As a sports physical therapist, one of the biggest problems I see in rehab is athletes being underdosed.
Underdosing means an athlete is given exercises that are not difficult enough, heavy enough, fast enough, or specific enough to prepare them for their sport.
The athlete may complete months of physical therapy, perform every exercise correctly, and even become pain-free. But when they return to practice, they quickly realize that their body was never prepared for sprinting, jumping, cutting, throwing, or competing at full speed.
If an athlete’s rehab never progresses beyond light resistance bands, bodyweight exercises, and basic balance drills, how can we expect them to safely return to the demands of high-level sports?
What Does Underdosing Look Like?
Every exercise creates a certain amount of stress on the body.
For the body to become stronger, more powerful, or better prepared for sports, that stress must be challenging enough to create an adaptation. If an exercise is too easy, the body has no reason to change.
Underdosing can include:
- Not using enough resistance
- Performing exercises that are too easy
- Failing to increase resistance over time
- Avoiding speed and explosive movements
- Not challenging single-leg strength and stability
- Stopping rehabilitation before introducing running, jumping, or cutting
- Using the same exercises for every athlete, regardless of their sport.
Obviously increasing the difficulty of exercises too quickly runs the risk of re injury, but being too timid in progression is just as detrimental to an athlete’s return to sport.
Why is Underdosing so Common?
In my experience there are 3 main reasons that athletes are underdosed in their rehab program:
- Most PT clinics don’t treat many athletes. Since athletes often make up only a small portion of their patients, many clinics are not equipped or experienced enough to prepare them for the demands of returning to sport.
- The demands of sport are often underestimated. Many physical therapists do not fully understand the strength, speed, power, and endurance athletes need to safely return to competition.
- Underdosing is common across all areas of PT. Unfortunately the medical system is failing more than just athletes and underdosing affects many different areas of rehab.
Most PT Clinics Don’t Treat Many Athletes
It is common for athletes to account for only 10–20% of the clinic’s patients. Often the caseload includes older adults, people recovering from surgery, patients with chronic pain, injured workers, and individuals trying to return to normal daily activities.
It’s true that there is nothing wrong with treating a wide variety of patients. But it’s also true that athletes require a more aggressive approach to treatment compared to most other groups. Most athletes tend to also continue their training while they are recovering and it’s important for a physical therapist to be able to guide an athlete in what they can and can’t do at every point of their recovery. Too many locations tell athletes to simply wait until PT is fully complete before returning to any level of their sport, and this simply is not the best approach (nor will athletes listen to it anyway).
If most patients only need to return to walking, climbing stairs, working, or completing household activities, the clinic may not be designed to prepare someone for the demands of competitive sports.
Athletes need to do much more than move without pain. Depending on the sport, they may need to:
- Sprint at full speed
- Jump and land repeatedly
- Rapidly change direction
- Accelerate and decelerate
- Produce and absorb large amounts of force
- Throw or swing at high speeds
- Maintain their performance while fatigued
- Tolerate contact from other athletes
A physical therapy clinic can successfully help an athlete become pain-free while still failing to prepare that athlete for these demands.
The Demands of Sports Are Often Underestimated
Physical therapists without a history in high-level sports may unintentionally underestimate how difficult sports really are on the body.
It is easy to choose exercises based only on the athlete’s injury. It is much more difficult to design rehab around the forces, speeds, positions, and repeated movements the athlete will experience during competition.
For example, an athlete with plantar fasciitis may be prescribed towel curls to strengthen the small muscles of the foot.
Towel curls may be appropriate during the early stages of treatment. However, that same athlete may need to return to full-speed sprinting.
The force placed through the foot during sprinting is significantly greater than the resistance created by curling a towel with the toes. If treatment stops there, the athlete’s rehab has not prepared the foot for the demands of the sport.
The same problem happens with many other injuries:
- A basketball player with knee pain completes basic bodyweight squats but never progresses to jumping, landing, and cutting.
- A baseball player with shoulder pain performs light resistance-band exercises but never rebuilds the strength, speed, and workload needed for throwing.
- A gymnast with an ankle injury practices balance exercises but never progresses to the explosive demands of tumbling.
These athletes may look great inside the clinic and then immediately experience risk of re-injury when they return to their sport.
Rehab Should Eventually Look Like the Sport
During the beginning stages, the goal may be to reduce symptoms, restore range of motion, and rebuild basic strength. As the athlete improves, however, the exercises must progress.
A complete sports rehab program should eventually address:
- Heavy strength training
- Single-leg strength and control
- Power and explosiveness
- Running and sprinting
- Jumping and landing
- Acceleration and deceleration
- Changing direction
- Sport-specific movements
- Conditioning and fatigue
A runner should eventually run. A baseball player should eventually throw. A gymnast should eventually tumble.
Unfortunately it’s very common for athletes to only receive a basic level of rehab from their medical provider, and they are left to figure out the rehab to return back to sport all on their own.
Underdosing Is Common Across All Areas of PT
Underdosing is a problem throughout the entire physical therapy profession, regardless of the patient population.
Research involving physical therapy in skilled nursing facilities and home health has shown that treatment does not always follow basic strength-training principles customized to each patient.
Older adults and medically complex patients are often given light exercises because therapists are concerned about safety. However, exercises that are too easy may not create the strength improvements needed to help someone walk, climb stairs, prevent falls, or remain independent.
Research has also shown that appropriately supervised, higher-intensity resistance training can be safe and beneficial for medically complex older adults in skilled nursing facilities.
The correct level of difficulty is different for every patient, but physical therapists in general rarely spend enough time with their clients to customize for each one. This leads to longer than necessary recovery times, and sometimes creates clients who believe they are beyond rehab because they have “failed PT.” They don’t realize that the PT they received does not represent the whole profession.
Regardless of the population, exercises must be challenging enough to move the patient toward their specific goal.
How Do You Know if Your Rehab Is Underdosed?
Your rehab may not be challenging enough if:
- You have performed the same exercises for several weeks without progression.
- You consistently finish every set without feeling challenged or fatigued.
- Your exercises do not resemble any of the demands of your sport.
- You are close to returning to sport but have not sprinted, jumped, landed, or changed direction.
- Your therapist only asks whether you have pain instead of evaluating your strength and joint stability.
- You feel good during physical therapy but do not feel confident returning to practice.
Ready to Return Better Prepared?
If you’re pain-free but still don’t feel strong, fast, or confident enough to return to your sport, your rehab may not have challenged you enough.
At Baldi Movement Group, we don’t just help athletes feel better—we build strength, power, speed, and sport-specific confidence through appropriately dosed rehab.
If you’re ready for physical therapy that prepares you for the real demands of your sport, schedule an evaluation with our team today.