What Managing My Own Knee Pain Has Reinforced About Rehab

Since I started running again almost a year ago, I’ve dealt with a few aches and pains. This most recent episode highlights a familiar situation for runners: staying active while still being smart with training.

Quick Summary
I had been consistent with my running into November, training four times a week with long, easy, and speed runs, while also lifting weights twice a week. During my first interval session of my program, I was exhausted early on and couldn’t complete the session. The following week, I noticed stiffness in my right knee when standing up from squatting while doing laundry, but I didn’t think much of it.

Over the next few weeks, travel and sickness disrupted my consistency. I still managed some runs, including an LSD PR of 13km, but during this run I noticed some lateral right knee pain. However, this didn’t affect my run and did not linger. Once I was back on track, I reorganized my plan to repeat a week, which led me to my 10km tempo run. At 4km I felt the same pain on my lateral knee and suddenly at 8km I was limping.

Even walking around the house, my knee was still hurting, but I still got outside for walks, trying to avoid hills as they were painful. About a week later, I attempted a run-walk to see if I could tolerate shorter runs interspersed with walking, but this was still immediately painful. Based on this, I decided to stop running until the pain improved. After doing some exercises and allowing the time, I ran the first kilometre of a 2km walk-run pain-free.

What the Heck is Going On?
Based on the location of the pain and how it worsened with bending and straightening my knee with running and walking, I would describe this as iliotibial band (ITB) related pain, a common running injury. The ITB is a thick, fibrous band of tissue formed by the gluteal muscles and inserting just below the knee. Its function is to increase the leverage of the gluteal muscles.

I don’t like calling this an “injury” as that implies damage to my knee, and there was no clear mechanism or event to suggest a tear. I feel it is more accurate to describe it as training errors leading to an overload and sensitization of my ITB causing pain.

Several factors in my training and life have led to this overload in my knee:

• I didn’t sleep well or fuel myself enough prior to that first interval session, and I was stressed about an upcoming meeting later that day; all not ideal to then be going for an intense run.

• Taking seven and 11 days off due to travel and sickness made my running volume inconsistent. While I hoped my capacity wouldn’t have dropped that much, running while sick was not ideal.

• The strength training portion of my program also lacked consistency during this entire time. I didn’t necessarily get weaker, but it was still a break in training.

• I jumped back in too quickly with a 10km tempo run despite slowing my pace. Although the distance was the same, it had been four weeks since my last tempo run.

What I am Doing to Manage
This became a red light situation for me, not because I was worried about damaging my knee, but because I knew based on the limping and lingering pain that running would only prolong this. I tried to compromise by doing the run-walk, but the immediate pain told me I needed a break until I could walk a significant time/distance (including hills) pain-free.

I chose to continue walking to stay active, trying to avoid hills and starting with slower and shorter walks. I also refocused on my strengthening, trying to find exercises that would be helpful. I started with some lateral hip and gluteal strengthening, which initially provided relief, but then focused on my quadriceps strength inspired by the pain with walking downhill. I chose Bulgarian split squats as my main exercise as I could load in a single-leg and bent knee position. My knee improved once I significantly increased the weight after the initial painful phase. I also added some hopping to re-accustom myself to the single leg loading of running.

Just last weekend, I went for a walk-run, opting to start with walking to get warmed up and stuck to a distance, even if it went well. The first kilometre of running was pain-free, but the second had some pain, though manageable. I plan to continue running as the pain is down to a yellow light, ensuring I continue to improve before restarting continuous running.

Even as an athletic therapist, I am still active myself. I started running again with walk-runs last January after 14 years, only to end up back at them and having to build myself back up. Like many setbacks though, the silver lining is the opportunity to reflect, evaluate your program, make changes, and learn from your mistakes. I now know for the future that even taking just a week or two off requires some adjustments to my running volume. I don’t feel this current pain was caused by running mechanics or lack of strength. While these factors are often cited as causes, they ignore all of the other factors that lower capacity and/or increase load. I don’t feel any single factor was the cause— they all contributed to create the ideal conditions for ITB-related pain.

To Summarize

• My ITB-related knee pain developed due to various factors, forming the perfect storm.

• This is not an injury, but pain due to overload and training errors.

• Several internal factors and a jump in interval volume likely triggered the knee sensitivity.

• I had gaps in my running and strengthening consistency, further lowering my capacity.

• I had two load spikes that were more than I could tolerate, resulting in the ITB pain.

• I remained active with walking despite some pain, and added strengthening exercises specific for my knee.

• I will continue to progress my walk-runs to continuous running, using pain both during and after to guide my progress.

Pain rarely comes down to one thing, and rehab rarely follows a straight line. What matters more than finding the “cause” is having a way to make decisions as symptoms change. This is the same framework I use with clients — not because it guarantees a perfect outcome, but because it gives us a clear way to adapt, stay active where possible, and keep moving forward even when things don’t go to plan.

