Functional Rehabilitation of Sports Injuries

Disease/Disorder

Definition

Functional rehabilitation is a restoration program designed to provide comprehensive treatment of the injured athlete. In contrast to traditional physical therapy, functional rehabilitation aims to reproduce the actions and forces an athlete will encounter in their sport with the goal of returning to full participation and ideally prior level of activity.¹ This progressive rehabilitation course requires restoration of form as well as function.^2–4 A functional rehabilitation program is designed to progress the athlete from simple activities, such as walking or jogging, to more physically demanding and sport-specific activities that require refined levels of proprioceptive acuity. In addition to strength and flexibility, a functional rehabilitation program necessitates agility, neuromuscular, and proprioceptive/kinesthetic retraining. Without appropriate rehabilitation, sustained injuries can result in significant physiological and functional losses, which increase the risk for reinjury of the affected area, as well as adjacent tissues and joints.³ While this model has primarily been applied to sports medicine and athletes, it is also appropriate for “industrial athletes”, employees who rely on their musculoskeletal system to perform their jobs, in order to facilitate return to work for the injured employee as quickly as possible while minimizing risk of reinjury.^5,6

Epidemiology including risk factors and primary prevention

Injuries are frequently encountered in sports. According to national health statistics reports, there was an average annual estimate of 8.6 million sports and recreation related injury episodes in the United States from 2011-2014, with higher injury rates among males, children aged 5-14 years, and non-Hispanic white persons.⁷ Approximately 2.7 million annual Emergency Department (ED) visits for sports injuries are made by patients aged 5-24 years old.⁸ According to the National Safety Council, this number has slightly decreased but is still prevalent with 4.4 million individuals across all age groups having been treated in the ED in 2024 for sports and recreational equipment related injury.⁹ Interestingly, there was a decrease in consumer product related injury following the COVID-19 pandemic with the largest decrease in sports-related injury, with the biggest fall seen in the young to late teen ages during this period likely as a result of school and youth sports leagues placed on pause during the pandemic. However, it is important to note that this number accounts for those who presented to the ED. We must be cognizant as well of individuals with non-critical injuries who may have refrained from a hospital encounter with COVID-19 present in the community. Nevertheless, increased risk of injury during sport has been associated with greater number of hours of practice per week, lack of a warmup phase, and inadequate sports facilities.¹⁰ Within the collegiate athlete population, there is a variable risk of injury depending on the sport played, athlete sex, and injury setting: practice vs competition.¹¹ See Table 1. In contrast to pre-COVID seasons, in 2020, NCAA D1 athletes sustained a 10.5% increase in injury incidence, with male team sports predominating in injury burden over female team sports.¹² Across all ages, each sport can see a unique distribution of injuries specific to the functional demands on the athlete.^13–16 Understanding this distribution is critical to developing a training and rehabilitation program that targets and prevents sports-specific injuries.

Functional Rehabilitation of Sports Injuries – Table 1

Primary prevention of injury can be accomplished through a thorough assessment of the athlete. Specifics include static and dynamic equilibrium, structural aspects of the body such as posture, and muscle stability during various sports-related tasks.^17,18 Corrective exercises to address premorbid patterns of dysfunction, sometimes referred to as prehab, should also be applied during the preventative phase.¹⁹Recent evidence suggests that neuromuscular training, rule modifications, and equipment recommendations have decreased injury incidence, particularly in young adults.²⁰ Emotional wellbeing is also an important factor in injury prevention and recovery. Movement inefficiency is strongly influenced by emotional states such as anger or anxiety, which can be expressed through impulsive postural maladjustments and mechanical changes.²¹ Studies suggest that preventative interventions incorporating psychological-based modalities may reduce the rate of injuries in soccer athletes.²¹ Thus, in addition to physical training, developing emotional coping strategies can be highly beneficial for athletes.

