Young baseball players could benefit from preseason arm injury prevention programs
Preseason prevention programs are beneficial to young baseball pitchers, according to research presented at the American Orthopaedic Society for Sports Medicine’s (AOSSM) Specialty Day. The study, the first to analyze a well-monitored preseason training program, showed numerous arm flexibility and strength improvements in participating athletes that could ultimately diminish the risk of injuries.
“Pitchers participating in this targeted prevention program demonstrated reduced internal rotation (IR) and horizontal adduction (HA) deficits,” commented corresponding author Charles A. Thigpen, PT, PhD, ATC, from ATI Physical Therapy in Greenville, South Carolina. “Improvements in these performance areas are important, as similar deficits have been linked to arm injuries in previous research.”
The study group included 143 pitchers at a median age of 15.7, of which 88 participated in additional preseason training and 76 continued with normal training. The prevention program was supervised by an athletic trainer and included resistance training with dumbbell weights and elastic tubing, as well as a focused flexibility program. This required an approximately fifteen minute commitment from pitchers, 4 times a week.
“Pitchers are most affected by arm injuries, in particular those who have had a prior injury,” noted Thigpen. “If we can encourage parents, coaches, and youth baseball organizations across the country to adopt similar programs, athletes may have a better chance for reducing time off the field because of injury, especially considering the increased effectiveness of the program in preventing subsequent arm injuries.”
Pitchers who had previous injuries and participated in the preseason training program were 4 times less likely to suffer an injury than those in the general arm care program. Further studies with follow-up are needed to confirm the benefits of these programs.
Dr. Kieran O’Sullivan THOUGHT LEADERS SERIES…insight from the world’s leading experts
How common is back pain and who does it usually affect?
Back pain is exceptionally common. In fact, to not experience back pain at some point of your life would be thoroughly abnormal.
Experiencing back pain is like becoming tired or becoming sad; we don’t necessarily like it, but it’s perfectly common.
What isn’t common, however, is that you don’t recover from back pain. A very small proportion of people experience back pain that either never goes away or it comes back so frequently or so commonly that it has a big impact on their life.
For example, sometimes people wonder “How do I prevent getting back pain?” It’s almost something that’s not worth trying to think about because you and I will both get back pain at some point in our lives. I’m fine with that, as long as it’s for a day or two and it still allows me to live a normal life.
The more important question is “How do I prevent my back pain lasting?” That’s a tricky question.
Does back pain affect people of all ages?
It’s very rare for people to get back pain before the age of about 12 or 13. But the rate of back pain increases quite a lot during the teenage years. It increases persistently then through until the midlife.
But then when you get to being beyond 50, back pain actually reduces slightly.
We see the peak onset of back pain being among teenagers and then increasing into adult life. But it is not, for example, a disease or condition of old people exclusively.
Why is back pain one of the most costly conditions to diagnose and treat?
We’ve probably treated back pain for too long as being an injury of tissues. For example, when somebody hurts their back and goes to see their family doctor or physiotherapist, they commonly get asked “How did you injure it?”
When you have persistent back pain, we’re not dealing any longer with a tissue injury – we’re dealing with pain.
An example I would give is you’ve probably had a headache yourself. Would you say that you’ve always injured your head when you’ve gotten those headaches? I would say probably not.
We’re quite comfortable with the idea that I can have abdominal pain or head pain without injury. But we have an assumption that back pain is always caused by and proportional to injury. Of course, that’s common because it often starts as an injury.
But what we know at this stage is that even if you look at things like whiplash or hurting your back while lifting at work, we know that it might be triggered initially by an injury. But the thing that stops you from getting better is not how badly injured the tissues are.
We’ve spent decades becoming obsessed with the idea that “If I just get the right diagnostic test or scan or assessment, I’ll find out which tissue is injured, be it a disk, ligament, or bone. Then I can just cut it out or rub the pain away.”
Unfortunately, what this has led to is more scans, more physiotherapy, more surgery, more medical interventions, and yet our outcomes are very poor.
If we compare ourselves to our colleagues who work in, for example, breast cancer care, we’re not giving the taxpayer the same value for money.
For example, the chances of somebody being disabled because of cardiovascular disease or breast cancer nowadays is thankfully much less. However, the likelihood of being disabled because of something like back pain has increased.
It’s not because back pain has become more common. It looks like it’s more so because we have ways of frightening people that are unhelpful.
For example, when you go for a back MRI, it is very rare for it to not show something. We used to think these things were always important, but it now looks like the things we see on MRI scans are a lot like finding some baldness on the top of your head or some wrinkles on the side of your eyes, that they are themselves not dangerous.
So, the pain is there and the pain is no fun, but it doesn’t look like it’s always very closely related to these scary things we see on MRI scans and so on.
What types of treatment have been used in recent decades to treat chronic back pain and how successful have they been?
If we look at the most common treatments over the last few decades, they tended to be one-dimensional and tried to fix one thing.
For example, there was an injection to numb or reduce inflammation around the nerve, or a physiotherapist might rub or crack something in your back, or a GP would give you drugs, or a psychologist would give you some cognitive behavioral therapy. Most of these things haven’t really been very good.
For example, they might have helped your pain and disability a little bit, and if I look particularly at the medical interventions that physiotherapists and doctors have used, they really have treated the back and not the person. So, we rubbed and stretched it, cracked it, injected it, cut it, but it hasn’t really done an awful lot for people.
In fact, what caused some people like me in my profession to get insecure is that many of the studies are showing that actually more treatment from physiotherapists, chiropractors, and more MRI scans, rather than being helpful, might actually be adding to people’s disability because we can make people more frightened that they have a serious problem.
There are times when more treatment is good, but, in the last few decades, these one-dimensional approaches, where we’ve given everybody exercise or everybody medication and not treated other aspects of their problem, haven’t really been effective. There is evidence that some people are better off without too much treatment.
But equally, there’s evidence that some people, because they have a very complex problem, need an awful lot of support. But that support probably needs to be individualized to what they actually need themselves and it has to cover physical factors as well as some important lifestyle and psychological factors.
Why do you think these treatments have only had marginal success?
It’s not that these treatments are necessarily bad, but they generally tend to look at one thing. So, if you come in with back pain and your back pain is related to being overweight, being stressed, having poor fitness, poor flexibility and those kind of things, doing a one-dimensional thing like strengthening your back muscles or going on a diet on its own isn’t going to fix all the components.