Is All Stress Bad?

When we hear the word “stress”, we tend to think of it as being a negative thing. Chronic stress can certainly have physical, emotional, and behavioural symptoms and sequelae affecting your health. But stress is the body’s natural response to pressure or demands, and in the short term, it can be extremely motivating, such as finishing a project before a deadline or running away from a dangerous situation.

But “stress” is also used in the strength and conditioning, training, and rehab world with a negative connotation. We hear people say, “don’t do the knee extension machine because it stresses your knees” or “deadlifts put stress on your low back.” While said with good intentions, there is a lot of context missing in these statements. Rather than viewing stress as only bad, we need to look back at the SAID principle to see how stress can be a good thing.

The stress we’re usually referring to in the rehab world is the physical demands we place on our bodies through physical activity. In material science and physics, the mathematical formula for stress is: stress = force / surface area. This formula explains why it is dangerous to step on a single nail but safe to lay on a bed of nails. When stepping on a nail, you have your entire body weight (the force) coming down through your foot onto the pinpoint (surface area) of a nail. But when you lay on a bed of nails, your body weight is displaced over a larger surface area, despite still being sharp nails.

This is usually the context that people use when it comes to stress and exercise. In the above comment about knee extensions stressing the knee, the implied warning is that weight, positioning, and movement from the knee extension machine applied more force over the small knee cap. What is usually offered as a safer alternative is squats, as the movement allows for more muscles and joints to be used to lessen the stress on the knee via a larger surface area.

While mathematically this may be true, it is important to remember that the human body is not a machine and is capable of adaptation. Just like you shouldn’t start your first day of running by doing a marathon, you should be selecting an appropriate weight for the knee extension machine. With time and consistency, you should be able to progress your weight because your body adapts and gets stronger, even if it is more “stressful” than other leg exercises. As well, the human body is highly individualistic. While one person may find the knee extension machine irritating for their knees, someone else may find this perfectly fine and a great quadriceps-isolation exercise. Differences in anatomy, training history, previous injuries, and beliefs are some examples of why an exercise would vary between people.

We can also refer to stress in a more general sense when we think of our training program and physical activities as a whole, and our ability to recover from them. This is where semantics may muddle things, as sometimes stress, load, and volume are used interchangeably when referring to the total amount of physical activity someone is doing. But in reality, when we do physical activity, we are increasing the demands on our cardiovascular, respiratory, and musculoskeletal systems, thereby “stressing” them. But this stress is needed, as it is the main driving force for adaptation and improving these systems. If we don’t stress our bodies enough, we don’t see improvements in our function, and we may even regress. If we over-stress our bodies with excessive activity, we’re not allowing for the recovery needed to cause improvements, and we may even be setting ourselves up for injury and burnout.

When we talk about stress in rehab, there needs to be context behind it. Stress is just a number, or rather just the representation of force over surface area - it means nothing without context and is inherently neither good nor bad. Stress, both the colloquial and mathematical meaning, in rehab is necessary for a full recovery. An injured muscle, tendon, ligament, or bone must be loaded and stressed in order to induce physiological adaptations leading to the healing of the tissue with greater strength capabilities if one hopes to return to physical activity pain-free. The timing of this stress and the amount of stress are key though in a rehab program— stressing a tissue too early or too much can certainly cause setbacks, but we also want to make sure we’re not delaying or under-stressing the tissue as this will not set us up for success.

Stress is necessary, but whether it helps or harms depends on how much you can tolerate at the time. Rehab then isn’t about avoiding stress, but about applying the right amount at the right time, based on what the person can tolerate.

Understanding the S.A.I.D. Principle in Rehab

An important concept I apply to my rehab, borrowed from the strength and conditioning world, is the SAID principle, which stands for Specific Adaptations to Imposed Demands. What this means is that how and what we train determines how our body adapts. Or even simpler, we get better at what we do.

For example, if a runner mainly trains with short sprints and drills to build maximum speed, they’ll become a better sprinter, but that won’t prepare them to complete a marathon. On the flip side, a runner focused on long distance endurance will do well in a marathon but won’t be the fastest sprinter. Both may include some elements of each other’s training, but their bodies adapt specifically to the type of work they do. That is the SAID principle in action- our body adapts to the demands we place on it.

In rehab, applying the SAID principle helps the body prepare for the stresses and demands of sport or activity. This becomes especially important in the later stages of recovery as we bridge the gap between rehab and competition.

Using our runner example again, after a hamstring strain, we want to load the hamstring early, but appropriately. This might start with a simple exercise like digging the heel into the floor and sliding it toward the hips at a tolerable intensity. From there, we’d progress to a weighted hamstring curl and gradually increase load. Because they’re a runner, we’d also include other lower-body exercises like leg extensions, hip abductions, and calf raises.

