Physical TheraPT
Clinical Wisdom
Shannon Vigil
Superbill Best Practices
The Recovery Mindset
Nina Szemis, ATC
Can You Outrun Illness?

General common sense, as well as scientific research, tells us that lifelong physical activity acts as a protecting agent against chronic illness and disease. If you’re able to consistently rack up 300 minutes of moderate intensity activity per week, you’re at much lower risk for things like cancer, cardiovascular disease and other inflammatory disorders. Regular physical activity also increases your resilience against communicable diseases, like bacteria and viral infections. However, here’s where the research starts to diverge.

SB2

Are You Spring Ready?

Spring sports ramp up fast — practices lengthen, intensity spikes, and competition schedules fill up. Whether you’re a high school athlete or a weekend warrior, your performance and durability are built long before the first game. In this blog, you’ll find tips for maximizing spring sport performance and the checklist every high school athlete and weekend warrior needs, covering strength, mobility, progressive speed exposure, and recovery strategies to set the stage for a healthy, successful season.

When the weather shifts, so does activity. Spring sports ramp up fast — practices get longer, intensity spikes, and competition schedules stack up quickly.

But here’s the truth:

Injuries don’t spike because spring arrived. They spike because preparation didn’t happen in winter.

Across both high school athletes and adult recreational athletes, research consistently shows the same pattern: early-season overload, overuse accumulation, and inadequate strength or tissue preparation drive injury rates up.

Let’s break it down.

 

High School Athletes: The Early-Season Risk Is Real

 

Track & Field

  • Overall injury rate: 0.84 injuries per 1,000 athlete exposures

  • Girls experience 37% higher injury rates than boys

  • Nearly 70% of track athletes sustain at least one injury in season-long studies

  • Training in spikes + ≥6 hours every two weeks increases injury risk 8-fold

Lower extremity injuries dominate — especially hamstrings, calves, knees, and ankles.

Translation: Winter should focus on posterior chain strength, tendon loading, and progressive speed exposure — not just mileage.

Baseball & Softball

  • Shoulder and elbow injuries are most common

  • Pitchers account for nearly 40% of shoulder injuries and 57% of elbow injuries

  • Injury rates are highest in the first month of the season

Translation: Arm care, scapular strength, and gradual throwing volume must begin in winter — not at the first bullpen.

Tennis (Youth)

  • Lower extremity injuries (knee & ankle) are most common

  • 43% of injuries cause >4 weeks missed

  • Training ≥3x/week or >4.5 hours/week doubles injury risk

Repetitive rotation + quick direction changes stress both lower body and shoulder complex.

Translation: Winter needs rotational strength, landing mechanics, and ankle stability work.

Weekend Warriors: The Spring Surge Problem

Adults face the same issue — compressed preparation and intensity spikes.

Recreational Runners (5K/10K Season)

  • Most common: shin splints, Achilles tendinopathy, patellofemoral pain

  • Median recovery time: 56 days

  • Poor sleep, high mileage (>20km/week), and higher bodyweight increase risk

Protective factor?
Foot-core strength training reduces injury risk by 60%.

Translation: Winter is the time to build tissue tolerance gradually — not jump into race mileage.

Adult Recreational Soccer

  • 60% sustain at least one time-loss injury per season

  • Knee (29.9%) and ankle (12.4%) most injured

  • 30% of injuries last >1 month

  • 14% are reinjuries

Contact accounts for over half of injuries — but many ligament injuries stem from poor neuromuscular control.

Translation: Winter should include deceleration drills, landing mechanics, and strength for joint stability.

Pickleball (Especially 50+)

  • 34% of recreational players report injury annually

  • Knee, elbow, shoulder most common

  • Achilles ruptures often require surgery

  • Fracture risk increases after age 60

Interestingly, experience and consistent play reduce injury risk — so if you’re gonna play, maybe don’t make it your annual “dust off the cleats and hope for the best” appearance.

Join a regular group. Your muscles (and your pride) will thank you.

Translation: Winter should emphasize balance, calf strength, and reactive footwork.

Why Winter Matters

The first month of spring season consistently shows the highest injury rates across multiple sports.

That tells us one thing:

The body wasn’t prepared for the demand.

Winter training should:

  • Build tendon resilience

  • Increase force production capacity

  • Improve neuromuscular control

  • Gradually expose athletes to speed and volume

Preparation reduces the “too much, too soon” spike.

Winter-to-Spring Readiness Checklist

High School Athlete Checklist

Strength

☐ 2–3x/week lower body strength (posterior chain focus)

☐ Single-leg strength work

☐ Core anti-rotation & rotational strength

☐ Arm care program (for overhead athletes)

Mobility

☐ Ankle dorsiflexion mobility

☐ Hip internal rotation

☐ Thoracic rotation

Speed & Conditioning

☐ Gradual sprint exposure (no sudden spikes)

☐ Acceleration + deceleration drills

☐ Progressive volume build

Recovery

☐ 8+ hours sleep

☐ At least 1 rest day/week

☐ Monitor soreness and early pain signals

 

Weekend Warrior Checklist

Strength

☐ 2x/week resistance training

☐ Calf and Achilles loading

☐ Knee control exercises

☐ Foot-core training (especially runners)

Volume Management

☐ Increase mileage or play time ≤10% per week

☐ Avoid jumping from “zero to league play”

Balance & Stability

☐ Single-leg balance drills

☐ Lateral movement prep

☐ Deceleration mechanics

Lifestyle Factors

☐ Prioritize sleep

☐ Manage stress

☐ Address lingering injuries before season start

Final Takeaway

Spring performance is built in winter.