Obviously we do need to look at the back muscles and at all the parts locally in the back, but also we need to look at the health of a person as a whole – their sleep, their stress, their fears, and as well, come back to what they think is wrong with their back; trying to identify what it is for that particular person.
For example, if the person is underweight, asking them to lose weight just plainly doesn’t make any sense. But for some people it might be important. If the person doesn’t have any stress in their life and is sleeping perfectly well, that wouldn’t be where we’d focus our treatment, but for some people that’s critically important.
How important is the way a person thinks about their back problem?
It’s hugely important in terms of how you recover from back pain. Again, there are parallels with most other health conditions.
Take obesity for example. If you wanted to help people lose weight, we know that diet is a huge part of that, but you can’t just tell people “Eat less.” You have to help change their beliefs about what is contributing to obesity and then try and help change their behaviors, because things like obesity are influenced by things like socioeconomic factors, your mood, your motivation and so forth.
Back pain is the same. If a person thinks their back is damaged and that movement and activity is dangerous, I wouldn’t blame them for avoiding things like movement and activity.
So, a lot of the first stage of what we do is we assure people, and this is the case in 99% of the patients that we see, that even though their pain is very sore and no fun for them at all, that movements and activities are generally very safe and actually useful for their back, if they can get some support to try and help them move a little bit better.
The problem here is that sometimes patients might think if I tell them to move, that I’m telling them to just put up with their pain or that I might be casting aspersions on them, and that’s not what it’s about. It’s about identifying why some person with persistent pain might not be healing and recovering.
One thing that very often helps patients, in terms of trying to understand how back pain is a health condition like any other, is talking about cold sores. We’re generally very comfortable with the idea that health conditions like cold sores have a biological trigger, like a virus. But also that that virus is only a problem if you’re a bit run down – maybe stressed or sleep deprived, or maybe drinking too much in Ireland, these kinds of things.
All of those parts are important. You wouldn’t have gotten the cold sore without the virus. But equally, I know myself, I’ve had cold sores in the past, that cold sore is not a problem at the moment because I’m otherwise healthy.
Again, if we look at things like headaches; you might have a previous disposition to headaches, but if you expose yourself to too much alcohol, or stress, or sleep deprivation, if you have a young baby in the house, they could easily come back.
We can look at back pain from that perspective. Yes, you may have some things that sound like wear or tear on an MRI scan, or you may have some muscles that are a little bit weak or a little bit tight, that might be one component of it.
But there are actually millions of people with short, tight back muscles and posture that might look a little bit suboptimal. But as long as their overall health is good, that doesn’t reach a threshold in which it causes endless pain.
Once they’re sleeping well, not under too much stress, their mental health is good, they have good family support structures, they’re not under huge financial pressure, their body can heal from the normal day-to-day stresses and strains of life.
Why does avoiding usual activities and moving too carefully limit the potential for recovery?
First of all, we know the body needs movement to heal. Disks and cartilage etc. need movement to get their blood supply.
Movement in itself is good, but actually moving carefully is a much harder thing to do for your body.
I often say to patients to, for example, lift their hands over their head five times and see how hard it is and how difficult it is, and then compare that to moving very slowly and very carefully. They’ll notice that it’s actually much, much harder moving slowly because you’re fighting against gravity for much longer. Whereas moving at a normal speed, like bending to put on your shoes at a normal speed, is actually much easier.
From a purely physical aspect, movement and activity is good for the tissues of the back, but unfortunately quite painful for people in pain because they tend to move in a way that’s far more careful and cautious, which in itself puts more stress on the back.
That’s one problem. The movement is definitely good, but the way in which people with back pain move tends to be difficult and awkward.
We see this manifested in things like sitting posture. If I told you now to look at your sitting posture, your instinct would probably be to do something like brace your shoulders back and sit up straight. That’s understandable.
If you really teased that out and I asked you “Why aren’t you sitting like that already?” you would probably tell me “Well, that’s because it’s uncomfortable and unnatural.”
If you think about the friends and the people you know or see in a cafe, the people who are sitting relaxed and looking comfortable are the people without pain and the people with the most distressing and disabling pain are sitting upright and fidgeting like crazy.
Movement is good, but particularly, relaxed movement is good. If you look at people with chronic back pain, they’ve almost forgotten how to move easily. They cannot sit easily, they cannot dress easily, they cannot roll in bed easily. Not only are these movements painful but it’s understandable that it causes people to stop moving and to avoid activity. But that leads to further deconditioning.
Our message in terms of usual activities and moving is it’s very good and we would be trying to help people to move with less pain because it makes them more comfortable.
If we don’t change people’s beliefs around the idea that their back is being damaged easily or that their back is vulnerable, I don’t think we can blame them for avoiding activity and exercise.
We spend a huge amount of our time not necessarily cajoling or trying to trick people into moving, but trying to show them that a lot of the time their current strategies for movement are unhelpful.
It’s not that they’re deliberately trying to make themselves worse, it’s just that their body hasn’t understood that there’s a plan B, and that plan B can be moving with confidence and with freedom. But of course, that’s easier said than done when you’ve got a lot of pain.
What are the main misconceptions about back pain and how do you plan to counter this misinformation?
A couple of years ago, we ran a national campaign here in Ireland, I was a chairperson, and it was called “Back Pain Myths.” It was a series of public talks and we focused on five or six of the key misunderstandings we felt that were seen in the evidence, that were seen to be important for the members of the public to get.
In amongst these, we were trying to get across the message that pain is very real and very disabling, but chronic back pain is not an injury anymore. It’s far more like a headache and stomach ache, where there are a whole range of factors involved.
We know that from all the studies that will say the correlation between what we see on scans or what surgeons feel when they go in to operate on people, and pain is very poorly related. The pain is real, but it’s no longer about injury. If people still think injury, they will think it’s like a sprained ankle – “I must rest it and avoid it.”
Another very important misconception related to that is the idea that scans and tests are always useful. For example, when somebody goes for an MRI scan for their back, unless they have cancer or they have a spinal cord compression, which again, would usually be obvious to any GP or physiotherapist or chiropractor, the MRI scan is highly unlikely to be of use.