Patho-anatomy/physiology

In most sporting activities, the human body does not move in a single plane of motion at any single instance, yet many methods of training focus on muscle isolation to “strengthen” specific muscles. Although isolating muscle groups to facilitate activation may provide benefit in certain cases, the goal of functional rehabilitation is to train utilizing three-dimensional movement patterns that prepare the entire body for sporting or recreational activities that may involve an element of unpredictable body movements.^22,23

Isolated movements are uncommon in sporting activities. For example, baseball pitching motion and a golf swing involve kinetic chain biomechanics in multiple planes. The trunk transmits energy from the lower quarter of the kinetic chain to the upper quarter through diagonal loops and slings, which involve the abdominal obliques, gluteal, pectoral and latissimus dorsi muscles.²⁴ The “core” is a key area in this type of dynamic movement²⁵ and consists of the abdominals, paraspinals, gluteal, diaphragm, pelvic floor and hip girdle musculature.²⁶ From a biomechanical and kinetic chain standpoint, stabilization of core muscle groups can improve injury recovery while promoting functional progression. A 2023 randomized control trial demonstrated that 8 weeks of core stability training improved hip strength and knee kinematics after ACL reconstruction in male athletes.²⁷

Specific secondary or associated conditions and complications

Restoration of function depends not only on symptomatic relief, but also on the maintenance of strength, neuromuscular retraining, early mobilization, as well as restoration of biochemical and biomechanical factors.^28,29 Unfortunately, localized injury can secondarily result in “detraining” or decreased general fitness and cardiovascular performance due to inactivity. See Table 2.

Functional Rehabilitation of Sports Injuries – Table 2

A reduced training or cross-training program during the process of rehabilitating an injury can assist with delaying the metabolic and physiologic changes associated with training cessation, and may also improve their overall fitness and performance.³¹ Psychosocial factors such as life stressors, anxiety, confidence, and associated behaviors influence overall wellbeing resulting in more positive rehabilitative outcomes.³²As a result, psychosocial factors should also be addressed in a functional rehabilitation program to restore comprehensive function and empower the athlete to return to their prior level of activity. Failure to provide adequate functional restoration can lead to recurrent injury, suboptimal performance, or delays in returning to full participation in an activity.

Essentials of Assessment

History

Obtaining a comprehensive history of the patient’s injury, including prior injuries and recovery timeline, treatment and therapies, training patterns and goals, and plans for return to work or sport/activities serve as a crucial initial step in developing a functional rehabilitation program.³³ Importantly, gathering information regarding the mechanism of the injury will provide critical information to help determine if the injury is (1) acute, (2) chronic, (3) acute-on-chronic, or a (4) subclinical maladaptation to athletic activity. This information will help the medical team with initiating appropriate and sport-specific rehabilitation interventions. Further information elicited in the history, including typical or baseline activities, current level of function, psychological state of the athlete including his/her support system, current medications or supplements, pain provoking movements, and goals of rehabilitation can also be used to assist with drafting a robust rehabilitation plan to facilitate a return to maximum function after injury.³³

Physical examination

A comprehensive physical assessment serves as the foundation of an effective functional rehabilitation program.³³ In addition to neurologic assessment, including muscle stretch reflexes and manual muscle testing, a functional physical examination should evaluate posture, balance, gait, muscle control, functional movements, and body stabilization. Additionally, static assessment of landmark symmetry such as shoulder height, iliac crests, greater trochanters and positioning of each calcaneus and arch should be observed. Three-dimensional or multi-planar active and passive range of motion of major joints is also important, in addition to the assessment of the quantity and quality of movement.³⁴ Static and dynamic body stability, neuromuscular control, and proprioception are elements that are often not included in standard rehabilitation assessments but are integral aspects of functional rehabilitation.^35,36 Examples include the patient’s ability to perform single leg squats, box jumps, and planks. The assessment should be guided by the patient’s presenting injury while also identifying pre-existing deficiencies that may have contributed to its occurrence, as well as any muscle imbalances or biomechanical deficits that could hinder full recovery. This type of assessment in the physical examination is essentially looking for the “rusty links” in the kinetic chain. Examples include assessing for deficits along the kinetic chain such as pes planus or weak hip abductors, poor transversus abdominis activation, and leg length discrepancies. See Figure 1. This initial assessment is critical to starting the rehabilitation program in the right direction. One must not overlook re-evaluation throughout the course of the program as this is also essential to ensuring successful completion of the program and preventing delays in recovery.