Whether you're a high school sprinter, a pitcher, a tennis athlete — or a 42-year-old signing up for a 10K — the research says the same thing:

Preparation determines durability.

Train smart now.
Load gradually.
Build tissue capacity before demand spikes.

Because the goal isn’t just starting the season.

It’s finishing it healthy. 

References:

  1. Epidemiology of Injuries in United States High School Track and Field: 2008-2009 Through 2013-2014. Pierpoint LA, Williams CM, Fields SK, Comstock RD. The American Journal of Sports Medicine. 2016;44(6):1463-8. doi:10.1177/0363546516629950.

  2. Prevalence, Incidence and Characteristics of Musculoskeletal Injuries in Athletics (Track and Field): A Systematic Review and Meta-Analysis. Edouard P, Tsukahara Y, Mann RH, et al. British Journal of Sports Medicine. 2026;:bjsports-2025-110541. doi:10.1136/bjsports-2025-110541.

  3. Epidemiology of Overuse Injuries in US Secondary School Athletics From 2014-2015 to 2018-2019 Using the National Athletic Treatment, Injury and Outcomes Network Surveillance Program. Post EG, Simon JE, Robison H, Morris SN, Bell DR. Journal of Athletic Training. 2022;57(5):510-516. doi:10.4085/1062-6050-600-20.

  4. Training in Spikes and Number of Training Hours Correlate to Injury Incidence in Youth Athletics (Track and Field): A Prospective 52-Week Study. Ek A, Kowalski J, Jacobsson J. Journal of Science and Medicine in Sport. 2022;25(2):122-128. doi:10.1016/j.jsams.2021.09.006. 

  5. Shoulder Injuries in US High School Baseball and Softball Athletes, 2005-2008. Krajnik S, Fogarty KJ, Yard EE, Comstock RD. Pediatrics. 2010;125(3):497-501. doi:10.1542/peds.2009-0961. 

  6. Epidemiological Features of High School Baseball Injuries in the United States, 2005-2007. Collins CL, Comstock RD. Pediatrics. 2008;121(6):1181-7. doi:10.1542/peds.2007-2572. 

  7. Epidemiology of Shoulder and Elbow Injuries Among United States High School Baseball Players: School Years 2005-2006 Through 2014-2015. Saper MG, Pierpoint LA, Liu W, et al. The American Journal of Sports Medicine. 2018;46(1):37-43. doi:10.1177/0363546517734172. 

  8. Incidence of Injuries in High School Softball and Baseball Players. Shanley E, Rauh MJ, Michener LA, Ellenbecker TS. Journal of Athletic Training. 2011 Nov-Dec;46(6):648-54. doi:10.4085/1062-6050-46.6.648.

  9. Epidemiological Analysis of Pediatric Baseball and Softball Concussions in United States Emergency Departments. Abed V, Hawk GS, Conley C, Akarakian R, Stone AV. The American Journal of Emergency Medicine. 2023;69:143-146. doi:10.1016/j.ajem.2023.04.025. 

  10. Injury Profile in Junior Tennis Players: A Prospective Two Year Study. Hjelm N, Werner S, Renstrom P. Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of the ESSKA. 2010;18(6):845-50. doi:10.1007/s00167-010-1094-4. 

  11. Racket Sports-Related Injuries in Youth Athletes: A Narrative Review. Shrestha M, Usmani A, Karlov S, Harris A, Patel DR. International Journal of Environmental Research and Public Health. 2026;23(1):135. doi:10.3390/ijerph23010135. 

  12. Epidemiology of Musculoskeletal Injuries in Tennis Players: Risk Factors. Minghelli B, Cadete J. The Journal of Sports Medicine and Physical Fitness. 2019;59(12):2045-2052. doi:10.23736/S0022-4707.19.09842-6. 

  13. Diagnoses and Time to Recovery Among Injured Recreational Runners in the RUN CLEVER Trial. Mulvad B, Nielsen RO, Lind M, Ramskov D. PloS One. 2018;13(10):e0204742. doi:10.1371/journal.pone.0204742. 

  14. Factors Associated With Lower Limb Injuries in Recreational Runners: A Cross-Sectional Survey Including Mental Aspects and Sleep Quality. Mousavi SH, Hijmans JM, Minoonejad H, Rajabi R, Zwerver J. Journal of Sports Science & Medicine. 2021;20(2):204-215. doi:10.52082/jssm.2021.204.

  15. Predictive Effect of Well-Known Risk Factors and Foot-Core Training in Lower Limb Running-Related Injuries in Recreational Runners: A Secondary Analysis of a Randomized Controlled Trial. Suda EY, Watari R, Matias AB, Taddei UT, Sacco ICN. The American Journal of Sports Medicine. 2022;50(1):248-254. doi:10.1177/03635465211056329. 

  16. Running With Injury: A Study of UK Novice and Recreational Runners and Factors Associated With Running Related Injury. Linton L, Valentin S. Journal of Science and Medicine in Sport. 2018;21(12):1221-1225. doi:10.1016/j.jsams.2018.05.021.

