Sep 24, 20238 min read

Return to Sport: Where rehab often falls short

Updated: Sep 26, 2023

In my opinion one of the biggest gaps in the traditional rehab process is in the return to sport phase, especially for many of the adult clients I see. In some cases it is a seamless transition from rehabbing an injury or surgery to going back to golf or other athletic activity. However, I have seen many people who have been discharged from physical therapy following an injury or surgery but then struggle to return to golf either with persistent pain or decreased performance. It can be very frustrating when people end up in these scenarios with chronic pain, recurring injuries or difficulty playing their sport to the level they want. After awhile it can be easy to accept that this is just the new normal. The good news is that in many cases something can be done about it. If you are struggling with this or know someone else who is keep reading to better understand why this might be happening and what you can do about it.

Here are a few of the shortcomings in the traditional rehab process that I think contribute to this issue:

1. Absence of pain does not mean that region of the body is back to normal

Following an injury the primary focus for most people is to understandably get rid of the pain and many times treatment initially is focused on this. This treatment can be in the form of a massage, cupping, scraping, dry needling, manipulation or any other modality. While these treatments can definitely relieve pain, this does not mean that the underlying cause of the pain has been addressed. If this is neglected, then it can be easy to get stuck in this chronic rehab cycle where you get temporary relief only to have the symptoms come back due to not addressing the underlying root cause.

2. The physical demands of sport are different than the physical demands of daily activities

Prior to starting my own practice I worked in an outpatient physical therapy setting with a hospital. During this experience I got to understand the inner workings of the healthcare system and working with insurance companies and Medicare. Unfortunately the insurance companies and Medicare are not concerned with your ability to return to sport. Many times the focus from these insurance companies is on activities of daily living or work. People are often discharged once these goals have been met, with little consideration for the athletic activity you would like to besides some generic advice.

However, the physical demands required to do daily activities such as walk or go up a set of stairs are much different than the demands of golf or other athletic activity. If your rehab has not built your body's capacity to meet the demands of the sport you are at an increased risk of injury upon returning and also leaving a lot on the table in being able to perform at your best. In addition many times people are not working with a healthcare provider who understands their sport or athletic activity and the physical demands required of the sport.

Do you know that previous injury is the #1 predictor of future injury?

Yes, research has shown that a previous injury is the #1 predictor of a future injury. I think two of the reasons mentioned above are common reasons why this is the case.

3. Most of time people are left to figure out the return to sport phase on their own

As mentioned above many people are discharged from physical therapy about the time they are starting to transition to the return to sport phase often with just some generic advice. However, there are many important factors to consider in the return to sport phase such as what is the correct volume of practice/play? How often should you practice and play? How should you progress over time? What is the appropriate rate of progression? What should you do if you experience an increase in pain or soreness? These are all valid questions, unfortunately many times go unanswered. In addition many times people are working with a therapist who doesn't fully understand the sport to give the best advice to these questions. Maybe you get lucky and find someone who specializes in or at the minimum has some knowledge of your sport or activity. However, the vast majority of the time this is not the case in the traditional outpatient physical therapy setting.

4. Avoidance of movements is setting you up for failure

Often times when people are dealing with persistent pain they unfortunately end up just avoiding movements that bother them. While this can work in the short term to manage the pain, unfortunately this is not a long term strategy and likely setting you up for failure in regards to re injury and successful return to sport. In one of the case examples below I will highlight why this strategy can create problems.

Here are a couple examples that come to mind of recent clients I have evaluated who were experiencing difficulty returning to golf and how we helped them

1. Golfer dealing with persistent back pain 2 years after surgery: The golfer was in his mid 40's and had a discectomy at L4-5 in his lower back. He was dealing with persistent lower back pain affecting daily activities and especially his golf game. Following his surgery he was advised that he should avoid any bending and twisting. Initially following the surgery this is appropriate advise to allow healing to occur. However, no one ever communicated to him when he could start doing these movements again and he resulted to avoiding the movements as described above. Unfortunately this is a nightmare scenario for successful return to golf. The golf swing involves bending and twisting of the spine and also at high speeds. By intentionally trying to avoid these movements entirely in his daily life the body was severely unprepared to handle the stresses of the golf swing. We were able to successfully start reintroducing these movements and eventually start adding more load and speed to these movements. This resulted in pain free golf and also a nice improvement in performance as well.