In fact, what it generally tends to do is increase fear and anxiety amongst people because once you reach the age of 14 or 15, I’m afraid you’re going to find some things. But these things are not damaging.
You can’t see this, but I’m getting balder. Every day I look in the mirror, I’m getting balder. But nobody would ask me if I’m getting terrible headaches because of it, because there’s no suggestion that – you could joke and say I have degenerative scalp disease, but really that’s just genetics and a process of aging.
The stuff we see on scans is very much like that. But people tend to think this disc degeneration is a pathology and it’s not, no more than baldness is a pathology.
Another misconception is that more treatment is always useful. We have a lot of evidence, and again this might sound like a bad business model for me to be saying this, that if you’ve got some back pain but you’re generally healthy and you’re able to cope and keep active, you would be better served by staying away from too many healthcare professionals and continuing to cope.
If you start entering the medical circle, especially if it’s in a privatized healthcare system, you can start getting pushed towards more scans, more tests, more interventions and more treatments. We know, first of all, that it might be a waste of money, but secondly, it might actually start making you paranoid about movement.
So, doctors, physiotherapists and other healthcare professionals are notorious for telling people what not to do. For example, they’ll tell people “Here’s a way you can get fit, but don’t swim, don’t walk, don’t bend, don’t garden, don’t golf, and don’t do this,” and we leave them very few options.
The last few misconceptions — the idea that if it hurts, it’s dangerous. Again, we’re not encouraging people to go out and injure themselves or make themselves very sore. But something can hurt and not be harmful, the reason being is that it looks like when you have chronic back pain, your alarm system has started to misfire.
In my home, intermittently the house alarm goes off if a bird flies into the window, for example. But the alarm system thinks somebody has broken the window because it’s the adjustment isn’t quite done right.
When you have persistent pain, your central nervous system, the nerves that give you the sensation of pain, become hypersensitive. So, even something simple, like stretching a ligament in your back, causes intense pain.
The patient understandably will think “Oh, that’s dangerous,” whereas what’s really happening there is the alarm has become hypersensitive and what we need to do is unwind that sensitivity. That includes activity, stress management, and sleep.
The big misconception, which I spend most of my time talking about, is like the cold sore, people think that back pain is either physical or psychological and nothing in between.
Whereas, if you look at, again I mentioned cold sores, but heart disease, we’re quite happy with the idea that heart disease can be linked to a physical thing you have to look at, like cholesterol and diabetes and obesity. But also we’re quite happy with the idea that stress can increase your blood pressure and risk for heart disease.
If you look at cancer, there’s significant evidence out there that genetic risk factors are involved in breast cancer, for example. But we also know that stress and other things lead to cancer.
Back pain isn’t different. Patients almost feel that nobody wants to sign up and say “Oh, I’ve got psychological back pain,” and I don’t ever say that my patients have. But what most patients have, when the pain has lasted a long time, is they have some very clear physical things that are unhelpful about the way they move.
But generally, their overall health. Not just psychological health, but their sleep, stress, mood and the fears and worries they have about their back pain can be a barrier. If we don’t label and identify them, and help people identify how to overcome them, we won’t have a meaningful impact on their pain.
What do you think the future holds for back pain treatments?
The optimist in me, based on recent high quality trials, tells me there’s actually a huge amount we can do for patients if we follow the evidence and we start differentiating pain from injury, and if we start treating the person and not their back.
For example, there’s been some very good studies done recently, showing that we can, compared to the old effects we were having on pain, have a big impact, have people with much less pain, much less disability and have a better quality of life.
It actually doesn’t have to cost a lot because we’ll treat those who don’t need much treatment very scarcely, we’ll stop sending people for unnecessary scans and we’ll start sparing that extra time and attention that we need and spend that on the people that need it most.
However, if I’m being perfectly honest, while I think that is definitely possible, the pessimist in me is telling me that this will be a pointless task if we’re doing one person at a time. For example, only seeing a few patients and changing them one at a time won’t do anything.
If we look at the smoking analogy again, the only way we have raised awareness in terms of preventing lung cancer is through mass media campaigns and every GP, physiotherapist, nurse, consultant singing off the same sheet.
So, if I go down the street tonight and I ask people “What do you think causes lung cancer and what would you do to reduce the effect?” The public knows, even if they’re a smoker, they know “Well, smoking is one of those things.” If you want to look at heart disease, people know “Well, heart disease is linked to things like diabetes and obesity and smoking.”
Whereas if I go down the street and ask “Well, what do you think causes back pain?” They generally come back with “It’s about physical things, like pulling, dragging, and lifting,” which is one part of it, but it’s just one part.
Or they’ll think it’s about damaged tissues in the back, like disks and bones and ligaments. They will have very little awareness of the role of overall health, sleep, stress, mood, fears, anxieties, and worries.
That’s why the pessimist in me thinks that while we can do a lot for people, it’s a huge uphill battle until we really get people thinking about the person and not the pain. That’s why I was involved in the back pain campaign in 2011, the Move For Health campaign, and that’s why we moved to launch our little website, Pain-Ed.com.
Both the campaign and the website are based on trying to get the public, and of course health care professionals, to understand all the little bits and pieces that are involved in their pain.
We know that when you change patient’s beliefs, you can empower them, make them betterconsumers of healthcare, but also help them control their own pain. In summary, I have a lot of hope for individual people and helping their pain but I’m quite pessimistic about where healthcare and society is at the moment.
Where can readers find more information?
I’d always tell patients to trust their own instincts about themselves, or someone close, because when I ask patients about our perspective on pain, this actually makes perfect sense to them.
When they discuss it with their family, the overwhelming majority says “Yeah, you know, I think there is something to this. I hurt my back and I sprained my back, but at this stage I can’t get it off my mind. I know I’m moving too carefully, I know I’m too stiff,” but they’re caught in this vicious circle where they’re in pain, they’re disabled, they’re weak, they’re deconditioned, they’re worried, they’re frustrated and we need to develop that sense of awareness.
People are intuitively able to understand this, but it’s almost as if as a society we haven’t really thought about the importance of it.
Dr. Kieran O’Sullivan is a Chartered Physiotherapist who lectures at the University of Limerick (UL) in Ireland. He completed his PhD in 2012 on low back pain (LBP).
He is currently coordinating several research projects including a multi-centre randomised controlled trial (RCT) on treatment of LBP.