As their strength improves, we can progress to multi-joint exercises like squats, deadlifts, or RDLs. Squats are great because they don’t heavily load the hamstrings but still strengthen the quads and glutes. Deadlifts and RDLs may also be well tolerated since they involve multiple muscles and place more emphasis at the hip — depending on the location of the strain.

Next, we’d add single-leg work, followed by plyometric or power exercises like hopping, skipping, and bounding. These more closely resemble the single-leg loading and push-off nature of running.

We’d also begin to reintroduce running itself — starting with slower speeds and shorter durations, then building from there. Returning to running is a graded exposure to the specific demands of running. It’s not about sport mimicry; it’s about directly applying the SAID principle by progressively exposing the hamstring to the real forces it will face.

Sometimes, though, the SAID principle is taken too far. We start believing every exercise must match or mimic the sport exactly — using single-limb movements, unstable surfaces, or weighted sport-specific motions. These have their place, but it’s important to recognize the different roles of strength training and sport practice.

• The goal of strength and conditioning is to build muscular strength and power — to help your body generate more force.

• The goal of sport and skills training is to improve coordination, timing, and technique within the sport itself.

Working out in the gym won’t automatically make you a better soccer player, just like playing soccer won’t make you jacked. Both are vital — but they need to be trained separately. If the goal is to build strength that transfers into sport, we need to maximize load on the muscles. Single-leg squats and lunges are useful, but they can’t be loaded as heavily as a barbell squat. Both can be included in a training week or within a periodized plan — but our gym sessions don’t need to look like our practice sessions.

Of course, the SAID principle can also be underused. Sometimes rehab consists only of a resistance band and a few easy exercises, with minimal load or challenge. In these cases, there’s not enough demand on the muscle to drive adaptation.

There’s always nuance and context to every rehab plan. But overall, we want to apply the SAID principle by ensuring our exercises appropriately load and challenge the injured area, progress in complexity and demand, and build capacity for return to sport. What we don’t need to do is make every exercise look like the sport itself — because we’ll reintroduce those sport movements separately, starting at low intensity and building from there.

In summary, the SAID principle reminds us that our body adapts to exactly what we demand of it. In rehab, that means loading the injured area appropriately and progressing toward the real demand of your sport, without trying to turn every exercise into a copy of the sport itself.

A Traffic Light Guide To Exercising With Pain

One of the harder parts of the rehab process from the practitioner side, and what makes rehab sometimes more of an art than science, is knowing when we accept pain during the rehab process. While we do have general guidelines, such as saving eccentrics for the later stages, or not progressing weights too quickly, we are working with human beings who are dealing with the experience of pain. The problem though is, pain is not always a reliable experience. The challenge then becomes when do we trust pain and when do we not? Or maybe a more relevant question is, when is it okay to work through pain? We’ve all experienced the “no pain, no gain” mentality in some form, but this may not always be the best approach depending on your injury.

The short answer is yes, it is okay to work through some pain, but with a bit of common sense. Of course context matters, so we’ll break it down a bit further, but knowing when to push and when to tweak or even hit pause can have a big impact on your recovery.

This is an important concept to address because pain is a complex, individual and multifactorial experience, meaning that everyone experiences it differently and there can be many factors influencing your pain. Pain is also contextual— we (patients and practitioners) seem to accept pain when we’re providing hands-on treatment. I lost track of the number of times someone would ask for more pressure during a massage despite them wincing in pain, or who thought that more would mean a faster recovery. But then when it comes to exercise, we tend to quickly abandon an exercise if the patient experiences any pain with it. So why do we accept pain in some cases, but not others (rhetorical question for the purpose of this blog).

Just know that pain doesn’t always mean damage during the rehab process. The tissue can still be sensitive to loading without resulting in further damage or reinjury.  When it comes to pain that develops through overuse or pain that lasts beyond the typical healing time, that’s when pain can be a bit more unreliable, and is still more about sensitivity than damage. Staying active and mobile can help with recovery, provided it is within reason. Being unsure of what is safe or not can certainly cause a dilemma with your recovery - if you back off you might be under-loading yourself, but if you keep going you might be overloading yourself. Neither of these are ideal. But there is a simple analogy you can use to help better gauge your pain and add some clarity to the decision to work through pain during your rehab— the traffic light.

