The performance model of injury rehabilitation

Note: I am not a medical doctor, physical therapist, or athletic trainer; I am simply a skeptic who thinks there is a better way. The following is in no way meant as medical advice.

Last spring, at the Boston Sports Medicine and Performance Group conference, Bill Knowles spoke about a performance-based model of reconditioning an athlete after an injury, and contrasted this model with a medical model. The following is my example of what I learned and took away from this talk and how it applies to a current situation.

Today, I watched a female player take a couple free throws. When she finished, I asked when she sprained her ankle. As it turned out, she sprained her ankle last April. After she answered, she asked how I knew, and I told her that I watched her move. She was surprised. I said that she probably did not rehabilitate her ankle after she injured it, and she agreed and said that she started to play two days later. I told her that it was affecting her movement, and her shooting, and that it was the reason for her inflamed Achilles tendon.

Last week, the physio called her coach and said that she needed to rest because her Achilles tendon. The player is too competitive and too important to her team to sit out because she feels a little pain. However, pain should not be ignored. The medical model would be to treat the player with rest and ice until the inflammation receded and then try to play again.

Knowles differentiated the performance model from the medical model by saying that the performance model concentrates on the athlete and the athlete’s movement, not the injury. Therefore, do not treat the Achilles tendon; treat the entire athlete. I had heard about the Achilles inflammation, but it was not on my mind because she is not one of my players. However, as I watched her move, I saw an issue, which I initially attributed to an ankle sprain, as my experience has shown that the lack of ankle mobility that I saw frequently is the result of an non-rehabilitated ankle sprain in basketball players.

As I watched her move, and thought about the potential ankle sprain, I remembered the call to her coach last week. I made the leap from the ankle to the Achilles without any examination – it made sense that a restriction due to the ankle sprain would lead to tightness in the Achilles, which potentially could cause inflammation.

This is along the lines of the performance model. I did not diagnose an injury (I’m not a doctor). I diagnosed a movement restriction. In my opinion and experience, addressing this restriction will improve performance. In the process of investigating potential causes of this movement restriction, I found out about a previous injury (it was my hunch), and then related that previous injury to a current diagnoses. Along this model, the treatment is not rest and ice for the Achilles, but restoring proper movement. My belief is that when proper movement is restored, the inflammation will subside.

I am not sure how the physio diagnosed the injury, but in my experience, most physios/athletic trainers have the athlete come into their office. The athlete sits down, and the physio examines the leg visually and by touch. This may help to identify the issue causing the pain (the inflammation), but it will not help to identify the underlying cause – the movement with an ankle with restricted mobility. The physio diagnoses a specific injury, but is not treating the athlete or the athlete’s movement.

Based on my beliefs, what should she do? We started with these exercises:

Also, after watching this video, I’m going to check and see if her skin around the Achilles tendon is junky. It could be that the reduced ankle mobility, or inability to dorsiflex her ankle all the way, is due to the skin, according to Kelly Starrett:

I am not a doctor, and I am not treating an injury. I am treating a movement dysfunction (one which likely is caused by a 5-month old injury). I am using the performance model – my concern is not the old injury or the new inflammation. My concern is optimal movement. In the process of returning optimal movement through the performance model, I believe the injury problems will be relieved. On the other hand, using the medical model, there is no guarantee that reducing inflammation in the Achilles will return her to optimal movement. It may treat the injury, but it is not treating the movement or the individual athlete.

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