  17. Injuries Among Spanish Male Amateur Soccer Players: A Retrospective Population Study. Herrero H, Salinero JJ, Del Coso J. The American Journal of Sports Medicine. 2014;42(1):78-85. doi:10.1177/0363546513507767. 

  18. Soccer Injuries and Recovery in Dutch Male Amateur Soccer Players: Results of a Prospective Cohort Study. van Beijsterveldt AM, Steffen K, Stubbe JH, et al. Clinical Journal of Sport Medicine : Official Journal of the Canadian Academy of Sport Medicine. 2014;24(4):337-42. doi:10.1097/JSM.0000000000000028. 

  19. Injuries in Formal and Informal Non-Professional Soccer - An Overview of Injury Context, Causes, and Characteristics. Gebert A, Gerber M, Pühse U, et al. European Journal of Sport Science. 2018;18(8):1168-1176. doi:10.1080/17461391.2018.1475507. 

  20. The Perils of Pickleball: A Two Decade Analysis of Upper and Lower Extremity Injuries From America's Fastest Growing Sport. Boroumand S, Park N, Katsnelson B, et al. Journal of Sports Sciences. 2025;43(14):1378-1385. doi:10.1080/02640414.2025.2496089. 

  21. Pickleball-Related Injuries Treated in Emergency Departments. Forrester MB. The Journal of Emergency Medicine. 2020;58(2):275-279. doi:10.1016/j.jemermed.2019.09.016. 

  22. Injury Risk and Epidemiology of Pickleball Players in South Korea: A Cross-Sectional Study. Jeong B, Lee KJ, Nam SH, et al. Frontiers in Public Health. 2025;13:1617291. doi:10.3389/fpubh.2025.1617291. 

  23. Pickleball: A Standard Review of Injury Prevalence and Prevention in a Rapidly Growing Sport. Azar FM, Lamplot JD, Bernholt DL, Spence DD. The Journal of the American Academy of Orthopaedic Surgeons. 2024;32(22):e1130-e1141. doi:10.5435/JAAOS-D-24-00151. 

  24. As Pickleball Continues to Gain Players, Injuries Are Increasing. Rodgers L. JAMA. 2025;:2840448. doi:10.1001/jama.2025.18833. 

  25. Emerging Patterns of Foot and Ankle Injuries in Pickleball Players: A Short Report. Kingston K, Parker EB, Higgins A, Smith JT. Foot & Ankle International. 2024;45(11):1266-1269. doi:10.1177/10711007241271215. 

  26. Common Sports Injuries in Young Tennis Players. Bylak J, Hutchinson MR. Sports Medicine (Auckland, N.Z.). 1998;26(2):119-32. doi:10.2165/00007256-199826020-00005.

The Rehab Hack Pro Athletes Swear By

“You need to rest after an injury.”  While in general this advice is true, what if there was a way to rebuild or at the very least maintain your muscle after an injury?  A way to put a healthy amount of stress through your tissues that allows you to return to the field quicker?

You may think this is a cheat code, or “bio-hacking” but in truth it’s simpler than that.  It is the secret that is used in professional athlete training rooms across the globe - Blood Flow Restriction Training (BFR).

 

What is BFR?

It’s not magic, it’s occlusion.  Specialized cuffs, similar to blood pressure cuffs, are wrapped around the upper portion of your arms or legs and inflated to 40%-90% of your arterial occlusion pressure.  This partially restricts the blow of blood into your limbs as you perform your exercise.  

The restriction of blood tricks your muscles into believing they are working harder; allowing you to benefit more from working at much lower, and safer, loads (20%-30% of 1RM)[2,3].  The metabolic effects from working out with BFR at 30% 1RM have been shown to provide similar results as working out at 70% 1RM.  Thus, making training while recovering safer during early rehab. [4]

 

The Secret? Metabolic Activity

Muscle growth depends on the nutrients being delivered to build up bigger, faster, and stronger.  BFR creates metabolic stress within the muscle which causes lactate accumulation, cellular swelling, and activation of growth pathways. [3]  

Using BFR also enhances type II, fast twitch, muscle recruitment while also promoting new blood vessel formation to help fuel those muscles. [2,3,5]

It’s tricking your body into thinking it’s working harder than it really is.  

 

Why do Pro Athletes use this technique?

Sports aren’t just a game to professional athletes, it’s a way of life.  Downtime from an injury affects more than just their playing time and muscle atrophy can delay the return to play. Here are a few advantages of using BFR during rehab: 

  • Preserve muscle mass [6,7]

  • Reduce mechanical stress on healing tissue [4]

  • Accelerate recovery timelines, returning athletes to the field sooner [6]

  • Safe early rehab option when protocols and precautions are followed [8]

 

PRODUCTS WE LOVE

While technique and programming drive effective Blood Flow Restriction Training, the right equipment plays a key supporting role. We consistently use and recommend SAGA and VALD BFR cuffs for their precision, safety, and reliability. When applied appropriately, these systems allow athletes to train at lower loads while still creating the metabolic stimulus needed to preserve muscle and support a safe return to play.

 
BUY ON AMAZON
BUY ON AMAZON
 
 

Is it safe?

In general, yes BFR is safe to use when applied properly and under the supervision of a trained professional.  A qualified provider should screen an athlete for any complications that could cause issues.  

Cardiovascular issues like a history of blood clots, severe hypertension, vascular issues, active infections, and cancer are all contraindications.  

 

What does a training program look like with BFR?