Green Means Go!
In these cases, the pain is mild— I usually consider this to be a self-rated 4/10 or less on the pain scale. This pain generally settles down fairly soon after exercise, or at least within 24 hours, and during the exercise you’re still moving well and feeling confident. This is a good space to work in. The pain is there, but it is not modifying how you perform. You might feel a twinge or ache, but you’re not doing any harm, and your body can handle this. This doesn’t mean that we’re in the clear to go crazy, but it does give an indication that we’re in a good spot with the loading. You should still continue to monitor the pain though, because that leads into…

Yellow Means Caution (and Adjust)
This is when the pain increases to a 5/10 or 6/10 on the pain scale, and usually the pain lingers longer than 24 hours before subsiding. Movements might feel a little forced or you might feel guarded, hesitant, deliberate, or cautious during activity. We may not be causing physical damage yet, but we’re certainly starting to push the limits of what the injured tissue can tolerate, and we need to adjust accordingly. The good news is we can still continue some form of exercise, and there are many ways you can adjust to get back into a green light— changing the movement or reducing the weight are just a couple of examples.

Red Means Stop (For Now)
I don’t like having patients stop their exercises, and there are always some unrelated activities they can do to remain active, but sometimes stopping an aggravating exercise is needed. These are cases when the pain is a 7/10 or more; the pain sticks around at that level for longer, or even worsens, and you’re uncomfortable or hesitant to move. This is your cue to rest or scale back to simpler movements that calm the area down, rather than push through and hope for the best because we are at a higher risk of injury. It may seem like we’re losing progress, when really it is just being smart—short-term sacrifice for long-term gain.

It’s okay to feel some pain during the rehab process— tolerable pain doesn’t mean something is injured further. In fact, some studies show it leads to better outcomes than completely avoiding pain (maybe the point when you feel pain is the lower end of the stimulus threshold to cause adaptation, so by avoiding pain you’re not providing adequate stimulation). There’s no need to panic, but it is still worth paying attention to to see how it changes. Maybe it is just a one-off thing because you didn’t sleep very well the night before or maybe it’s a sign that you are not tolerating the exercise well and an adjustment is needed.

Staying active helps the healing process, as long as we are respecting that process and respecting where your body is at.

Ways to Reduce Pain Without Stopping an Activity

One of the most frustrating parts of dealing with an injury is when it takes us away from the things we enjoy- sports, training and daily movement. Sometimes the pain itself forces us to stop, but even when it’s manageable, many people still choose to stop. Hoping the pain goes away on its own, fear of making things worse, fear of more pain, uncertainty, or apprehension are all reasons we stop. This can be especially confusing when the pain only bothers during activity, and not with everyday life.

For the majority of injuries, maintaining some level of activity, even with some pain, is still okay, and in many cases encouraged. We still want to load the painful area so it can adapt, get stronger and become less sensitive. There are many ways to do this, but they mainly fall into three categories.

There are a couple of caveats to this though. Some injuries, such as high-risk bone stress fractures, do require rest. The pain also needs to be at a tolerable level. Pain over a self-reported 7/10 is usually a red light for me as it means the load is too much. It is always important to get a proper assessment so you know whether continuing is safe.

With that said, the three major ways to keep training while managing pain are: movement preparation, movement modification and load adjustment.

Movement Preparation
Sometimes a thorough warm-up or a few targeted exercises to the specific injured/painful area can make a big difference. Increased body temperature, increased blood flow, muscle activation/priming (even though muscles are technically always active unless there’s a nerve injury) and mental preparation all help modulate pain during your session.

Take a runner who feels calf tightness, especially at the start of a run. Exercises like calf stretching, calf raises, double leg hopping, skipping or bounding before the run can help. These exercises prepare the calf muscles for what’s coming and give you way more control over intensity and progression compared to jumping straight into the run.

Movement Modification
Small changes to how you perform an exercise can go a long way for some people when dealing with an injury. The goal here is to train the same muscle groups but in a way that you tolerate more. If someone has shoulder pain when doing lateral raises with their palms down, switching to a more thumbs-up position or bringing their arms forwards a bit can reduce sensitivity. Sometimes it is just specific movements that are irritated. Switching a squat to a leg press machine, or adjusting cadence (step frequency) when running can immediately make training more tolerable.

Load Adjustment
Often the issue isn’t the movement itself — it’s that the load exceeds what your body can currently handle, and usually the simplest step is to temporarily reduce the load. Yes, people dislike lowering weights, but it’s a straightforward and effective strategy. Reducing volume (sets × reps) or training frequency are other options. You’re still doing the activity — just at a level your body can manage right now. Think quality over quantity. For a runner who consistently notices pain getting worse around the 5 km mark, dropping to 4 km and building back up is a perfectly valid approach. Or changing from five runs per week to three, or removing the most stressful run from the schedule.

The key to any of these changes is trial and error. Everyone is different and everyone’s pain experience is different, which makes blanket recommendations tough. The good news is that we have lots of options available to us, which makes the chances of finding something that works very high. The other thing to remember is these changes are temporary. They are short term changes to help bring the pain down while still staying active. Once pain is more under control, then we start progressing back towards our previous levels.

