together to generate, transfer, and dissipate force. Having a strong core prevents excessive force from damaging another link in the kinetic chain and maximizes sports performance. Herring notes that hip and pelvis strengthening is especially important for women, and Dec comments that women's injuries are more readily diagnosed today.

Role of Technology

In the last 30 years, imaging technology (eg, magnetic resonance imaging, computed tomography) has become a mainstay in diagnosing musculoskeletal injuries, but it has not supplanted the importance of hands-on knowledge. Laskowski says, "I have been impressed with the consistent focus in the sports medicine literature on the continued development, validation, and application of our physical exam techniques. Diagnostic tools can be helpful, but there is still nothing that replaces an accurate history and physical examination." Dec adds, "Some of the same tests from 30 years ago are still the key clinical tests for diagnosis of injuries today."

Technology has also affected the acute care (eg, pain management, casting materials) and treatment of injuries (eg, arthroscopy, artificial joints). Because surgical techniques are less invasive, patients benefit from early mobility and preserved range of motion. Herring notes that 30 years ago an anterior cruciate ligament (ACL) injury meant open surgery, a cast for several months, and a long period of inactivity. Today, better surgical techniques mean that ACL repair is performed arthroscopically, patients go home from the hospital the same day or the next, and aggressive activity begins right away. These advances have become available to the general public, whereas they were once reserved for elite athletes.

Marching Forward

Much greater emphasis is now placed on preventing injury through proper performance of sports skills. Pitching coaches, tennis instructors, and golf pros teach active people how to move correctly and emphasize core stability and muscle development to protect vulnerable joints. Techniques of rehabilitation have morphed into "prehabilitation" that is done year-round as part of general fitness training, rather than simply being done to enhance performance during the season.

Whether an injury is caused by sudden trauma or a subtle flaw in technique that led to an overuse injury, "rehabilitation and performance are opposite sides of the same coin," says Herring. He adds, "Rehabilitation is a process, not an event. It is more than getting rid of pain. The goal is to maximize the chance of return to activity at no less than the preinjury level of skill and to avoid reinjury."


  1. MacLean N, Shannon B, Palmer P (eds): Who's Who in Baseball: Official Lifetime Records of Major League Players. New York City, Who's Who in Baseball Magazine Co, 2021, p 253

Patricia Mees is the assistant editor of The Physician and Sportsmedicine.