  • Athletes should look to train 2-3 times a week, but more than 3 times a week has shown favorable outcomes. [10]

  • Cuff should be inflated to ≥160 mmHg or 40-90% of arterial occlusion pressure

  • Select a weight that is 20%-30% of 1RM

  • 1-3 exercises are selected to be performed with the cuff inflated

  • An example repetition protocol would be [4]

    • 30 reps

    • Rest 30 seconds

    • 15 reps

    • Rest 30 seconds

    • 15 reps

    • Rest 30 seconds

    • 15 reps

 

Do I need to be a professional athlete to use BFR?

No! BFR is a valid treatment option for anyone looking to supplement their current workout, or utilize while injured.  Some great options for adding in BFR include[12,3]:

  • Adding BFR work at the end of regular strength sessions for additional volume without excessive fatigue

  • Using BFR during taper periods to maintain muscle mass while reducing mechanical load

  • Incorporating BFR during in-season training when recovery demands are high

Before starting any BFR training it is important to consult with your healthcare provider, proper screening is essential for safe implementation. 

 

References

  1. Blood Flow Restriction Therapy After Anterior Cruciate Ligament Reconstruction. Johns WL, Vadhera AS, Hammoud S. Arthroscopy : The Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2024;40(6):1724-1726. doi:10.1016/j.arthro.2024.03.004.

  2. Blood Flow Restriction Therapy: Where We Are and Where We Are Going. Vopat BG, Vopat LM, Bechtold MM, Hodge KA. The Journal of the American Academy of Orthopaedic Surgeons. 2020;28(12):e493-e500. doi:10.5435/JAAOS-D-19-00347.

  3. Physiological Adaptations and Practical Efficacy of Different Blood Flow Restriction Resistance Training Modes in Athletic Populations. He C, Zhu D, Hu Y. Frontiers in Physiology. 2025;16:1683442. doi:10.3389/fphys.2025.1683442.

  4. Blood Flow Restriction Training. Lorenz DS, Bailey L, Wilk KE, et al. Journal of Athletic Training. 2021;56(9):937-944. doi:10.4085/418-20.

  5. Blood Flow Restriction Training and the High-Performance Athlete: Science to Application. Pignanelli C, Christiansen D, Burr JF. Journal of Applied Physiology (Bethesda, Md. : 1985). 2021;130(4):1163-1170. doi:10.1152/japplphysiol.00982.2020.

  6. Time to Save Time: Beneficial Effects of Blood Flow Restriction Training and the Need to Quantify the Time Potentially Saved by Its Application During Musculoskeletal Rehabilitation. Bielitzki R, Behrendt T, Behrens M, Schega L. Physical Therapy. 2021;101(10):pzab172. doi:10.1093/ptj/pzab172.

  7. Editorial Commentary: Blood Flow Restriction Therapy Continues to Prove Effective. LaPrade RF, Monson JK, Schoenecker J. Arthroscopy : The Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2021;37(9):2870-2872. doi:10.1016/j.arthro.2021.04.073.

  8. The Safety of Blood Flow Restriction Training as a Therapeutic Intervention for Patients With Musculoskeletal Disorders: A Systematic Review. Minniti MC, Statkevich AP, Kelly RL, et al. The American Journal of Sports Medicine. 2020;48(7):1773-1785. doi:10.1177/0363546519882652.

  9. Comparison of Blood Flow Restriction Interventions to Standard Rehabilitation After an Anterior Cruciate Ligament Injury: A Systematic Review. Colombo V, Valenčič T, Steiner K, et al. The American Journal of Sports Medicine. 2024;52(14):3641-3650. doi:10.1177/03635465241232002.

  10. Effects of Blood Flow Restriction Training on Physical Fitness Among Athletes: A Systematic Review and Meta-Analysis. Yang K, Chee CS, Abdul Kahar J, et al. Scientific Reports. 2024;14(1):16615. doi:10.1038/s41598-024-67181-9.

  11. Application of Blood Flow Restriction Training in Adolescents: A Narrative Review. Chen ZL, Zhao TS, Ren SF, et al. Medicine. 2025;104(29):e43084. doi:10.1097/MD.0000000000043084.

  12. Where Does Blood Flow Restriction Fit in the Toolbox of Athletic Development? A Narrative Review of the Proposed Mechanisms and Potential Applications. Davids CJ, Roberts LA, Bjørnsen T, et al. Sports Medicine (Auckland, N.Z.). 2023;53(11):2077-2093. doi:10.1007/s40279-023-01900-6.

  13. A Useful Blood Flow Restriction Training Risk Stratification for Exercise and Rehabilitation. Nascimento DDC, Rolnick N, Neto IVS, Severin R, Beal FLR. Frontiers in Physiology. 2022;13:808622. doi:10.3389/fphys.2022.808622.

Water Wins

You've probably heard you need to drink lots of water after a massage. But is that really necessary? Let's look at what the science actually says about hydration, massage, and athletic performance.

