How to accomplish a successful rehabilitation, improve performance and still avoid the negative effects of overtraining

 In Exercise and Health


Firstly I would like to introduce you to the concept of ‘tissue capacity’. In the context of exercise and performance, capacity is a term one can easily link with the idea of being able or not able to cope with, complete or participate in physical activity. In other words, it is relative to the physical demands of the task. For instance, one’s Achilles tendon can cope with a 5km walk just fine but become symptomatic with a 10km walk. Another example, for a given individual, 10 body-weight chin-ups represent the largest amount of non-stop repetitions that can be achieved. However, by building muscle capacity that same individual can get to 15 repetitions of non-stop body-weight chin-ups.

So capacity is an umbrella term which can be broken down into strength, power, endurance, resilience or any other specific tissue property needed for a given outcome to occur.

Capacity is an umbrella term which can be broken down into strength, power, endurance, resilience. #performbetter @pogophysio Click To Tweet

Here is the definition from Cook & Docking 2015: “A tissue is at full capacity when the individual is able to perform functional movements at the volume and frequency required without exacerbating symptoms or causing tissue injury”.

By default, elite athletes require greater tissue capacity than recreational athletes, ageing decreases tissue capacity and pathological tissue has less capacity than normal tissue, quite simple.

Now that the concept is crystal clear, we can understand that musculoskeletal injury occurs when the capacity of the weakest link is exceeded. For example, a tendon, muscle or ligament working under great strain.

Musculoskeletal injury occurs when the capacity of the weakest link is exceeded. #performbetter @pogophysio Click To Tweet

So in terms of rehabilitation, loading programs must be specific to address the needs of the tissue in order to build capacity. The two main rules are:

  • Load the injured tissue and allow a period for adaptation;
  • Load multiple tissues within the kinetic chain.

The most common pitfalls I see are related to not following these golden rules:

  • If you do not allow time for tissue adaptation the only possible body response will be further tissue breakdown and pathology;
  • If you only focus on the injured site you will neglect surrounding tissues that had their capacity decreased as a consequence of the initial injury. Remember, the injury happens at the weakest link inside the kinetic chain, which optimal functioning depends on mutual collaboration from surrounding structures.
  • If you do not build enough tissue capacity in order to meet the demands of the task by focusing on symptom cessation alone, your rehabilitation is bound to fail.

On the next step, you want to be able to monitor loads safely. One of the best current concepts is the Acute:Chronic Workload Ratio (ACWR). My physio colleague Lewis Craig has written an entire blog about it which contains all the steps to measure your ACWR, Click HERE>>>.

Lastly you want to be equipped with the knowledge that allows you to monitor fatigue and recovery during your training/rehabilitation plan. For most athletes there is an overlap of rehabilitation exercises and training loads when recovering from injury. Both must be taken into account and closely monitored to avoid tissue breakdown due to excessive loading, fatigue and lack of recovery.

On that note, it is important to mention fatigue is not necessarily bad. What can be potentially harmful is to not recognise it by pushing through it and not planning recovery accordingly. So again, measuring loads and training response is the answer.

What can be potentially harmful is to not recognise it by pushing through it and not planning recovery accordingly. #performbetter @pogophysio Click To Tweet

Commonly exercise medicine professionals will monitor objective measures such as heart rate at rest, blood markers, oxygen consumption and so forth. Nevertheless, current literature also supports the use of subjective measures as being, in some instances, more accurate in detecting negative effects of overtraining. For example questionnaires enquiring around an athlete’s mood, sleep pattern, perceived stress etc. can be applied. A systematic review by Saw et al. 2016 reports that subjective measures are more sensitive to change than objective data and also responsive to acute and chronic training loads. There is no association between the two different types of measures which allows these authors to support the idea that both can complement each other.

Broader measures that cater for multiple constructs and are athlete-specific correlate better with performance capacities. Two questionnaires are suggested due to their comprehensive measuring properties, the Recovery Stress Questionnaire for Athletes (RESTQ-s) and the Multi-Component Training Distress Scale (MTDS).

And how exactly that affects the normal person that is not an elite athlete? It means not only elite level athletes but also those involved with physical activity at amateur level do not need a full lab or expensive equipment at their disposal, in order to reliably monitor fatigue and recovery in response to their training loads. Bear in mind, at professional level a combined analysis of subjective and objective measures is gold standard.

Acknowledging that poor sleeping habits, fatigue, lack of vigour, non-training stress and others are not only interfering with your performance but can also be used to evaluate and adjust your training loads is the main take home message of this blog. The benefit of adopting that practice is well known among exercise medicine professionals because it allows for better training periodisation.

Lastly, Halson (2014) paper describes in more detail the pros and cons of different methods for monitoring internal and external loads. The full list is beyond the scope of this blog; however, this author supports the idea of implementing systematic load monitoring strategies for better performance. For instance, applying a taper at the right time into one’s periodisation schedule and measuring performance results post-taper can not only improve performance but also prevent tissue breakdown and unwanted time-off. On the next blog I will talk more about periodisation and how one can approach it. I hope today’s read has added value to you.

Bruno Rebello (APAM)


Bruno Rebello


Cook, J., & Docking, S. (2015). “Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ‘tissue capacity’: A core concept for clinicians. British Journal of Sports Medicine Br J Sports Med, 49(23), 1484-1485. doi:10.1136/bjsports-2015-094849

Gabbett, T. J. (2016). The training—injury prevention paradox: Should athletes be training smarter and harder? British Journal of Sports Medicine Br J Sports Med, 50(5), 273-280. doi:10.1136/bjsports-2015-095788

Saw, A. E., Main, L. C., & Gastin, P. B. (2015). Monitoring the athlete training response: Subjective self-reported measures trump commonly used objective measures: A systematic review. British Journal of Sports Medicine Br J Sports Med, 50(5), 281-291. doi:10.1136/bjsports-2015-094758

Halson, S. L. (2014). Monitoring Training Load to Understand Fatigue in Athletes. Sports Medicine, 44(S2), 139-147. doi:10.1007/s40279-014-0253-z

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