Figure 1: Effect of overpronation of the foot on the kinetic chain (Please see: https://athleticlab.com/importance-lumbopelvic-hip-complex-1/kinetic-chain/)

Functional assessment

Functional assessment should incorporate identification of the tissue injury complex, clinical symptom complex, functional biomechanical deficits, the functional adaptation complex and the tissue overload complex.^37,38 The first of these is the actual site of tissue injury, while the second may include the site of injury or the location of referred pain symptoms. Functional biomechanical deficits arise from the body’s compensation to the injury and related pain and range of motion (ROM) limitations. This can be seen with weak or inhibited muscles in one body region or tightness in others, such as in lower crossed syndrome where joint dysfunction is created by imbalance between tightness in thoracolumbar extensors, the iliopsoas, and rectus femoris, and weakness of the deep abdominal muscles gluteus maximus and medius.³⁹ The functional adaptation complex is a series of changes that develop as a result of the functional biomechanical deficits and can be seen either distal or proximal to the tissue injury complex. The tissue overload complex is defined by increased stress placed on adjacent or biomechanically related structures. As an example, in sacroiliac joint (SIJ) dysfunction, the tissue overload complex would include increased stress across the lower lumbar and lumbosacral zygapophyseal joints, contralateral SIJ, hip joints, and even the knee.⁴⁰

Therefore, a functional assessment should incorporate a comprehensive evaluation of the entire kinetic chain to identify biomechanical deficits arising from injury or resulting from deconditioning. This is important in both the athlete and industrial athlete as a holistic evaluation of the body and elements that contribute to biomechanics are crucial to achieving peak performance in one’s respected field. Muscular imbalances and limitations in flexibility should be systematically documented as they have been implicated as risk factors for both injury and its subsequent complication.³⁹Accordingly, a rehabilitation program that emphasizes isolated muscle treatment will often be insufficient to restore athletes, particularly those at an elite level, to their pre-injury level of performance.⁴¹

Another essential component of a successful functional rehabilitation program is the quality in which the athlete executes the prescribed exercise or activity. Proper technique is crucial for effective rehabilitation as incorrect execution of a movement or exercise may result in further injury or a prolonged recovery time. Ensuring that an athlete is performing a prescribed movement or exercise correctly while reviewing the athlete’s technique for warm up, training or cool down exercises will aid the individual in achieving a successful outcome. This same principle applies to the industrial worker who, much like a professional athlete, requires strength, endurance, and conditioning to carry out their tasks. Thus, a culture promoting safety alongside proper physical conditioning and injury prevention is crucial to optimizing musculoskeletal health and overall job performance.

Imaging

Accurate diagnosis is important to facilitate proper rehabilitation. While functional rehabilitation lends itself to functional diagnostic methods, imaging can provide valuable information to further investigate specific pathologies. X-ray and CT are most useful in imaging ossified or calcified structures, while MRI provides high resolution imaging of soft tissue structures without ionizing radiation. While imaging provides useful diagnostic information for specific pathologies, it is important to take into account how the patient presents clinically. A 2026 systematic review of muscle injuries in professional soccer players found that while MRI plays a valuable role in guiding return-to-play decisions, it should be used alongside clinical assessment and functional testing to provide a more comprehensive evaluation.⁴²

Ultrasonography is also increasingly utilized for evaluating the neuromusculoskeletal system due to its accessibility, safety, and cost-effectiveness.²¹ It also allows for dynamic assessment of joint and muscle structures that are not currently feasible with XR, CT or MRI. Ultrasound can also be used to assess activation of deeper muscular structures, such as the transversus abdominis, and can be used as biofeedback to aid in rehabilitation.⁴³

