Prepare for the real demand: my approach to rehabilitation

Someone can look excellent in a clinic and still be unprepared for sport.

They may have good range of motion, little pain, respectable strength numbers, and a clean-looking hop. Then they return to an environment with speed, fatigue, opponents, decisions, contact, imperfect positions, and consequences. The problem is not that the clinic work was useless. The problem is that it was only part of the job.

I am a Registered Kinesiologist in Ontario, a former coach, and I have worked in sports medicine with wrestlers. That experience shaped a simple view of rehabilitation: respect the person, their history and biology, and the demands they need to return to. Do what the situation requires. Protocols can provide important safety guardrails, but they cannot replace assessment or an understanding of the athlete and the destination.

My working pathway

1. 1.Examine
2. 2.Manage constraints
3. 3.Build qualities
4. 4.Train the sport
5. 5.Participate
6. 6.Compete

Those stages overlap. People can often begin a modified version of sport before every impairment has disappeared. The point is not to rush. It is to avoid treating rehabilitation and sport as two worlds separated by a clearance date.

Training qualities is not the same as training the sport

This distinction is central to how I work.

Strength-and-conditioning training develops useful physical qualities: strength, speed, endurance, mobility, coordination, power, and the ability to repeat hard efforts. These qualities should be organized around the athlete and their sport rather than a one-size-fits-all program ( Human Kinetics).

Gym exercises do not need to look like the sport. A squat does not need to resemble a wrestling shot. A row does not need to imitate hand fighting. A cable exercise does not become functional because it looks vaguely like a throw.

Exercise selection should respect medical constraints and target qualities that matter for success. But disguising a gym exercise as a sport skill can produce a poor version of both.

Sport training has a different job. It develops technique, timing, perception, decision-making, interaction, and adaptability. A wrestler has to read pressure and position, respond to an opponent, and produce the right action at the right time. Those abilities cannot be fully recreated with a band or cable. They require wrestling.

Rehabilitation should include two connected streams:

1. 1. Train the qualities that support the sport.
2. 2. Practise the sport within the athlete's current constraints.

The research on on-field rehabilitation makes a similar distinction by including physical conditioning, movement, sport skills, and progressive training exposure. The control-chaos continuum describes a gradual move from predictable work toward faster, reactive, less controlled situations. These are useful frameworks, not universal recipes.

Sport exposure can often begin early in a reduced form: technical rehearsal, controlled footwork, positional work, lower-speed practice, fewer repetitions, a cooperative partner, or a smaller range of options. What is appropriate depends on the diagnosis and the athlete. After some injuries, especially concussion or conditions with strict healing constraints, the safety rules are different. The current concussion consensus, for example, uses condition-specific staged progression and clinical oversight.

The principle is not “do your sport no matter what.” It is “preserve and rebuild as much meaningful participation as the situation safely allows.”

Start with the destination

When someone tells me they want to get back, I need to know what that means.

What were they doing before? What are they doing now? What sport, position, level, schedule, surface, and training environment are they returning to? What does a full practice require? What happens late in a match or after several hard days? What does their job or home life add to the total?

Return-to-sport experts increasingly describe return as a continuum rather than a single clearance event. The Bern consensus separates return to participation, return to sport, and return to performance. The PAASS ankle framework includes pain, impairments, athlete perception, sensorimotor control, and sport performance. The details differ by condition, but the common message is clear: readiness has several dimensions.

A strength target without a demand analysis is just a number. A running goal without a required speed, volume, surface, and recovery schedule is incomplete. Rehabilitation becomes more useful when we work backward from the destination.

Pain is information, not a moral judgment

Pain is real. It is also not a direct meter of tissue damage or proof that someone moved wrong. Pain reflects the person, the tissue, the nervous system, the task, their expectations, and the environment. A useful sports medicine paper puts it plainly: there is more to pain than tissue damage.

I often use Greg Lehman's cup analogy. Training, work, poor sleep, stress, symptoms, and life all fill the cup. When the total exceeds current capacity, it can overflow. We can remove some load, build a bigger cup, or do both.

This is an analogy, not a diagnosis. New trauma, severe or rapidly changing symptoms, neurological signs, illness, and other warning signs need appropriate assessment. But for many rehabilitation problems, symptoms help us adjust the dose rather than automatically banning movement. In Achilles tendinopathy, for example, continued activity guided by a pain-monitoring model did not worsen outcomes in a randomized trial ( Silbernagel and colleagues). That finding is condition-specific, but it illustrates the difference between monitoring pain and fearing all pain.

Build a plan everyone can use

Coaches are essential because they understand the environment the athlete must re-enter. They can change constraints: speed, space, opponent behaviour, repetition, contact, work-to-rest ratio, tactical options, and total practice load. A coach should not be asked to diagnose an injury or provide medical clearance. The clinician explains the athlete's current constraints; the coach helps create meaningful sport inside them; the athlete reports what they experience.

For younger athletes, a parent or guardian may also need to understand the plan. The athlete should still be included in the conversation and know what is happening, why it is happening, and how to speak up.

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