• Eurico Marques // BSc Physiotherapy

Pushing the Envelope

As discussed in Part 1, I prefer to use the pathophysiological model to patellofemoral pain to educate and empower my clients. If you haven’t read Part 1 (click here) I would suggest you do reading further. Athlete education is paramount to ensure the success of any intervention. Once they understand what we are trying to achieve the amount of feedback and ideas that they produce is phenomenal. This empowers them to become active participants in their own rehabilitation.

Determining the athlete’s current envelope of function starts off with a detailed subjective assessment. The athlete’s story is the foundation of all rehabilitation programs. Analysing their aggravating and easing factors should alert you to their current level of function. This helps set a starting point and provides the clinician with re-assessment tests that are relevant for the athlete. Standardised assessment tools can still be used to further expand on the degree of injury, but providing the athlete with a test in which they see the direct correlation to their story and sport is important for further strengthening their buy-in.

I tend to use body weight assessments measuring repetitions as my starting point for assessments. This allows me to reassess the athlete’s capacity in a reproducible manner. It is important to determine where on the scale of function the athlete is and thus allow for an adequate load to be applied. As a practical starting point, I like to use the simple flow below (fig. 1) to place the athlete on the path to recovery. This flow is not determined by the injury, but rather the response to exercise. I often include different modes of load depending on the athlete’s response. An example would be in the case of hamstring strains where knee and hip strategies are required in rehabilitation. An athlete may be able to cope with an eccentric lunge but need isometric knee flexion.

When determining response to load, I use the Numeric Rating Scale (NRS) (fig. 2)[1]. I simply ask the athlete “can you tolerate this?” as I prefer to allow them to determine their own tolerance and will often push them beyond this level in the assessment to ensure that I am indeed loading in the “zone of supraphysiological overload” or the “Growth Zone” (fig. 5). Once this “zone” has been established the intensity, frequency, and mode can be tinkered with for each exercise.

​​Using (fig. 3) I show athletes which degrees of tolerance I would like them to utilise. It should be noted that I show the athletes this figure once I am confident that they understand the NRS to ​​avoid them giving me the answer I want to hear, but instead empower them to control their own ​​tolerance level. Researchers have demonstrated that exercising with pain is not detrimental and may offer significant benefit over the short term[3]. Please note that this approach is not for every athlete and a degree of clinical reasoning is required when deciding on interventions and pain tolerance[3]. I tend to encourage my athletes to keep their NRS to 3 or less. Another practical tool I use is their immediate response to the load. If their symptoms settle shortly after cessation of the exercise this would indicate a low irritability and a licence to load.

It should be noted that I tend to complete the program as prescribed with the athlete before sending them on to continue unsupervised. This ensures that as fatigue sets in during the exercise, we are not reaching beyond into the “zone of structural failure”. This also provides the athlete with confidence in the program and we are now aware, more than ever, that the psychological aspects of rehabilitation play a vital role in return to previous function. Once the athlete has confidently completed the program, I follow-up with them the next day to monitor their response.

Using the Goldilocks Principle (fig. 4), we can continuously monitor in which zone the athlete trains. Exercising with pain is daunting for many practitioners and athletes. As this is a post on its own, I would like to refer you to this thought provoking post by Adam Meakins (@adammeakins) that provides further insight into prescribing load.

Using the Envelope of Function Model by Scott Dye’s (fig. 5), there are two factors that can be adjusted once you have found the appropriate exercises; load and frequency[4]. Deciding on frequency and mode of the load (isometric, concentric, eccentric or plyometric) requires a fair bit of experimentation. Don’t be afraid to try something, assess their response, and then alter either the frequency (reps, time etc.), the mode of the load and intensity. This blog by Tom Goom (@tomgoom) provides an alternative perspective on finding the optimal loading zone.

Ultimately, optimal loading is not a definitive value or set of exercises. I believe it is an ever-changing range of movements that provides the athlete with the stimulus that promotes recovery and enhances resilience. No two athletes are the same, and thus no two rehabilitation programs are the same. The complexity of the psycho-social aspects in rehabilitation means that although two athletes may present with the exact same injury, their response to a load is likely to be different. Don’t be afraid to confront your athlete with a challenging load. Allow them to develop and progress by providing reassurance and guidance throughout their rehabilitation.

In closing, the foundation to all successful rehabilitation programs is compliance and consistency. Education is key, so that athletes can take control of their own rehabilitation and feel confident enough to amend their programs independently. Successful programs are monitored by physiotherapist but controlled by athletes. Using Dyes model of the Envelope of Function to find the optimal loading zone is simple for the athlete to understand and gives them the necessary foundational knowledge to take control of their rehabilitation. I have found that after explaining this model to athletes, I get a flurry of questions. This, in my opinion, is the perfect response, as now my athletes are thinking and engaging with their rehabilitation program. Athlete awareness and education are the cornerstones to developing a rehabilitation program that is optimal. Now go out there and promote athletes to explore and find their “optimal” loading zone.

  1. Childs, J. D., Piva, S. R. & Fritz, J. M. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine (Phila. Pa. 1976). 30, 1331–4 (2005).

  2. Hawker, G. A., Mian, S., Kendzerska, T. & French, M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF. Arthritis Care Res. (Hoboken). 63, S240–S252 (2011).

  3. Smith, B. E. et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br. J. Sports Med. 51, 1679–1687 (2017).

  4. Dye, S. F. The Pathophysiology of Patellofemoral Pain A Tissue Homeostasis Perspective. (2005). doi:10.1097/01.blo.0000172303.74414.7d

#Physiotherapy #Rehab


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