How to Tell If Physical Therapy Is Working for Your Athlete

Her son plays first base. On the first play of the first game of summer ball, he stretched for a throw and felt four pops in the back of his leg. Imaging called it a hamstring strain.

Six weeks later he could walk. He could not run. And his rehab was still nerve glides and hamstring stretches, the same things he was doing in week one.

I want to be fair here. Those are reasonable exercises for the first week. Nothing about them was wrong. The problem was that week six looked exactly like week one, and nobody in that family could tell you whether he was any closer to playing than he was a month before.

That's the part I want you to notice. Not the exercises. The fact that there was no way to tell.

Most parents judge rehab the way anyone would. Does it hurt less? Does he seem happier? Is he doing more than he was?

Those are fair questions. They just don't tell you much.

Pain goes down for a lot of reasons. Rest takes pain away. So does time. So does doing less. An athlete can be pain-free because the tissue got stronger, or pain-free because he stopped doing the thing that hurt it. From the outside those two look the same. They are not the same athlete.

Effort doesn't tell you much either. A kid can work hard three days a week on a plan that never asks his body for more than it could already handle. That's not his fault, and usually it isn't the clinician's fault either.

A lot of rehab is built to get someone out of pain and moving normally again. It does that job, and that job matters. It just isn't built to take an athlete the rest of the way back to his sport. Getting a pitcher ready to throw 80 pitches, or a first baseman ready to sprint and stretch, takes load, progression, and time. If the plan isn't set up for that, it doesn't happen.

So families get stuck. They sense something is off. They can't point to anything specific. And nobody wants to be the parent who second-guesses the professional.

Here is the plain version of what I believe. It's the whole point of this post.

One strong sign physical therapy is working is when a measure that matters for his sport is moving toward an individualized target, and somebody is checking it on a schedule.

Not only when it hurts less. Not only when he's busy. When something is measured, measured again, and getting closer to where it needs to be.

Let me show you what that looks like with a real athlete.

Ian is a high school pitcher. He came to me this summer with posterior elbow impingement, which is pain in the back of the elbow that usually shows up as the arm finishes the throw. He had already spent about six months working on the same problem with another provider.

I don't know what was or wasn't tested before he got to me, and it isn't my place to guess. What I can tell you is what I tested on day one, and what those numbers did over the next three months.

On his first visit, I tested his shoulder strength on a force plate. He lies face down and pushes into the plate with his arm out in a few positions, and the plate tells me how much force he can make relative to his bodyweight. It's called the athletic shoulder test.

His throwing arm made 1.1 newtons per kilogram. His other arm was about 25% stronger.

For a pitcher, that's backwards. The throwing arm takes far more stress than the glove arm. I want it to be at least as strong.

I also measured how fast he could get to that force. That's called rate of force development. A pitch happens in a fraction of a second, so strength he can't reach quickly doesn't do much for his arm. His throwing arm got to about 150 newtons per second.

Then I measured how strongly he could rotate his shoulder in and out, the two motions the rotator cuff controls. Internal rotation was about 33 pounds. External rotation was about 37.

That was the starting line. Everything after it got judged against those numbers, not against how the week felt.

Here is the part most rehab stories leave out.

For the first six weeks, his numbers didn't climb. His shoulder test actually dipped. His rate of force development sat flat.

If you were judging by feel, you could have read that stretch either way. His arm wasn't bad. He was showing up. He was doing his work. And the numbers said we weren't getting anywhere.

This is the point where a lot of families quit. It's also the point where a lot of plans just keep going the same way and hope. Neither one is a decision.

A flat number is not a failure. It's information. It tells you something in the athlete's week is cancelling out the work, and the job is to go find it.

So I went looking.

Around the six week mark I got on a call with Ian and his throwing coach. We had split the work. I handled the elbow. He handled the throwing.

His coach opened with something useful. Ian's arm was feeling good overall, but he'd had a dead-arm feeling going into his last bullpen. He hadn't gotten much of a break from throwing that week.

Then Ian told us something I didn't know. School had just started, and he was in a weight training class. Push, pull, legs, three heavy days a week, sets to failure. The day before, it had been barbell rows, hammer curls, shrugs, RDLs and plate raises, five sets each. By the time he got to his afternoon work, he was cooked.

