The Tribune

By DR KENT L BAZARD

Sports Medicine Physician

“DOC, it’s the same hamstring again.”

It is a sentence I hear far too often in sports medicine. Sometimes it is the hamstring that has now strained for the third time. Sometimes it is an ankle that seems to turn every basketball season, a shoulder that settles down during rest but begins hurting again as soon as throwing increases, or a knee that feels perfectly fine until jumping and running resume.

Understandably, the athlete becomes frustrated. They rested. They iced it. The swelling disappeared. The pain went away. They returned to sport. So why has the injury come back?

The answer often begins with a misunderstanding of what it means to be “healed.”

An athlete can feel considerably better before the injured area has regained everything required for high-level sport. Pain resolution, tissue healing, restoration of strength and actual readiness for competition are related, but they are not the same thing. This is one reason modern return-to-sport recommendations increasingly treat return as a process involving progressive loading, functional assessment, sport-specific conditioning and risk evaluation rather than simply a date on the calendar.

After an injury, tissue goes through a biological repair process. Although the exact sequence differs between muscle, tendon, ligament and bone, we commonly describe overlapping phases of inflammation, proliferation and remodeling.

Early inflammation helps initiate repair. New tissue is then produced, including collagen in many musculoskeletal structures, before that tissue gradually reorganises and remodels in response to the forces placed upon it.

Tendons and ligaments are particularly slow to remodel because of characteristics such as relatively limited vascularity and slow collagenturnover. Importantly, newly repaired tissue does not immediately possess the organisation, mechanical properties or load tolerance of mature healthy tissue.

This is where the athlete can be fooled. Daily life is not sport. Being able to walk without hamstring pain does not mean that hamstring is prepared for maximal sprinting. Climbing stairs comfortably does not prove that a patellar tendon can tolerate repeated maximal jumps. Being able to raise your arm without shoulder pain does not mean that the shoulder can tolerate 80 high-velocity throws. The demands placed on tissue during competition can be several steps beyond what the athlete experiences during ordinary activity.

Think about injury rehabilitation as a balance between capacity and demand. Every tissue has a certain capacity to tolerate load. Sport creates a certain demand. If the demand remains below the athlete’s capacity, the body generally tolerates the activity. If the demand repeatedly exceeds that capacity, symptoms or injury become increasingly likely.

Following injury, capacity frequently falls. Good rehabilitation progressively rebuilds it until the athlete can tolerate not only everyday movement but also the forces, speeds, repetitions and fatigue associated with the sport. This is particularly important with hamstring injuries. A hamstring may feel completely comfortable during walking, cycling, light strengthening and even moderate running, but sprinting creates a very different mechanical challenge.

During high-speed running, particularly late in the swing phase, the hamstrings must rapidly produce and absorb considerable force while lengthening. That is one reason contemporary hamstring rehabilitation places importance on progressive strengthening, running and eventually exposure to sprinting rather than simply waiting for pain to disappear.

An international consensus on hamstring rehabilitation specifically emphasises individualising rehabilitation according to the athlete, injury and sporting demands, while restoring the capacity required for running, sprinting and eventual match play.

There is also a nervous-system component that athletes rarely consider. Injury changes more than the damaged tissue. Pain, swelling and reduced activity can alter how muscles are recruited and how movement is coordinated. The athlete may subconsciously protect the injured side. Strength can decline. Rate of force development can change. Balance andproprioception - the nervous system’s ability to recognise and control joint position - may be impaired. Even after pain disappears, some of these deficits may remain.

The recurrent ankle sprain is an excellent example. An athlete rolls the ankle, rests for several days, applies ice, perhaps wears a brace, and returns when walking and jogging are comfortable. Yet the original injury may have left deficits in balance, proprioception and neuromuscular control. The athlete can run forward perfectly well but still struggle when landing on another player’s foot, cutting suddenly or reacting to an unpredictable movement.

Clinical guidelines therefore recommend balance- and proprioception-focused therapeutic exercise, and in appropriate athletes bracing, to reduce the likelihood of subsequent lateral ankle sprains. Exercise-based interventions have been shown to reduce recurrence compared with usual care.

Shoulder injuries demonstrate the same principle in a different way. Consider a baseball pitcher, cricket bowler, tennis player or swimmer. Rest may reduce shoulder pain, but rest alone does not necessarily correct the reason the shoulder became overloaded. We may need to assess rotator-cuff strength, scapular control, thoracic mobility, shoulder range of motion and the contribution of the trunk, hips and lower body to the sporting movement.

We also have to examine how much the athlete is throwing or swimming. If the athlete rests until symptoms disappear and then immediately returns to the same workload that caused the problem, we should not be surprised when the shoulder begins hurting again.

Sometimes, therefore, the painful structure is the victim rather than the entire cause of the problem.

A recurrent hamstring injury may require us to look beyond the hamstring at sprint mechanics, pelvic and trunk control, strength, fatigue and exposure to high-speed running.

Recurrent knee symptoms may require examination of hip strength, ankle mobility, landing mechanics and overall training load. Recurrent shoulder symptoms may involve the kinetic chain rather than simply a “weak shoulder.” Treating only the place where an athlete feels pain can sometimes mean repeatedly treating the consequence while leaving important contributing factors unchanged.

Training load is another major part of the recurrent-injury puzzle. Imagine an athlete who has spent four weeks rehabilitating in a controlled environment. The athlete has been doing strength exercises, some running and perhaps sport-specific drills. They feel good. On Monday they are cleared, and by Tuesday they are completing full practice. Wednesday brings another hard session, Friday a game, and Saturday a tournament.