What’s in your cup? The Load-Capacity Framework in Rehab

The load-capacity framework can also guide our treatment plan and what we work on in our rehab. As a reminder, injuries occur when a load on your body exceeds your body’s capacity to handle it. That leaves us with two main ways to help someone- decrease the load or increase their capacity.

A great analogy for this comes from Greg Lehman when he asks, “what’s in your cup?” Imagine yourself as a cup filled with water. The water represents all the loads you face — not just physical activity, but also work stress, family demands, past injuries, and changes in training or routine. Your cup represents your current capacity to handle these loads. Things like anxiety, lack of sleep, prior beliefs about injury, or self-confidence can all change your cup’s size. Sometimes factors, such as your health status, can both add water and limit your cup’s size.

In rehab, our goal is to either limit the water or build a bigger cup. Limiting water could include adjusting your training program (like decreasing running volume or intensity), managing stress, or changing certain habits. Building a bigger cup might involve strengthening tissues, improving nutrition and hydration, or addressing fears about a specific movement.

Ideally, we can do both at the same time — reduce water and expand the cup. But sometimes we can only tackle one at a time. And sometimes, we can’t change either — reducing work stress might not be realistic, for example. That’s okay. The cup analogy is a way to acknowledge the factors influencing how we feel, and to understand that they’re always changing. Some days it’s like water slowly dripping into a pint glass. Other days, it’s like the Torc Waterfall into a shot glass, and it’s overwhelming.

Recognizing this helps you make informed decisions in training and rehab. A small change — decreasing intensity, taking an extra rest day, or adding one isolation exercise to the painful area — can be enough to manage the load or grow your capacity.

Rehab can be simple but also complex. The simple part is knowing to reduce load temporarily and increase capacity. The complex part is figuring out how, because everyone is different. That complexity might feel intimidating, but it also gives us freedom to find what works best for you.

Reference: Lehman, G. Do our patients need fixing? Or do they need a bigger cup? Online source, 02/05/2018.

Understanding Load and Capacity

One concept I talk a lot about with patients is the load-capacity framework for explaining how injuries and pain happen. Simply put, injuries occur when a load placed upon the body is greater than the body’s capacity to tolerate that load. Load is any kind of stress or physical demand placed on the body, such as lifting weights, or going for a run, or even painting. Capacity is how much stress your tissues can handle at that moment.

From an acute injury standpoint, this framework makes sense, but even then, many factors influence both load and capacity. When we talk about pain though, things get a bit trickier. Pain is real, but it’s also a very individual experience, and it doesn’t always line up perfectly with what’s happening in the tissues. Load and capacity may still play a role, but they’re just one part of the picture.

Still, the framework is useful, so here are a few examples that help make it clearer:

Rolling your ankle:
You’re out for a run when you hit a divot and you roll your ankle inwards- a classic ankle sprain. In that one moment, the ligaments on the outside of your ankle were suddenly exposed to a large load and were stretched beyond their capacity. This is an example of an acute injury where the load spikes and exceeds what the tissue can handle.

Acute injury- a one-time quick exposure to a large load that causes tissues injury.

Increasing training too quickly:
Let’s say your run doesn’t have any surprises, and you’ve been progressing nicely, adding a little distance each week. You’re feeling good, so instead of the planned 500m increase, you bump it up by 1km. And the next week, you do the same. Now you’re noticing your Achilles tendon is sore and walking is uncomfortable. You didn’t tear your Achilles, but you increased your running (the load) at a faster rate than your body was adapting (your capacity). That’s a chronic overload issue and more of a sensitivity response than an actual tissue injury.

Injury due to training errors- making increases in your training (intensity, frequency, duration) faster than what your tissues can adapt to.

Repetitive or unaccustomed activity:
Now you’re finally getting around to painting your living room after putting it off for weeks. You want to get both coats done this weekend, so you spend long days painting. As you work, your forearm and elbow start to get more and more sore. Painting isn’t “hard,” but it’s repetitive and not something you normally do, putting a repetitive load on your forearm muscles. This is an example of a chronic injury due to repetitive activity but also a new or unaccustomed activity. Because your tissues weren’t used to that specific load, their capacity for it was low, and by the end of the weekend you’re feeling it.

Low load repetition- repeated actions over a long period of time.
Unaccustomed activity- exposing yourself to loads you are not used to.

When capacity drops:
These are all examples of when load increases beyond our capacity, but what about when the load stays the same and capacity changes? You’re still running and following your plan perfectly, but life is chaotic—work is busy, the kids have a million activities, your sleep is off, and you’re skipping breakfast as you race out the door. You’re tired but you’re getting your runs in and now your knee starts hurting. Even though your running hasn’t changed, your capacity has. The load didn’t increase, but your capacity dropped because everything else in life is impacting your recovery.

Reduced capacity- the load remains the same, but your ability to tolerate it is lowered.