He has been awarded “specialist” physiotherapist status by the national Physiotherapy Society (ISCP).
He has published over fifty peer-reviewed articles, as well as one book and three book chapters.
Lower back pain is an almost universal if unwelcome experience. About 80 percent of those of us in the Western world can expect to suffer from disruptive lower back pain at some point in our lives. But if we begin and stick with the right type of exercise program, we might avoid a recurrence, according to a comprehensive new scientific review of back pain prevention.
Lower back pain develops for many reasons, including lifestyle, genetics, ergonomics, sports injuries, snow shoveling or just bad luck. Most often, in fact, the underlying cause is unknown.
For most people, a first episode of back pain will go away within a week or so.
However, back pain recurs with distressing frequency. By most estimates about 75 percent of people who have had one debilitating episode of lower back pain will have another within a year.
These repeated bouts can set off what doctors and researchers call a “spiral of decline,” in which someone takes to his or her couch because of the pain; this inactivity weakens muscles and joints; the person’s now-feebler back and core become less able to sustain the same level of activity as before and succumb when he or she tries to return to normal life, leading to more pain and more inactivity; and the spiral accelerates.
This scenario obviously makes preventing back pain, especially in someone who already has undergone at least one episode, extremely desirable. But until now, few studies have systematically examined what really works against repeated back pain and what doesn’t.
So for the new review, which was published in JAMA Internal Medicine, researchers affiliated with the George Institute for Global Health at the University of Sydney in Australia and other institutions set out to gather and analyze as many relevant studies as possible.
There were surprising few high-quality studies, meaning those that had randomized participants to be treated or not. But after scouring through more than 6,000 studies about back-pain prevention, the researchers settled on 23 that they felt to be methodologically robust. These studies had examined, in total, more than 30,000 participants with back pain.
The prevention techniques under review included education about lifestyle changes, shoe orthotics, back belts, various types of exercise programs and exercise programs that also included some type of education about back-pain prevention.
For the purposes of the review, a successful prevention program was one that had kept someone from reporting another bout of back pain within a year or longer or that had staved off lost work time due to back problems.
Such success, as it turned out, was discouragingly limited. Educational efforts by themselves showed essentially zero ability to prevent a recurrence of back pain, the researchers found. Back belts and orthotics likewise were almost completely ineffective, leaving people who employed either of those methods very prone to experiencing more back pain within a year.
But exercise programs, either with or without additional educational elements, proved to be potent preventatives, the researchers found.
In fact, “the size of the protective effect” from exercise “was quite large,” said Chris Maher, a professor at the George Institute, who oversaw the new review. “Exercise combined with education reduced the risk of an episode of low back pain in the next year by 45 percent. In other words, it almost halved the risk.”
Interestingly, the type of exercise program didn’t matter. In some of the experiments that Dr. Maher and his colleagues reviewed, the regimens focused solely on strengthening the core and back muscles. In others, the training was more general, combining aerobic conditioning with strength and balance training. Most asked participants to complete two or three supervised sessions every week, typically for about two months, although some lasted longer. A few included education programs as well.
The end result was that if someone with a history of back pain exercised in a regular way, he or she was considerably less likely to be felled by more back pain within a year.
However, the protective effects typically wore off after that, with recurrences rising after 12 months, probably because many of the people who’d been involved in the studies stopped exercising, Dr. Maher said, and their back problems returned.
So based on the currently available evidence, he said, it’s still impossible to know whether exercise improves back health in the long-term, or if one type of exercise program is measurably better than others. He and his colleagues hope to mount studies comparing different routines head-to-head and follow people for several years.
But for now, he says, “of all the options currently available to prevent back pain, exercise is really the only one with any evidence that it works.”
If you are curious about the particulars of an effective back-exercise program, Dr. Maher points to one example, a full regimen of exercises from a 1991 study in the journal Physical Therapy, one of the studies included in the new analysis. Its suggested workout soundtrack of 1990s Swedish pop tunes is, however, optional!
Female Athlete Triad is a syndrome that involves an unbalanced relationship among a female athlete’s energy levels, bone mineral density (BMD), and menstrual function that can lead to a series of health concerns. Female Athlete Triad can have negative effects in the early stages of its development, and have long-term effects on overall health and well-being as females age.
What is Female Athlete Triad?
Female Athlete Triad is a syndrome that can manifest across a broad spectrum, but involves the interplay between three measurable factors: how much energy you have available to use for activity, the quality and strength of your bones, and your menstrual cycle. Clinically, imbalances in any one of these areas can lead to eating problems, osteopenia/osteoporosis, and/or menstrual dysfunction. The Triad has been described as a syndrome that involves both the physical and mental aspects of health.
Energy availability is calculated by how much energy you gain from dietary sources minus the amount of energy that you expend during activity. Typically with the Triad, poor energy availability is the driving force behind abnormal BMD and menstrual dysfunction. Nutrients act to provide the necessary source of fuel for bones and muscles. Poor nutrition can also have a negative effect on the part of the brain that controls hormones that regulate the menstrual cycle.
Bone mineral density defines one aspect of bone health. When your bones are not supplied with necessary nutrients or are stressed too much through overexercising, they may begin to weaken. This can lead to osteopenia (lower than normal BMD) and further, osteoporosis (a loss of bone strength that predisposes a person to increased risk of fractures). When a person has low BMD, she may be at an increased long-term risk of bone mineral loss and fracture as she ages.
Menstrual dysfunction refers to abnormal menstrual periods. This spectrum can range from eumenorrhea (normal menstruation) to oligomenorrhea (inconsistent menstrual cycles) to amenorrhea (absence of a menstrual period) in females who are of a reproductive age.
Female athletes are at an increased risk of developing the Triad due to the high demand that athletics place on the female body physically, as well as the increasing societal pressures for performance and image. For example, a female runner may feel that altering or restricting caloric intake will make her a faster runner, therefore gaining an edge on the competition and earning greater success in her sport. The Triad can be present in any female athlete, from the elite athlete striving to reach high-performance goals, to the adolescent female whose body is going through normal changes related to puberty. In any case, there are physical and psychological aspects of this syndrome that affect its extent, impact, and treatment.
How Does it Feel?