Within days, the recently rehabilitated tissues have gone from carefully controlled loading to demands they have not experienced for weeks. The problem may not be that the rehabilitation “failed.” The transition may have been too abrupt.

Return-to-sport research increasingly recognises this as a risk-management problem. The question is not simply whether an athlete can participate, but whether the athlete has rebuilt enough capacity to tolerate the expected cumulative stress of participation.

Consensus guidance also emphasises that return to sport should include functional and sport-specific testing and consideration of workload rather than being treated as one isolated decision at the end of rehabilitation. This is also why the calendar can be misleading.

Athletes frequently ask, “How many weeks until I can play?” Time matters because biology requires time to heal, but time alone does not rehabilitate an athlete. Two people can sustain apparently similar injuries on the same day and be at very different levels of readiness six weeks later.

Injury severity, age, previous injuries, training history, rehabilitation quality, sport, position, psychological readiness and many other factors influence recovery. The return-to-sport literature recognises that timelines can vary considerably even within similar injuries.

A more useful question is: What can you do now that you could not do two weeks ago, and what must you still be able to do before returning to competition? This is where objective testing becomes valuable. At Empire Sports Medicine & Performance, I do not want the only return-to-play question to be, “Does it still hurt?”

Depending upon the injury and sport, we may measure strength, compare one side with the other, evaluate range of motion, assess hamstring force production, examine movementquality and progressively introduce jumping, landing, acceleration, deceleration, change of direction or sprinting.

With tools such as our VALD Dynamo and NordBord systems, we can quantify aspects of strength rather than relying solely on how strong an athlete feels.

Testing does not eliminate injury risk - nothing can - but it gives us considerably more information than pain alone.

Fatigue also matters. An athlete may perform beautifully for the first five repetitions and lose control on the fifteenth. A hamstring may tolerate several sprints but struggle with repeated high-speed efforts. A knee may control the first few landings well but demonstrate deteriorating mechanics as the athlete becomes tired. Sport rarely asks athletes to produce one perfect movement while completely rested.

Return-to-sport assessment should therefore increasingly resemble the actual demands the athlete is returning to. This principle is consistent with consensus recommendations that functional testing should reflect the reactive and decision-making elements encountered in sport.

Nutrition is another part of rehabilitation that deserves considerably more attention. Tissue repair requires energy and raw materials. An injured athlete sometimes makes the mistake of drastically reducing food intake because training volume has decreased and they are afraid of gaining weight. But severe under-fuelling during rehabilitation may be counterproductive.

Adequate energy availability and protein intake support tissue repair, muscle preservation and the ability to tolerate progressive rehabilitation. Current reviews of tendon and ligament rehabilitation identify adequate energy and protein as foundational nutritional priorities.

Protein should be distributed across the day to support muscle protein synthesis, while adequate carbohydrate remains important as rehabilitation becomes more physically demanding. Micronutrient deficiencies should be addressed where present.

There is also growing interest in collagen or gelatin with vitamin C around connective-tissue loading sessions, although the evidence needs to be interpreted appropriately. The biological rationale is promising, but we do not yet have strong evidence that supplementation by itself shortens return-to-sport time or prevents reinjury.

Nutrition should support rehabilitation; it cannot replace progressive mechanical loading.Sleep and recovery belong in the same conversation. Rehabilitation is itself training. A tissue is loaded, allowed to recover and then exposed to progressively greater demands. If an athlete is simultaneously sleeping poorly, under-eating, participating in multiple teams and adding extra unsupervised workouts, the rehabilitation programme does not exist in isolation. The body experiences the total stress.

There is also a psychological side to recurrent injury. After being injured several times, athletes may become afraid of the movement associated with the injury. A sprinter may subconsciously hold back at maximal velocity. A basketball player with repeated ankle sprains may hesitate when landing. An athlete returning after an ACL reconstruction may possess excellent physical test results but still lack confidence in cutting or changing direction. Psychological readiness is therefore part of modern return-to-sport decision- making, not an afterthought.

This is why I prefer to think of rehabilitation as having several goals. First, allow the injured tissue to heal.

Second, restore what was lost because of the injury - strength, mobility, proprioception, power and conditioning.

Third, identify and address modifiable factors that may have contributed to the original problem.

Fourth, progressively expose the athlete to the specific demands of the sport. Finally, determine whether the athlete is ready not simply to participate, but eventually to perform. Those are very different standards.

A football player may be able to jog with the team before being ready to practice. They may practice before being ready for unrestricted competition. They may compete before they have returned to their previous performance level. Return to participation, return to sport and return to performance should be viewed as points along a continuum rather than one magical day when the athlete suddenly becomes “cleared.”

For parents and coaches, perhaps the most important lesson is not to rush the final stages because the athlete looks good. The last 10 or 20 per cent of rehabilitation is often where we begin recreating the very demands that caused the injury in the first place. It is also the stage athletes are most tempted to skip because they no longer feel injured. That is precisely when discipline matters.

Rest can make an athlete feel better. Rehabilitation should make the athlete better prepared. The absence of pain tells us that an athlete feels better. It does not necessarily tell us that the athlete is ready.

Returning safely requires us to consider tissue healing, strength, movement, conditioning, confidence, workload and the actual demands of the sport.

So when an athlete tells me, “Doc, it happened again,” my first question is not simply what happened this time. I also want to know what happened the last time. How was the injury rehabilitated? What deficits remained? How quickly did training resume? Was strength objectively restored? Was the athlete exposed progressively to speed and sport-specific demands? Were nutrition and recovery adequate? Did we treat the underlying problem, or did we simply wait for the pain to stop?

Because when the same injury keeps “coming back,” sometimes the most important question is whether it was ever completely prepared to leave.