Electrodiagnostic medicine (electromyography and nerve conduction studies) may also be helpful in a functional rehabilitation program with use of biofeedback.⁴⁴ Electromyography has diagnostic utility and in some cases prognosticating time to recovery.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Once an injury has been fully assessed and an accurate diagnosis is made, a rehabilitation plan with consideration of specific adaptation to imposed demand (SAID) should be developed.¹As the human body adapts to biomechanical demands, the desired training effect should guide the design of the prescribed exercise protocol. Fundamental components of an exercise program include intensity, duration, frequency, and mode. Careful specification of these components is essential for optimizing rehabilitation outcomes, promoting adequate psychophysiologic recovery, preventing overtraining, and ensuring the integration of sport-specific training elements.

Overall progression within the rehabilitation protocol should be centered on the injury, healing process, and the sequential steps of the aforementioned components. The program itself should consider the individual athlete, psychological aspects of the injury and recovery, the phases of healing, and the rehabilitation progression.

Practice recommendations for functional rehabilitation remain limited by the lack of strong evidence-based studies and are currently guided by expert opinion. Keeping this limitation in mind, some of the current recommendations are as follows:

Herring and Kibler describe a basic two phase model consisting of acute and recovery stages.¹ The initial (acute) stage of rehabilitation focuses on the clinical symptom complex and tissue injury complex. It incorporates rest and/or immobilization, physical modalities, medications, manual therapy, initial exercise or perhaps surgical intervention. To advance to the next stage, the patient needs to achieve adequate pain control and tissue healing, near-normal ROM and tolerance for strengthening. The recovery stage of rehabilitation focuses on the tissue overload complex and functional biomechanical deficit complex. It may also utilize manual therapy, flexibility training, proprioception and neuromuscular control training and specific, progressive exercise. Criteria for advancement include: no pain, complete tissue healing, full pain-free ROM, good flexibility, 75-80% or greater strength as compared with uninjured side, and good strength balance. Their final stage of rehabilitation is the functional stage. The focus in this stage is on the functional biomechanical deficit complex and subclinical adaptation complex. This stage uses power and endurance exercises, sports or activity-specific functional progression and technique/skills instruction. As long as the participant demonstrates full pain-free ROM, normal strength and balance, normal sports mechanics and sports-specific skills, they should be recommended to return to play. Despite clearance, the athlete should continue to work on an ongoing injury prevention program.

Draovitch et al provides a 5 stage framework of sport specific rehabilitation.⁴⁵ Phase 1 is the repair stage with goal reducing swelling, inflammation and ensuring proper muscle activation of the affected region in both open and closed chain movements. Phase 2 is the rehab/recovery phase focused on restoring normal preinjury arthro-kinematics and developing tissue strength and postural stability. Phase 3 focuses on reconditioning and developing force and load tolerance replicating sport specific requirements as tolerated. Phase 4 and 5 is the performance/preseason phase with return to full capacity and consideration for future participation. Each stage builds upon the previous one and progression through each stage is based on satisfactory scores in the categories such as movement and core, strength, endurance, power, conditioning, load performance and self-reported outcome.⁴⁵

Biagioli simplifies the recovery from acute sports injury into three major phases while acknowledging that physical therapy protocols may divide these phases further for precise therapy implementation.¹⁹See Table 3.

Functional Rehabilitation of Sports Injuries – Table 3

Coordination of care

Functional rehabilitation is most effectively carried out through an interdisciplinary team approach involving physiatrists, physical therapists, athletic trainers and strength and conditioning coaches. The role of each team member must be clearly defined to facilitate a cohesive program for the athlete or patient. In addition to providing a timely and accurate diagnosis as well as managing the medical aspect of treatment, it is the responsibility of the physician to determine when a patient is able to return to play.³³ Return to play criteria is met when the patient is ready to resume full participation in a sport and competition. The decision to return a player should be made using objective data provided by the care team.