Why Water Matters for Athletes

Water makes up about 60% of your body weight and plays essential roles in nutrient transport, temperature regulation, and joint lubrication. For athletes and active individuals, staying hydrated is particularly important because it affects how your muscles and tissues function.[1]

When you're dehydrated, your tissues become stiffer and less flexible. Research shows that dehydration increases the force needed to compress soft tissues and reduces tissue thickness. Even mild dehydration (losing just 3% of your body weight in fluids) can decrease muscle endurance by about 8% and reduce strength by about 5%.[2][3]

Dehydration also creates extra stress on your muscles at the cellular level. Studies show that exercising while dehydrated increases oxidative stress and can impair muscle protein metabolism. Over time, severe dehydration may even slow down muscle recovery and glycogen (energy) storage after workouts.[4][5]

 

The Truth About Massage and "Toxins"

Here's the reality: the idea that massage releases toxins requiring extra water is a myth. There's no scientific evidence supporting this claim.[6][7][8]

Your body already has highly effective systems for removing waste products—your liver, kidneys, and lymphatic system handle this 24/7. Massage doesn't create a sudden release of toxins that needs to be flushed out with water.

What about lactic acid? This is another common misconception. Lactic acid doesn't cause muscle soreness, and it's cleared from your muscles within 30-60 minutes after exercise—long before you'd typically get a massage. Massage doesn't remove lactic acid, and you don't need extra water to flush it out.[9][10][11]

That said, massage does produce real physiological effects. Studies show it can temporarily reduce cortisol (a stress hormone), lower heart rate, and cause modest changes in inflammatory markers. But none of these effects require you to drink extra water.[12][13][14]

 

How Much Water Do You Actually Need?

For general health, aim for about 40-45 mL per kilogram of body weight per day from all beverages and food combined. For a 150-pound (68 kg) person, that's roughly 2.7-3 liters (90-100 ounces) total per day.[15][16]

If you're training hard or sweating heavily, you'll need more. A good rule of thumb: replace about 1.5 times the fluid you lose during exercise. For example, if you lose 1 pound during a workout, drink about 24 ounces of fluid.[17]

Simple ways to monitor your hydration:

  • Check your urine color—pale yellow is ideal

  • Pay attention to thirst during moderate activity

  • Weigh yourself before and after intense workouts to estimate fluid loss

  • Add 0.5-1 liter of water after high-sweat sessions


Important: Don't overdo it. Drinking excessive plain water during prolonged exercise can dilute your sodium levels and cause problems.

 

The Bottom Line

Hydration is important for athletic performance and recovery—but not because of massage. Staying well-hydrated helps maintain tissue flexibility, supports muscle function, and enables efficient recovery from training.[2][4][3]

After your next massage, feel free to drink water if you're thirsty. But don't feel pressured to chug extra water based on myths about toxins or lactic acid. Instead, focus on consistent daily hydration as part of your overall training and recovery strategy.

The real reason to stay hydrated isn't about flushing anything out—it's about keeping your body functioning at its best.

 

References

  1. Water as an Essential Nutrient: The Physiological Basis of Hydration. Jéquier E, Constant F. European Journal of Clinical Nutrition. 2010;64(2):115-23. doi:10.1038/ejcn.2009.111.

  2. Investigating the Impact of Dehydration and Hydration on in-Vivo Hip Soft Tissue Biomechanics. Khorami F, Foroutan Y, Sparrey CJ. PloS One. 2025;20(8):e0328054. doi:10.1371/journal.pone.0328054.

  3. Effect of Hypohydration on Muscle Endurance, Strength, Anaerobic Power and Capacity and Vertical Jumping Ability: A Meta-Analysis. Savoie FA, Kenefick RW, Ely BR, Cheuvront SN, Goulet ED. Sports Medicine (Auckland, N.Z.). 2015;45(8):1207-27. doi:10.1007/s40279-015-0349-0.

  4. Passive Dehydration Increases Oxidative Stress and mTOR Signalling Pathway Activation in Young Men Following Resistance Exercise. Luk HY, Jiwan NC, Appell CR, et al. The Journal of Physiology. 2025;603(12):3551-3570. doi:10.1113/JP288434.

  5. Hydration, Hyperthermia, Glycogen, and Recovery: Crucial Factors in Exercise Performance-a Systematic Review and Meta-Analysis. López-Torres O, Rodríguez-Longobardo C, Escribano-Tabernero R, Fernández-Elías VE. Nutrients. 2023;15(20):4442. doi:10.3390/nu15204442.

  6. Side-Effects of Massage Therapy: A Cross-Sectional Study of 100 Clients. Cambron JA, Dexheimer J, Coe P, Swenson R. Journal of Alternative and Complementary Medicine (New York, N.Y.). 2007;13(8):793-6. doi:10.1089/acm.2006.6401.

  7. The Safety of Massage Therapy. Ernst E. Rheumatology (Oxford, England). 2003;42(9):1101-6. doi:10.1093/rheumatology/keg306.

  8. The Mechanisms of Massage and Effects on Performance, Muscle Recovery and Injury Prevention. Weerapong P, Hume PA, Kolt GS. Sports Medicine (Auckland, N.Z.). 2005;35(3):235-56. doi:10.2165/00007256-200535030-00004.

  9. Delayed Onset Muscle Soreness : Treatment Strategies and Performance Factors. Cheung K, Hume P, Maxwell L. Sports Medicine (Auckland, N.Z.). 2003;33(2):145-64. doi:10.2165/00007256-200333020-00005.

  10. Delayed Muscle Soreness: A Review. Francis K. The Journal of Orthopaedic and Sports Physical Therapy. 1983;5(1):10-3. doi:10.2519/jospt.1983.5.1.10.

  11. Lactate: Friend or Foe. Hall MM, Rajasekaran S, Thomsen TW, Peterson AR. PM & R : The Journal of Injury, Function, and Rehabilitation. 2016;8(3 Suppl):S8-S15. doi:10.1016/j.pmrj.2015.10.018.