He had already gone to the class coach and told him he couldn't do heavy shoulder work the day after he threw. Nobody told him to. He figured it out because his external rotation holds that week felt like half reps.

I'll be honest. I didn't know about the school lifting until that call, and it changed things.

Think about his week from his arm's point of view. A throwing program. A rehab program. A school weight room. A high school coach. Three or four people each handing him a full bucket of work, and nobody adding the buckets together.

You can't out-rehab that. You just can't.

We didn't add anything. We took things away.

Throwing volume came down for a while. Intensity stayed high. His coach moved him toward a long toss progression with less mound work. Three throwing days a week, with an optional fourth if he felt good. His hardest day landed on the weekend, when he was the most recovered from school.

On my side, I pulled back to the true elbow rehab and let the training side fill in around it. This is the hardest time of year for high school baseball players, because school training starts back up all at once. When I program for high schoolers in that window, it's usually about three exercises, two to three times a week. Intensity is relatively high. Volume is super low. They are already getting crushed in their school weight room. They don't need more stress. They need the right amount.

Then every session started with the same quiet check. What did you throw? How hard? How's the arm? Are you sleeping?

One afternoon he told me he'd made ten throws, aired out, and his arm was a little sticky but not sore. He was still sleeping and recovering well. His next throw was Sunday. So that was the day we did his heavier arm care, because there were recovery days behind it.

That isn't a new exercise. That's the dose being set by what is coming next on his calendar. Most arm care advice is a list of exercises. The skill is knowing which day to do them.

After that, the line bent.

By his last session, three months after the first one, his throwing arm's shoulder test had gone from 1.1 to 2.0 newtons per kilogram. That's close to double. The arm that started weaker than his other arm finished about 18% stronger than it.

His rate of force development went from about 150 to 480 newtons per second.

His internal rotation went from about 33 to 43 pounds. His external rotation went from about 37 to 40.

His elbow calmed down. He was fully discharged.

I'd love to tell you that happened because of some special exercise. It didn't. The biggest lever was working with his throwing side and getting the volume right. The numbers are how we knew it was working. Together with his symptoms and throwing progression, they supported the decision to discharge him.

Put the two stories side by side.

Two athletes. Both about six weeks into rehab. Both not clearly better. If you had asked either family how it was going, you'd have gotten the same shrug.

One had no number. Nobody could say whether he was closer to running than a month before, so the plan kept going the way it had been going.

The other had a number, and the number was flat. That flat number is what sent me looking at his whole week. It's what got the school weight room into the conversation and the throwing volume down. Without it, Ian's six weeks would have looked just like the first baseman's six weeks. A kid working hard, a parent with a bad feeling, and nobody able to say why.

The difference was never effort, or how much either kid cared. One family could see the problem. The other could only feel it.

You don't need a force plate at home to figure this out. You need clear answers to a few questions. They are fair to ask any provider, me included.

1. What was tested on day one? Not how it feels. What was measured, with what, and what was the number.
2. What is the target? Where does that number need to be for his sport and his position? A pitcher's shoulder and a soccer player's knee need different targets.
3. When is the next retest? If nobody can tell you, nothing is being tracked.
4. What happens if the number is flat? A good answer sounds like "then we look at what else is going on in his week." Not "we keep going."
5. Does the plan know about the rest of his week? School lifting, club practice, games, lessons. If the rehab plan doesn't account for them, it's only planning for part of his week.
6. Is it different from week one? Not harder just to be harder. Different in a way that is closer to what his sport asks of him.

If the answers come back clear, that's a good sign, even when progress is slow. Slow and measured is fine. Ian sat flat for six weeks before anything moved.

If the answers come back vague, that doesn't mean anyone did anything wrong. It means you don't have enough information to know yet, and you're allowed to ask for it.

The last conversation I had with Ian wasn't really about his elbow. His numbers, symptoms, and throwing progression supported discharge, so my part was done. At that point he just needed to go train hard and often, so he can do what he wants to do, which is pitch in college.

That's what physical therapy working actually looks like. Not a kid who is pain-free and still coming in every week with no end in sight. A kid whose numbers, symptoms, and sport progression support his readiness, and who leaves.

The goal was never to keep him in rehab. The goal was to keep him available.