In practice, return to sport involves a progressive escalation of physical activity, advancing from the strictest precautions to unrestricted competitive performance.³³ Communication the care team, particularly coaches and athletic trainers, should be made aware of proper practices, including the graded approach to return to play, preventing reinjury, and the impact that an injury will have on a competitive athlete’s season.³³ For the industrial athlete, this same principle applies in developing a proper return to work program with coordination of care particularly centered on work schedule, expenses, transportation, clinic appointments, and the industrial athlete’s unique needs.

Patient & family education

Patients and their families need to be educated in the training required to restore full function and avoid re-injury. Treatment failure or re-injury results from returning too prematurely.⁴⁶ Conversely, failing to advance training when appropriate can result in deconditioning and lost opportunities, whereas for the “industrial athlete”, unnecessarily prolonged periods away from work can place the patient at risk of lost wages. As a result, it is important for physiatrists to evaluate and discuss a comprehensive functional rehabilitation program which accounts for an injured person’s restrictions and capabilities while factoring their occupation-specific conditions to provide patient-centered care and accommodations as indicated.³⁴

Emerging/unique interventions

Successful outcomes can be demonstrated with return to work or sport at the prior level of function.

Physicians should be cognizant of the growing commercialization of internet-based exercise training (IBET) programs with varying emphasis on sports medicine principles such as functional movement and stability, or meditative and modified yoga practices. These programs, developed by the fitness industry and popular on social media, cater to a broad group including non-athletes with musculoskeletal pain, the lay athlete, and to high-performing competitors. Further driven by the COVID-19 pandemic, IBET programs delivered via services such as Facebook and YouTube, as well as fitness trackers such as Fitbit and Apple Watch have seen a rise in popularity due to ease of access, convenience, and in-person restrictions.⁴⁷ The benefit provided by these programs has shown some promise. For a common complaint such as knee pain in the setting of osteoarthritis, IBET programs have demonstrated improvement in functional performance when compared to self-managed care.⁴⁸ However, no direct comparison studies to formal physical therapy have yielded superior results.⁴⁹ Patients may ask their physicians about the value of these programs and may benefit from further education. Greater physician awareness of these types of programs can help physiatrists understand the options available to patients outside of formal physical therapy.

Moreover, physicians should also be cognizant of emerging technologies and exercise modalities in the field. For example, anti-gravity treadmills are being investigated for improved rehabilitation outcomes following total knee arthroplasty⁵⁰ which may have promising translation into rehabbing of sports and industrial athletes. Consumer wearable technologies have also grown more prominent in the space with global positioning systems (GPS) and heart rate monitoring sensors utilized to help quantify workload.⁵¹This technology can help the athlete assess their cumulative workload throughout their rehabilitation phase and into the season while the industrial athlete can track their physiologic demands while on the job. Additionally, GPS Tracking has been utilized as a major metric in activity monitoring in athletes undergoing a return to sport program.⁵²These new and emerging technologies pose a promising avenue for further innovation and is deserving of more thorough investigation.

Translation into practice: Practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Physicians should incorporate functional diagnostic assessments into the evaluation of patients and integrate functional rehabilitation strategies into their rehab prescriptions. This approach is beneficial not only for athletes, but also within geriatric and disabled populations. Functional rehabilitation is built upon traditional therapy models. It should be stated that an overly progressive approach that de-emphasizes classic exercises and techniques may be detrimental to rehabilitation. Indeed, many classic exercises and techniques are critical to success in sports training and should be included.¹⁰

Cutting Edge/Emerging and Unique Concepts and Practice

For many physiatrists and rehabilitation professionals, “functional rehabilitation” is the only approach to recovery from an injury. Educating patients that the absence of pain does not necessarily signify full recovery may facilitate more comprehensive rehabilitation and reduce the risk of injury recurrence. Caution should also be expressed to those trying to start a high-intensity exercise/fitness program, regarding the potential risks of beginning at too-high of an activity level or increasing too rapidly without appropriate preparation.