  12. Physiological Adjustments to Stress Measures Following Massage Therapy: A Review of the Literature. Moraska A, Pollini RA, Boulanger K, Brooks MZ, Teitlebaum L. Evidence-Based Complementary and Alternative Medicine : eCAM. 2010;7(4):409-18. doi:10.1093/ecam/nen029.

  13. Influence of Classical Massage on Biochemical Markers of Oxidative Stress in Humans: Pilot Study. Skubisz Z, Kupczyk D, Goch A, et al. BioMed Research International. 2021;2021:6647250. doi:10.1155/2021/6647250.

  14. Effect of Single Session of Swedish Massage on Circulating Levels of Interleukin-6 and Insulin-Like Growth Factor 1. Stenbäck V, Lehtonen I, Mäkelä KA, et al. International Journal of Molecular Sciences. 2024;25(17):9135. doi:10.3390/ijms25179135.

  15. Hydration for Health Hypothesis: A Narrative Review of Supporting Evidence. Perrier ET, Armstrong LE, Bottin JH, et al. European Journal of Nutrition. 2021;60(3):1167-1180. doi:10.1007/s00394-020-02296-z.

  16. Hydration and Health at Ages 40-70 Years in Salzburg Austria Is Associated With a Median Total Water Intake Over 40 mL/kg Including at Least 1 L/D Plain Drinking Water. Stookey JD, Langthaler PB, Felder TK, et al. Frontiers in Public Health. 2025;13:1668981. doi:10.3389/fpubh.2025.1668981.

  17. Selected Issues for Nutrition and the Athlete: A Team Physician Consensus Statement. Medicine and Science in Sports and Exercise. 2013;45(12):2378-86. doi:10.1249/MSS.0000000000000174.

When Is an Athlete Actually Ready?

Ever watch an athlete pass every physical test with flying colors but still hesitate when it's time to compete? Or see someone who's technically cleared but just doesn't look like themselves on the field? That's the psychological side of injury recovery — and it's just as important as the physical side.

Here's what many don't realize: an athlete who returns to sport when not psychologically ready may be at increased risk for mental health crisis, physical injury, or both. Let's break down the mental obstacles high school athletes face after ACL injuries, shoulder dislocations, and ankle sprains — and what actually helps them overcome these barriers.

 

The Mind-Body Connection: Why Psychology Matters

Psychological readiness is the critical missing piece in return-to-sport decisions. After ACL reconstruction, mental health scores directly correlate with successful return to sport. In fact, a recent analysis found that psychological readiness was the most effective predictor of return-to-sport success, with an effect size of 1.55 — outperforming physical tests like hop tests and limb symmetry indices.

The numbers tell a sobering story. Despite technical surgical successes and well-designed rehabilitation programs, many athletes never reach their preinjury athletic performance level, and some never return to their primary sport at all. This gap between physical capability and actual return suggests that factors beyond muscle strength and joint stability are at play.

 

The Psychological Obstacles: What Athletes Actually Face

Fear is the biggest mental barrier — specifically, fear of reinjury and fear of movement (kinesiophobia). Research on teens and young adults after ACL reconstruction found that each one-point increase in kinesiophobia was associated with a 28% higher likelihood of reporting unacceptable psychological readiness. Greater psychological readiness was strongly associated with lower kinesiophobia in both teens and adults.

The emotional landscape of injury recovery includes several warning signs that indicate poor adjustment:

  • Unreasonable fear of reinjury

  • Loss of athletic identity

  • Continued denial of injury severity

  • General impatience and irritability

  • Rapid mood swings

  • Withdrawal from teammates and support networks

  • Extreme guilt about letting the team down

  • Dwelling on minor physical complaints

  • Obsession with the question of when they can return

Nearly half of young athletes score below acceptable thresholds for psychological readiness after ACL reconstruction, highlighting just how common these struggles are.

 

What Psychological Readiness Actually Looks Like

An athlete who is psychologically ready to play has three key characteristics: realistic expectations of performance, high self-efficacy, and low anxiety. But here's an interesting finding: perceived physical competence matters more than actual physical competence when it comes to psychological readiness.

In a study of young athletes after ACL reconstruction, meeting criteria for perceived physical competence was associated with higher psychological readiness to return to sport, while meeting actual physical competence criteria showed no association with psychological response. This suggests that how athletes feel about their abilities may be more important than objective measurements alone.

For adolescent athletes specifically, the emotional response appears more influential than confidence in performance or risk appraisal. ACL-RSI scores increased significantly between 6 and 12 months post-surgery (from 55 to 71), and the emotions factor had better predictive ability for return to play than the confidence and risk appraisal factors.

 

Evidence-Based Assessment Tools

Several validated screening tools can help identify athletes who need psychological support:

Injury-specific tools:

  • ACL-Return to Sport after Injury scale (ACL-RSI): The gold standard for assessing psychological readiness after ACL reconstruction, with a cutoff score of 77 distinguishing acceptable from unacceptable readiness

  • Injury-Psychological Readiness to Return to Sport questionnaire (I-PRRS): Psychometric test specifically designed to assess psychological readiness of injured athletes

  • Tampa Scale of Kinesiophobia (TSK-11): Measures pain-related fear of movement

  • Reinjury Anxiety Inventory (RIAI): Specifically measures reinjury anxiety

General mental health screening:

  • Patient Health Questionnaire-9 (PHQ-9): Assesses presence of depression

  • Generalized Anxiety Disorder-7 (GAD-7): Assesses anxiety symptoms

  • Athlete Sleep Screening Questionnaire (ASSQ): Evaluates sleep disturbance

  • Sport Mental Health Assessment Tool 1 (SMHAT-1): Developed by the International Olympic Committee for comprehensive mental health assessment in athletes

Serial assessments using these tools offer a continuing profile of the athlete's psychological progression throughout recovery.