The Triad is not caused by a sudden traumatic injury, so there are typically no immediate symptoms. Instead, symptoms related to the 3 components of the Triad may develop over time, ranging from months to years.
A female athlete may begin experiencing the following symptoms, conditions, or changes (separately or together) that may indicate she is developing Female Athlete Triad:
•Low energy during school, work, or exercise
•Irregular or absent menstrual cycles
•Stress-related bone injuries (stress reactions or fractures)
•An unexplained drop in performance
•Changes in eating habits
•Altered sleeping patterns
•An unusually high focus on performance or image
•Experiencing high levels of stress
How Is It Diagnosed?
A multi-disciplinary team of medical providers typically diagnoses Female Athlete Triad. The team may include medical doctors, nutritionists, physical therapists, certified athletic trainers, and psychologists. However, nonmedical individuals, such as parents, friends, coaches, teammates, teachers, and work colleagues can also be resources to help identify female athletes who demonstrate signs of the Triad, as these are all people who spend time with the athlete.
If it is suspected that an athlete may be demonstrating 1 or more components of the Triad, various medical and psychological tests and consultations may be recommended, including:
•Diagnostic imaging of bone health: x-ray, bone density scan (DEXA), MRI
•Referral to a nutritionist for dietary assessment
•Referral to a primary care/family medical doctor for monitoring of menstrual function or related medical tests (blood tests, assessment of the natural stages of development, such as the onset of puberty, etc.)
•Referral to a physical therapist for functional assessment (motion, strength, movement quality)
•Because the Triad involves multiple components of health, an athlete who is able to receive care from all relevant health care practitioners has the best chance of developing a comprehensive plan to return to good health and athletic participation/performance.
How Can a Physical Therapist Help?
Physical therapists are trained to identify signs and symptoms of the Female Athlete Triad and initiate multidisciplinary care as appropriate and needed. They are also trained to understand the implications that the Triad may have on exercise prescription. For example, it would not be recommended that an athlete with a stress fracture due to low BMD perform jumping and running activities. Once an athlete’s symptoms are resolved, her physical therapist will be able to design an individualized return to activity program that encourages a safe, progressive level of activity. Physical therapists are trained to educate athletes and their families on the Female Athlete Triad, and work with athletes to prevent or resolve the condition, and guide the athlete back to safe, optimal performance levels. In many cases, this attention to and care for a female athlete’s overall health can improve performance in school and athletics, and even overall self-esteem. Many athletes report that they are more confident, stronger, and better equipped to achieve their goals when they feel they have a strong support and a plan for sustained health.
Can this Injury or Condition be Prevented?
The Female Athlete Triad is a very preventable condition.
The most effective approach to prevention is education. As both the level of female participation in competitive sports and the incidence of the Triad have risen over the last 2 decades, a stronger emphasis has been put on educating athletes, parents, and coaches on strategies to prevent the development of causal factors for the Triad. It is important to begin educating young female athletes as early as middle-school age on topics such as healthy eating, smart physical training, recovery and rest, and taking care of their bodies.
Coaches should monitor training and its impact on the overall health of the athlete by encouraging pain-free participation in sports; they may also track training and performance in order to notice any abnormal health or behavioral signs. Individuals involved in the life of a female athlete should promote an open, honest, and safe environment for the athlete so that she feels comfortable discussing challenges or issues she may be facing without the risk of external pressure or judgment.
Real Life Experiences
Jenna is a 17-year-old junior in high school who runs cross-country and track, and swims on a competitive, year-round club swim team. Jenna is a very talented athlete. She has been swimming since age 5, and last year, at the encouragement of her coaches, she decided to start running to improve her fitness for swimming. She immediately was in the top 5 runners on the school’s cross-country team. Jenna recently started receiving phone calls from college swim coaches. It has been her dream to earn a scholarship to swim in college, and as she begins to feel like it may be a real possibility, she commits to training harder than ever for both running and swimming.
For several weeks, she practices both sports every day, rushing from the track to the pool with no time to rest or grab a snack. Junior year is the hardest academic year at her school, so she has been swamped with homework and only gets around 5 hours of sleep each night.
After finishing in the top 10 at the state cross-country meet in November, Jenna started 2-a-day swim practices without taking any time off. During her weight-room sessions, she started noticing that her shin was growing very sore with each workout, and she wasn’t able to increase her weights like she did last season. Her shin didn’t bother her in the pool, but she had a hard time completing workouts and hitting her running times. She just felt tired all the time, and began to grow discouraged and unmotivated. Her mom took her to see a physical therapist.
Jenna’s physical therapist asked her specific questions about her training. Jenna felt comfortable being honest with her. Jenna mentioned she had started skipping lunch so that she wouldn’t feel lethargic for practice, and rarely had time to eat a full dinner because of her homework load. She told her physical therapist that she was beginning to feel like her chances of getting a college scholarship were slipping away.
Jenna and her physical therapist had a long discussion about the best plan to help her return to good health and achieve her goals. Her physical therapist helped her see that her desire to perform at a high level had become out-of-balance with her ability to take care of her body. She encouraged Jenna not to feel guilty, but to feel positive about her opportunity to address her challenges. Jenna was frustrated by the situation, but excited to work toward returning to full health. They discussed the plan with her coaches and parents, and everyone was on board.
Jenna’s physical therapist referred her to an orthopedic physician for evaluation of her bone health, as well as to a nutritionist to evaluate her diet and come up with a proper fueling plan that met the high physical demands of swimming and running. After resting for several weeks, Jenna returned to physical therapy, and learned an individualized program to restore and enhance her strength, endurance, and movement quality. She and her coaches worked on a training plan that would allow adequate rest and recovery.
By the national swim meet that March, Jenna was in the best shape of her life and placed first in her event, setting a new personal-best time. That summer, the college of her choice called with a scholarship offer. Jenna felt happy and healthy entering her senior year, excited for the adventures ahead!
Bicycle-related pain and injuries are commonly associated with poor bike fit. If you have pain related specifically to cycling, you might have a bike fit problem.
Bike Fit Basics
•Keep a controlled but relaxed grip of the handlebars.
•Change your hand position on the handlebars frequently for upper body comfort.
•When pedaling, your knee should be slightly bent at the bottom of the pedal stroke.
•Avoid rocking your hips while pedaling.