In all of these scenarios, the relationship between load and capacity is a big part of what’s going on. Injuries and pain are often a web of different factors that culminate in the load being greater than our capacity. Acute injuries are frustrating because sometimes they are just bad luck. Chronic injuries can build up slowly without one clear moment you can point to. The good news is that if you pay attention to the little niggles early on, small adjustments to your training or routine are often enough to calm things down before they turn into something bigger.

Pain and injury rarely come down to one single cause, but understanding how load and capacity interact helps you make informed choices about your training and daily life. By adjusting what you can control and supporting your overall wellbeing, you can keep moving towards the activities you love with more confidence and less frustration.

*Adapted from a similar blog article I wrote in 2023 for Elite Sports Medicine and Conditioning.

My Five Guiding Principles

Since becoming a certified athletic therapist in 2017, my approach to sport injury rehab has evolved. Like many therapists, I initially followed my school teachings, but over time, I’ve learned from my experiences, colleagues, and continuing education. I’ve identified what resonates with me, guides me, and works best for me. I’ve ‘found my flow,’ as described in school.

While I aim to continuously learn and adapt, there are five principles that I believe are not only foundational to me but are likely to remain constant.

The Body is Adaptable
I think at the forefront is the idea that the body is adaptable. We know this occurs because we have concepts like Wolff’s Law (which describes how bones remodel to load), Davis’s Law (same as Wolff’s but for muscles, tendons, ligaments, etc…) and the SAID principle (specific adaptations to imposed demands- we get better at what we practice). A perfect example of this is when we workout at the gym and we do bicep curls (with progressive weight and adequate recovery), our biceps get bigger. When we stop working out, our biceps get smaller. But guess what- we can make them big again by doing curls again.

Our body can change and it responds to the loads and forces that we place (or don’t place) upon it. Obviously I like to focus on the good, but certainly if we train really hard, don’t allow for adequate recovery and experience injuries, we’re going to have a negative adaptation, ie injury. A lot of people may refer to this as “wear and tear” as if we’re a machine, but when we apply the right load and recovery throughout our training, it becomes “wear and repair”.

Load Drives Recovery
To piggyback on our adaptability, it all comes down to appropriate loads on the body, and this drives recovery from injury. Our body needs a mechanical or physical stimulus regularly and progressively in order to drive these adaptations if we want to get back to our sports and reduce our risk of reinjury. We need to prepare our body again for the demands it is going to face in our sport.

Rehab Should Be Active, Not Passive
Rest and passive treatments do play a role the role of pain management in our recovery process, but this should only be within the first few days (ie the inflammation stage of healing) and should wane and give way to progressive exercises. The problem with passive treatment is two-fold: it doesn’t load and prepare the body for physical activity, and it can make patients dependent on their therapist to get them better. Patients have better results when they are active in their recovery, literally and figuratively.

Education First
If you don’t know what you’re dealing with, how can you expect to manage it? The British physiotherapist Louis Gifford believed that patients want to know four things:

• “What’s wrong with me?” They want to have an accurate diagnosis.

• “How long is it going to take to get better?” Having a prognosis can help them plan their future.

• “Is there anything I can do to help get better?” They want some self-management techniques.

• “What can you do to help me?” This can include any number of things to help you feel better.

If I can provide an accurate diagnosis and explanation for someone’s injury, provide a timeline and idea for what recovery is going to look like, give them ways to help their own symptoms and provide a plan for a fully recovery, I am going to do a lot to help them with any anxiety and fears and help them take control and empower them throughout the process.

Resilience is the Goal
Ultimately, resiliency (the ability to adapt to stress and bounce back) is the goal. A patient should not feel broken or something is wrong with their body whenever they come into an appointment. They should not feel like they have to come in regularly in order to continue their sport. They should feel strong and confident in their body to compete after an injury. They should feel they were active and driving the recovery, and that if something does come up, they have the tools and resources to manage without feeling like they’re broken again.

Making Virtual Rehab Work For You

Some people may still be on the fence about virtual athletic therapy, even knowing it can be just as effective as in-person care. While virtual care has its limitations, there are simple ways we can address them and make the experience more personal, effective, and rewarding.

The virtual element
It is understandable that some patients feel more comfortable talking about their pain and injuries face-to-face with a practitioner as there is that physical interaction. Talking through a computer screen may feel distant, cold, and ineffective at first, but they get easier with consistency and practice. It is still possible to build trust and alliance through a screen, and this can be done with clear communication and open conversation. As well, making sure you are in a well-lit and open space and in comfortable clothing to move can help the session feel more natural. The first session might feel awkward, but by the second or third, it starts to feel familiar.