 

What Actually Helps: Evidence-Based Interventions

Three psychological elements are most important for positive rehabilitation and return to preinjury level of play: autonomy, competence, and relatedness (from self-determination theory).

Specific strategies that support positive return to sport experiences include:

  1. Reducing reinjury anxieties using modeling techniques — connecting athletes with others who have successfully recovered from similar injuries

  2. Building confidence through functional testing and goal setting — establishing both short- and long-term recovery goals

  3. Providing social support — keeping athletes involved with their team, teammates, and friends throughout recovery

  4. Reducing stressors related to premature return — ensuring athletes understand realistic timelines and expectations

  5. Fostering athlete autonomy — involving athletes in decision-making about their recovery

  6. Teaching specific stress coping skills:

    • Positive self-talk and cognitive restructuring

    • Relaxation techniques (meditation, deep breathing, progressive muscle relaxation)

    • Imagery and visualization

    • Goal setting

Research shows that psychological strategies like goal setting, positive self-statements, cognitive restructuring, and imagery/visualization are associated with faster recovery.

 

Building Trust and Addressing Misinformation

The foundation of psychological support starts with the healthcare team. Critical factors include:

  • Building trust and rapport — listening not only to make a medical diagnosis but also to assess and monitor emotional state

  • Educating the athlete about the injury — providing clear explanations in terms they can understand, with opportunities to ask questions

  • Identifying misinformation — athletes may obtain inaccurate information from parents, coaches, teammates, or the internet that contributes to confusion and emotional upheaval

  • Preparing parents, coaches, and other stakeholders — with the athlete's permission, educating support networks that injury management is individualized

  • Assessing the social support network — understanding who the athlete can rely on and their perception of that support

 

When to Refer to Mental Health Professionals

Athletes with problematic emotional reactions should be referred to licensed mental health professionals, preferably those with experience working with athletes. Early intervention and referral to the mental health network is important.

The American College of Sports Medicine recommends integrating sports psychologists and other mental health professionals into the athletic care network and coordinating referrals for mental health services as needed.

 

The Unique Challenges for High School Athletes

Adolescent athletes face specific psychological challenges. Adults were twice as likely as teens to report unacceptable psychological readiness after ACL reconstruction, suggesting that younger athletes may have different psychological responses or support needs.

Additionally, athletes with moderate preinjury adversity experienced less negative psychological responses compared to those with low or high preinjury adversity, suggesting that some prior experience with challenges may build resilience.

 

TOOLS FOR BUILDING CONFIDENCE

Resistance bands, balance pads and boards, and BFR cuffs are a few of the essential tools in rehabilitation. Resistance bands safely build strength, balance pads enhance coordination and stability, and BFR cuffs accelerate recovery through low-load training.

Below are our top 5 recommended products to use as a recovering athlete.

 
 

Click the image to shop on Amazon through our affiliate links and access possible discounts!

 
 

The Bottom Line

Physical clearance is only half the battle. Psychological readiness should be evaluated and incorporated into return-to-sport decision-making for all injured high school athletes, not just those recovering from ACL injuries.

The good news? High levels of optimism and self-efficacy and lower levels of depression and stress are associated with improved recovery from injury. Athletes who maintain optimism, believe in their ability to recover, and receive strong social support while managing stress and depressive symptoms are more likely to complete rehabilitation successfully, return to sport faster, and achieve better functional outcomes.

The key is recognizing that physical healing and psychological readiness must progress together — and when they do, high school athletes have the best chance of not just returning to their sport, but thriving in it.

 

References

Getting Back Out There, The Right Way

Ever watch your star player go down with a knee injury, see a shoulder pop out during a tackle, or witness an ankle roll on the court? These moments are gut-wrenching for athletes, parents, and coaches alike. But here's the good news: most high school athletes can successfully return to their sport after these common injuries — if they follow the right roadmap for physical recovery.

Let's break down what it takes to get physically cleared for return to play after an ACL tear, shoulder dislocation, or ankle sprain.

 

The ACL Injury: A Marathon, Not a Sprint

An ACL tear is one of the most feared injuries in youth sports, and for good reason. Nearly a quarter of a million ACL injuries occur annually in the US and Canada, with rates in high school athletes reaching 5.5 per 100,000 athlete exposures. But here's what many don't realize: getting back on the field isn't just about healing — it's about meeting specific physical benchmarks.

The minimum timeline is 9 months from surgery, and that's not arbitrary. Your body needs time for the graft to incorporate biologically, and rushing back increases reinjury risk dramatically. In fact, athletes who returned before 9 months had significantly higher rates of reinjury compared to those who waited.

But time alone isn't enough. Athletes must achieve at least 90% limb symmetry index (LSI) for both quadriceps strength and hop testing before getting cleared for competition. This means the injured leg needs to perform at 90% or better compared to the uninjured leg. Athletes who met these criteria had a reinjury rate of just 4.5% within 2 years, compared to 33% in those who didn't meet the criteria.