Problems and Possible Solutions
Problem: Anterior (Front) Knee Pain
Possible causes are having a saddle that is too low, pedaling at a low cadence (speed), using your quadriceps muscles too much in pedaling, misaligned bicycle cleat for those who use clipless pedals, and muscle imbalance in your legs (strong quadriceps and weak hamstrings).
Problem: Neck Pain
Possible causes include poor handlebar or saddle position. A poorly placed handlebar might be too low, at too great a reach, or at too short a reach. A saddle with excessive downward tilt can be a source of neck pain.
Problem: Lower Back Pain
Possible causes include inflexible hamstrings, low cadence, using your quadriceps muscles too much in pedaling, poor back strength, and too-long or too-low handlebars.
Problem: Hamstring Tendinitis
Possible causes are inflexible hamstrings, high saddle, misaligned bicycle cleat for those who use clipless pedals, and poor hamstring strength.
Problem: Hand Numbness or Pain
Possible causes are short-reach handlebars, poorly placed brake levers, and a downward tilt of the saddle.
Problem: Foot Numbness or Pain
Possible causes are using quadriceps muscles too much in pedaling, low cadence, faulty foot mechanics, and misaligned bicycle cleat for those who use clipless pedals.
Problem: Iliotibial Band Syndrome (ITBS)
Possible causes are too-high saddle, leg length difference, and misaligned bicycle cleat for those who use clipless pedals.
An Achilles tendon injury (tendinopathy) is one of the most common causes of pain felt behind the heel and up the back of the ankle when walking or running. While Achilles tendinopathy affects both active and inactive individuals, it is most common in active individuals; 24% of athletes develop the condition. Males experience 89% of all Achilles tendon injuries, and an estimated 50% of runners will experience Achilles pain in their running careers. In all individuals, Achilles tendinopathy can result in a limited ability to walk, climb stairs, or participate in recreational activities.
Achilles Tendon Injuries (Tendinopathy)
Achilles tendinopathy is an irritation of the Achilles tendon, a thick band of tissue along the back of the lower leg that connects the calf muscles to the heel. The term tendinopathy refers to any problem with a tendon, either short or long term. The Achilles tendon helps to balance forces in the leg and assists with movement of the leg and the ankle joint. Achilles tendinopathy results when the demand placed on the Achilles tendon is greater than its ability to function. This can occur after 1 episode (acute injury) or after repetitive irritation or “microtrauma” (chronic injury).
The severity of acute injuries is graded based on the amount of damage to the tendon:
•Grade I: Mild strain, disruption of a few fibers. Mild to moderate pain, tenderness, swelling, stiffness. Expected to heal normally with conservative management.
•Grade II: Moderate strain, disruption of several fibers. Moderate pain, swelling, difficulty walking normally. Expected to heal normally with conservative management.
•Grade III: Complete rupture, often characterized by a “pop,” immediate pain, inability to bear weight. Typically requires surgery to repair.
Most often, Achilles tendon pain is the result of repetitive trauma to the tendon. This repetitive strain can result in chronic Achilles tendinopathy, which is a gradual breakdown of the tissue and is most often treated with physical therapy.
Achilles tendinopathy may result from a combination of several different variables, including:
•Abnormal foot structure
•Abnormal foot mechanics
•A change in an exercise routine or sport activity
Pain can be present at any point along the tendon; the most common area to feel tenderness is just above the heel, although it may also be present where the tendon meets the heel.
How Does it Feel?
With Achilles tendinopathy, you may experience:
•Tenderness in the heel or higher up in the Achilles tendon
•Tightness in the ankle
•Tightness in the calf
•Swelling in the back of the ankle
•Pain in the back of the heel
•Pain and stiffness with walking, worst with the first several steps
How Is It Diagnosed?
Your physical therapist will review your medical history and complete a thorough examination of your heel. The goals of the initial examination are to assess the degree of the injury and determine the cause and contributing factors to your injury.
It is common for your physical therapist to perform a movement assessment. This may include watching you walk, squat, step onto a stair, or balance on 1 leg. The motion and strength in your leg will also be assessed.
Your physical therapist may also ask questions regarding your daily activities, exercise regimens, and footwear to identify other contributing factors.
Imaging techniques, such as x-ray or MRI, are often not needed to diagnose Achilles tendinopathy.
How Can a Physical Therapist Help?
You and your physical therapist will work together to develop a plan to help you achieve your specific goals. To do so, your physical therapist will select treatment strategies including any or all of the following areas:
•Pain. Many pain-relief strategies may be implemented, such as applying ice to the area, putting the affected leg in a brace, or using therapies such as therapeutic ultrasound.
•Range of motion. Your ankle, foot, or knee joint may be moving improperly, causing increased strain on the Achilles tendon. Self-stretching and manual therapy techniques (massage and movement) applied to the lower body to help restore and normalize motion in the foot, ankle, knee, and hip can decrease this tension.
•Muscular strength. Muscular weaknesses or imbalances can result in excessive strain on the Achilles tendon. Based on your specific condition, your physical therapist will design an individualized, progressive, lower-extremity resistance program for you. You may begin by performing strengthening exercises in a seated position — for example, pushing and pulling on a resistive band with your foot. You then may advance to exercises in a standing position — for example, standing heel raises.
•Manual therapy. Your therapist may treat your condition by applying hands-on treatments to move your muscles and joints in order to improve their motion and strength. These techniques often address areas that are difficult to treat on your own.
•Functional training. Once your pain, strength, and motion improve, you will need to safely transition back into more demanding activities. To minimize the tension on the Achilles tendon and your risk of repeated injury, it is important to teach your body safe, controlled movements. Based on your goals and movement assessment, your physical therapist will create a series of activities that will help you learn how to use and move your body correctly to safely perform the tasks required to achieve your goals.
•Patient education. Your therapist will work with you to identify, and establish plans to address, any possible external factors causing your pain, such as faulty footwear or inappropriate exercises. He or she will assess your footwear and recommend improvements, and develop a personal exercise program to help ensure a pain-free return to your desired activities.
Physical therapy promotes recovery from Achilles tendon injuries by addressing issues such as pain or swelling of the affected area, and any lack of strength, flexibility, or body control. When the condition remains untreated, pain will persist and may result in a complete tear of the Achilles tendon, which often requires surgery to repair.