No hands-on assessment
There is no denying that physical touch is an important part of in-person rehab as touch can have many direct and indirect benefits during assessment and treatment. But much of what we learn through hands-on testing can still be gathered virtually. Guided movement tests and a clear history provide just as much insight into your pain and limitations. Many of the traditional “special tests” used in clinics don’t always have great accuracy anyway, so what really matters is understanding how you move and what you feel. A lot of valuable information can be gathered through an open and honest conversation to make an accurate assessment.

No hands-on treatment
Much like assessment, physical touch and rehab treatments are thought of going hand in hand (no pun intended). Patients expect, when coming into a treatment session, to be massaged, rubbed, stretched, or cued through exercises. They often expect something to be done to them, whereas virtual care focuses on what they can do. Without the physical interaction, the treatment shifts to self-management strategies and exercises for the patient to do on their own for long-term improvement.

Technology isn’t always perfect
Technology has a habit of acting up at the worst times. Some simple steps prior to the appointment to ensure an enjoyable experience include making sure you have an adequate internet connection and that your device’s speakers and microphone work can help ensure the call quality is optimal. There will also be a plan in place with instructions prior to the appointment should the session be interrupted.

Not suitable for every condition
Some conditions will always benefit more from in-person care, but others can be managed surprisingly well online. In the study (Lawford et al., 2018), some participants noted being skeptical at first of receiving care for their knee osteoarthritis via telephone appointments, but later embraced it. Others (Fraser et al., 2019) thought themselves unsuitable for virtual care but were still willing to try. This is to say that there is no harm in setting up a consultation to ask questions about your suitability for virtual care.

Perception of Inferiority
Overall, many patients may feel that virtual care is inferior to in-person due to the lack of physical interaction and hands-on contact. They may feel that education, advice, reassurance, and exercise prescription are not enough. A shift in mindset and embracing self-management may be needed, but this is not easy to overcome and will take time. It is important to remember that the quality of care isn’t defined by the format, but by the communication, planning, and consistency of a rehab treatment.

Some people will always prefer in-person care — and that’s completely fine. Virtual care isn’t here to replace it, but to make rehab more accessible, flexible, and practical. What matters most is that you find a therapist you trust and a plan that fits your life. If you’ve felt stuck with in-person appointments, virtual care might be the change that helps you move forward.

References:
Fraser C, Beasley M, Macfarlane G, Lovell K. Telephone cognitive behavioural therapy to prevent the development of chronic widespread pain: a qualitative study of patient perspectives and treatment acceptability. BMC Musculoskelet Disord. 2019; 20 (1):198-1008. doi: 10.1186/s12891-019-2584-2.

Lawford BJ, Delany C, Bennell KL, Hinman RS. "I was really sceptical...But it worked really well": a qualitative study of patient perceptions of telephone-delivered exercise therapy by physiotherapists for people with knee osteoarthritis. Osteoarthritis Cartilage. 2018; 26 (6):741-750. doi: 10.1016/j.joca.2018.02.909.

Virtual Care: What It Can’t Do (And Why That’s Okay)

While research shows virtual rehabilitation can be as effective as in-person care, it’s important to recognize that it isn’t perfect. Understanding its limitations helps patients make informed choices and know what to expect before starting virtual care.

Lack of Physical Interaction
One of the most common themes in the research evaluating virtual care is how patients view the physical aspect of injury assessment and treatment. Obviously, physical interaction is not there with virtual care, which many patients felt affected their ability to develop rapport with their therapists, leading to an impersonal relationship. Some people feel more natural and personable when they are face-to-face with a therapist as they can get a better sense of tone and body language. It can be hard for some to replicate casual conversation through a computer screen and therefore may find it harder to build that connection and trust.

Lack of Physical Contact
Understandably, many patients feel a big part of the injury rehabilitation is the physical touch aspect. Physical touch is used in many ways during assessment, such as to test range of motion and strength, feel for muscle tone and tenderness, see swelling and movement tests, or even just to provide comfort and reassurance. As well, many people value the physical contact during treatments through either manual therapy or assistance with exercises. While manual therapy is not the main driver of recovery, it can play an important role in calming symptoms, relieving stress, restoring comfort, and building confidence in movement, all things that can make a difference early in rehab.

Perception of Inferiority
Because of the lack of physical interaction and touch, some patients may feel virtual care is inferior to in-person care. Some patients have noted not feeling confident in the therapist’s assessment because of this lack of touch, and may feel that advice, education, and guided exercises are not adequate enough. This can have an impact on motivation and expectations, which affect the outcomes of treatment.

Not Suitable for Every Condition
While virtual care is suitable for many of the common musculoskeletal conditions, it does not work well for all. Post-operative patients usually require early and consistent mobilization— while this can certainly be guided virtually, having that physical touch and leverage can help patients push a bit further than they might on their own. When it comes to return-to-play decisions, having valuable objective measures like equal range of motion, strength, and power can make better informed decisions. Certain symptoms like numbness or loss of strength may require a more thorough neurological exam that is better done in person. Patients may even feel safer when completing exercises by having someone beside them to guide or adjust movements or even motivate them. These are examples where in-person care may be more beneficial, but virtual care can still play a role in determining what’s appropriate and in helping guide recovery.