The recovery follows a structured, mulit-phase approach:

  • Early phase (weeks 0-6): Focus on reducing swelling, restoring range of motion to 0-115 degrees, and achieving 60% quadriceps strength symmetry

  • Intermediate phase (weeks 7-9): Progress to 70% strength symmetry with full, symmetrical range of motion

  • Late phase (weeks 10-16): Reach 75-80% strength symmetry and begin running when you hit 80% and can demonstrate single leg squats, step downs and hops with good mechanics

  • Transitional phase (months 4-6): Introduce jumping, sprinting, and agility drills at 85% strength symmetry

  • Return-to-sport phase (months 6-12): Sport-specific training with final clearance requiring 90% symmetry, no pain or swelling, and adequate confidence levels

Here's the reality check: only 40-55% of athletes return to their pre-injury activity level after ACL reconstruction. Even among highly motivated European professional soccer players with excellent resources, only 65% returned to their previous level. This isn't meant to discourage — it's meant to emphasize the importance of working with a sports physical therapist and following a comprehensive plan.

 

Shoulder Dislocations: High Risk, But Quick Recovery Possible

The shoulder is the most commonly dislocated joint in the body, and it usually dislocates anteriorly (toward the front). For high school athletes, especially those in contact and collision sports, this injury comes with a sobering statistic: recurrence rates can reach up to 90% in active patients younger than 25 years.

But here's where shoulder dislocations differ from ACL injuries: return to play can happen as early as 2-3 weeks after injury for athletes who are pain-free, have symmetrical shoulder range of motion, and can perform sport-specific motions. Some athletes with recurrent dislocations who experience easy relocation, minimal pain, full range of motion, and protective strength may even return the same day.

The treatment approach depends on several factors:

Immediate management:

  • Attempted relocation on the field before muscle spasm develops

  • Neurovascular assessment before and after reduction

  • Immobilization and pain management after successful reduction

  • Post-reduction radiographs after first-time dislocation

Recovery protocol:

  • Sling use for 2-4 weeks for comfort (though current evidence doesn't mandate a specific duration)

  • Graduated rehabilitation focusing on passive and active range of motion

  • Physical therapy addressing joint range of motion, scapular control, rotator cuff strength, and sport-specific conditioning

Surgical considerations: Surgery should be considered for first-time dislocations in active patients under 25 due to the extremely high recurrence rate, or when there are complications like large bony defects.

Interestingly, research on high school athletes shows that 85% of those treated nonoperatively successfully returned to their sport and completed at least one full season without additional injury. Athletes with subluxations (partial dislocations) fared even better, with an 89% success rate compared to 26% for complete dislocations.

 

Ankle Sprains: The Most Common Culprit

Ankle sprains are the most common foot-ankle and sports-related injury for which people seek medical care. Four in every 10 first-time ankle sprains occur during sports participation. The good news? Most athletes bounce back quickly.!

High school athletes have a 75% chance of returning to sport within 3 days after a first-time , Grade I ankle sprain, and a 95% chance within 10 days. In college athletics, 44.4% of athletes returned to play in less than 24 hours. However, more severe Grade II and III sprains involving multiple ligaments can sideline athletes for more than 3 weeks.

The key to successful return involves addressing five critical domains — the PAASS framework:

  • Pain: Both during sport participation and over the last 24 hours

  • Ankle impairments: Range of motion, muscle strength, endurance, and power

  • Athlete perception: Confidence, reassurance, stability, and psychological readiness

  • Sensorimotor control: Proprioception and dynamic postural control/balance

  • Sport/functional performance: Hopping, jumping, agility, sport-specific drills, and ability to complete a full training session

Supervised exercise programs addressing strength, coordination, proprioception, and functional deficits lead to faster return to sports. Evidence also supports the use of compression stockings and anteroposterior ankle joint mobilization for quicker recovery.

General return-to-work and sport guidelines suggest:

  • Return to sedentary work: 2-6 weeks following injury

  • Return to physical occupations and sports: 6-8 weeks

These timelines should be adjusted based on injury severity, rehabilitation response, and specific task requirements. Working with a sports medicine clinician will be key for determining optimal readiness.

 

TOOLS FOR BUILDING CONFIDENCE

Resistance bands, balance pads and boards, and BFR cuffs are a few of the essential tools in rehabilitation. Resistance bands safely build strength, balance pads enhance coordination and stability, and BFR cuffs accelerate recovery through low-load training.

Below are our top 5 recommended products to use as a recovering athlete.

 
 

Click the image to shop on Amazon through our affiliate links and access possible discounts!

 
 

The Bottom Line

Physical clearance for return to play isn't one-size-fits-all. ACL injuries require the longest recovery with the most stringent criteria — minimum 9 months and 90% strength symmetry. Shoulder dislocations can allow quicker return (2-3 weeks) but carry high recurrence risk in young athletes. Ankle sprains typically resolve fastest, with most athletes back within days to weeks.

The common thread? Meeting objective physical criteria matters more than arbitrary timelines. Pain-free movement, symmetrical strength, full range of motion, and sport-specific performance capabilities aren't just checkboxes — they're your best insurance against reinjury.

In Part 2, we'll explore the mental side of return to play — because as we've learned, physical readiness is only half the battle.

 

References