If your surgeon decides that surgery is needed, physical therapy will be necessary after surgery for several months. Immediately after surgery, your ankle will be placed in a splint or cast with crutches to allow the repaired tissue to heal. Once sufficient healing has occurred, you will work with your physical therapist to progressively regain your ankle mobility and leg strength. He or she will also help you regain your ability to walk without assistance—and carefully guide your return over time to your desired recreational activities.
Can this Injury or Condition be Prevented?
Maintaining appropriate lower extremity mobility and muscular strength, and paying particular attention to your exercise routine—especially changes in an exercise surface, the volume of exercises performed, or your footwear are the best methods for preventing Achilles injuries.
Your physical therapist will help guide you through a process that will progressively reintegrate more demanding activities into your routine without overstraining your Achilles tendon. Keep in mind that returning to activities too soon after injury often leads to persistent pain, and the condition becomes more difficult to fix.
Real Life Experiences
Kevin is a 45-year-old recreational distance runner training for his second 5K road race. He runs 3 to 4 days each week. Over the past 2 months, he has begun to experience pain in the back of his right heel. His pain is worst at the beginning of his training runs; he also experiences pain and stiffness when taking his first steps in the morning and after standing up from his desk at work. He typically performs stretches for 5 minutes before or after his runs and is wearing running shoes that he purchased 10 months ago.
Kevin is becoming impatient as his pain is not improving, despite the fact that he has decreased the length of his runs. He is worried about his ability to train for and compete in an upcoming race, and consults his physical therapist.
The physical therapist conducts a comprehensive examination of Kevin’s motion, strength, balance, movement, and running mechanics. Kevin describes his typical daily running routine, including distance, pace, and running surface; his stretching routine; and his footwear. Based on these findings, the physical therapist diagnoses Achilles tendinopathy.
Kevin and his physical therapist work together to establish short- and long-term goals and identify immediate treatment priorities, including icing and stretching to decrease his pain, as well as gentle foot and ankle strengthening exercises. They also discuss temporary alternative methods for Kevin to maintain his fitness without continuing to aggravate his injury and prolong his recovery, including swimming, biking, and aqua jogging. Kevin is also prescribed a home exercise program consisting of a series of activities to perform daily to help his recovery.
Together, they outline an 8-week rehabilitation program for Achilles tendinopathy. Kevin visits his physical therapist 1-2 times each week; she assesses his progress, performs manual therapy techniques, and advances his exercise program as appropriate. She also advises him when it is appropriate to resume running, and establishes a day-by-day plan to help him safely build back up to his desired mileage. They also discuss the appropriate running footwear, given Kevin’s foot shape, movement patterns, and injury history. Kevin also performs an independent daily exercise routine at home, including stretching and strengthening activities. After 8 weeks of patience and diligence, Kevin no longer experiences pain or stiffness in the affected leg and resumes his desired training program without pain in preparation for his upcoming 5K race.
Iliotibial band syndrome (ITBS) occurs when excessive irritation causes pain at the outside (or lateral) part of the knee. The iliotibial band (ITB) is a type of soft tissue that runs along the side of the thigh from the pelvis to the knee. As it approaches the knee, its shape thickens as it crosses a prominent area of the thigh (femur) bone, called the lateral femoral condyle. Near the pelvis, it attaches to 2 important hip muscles, the tensor fascia latae (TFL) and the gluteus maximus.
Irritation and inflammation arise from friction between the ITB and underlying structures when an individual moves through repetitive straightening (extension) and bending (flexion) of the knee. Typically, ITBS pain occurs with overuse during activities such as running and cycling.
ITBS involves many lower extremity structures, including muscles, bones, and other soft tissues. Usually discomfort arises from:
•Abnormal contact between the ITB and thigh (femur) bone
•Poor alignment and/or muscular control of the lower body
•Prolonged pinching (compression) or rubbing (shearing) forces during repetitive activities
The common structures involved in ITBS are:
•Bursa (fluid-filled sack that sits between bones and soft tissues to limit friction)
ITBS can occur in:
•Athletes performing repetitive activities, such as squatting, and endurance sports such as running and cycling
•Individuals who spend long periods of time in prolonged positions, such as sitting or standing for a long workday, climbing or squatting, or kneeling
•Individuals who quickly start a new exercise regimen without proper warm-up or preparation
Signs and Symptoms
With ITBS, you may experience:
•Stabbing or stinging pain along the outside of the knee
•A feeling of the ITB “snapping” over the knee as it bends and straightens
•Swelling near the outside of your knee
•Occasionally, tightness and pain at the outside of the hip
•Continuous pain following activity, particularly with walking, climbing, or descending stairs, or moving from a sitting to standing position
Pain is usually most intense when the knee is in a slightly bent position, either right before or right after the foot strikes the ground. This is the point where the ITB rubs the most over the femur.
How Is It Diagnosed?
Your physical therapist will ask you questions about your medical history and activity regimen. A physical examination will be performed so that your physical therapist can collect movement (range of motion), strength, and flexibility measurements at the hip, knee, and ankle.
When dealing with ITBS, it is also common for a physical therapist to use special tests and complete a movement analysis, which will provide information on the way that you move and how it might contribute to your injury. This could include assessment of walking/running mechanics, foot structure, and balance. Your therapist may have you repeat the activity that causes your pain to see firsthand how your body moves when you feel pain. If you are an athlete, your therapist might also ask you about your chosen sport, shoes, training routes, and exercise routine.
Typically, medical imaging tests, such as x-ray and MRI, are not needed to diagnosis ITBS.
How Can a Physical Therapist Help?
Your physical therapist will use treatment strategies to focus on:
Range of motion
Often, abnormal motion of the hip and knee and foot joint can cause ITBS because of how the band attaches to hip muscles. Your therapist will assess the motion of your injury leg compared with expected normal motion and the motion of the hip on your uninvolved leg.
Hip and core weakness can contribute to ITBS. The “core” refers to the muscles of the abdomen, low back, and pelvis. Core strength is important, as a strong midsection will allow greater stability through the body as the arms and legs go through various motions. For athletes performing endurance sports, it is important to have a strong core to stabilize the hip and knee joints during repetitive leg motions. Your physical therapist will be able to determine which muscles are weak and provide specific exercises to target these areas.