Technology Isn’t Always Perfect
Current technology is amazing, but it is not always easy to use or reliable. Bad internet connection leading to audio and visual lagging or poor lighting and camera angles can make an appointment frustrating and a less than ideal experience. Comfort and technology literacy can be an issue too, as some patients may not feel confident doing video calls or using the programs/websites that provide their home exercise program. Some patients may even have concerns regarding the safety, privacy, or confidentiality of online video calls. While the programs that Bend Without Breaking use are GDPR-compliant, these are still valid and understandable concerns.

Some patients in the literature reported being sceptical of virtual care at first but later embraced it. Still, virtual care isn’t for everyone — and that’s okay. Some people simply prefer the structure, environment, and physical interaction of in-person care. What matters most is that your treatment feels valuable and effective for you. Virtual care isn’t here to replace in-person care, but to make quality rehab more accessible, practical, and convenient.

References:
Barton, C. J., Ezzat, A. M., Merolli, M., Williams, C. M., Haines, T., Mehta, N., et al. “It's second best”: A mixed-methods evaluation of the experiences and attitudes of people with musculoskeletal pain towards physiotherapist delivered telehealth during the COVID-19 pandemic. Musculoskeletal Science and Practice. 2022; 58, Article 102500. https://doi.org/10.1016/j.msksp.2021.102500.

Bennell KL, Marshall CJ, Dobson F, Kasza J, Lonsdale C, Hinman RS. Does a web-based exercise programming system improve home exercise adherence for people with musculoskeletal conditions?: A randomized controlled trial. Am J Phys Med Rehabil. 2019; 98 (10): 850-858. doi: 10.1097/PHM.0000000000001204.

Bucki FM, Clay MB, Tobiczyk H, Green BN. Scoping review of telehealth for musculoskeletal disorders: applications for the COVID-19 pandemic. J Manipulative Physiol Ther. 2021; 44 (7): 558-565. doi: 10.1016/j.jmpt.2021.12.003.

Cottrell MA, Galea OA, O’Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clin Rehab. 2017; 31 (5): 625-638. doi: 10.1177/0269215516645148.

Cottrell MA, O’Leary SP, Raymer M, Hill AJ, Comans T, Russell TG. Does telerehabilitation result in inferior clinical outcomes compared with in-person care for the management of chronic MSK spinal conditions in the tertiary hospital setting? J Telemed Telecare. 2021; 27 (7): 444-452. doi: 10.1177/1357633X19887265.

Cottrell MA, Russell TG. Telehealth for musculoskeletal physiotherapy. Musculoskelet Sci Pract. 2020 ;48: Article 102193. doi: 10.1016/j.msksp.2020.102193.

Cronström A, Sjödahl Hammarlund C. "A feeling of being part of the future": a qualitative study on physical therapists' experiences of delivering digital first-line treatment for hip and knee osteoarthritis. Physiother Theory Pract. 2025;41 (5): 998-1007. doi: 10.1080/09593985.2024.2380478.

Fernandes LG, Devan H, Williams CM. At my own space, pace and place: a systematic review of qualitative studies of enablers and barriers to telehealth interventions for people with chronic pain. Pain. 2022; 163 (2): e165-e181. doi: 10.1097/j.pain.0000000000002364.

Fraser C, Beasley M, Macfarlane G, Lovell K. Telephone cognitive behavioural therapy to prevent the development of chronic widespread pain: a qualitative study of patient perspectives and treatment acceptability. BMC Musculoskelet Disord. 2019; 20 (1):198-1008. doi: 10.1186/s12891-019-2584-2.

Koppenaal T, Pisters MF, Kloek CJ, Arensman RM, Ostelo RW, Veenhof C. the 3-month effectiveness of a stratified blended physiotherapy intervention in patients with nonspecific low back pain: cluster randomized controlled trial. J Med Internet Res. 2022; 24 (2): e31675. doi: 10.2196/31675.

Lawford BJ, Delany C, Bennell KL, Hinman RS. "I was really sceptical...But it worked really well": a qualitative study of patient perceptions of telephone-delivered exercise therapy by physiotherapists for people with knee osteoarthritis. Osteoarthritis Cartilage. 2018; 26 (6):741-750. doi: 10.1016/j.joca.2018.02.909.

Seron P, Oliveros MJ, Gutierrez-Arias R, Fuentes-Aspe R, Torres-Castro RC, Merino-Osorio C, et al. Effectiveness of telerehabilitation in physical therapy: a rapid overview. Phys Ther. 2021; 101 (6): 1-18. doi: 10.1093/ptj/pzab053.