Developing better methods to prepare athletes following injury

Bill Knowles, Director of Reconditioning and Athletic Development

For over 25 years I have been working with professional, world-class, and Olympic level athletes in the field of sports reconditioning and performance training. This journey continues to explore the relationship between evidence-based medicine and experience-based evidence. Even with today’s emphasis on evidence-based practice, there continues to be a blend of the “art” and the “science” when working with elite or professional athletes. 

For many years now I have seen post-op rehabilitation protocols designed by sports medicine specialists for world-class, professional or elite level athletes that attempt to return that individual back to the highest level of competition. This is where many medical professionals confuse treating the injury versus athletic preparation following injury or surgery. 

Question: If you are not qualified or experienced enough to design a performance training program for a professional, world-class, or elite athlete pre-injury, how are you able to effectively design a performance training program or Return to Competition strategy post-injury? 


REHABILITATION is a medical or clinical model for treating individuals who may or may not be athletes. A specialist orthopedic surgeon typically designs and/or approves this protocol. The focus of the program is on the surgery/damaged tissue and the early stages of rehabilitation. The rehabilitation protocol is designed to protect the peripheral lesion first, and promote slow controlled healing of the injury. This usually continues for many weeks or months with the aim on “doing no harm” to the healing tissue. True athletic preparation is typically encouraged to begin once biological healing time of the tissue has significantly advanced.


RECONDITIONING is a performance-based model for training athletes following injury or surgery. It is directed by a performance team and medically supported. The program design begins with the end goal in mind, which is a return to competition. We then design a progression backward to the surgery. This process allows the performance team to address all aspects of athletic development immediately post-injury or surgery to best prepare the individual for the true demands of competition that lay ahead. 

Reconditioning follows a functional path immediately post-injury and continues this progression until the athlete has returned to competition. We recognize that a serious joint/tendon/muscle injury should be looked upon as a neurophysiologic dysfunction, not just a basic peripheral musculoskeletal injury. With this in mind we must train movements, not muscles during all stages of post-injury care. Most protocols that restrict motion, brace joints, assist motion (CPM), or restrict loading are affecting the normal patterning that an athlete needs in order to best prepare for higher quality training in the weeks and months to come. The best “brace” for any injury is neuromuscular control and coordinated movement patterns. These CAN be developed early and often if encouraged to do so. Unfortunately I find many rehabilitation protocols are more centered on what an athlete CAN’T do versus what an athlete CAN do. This is often designed to protect the healing tissue, but I find the limitations imparted compromise the short and long term movement qualities of the athlete.

Training Around the Injury: The reconditioning model respects doing no harm and maintaining joint homeostasis, but encourages more creative ways to train the athlete in all phases of recovery. Because reconditioning is performance based, we prepare the athlete- not just treat the injury. Whether the response is physiological and/or psychological the outcomes are excellent. I find the medical model of rehabilitation focuses more on the injury and underestimates the positive healing response of training the entire individual. 

Longer Preparation Period: Many post-op rehabilitation protocols consider themselves progressive by offering accelerated programs and return to play strategies that get athletes back to competition very early. I am not in favor of these strategies. Reconditioning is a performance-based model that values a longer preparation period, NOT an earlier return to competition. 

PREPARATION means establishing the highest level of training within the shortest period of time, (while respecting homeostasis) and then staying there for many weeks to demonstrate the ability to sustain the stress over time. We must remember; it is easy to get them back, but difficult to keep them back.

The Performance Team: A performance-based model needs a performance team to monitor all aspects of athletic development from post-injury to a return to competition. The medical team is a part of this group, but should not fully control access to the athlete nor the entire protocol the athlete follows. This must be a shared venture with the fitness coaches, strength coaches, performance coaches, nutrition staff and the technical coaches as well. The performance team must have a solid understanding of how they will implement a reconditioning strategy and create a partnership with the orthopedic surgeon. 
The difference between clinical rehabilitation and reconditioning is significant. If a professional athlete is following the same post-injury program for the first 6-8 weeks that his mother would follow for the same injury, then the understanding of “sports therapy-sports medicine” is greatly misunderstood by the practitioner designing and/or implementing such protocol. We must continue to advance the quality of post-injury protocols for athletes by having discussions and sharing experiences with the orthopedic community as they can significantly influence the path reconditioning can follow. By getting performance coaches at the same table with medical science and surgeons we may further understand that full athletic preparedness is not a given just because the peripheral musculoskeletal injury was repaired.