2. Golfer returning to golf following left hip replacement: There are actually several examples that come to mind in this scenario, but one in particular really stands out. This golfer was in his mid 50's who had hip replacement three years ago. He had dealt with hip pain for a while before deciding to have the surgery. His golf game also declined significantly during this time before finally having the surgery. It became so severe he was significantly altering how he was swinging the club to get through a round of golf. He had the surgery and completed a brief period of physical therapy which helped provide some relief. However, he stopped doing the exercises shortly after discharge from PT and wasn't involved in much physical activity outside of golf. As he returned to golf he was dealing with continued left hip pain which is primarily muscular in nature, lower back pain and was dealing with some of the same issues on the golf course. Almost two years passed and these issues were still going on.

During my evaluation with him there were several issues in mobility/flexibility of the lead hip and significant strength and stability deficits. These were contributing to pain, but also effecting performance on the course. Physical limitations such as these can have a strong relationship to swing characteristics in the golf swing.. The picture on the left is of the golfer's swing. If you look at the left leg (lead side of the golf swing) you can see the left leg collapse and slide into impact. These characteristics are very common in people with some of the hip limitations mentioned above. The colored graphs on the right are also showing his ground reaction forces during the swing. The blue line is showing his vertical force, which unfortunately is almost non existent. The lead side contributes about 80% of the vertical forces in a normal swing, but in this case was getting minimal contribution from the lead leg. This is leaving a lot on the table in regards to speed production but is also going to create issues with consistency and ball striking.

I have several examples in the last year of very similar scenarios to this. In the area I live in Indiana most of the time no rehab is ordered following hip replacement. Most patients following a hip replacement are given a handout with a few exercises and told to get on a walking program as the extent of their rehab. I know plenty of people that have transitioned back to normal activity and golf without issue following a hip replacement and in general it tends to be a much easier recovery compared to a knee replacement. However, I have seen may too many cases where there are some lingering deficits in that hip/leg that are effecting the golfer's performance and health on the golf course. Even for years after the procedure. The hips play a significant role in the golf swing and some of these physical limitations can be impacting your swing and performance on the course.

So what's the potential solution for those experiencing these issues?

This post is primarily directed at those who are dealing with chronic pain, recurring injuries or frustrations with their rehab process. Every injury and rehab process is unique. The majority of the time many people are able to transition back to sport without issue, but I have seen enough cases where this is not the case and I believe this post addresses some of the reasons why. If you can relate to one of these scenarios here are a couple pieces of advice:

Make sure you are working with a professional who understands your sport. Rehab professionals such as physical therapists and chiropractors can have varied skill sets and specialties. It is important to make sure that the person you are working with has a good understanding of the demands of your sport to best prepare you for successful return to sport
Just because you have been discharged from physical therapy doesn't mean the rehab process is over as you return to sport. This specifically applies to post operative rehab. As mentioned above formal physical therapy often stops right around the time you are cleared to resume your sport or athletic activity. With this many times people start to become less complaint with their home exercise program. They also lose guidance to the important recommendations and monitoring of their status from their physical therapist or doctor during this important return to sport phase. Having a resource to consult with during this time is important.
Be your own advocate for your health. If something doesn't feel right or you don't feel prepared for sport despite being discharged you should know that there are other resources out there to help. Do not hesitate to get a second opinion or accept that this is the way it has to be.

Our return to golf program is one such solution. This program was designed for these specific scenarios to fill this big gap in the rehab process that many people encounter. The return to golf program evaluates your body's current level and bridges the gap between rehab and performance on the golf course. The program varies depends on each person's unique needs, goals and health history. In some cases it could involve an extensive program, in other cases it could be periodic consultation sessions to touch base and reevaluate progress. I also work closely alongside golf professionals in these cases to help with the sport specific technical and skill work that may be needed alongside physical improvements with the body.