“Prehabilitation” or “prehab”, which traditionally referred to a period of physical therapy prior to a surgical procedure in order to improve the functional capacity of the patient, has recently gained greater visibility and mainstream interest for injury prevention outside the surgical context.⁵³ “Prehabilitation”, or pre-rehabilitation, in sports medicine focuses on injury prevention through targeted therapies, and can include strength training and identification and correction of anatomical or kinesiologic factors that may predispose an athlete to injury.^54,55

Two examples of “prehab” that have gained attention are those for ACL injury prevention and prevention of glenohumeral internal rotation deficiency (GIRD) in pitchers. ACL injury prevention training programs typically utilize a combination of plyometrics, strengthening and balance exercises. A systematic review has shown that patients undergoing prehabilitation prior to ACL reconstruction have expedited post-operative recovery and also maintain functional improvements up to 10 years post-operation.⁵⁶ There has been a similar focus on prehab for throwing athletes for prevention of shoulder pathology that has been correlated with the development of GIRD. GIRD is thought to be an adaptive process due to the repetitive cocking during the overhead throwing motion.⁵⁷ One study found that implementing a sleeper stretching program, recovery of internal rotation loss is seen potentially mitigating the cumulative effects over the course of the season.⁵⁸

While prehab is distinct from functional rehabilitation, incorporation of a prehab protocol in a recovered athlete can effectively prevent reinjury or new injuries and should be considered in a comprehensive approach in the management of athletes.

Gaps in the Evidence-Based Knowledge

There is limited evidence demonstrating the clear benefit of functional rehabilitation over other categories of rehabilitation programs. Many studies demonstrate the benefits of rehabilitation for musculoskeletal injuries and for returning someone to activity after injury, but there is overall a lack of high-quality comparative studies currently available. Barrett et al. describes a case series that directly compared two distinct exercise regimens for nonspecific shoulder pain, one focusing solely on the shoulder and one that also incorporated thoracic exercises and the kinetic chain as a functional rehab approach. After six weeks, both programs yielded clinically significant improvement of symptoms despite lack of evidence to support one program to be superior to the other.⁵⁹ Additionally, some studies have compared traditional and functional rehabilitation programs by examining patterns of muscle activation. Richardson et al. utilized EMG to show increased axioscapular muscle recruitment in those who participated in a rehabilitation program with a kinetic chain approach.⁶⁰ It is postulated that by having increased activation of the whole and lower trapezius, there is a reduced demand on the rotator cuff which would aid in preventing recurrent injury.

The challenge of reporting outcomes in musculoskeletal research is widely acknowledged and is hypothesized to be due in part to bias phenomenon of outcome measures; low treatment fidelity; the presence of common mediators among different treatment arms, impeding the ability to demonstrate differences between specific mechanisms; and non-specific influencers inherent in certain treatment modalities.⁶¹

As evidence-based recommendations continue to evolve, expanding advocacy for extended and more comprehensive insurance coverage to support full functional recovery will further advance the adoption of functional rehabilitation. Moreover, additional research into the specific benefits of functional rehabilitation is greatly needed as this will enhance outcomes for patients while strengthening our understanding of functional rehabilitation and its incorporation into professional practice.

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Original Version of the Topic:

Adam P. Cugalj, DO. Functional Rehabilitation. 9/20/2014

Previous Revision(s) of the Topic:

Haewon Lee, MD, Christopher Plastaras, MD. Functional Rehabilitation. 9/6/2018

Alyssa Marulli, MD, Esme Irvine, DO, Hector Moreno Rojas, MD. Functional Rehabilitation of Sports Injuries. 6/29/2023

Author Disclosure

Rafaello U Ibrado, MD
Nothing to Disclose

Daniel Kiehl, DO
Nothing to Disclose

Matthew Lamagna, DO
Nothing to Disclose