Many physical therapists are trained in manual therapy, which means they use their hands to move and manipulate muscles and joints to improve motion and strength. These techniques can target areas that are difficult to treat on your own.
Even when an individual has normal motion and strength, it is important to teach the body how to perform controlled and coordinated movements so there is no longer excessive stress at the previously injured structures. Your physical therapist will develop a functional training program specific to your desired activity. This means creating exercises that will replicate your activities and challenge your body to learn the correct way to move.
Your physical therapist will also work with you to develop an individualized treatment program specific to your personal goals. He or she will offer tips to help you prevent your injury from reoccurring.
Can this Injury or Condition be Prevented?
Maintaining core and lower extremity strength and flexibility and monitoring your activity best prevents ITBS. It is important to modify your activity and contact your physical therapist soon after first feeling pain. Research indicates that when soft tissues are irritated and the offending activity is continued, the body does not have time to repair the injured area. This often leads to persistent pain, and the condition becomes more difficult to resolve.
Once you are involved in a rehabilitation program, your physical therapist will help you determine when you are ready to progress back to your previous activity level. He or she will make sure that your body is ready to handle the demands of your activities so that your injury does not return. You will also receive a program to perform at home that will help you maintain the improvements that you gained during rehabilitation.
Real Life Experiences
Sarah is a 31-year-old mother training for her first triathlon. With a young child at home, she has to squeeze in her training sessions early in the morning. She rarely has time to cool down or stretch after riding her bike or running because she has to get home before her child wakes up.
Sarah signs up for her first race and begins to increase her cycling and running in preparation. One day during the middle of a long run, she feels a sharp pain at the outside of her knee. It starts hurting with every step, and doesn’t go away, even after she stops and stretches. Far from home, she has to finish her run despite the nagging pain. When she gets home, she puts ice on it, but for the rest of the day she has trouble going up and down stairs, or squatting to pick up her son, and feels pain when standing up after driving the car. The next day, she tries to ride her bike, but the knee pain is still there and feels worse.
Wisely, Sarah stops running and cycling and contacts her physical therapist.
Sarah’s physical therapist conducts a comprehensive evaluation of her hip and knee motion, strength, balance, and running mechanics. She uses special tests and measures to determine if Sarah’s pain is related to her iliotibial band or if there are other problems occurring simultaneously. She talks with Sarah about her training routine, including equipment (shoes, position on the bike, etc), the routes she runs and their surfaces, and her stretching program. The therapist diagnoses Sarah with iliotibial band syndrome. She guides Sarah through specific exercises in the clinic, including manual stretching of the hip joint by the therapist, sidelying leg raises for hip strengthening, and single leg squats to promote integrated core, hip, knee, and ankle function. Sarah will also perform these exercises at home as a part of her daily exercise routine to maximize improvement and help ensure her sustainable success.
Sarah’s physical therapist helps her develop strategies for training, taking into consideration her lifestyle as a busy mother, to help her stay injury-free. Together, they outline a 6-week rehabilitation program for iliotibial band syndrome. Sarah will come to the clinic 1-2 times each week, where her therapist will assess her progress, perform manual therapy techniques, and advance her exercise program as appropriate. Sarah will also have a daily exercise routine to perform independently at home, including stretching and strengthening activities.
In 6 weeks, Sarah has met all of her physical therapy goals and completes her rehabilitation in the clinic. After building her training gradually over the next month, she is able to train and successfully crosses the finish line just as planned!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries. You may want to consider:
•A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, injuries.
•A physical therapist who is a board-certified specialist or who has completed a residency in orthopedic or sports physical therapy, as he or she will have advanced knowledge, experience, and skills that apply to an athletic population.
General tips when you’re looking for a physical therapist (or any other health care provider):
•Get recommendations from family and friends or from other health care providers.
•When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in helping people with ITBS.
•During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.
The American Physical Therapy Association believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of ITBS. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Strauss EJ, Kim S, Calcei JG, Park D. Iliotibial band syndrome: evaluation and management. J Am Acad Orthop Surg. 2011;19:726–736. Free Article.
Ellis R, Hing W, Reid D. Iliotibial band friction syndrome: a systematic review. Man Ther. 2007;12:200–208. Article Summary on PubMed.
Fredericson M, Weir A. Practical management of iliotibial band syndrome in runners. Clin J Sports Med. 2006;16:261–268. Article Summary on PubMed.
Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Med. 2005;35:451–459. Article Summary on PubMed.
Levin J. Run down: battling IT band syndrome in long distance runners. Biomechanics. 2003;1:22–25. Article Summary Not Available.
Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sports Med. 2000;10:169–175. Article Summary on PubMed.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Physical therapists are evidence-based health care professionals who offer cost-effective treatment that improves mobility and relieves pain, reduces the need for surgery and prescription drugs, and allows patients to participate in a recovery plan designed for their specific needs. Improve Mobility & Motion
Physical therapists are experts in improving mobility and motion. Pain-free movement is crucial to your quality of daily life, your ability to earn a living, your ability to pursue your favorite leisure activities, and so much more.
Movement is essential to physical activity, which is necessary to prevent obesity, which is responsible for at least 18% of US adult deaths.
Mobility is crucial for physical independence, and studies suggest that walking alone can reduce the risk of heart attack and stroke, hip fracture, and knee arthritis, among other benefits.
Consistent movement is vital to maintaining a healthy balance system, which can help prevent costly falls.
Avoid Surgery and Prescription Drugs
While surgery and prescription drugs can be the best course of treatment for certain diagnoses, there is increasing evidence demonstrating that conservative treatments like physical therapy can be equally effective (and cheaper) for many conditions.
Low back pain is routinely over-treated despite abundant evidence that physical therapy is a cost-effective treatment that often avoids advanced imaging scans like MRIs that increase the cost of care and the likelihood for surgery and injections.
Physical therapy has proven as effective as surgery for meniscal tears and knee osteoarthritis, rotator cuff tears, spinal stenosis, and degenerative disk disease, among other conditions.
Participate In Your Recovery
Physiotherapists routinely work collaboratively with their patients. Treatment plans can be designed for the patient’s individual goals, challenges, and needs. Receiving treatment by a physical therapist is rarely a passive activity, and participating in your own recovery can be empowering. In many cases, patients develop an ongoing relationship with their physical therapist to maintain optimum health and movement abilities across the lifespan.