Overuse Injuries and Stalled Gains: Why It Might Not Be the Rehab Program
- Look beyond biomechanics: When non-contact injuries occur or tissues fail to heal as expected, the musculoskeletal issue is rarely an isolated problem. The athlete's internal environment including fueling and sleep can be a limiting factor.
- Don't blame the program first: If an athlete isn't making expected strength, power, or hypertrophy gains from a well-designed program, evaluate their biological supply lines before overhauling sets and reps.
- Use narrative mapping instead of checklists: Asking "How much do you sleep?" triggers defensiveness and lectures. Asking "Walk me through your day from when you wake up to bedtime" creates a judgment-free space that reveals accurate recovery and fueling metrics.
- Reframe food as fuel: Shift the conversation from "diet" to "fueling for tissue repair and performance" to destigmatize nutrition and screen for Relative Energy Deficiency in Sport (RED-S).
We’ve all been there. You’re working with a patient with patellar tendinopathy or medial tibial stress syndrome. You’ve got the load dialed in, you’ve been working on their movement, but they just won’t heal. When our ideal rehab isn’t quite working, or when an athlete isn't seeing the strength and hypertrophy gains you'd expect from a high-quality program, it's easy to second-guess the plan.
We're often a little bit too quick to blame the program. But we actually need to look bigger and broader than that. We need to look beyond the musculoskeletal problem. The person they were when they got this injury is the reason they got injured in the first place. If we're not addressing how they are fueling and how they are recovering, we're missing out on a lot of healing potential. That is the most likely underlying culprit of their lack of progress.
The "Walk Me Through Your Day" Strategy
Managing all the things that go into an athlete is complex. When I'm trying to figure out exactly what's going on globally, I need to know everything about their nutrition, their load, and their sleep. But getting that information can be challenging. If I ask a patient, "How much sleep are you getting at night?" it immediately feels like I'm judging them, and they expect a lecture about how they need to sleep more.
Just say, "Hey, start me from when you wake up in the morning till when you go to bed at night. Talk to me about what you're doing and what you're eating."
This provides a judgment-free zone. I can get all the calculations I need, understand their energy availability, and pick up a ton of clues about what's going on systematically. Words matter. By framing it as a conversation about fueling their activity and healing, rather than a critique of their diet, you keep the athlete engaged in their own recovery.
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The Person They Were When They Got Injured
When an athlete experiences a non-contact injury or fails to heal along a normal biological timeline, focusing purely on local tissue mechanics misses the mark. Movement impairments and strength deficits certainly matter, but they do not exist in a vacuum. The person they were when they got injured combined with load is the reason they got injured. If an athlete sustained a tissue breakdown under routine athletic loading, their physiological resilience was compromised. Musculoskeletal tissues require continuous cellular turnover, hormonal support, and inflammatory regulation to repair and adapt. When that system is starved of fuel or short on restorative sleep, tissue tolerance drops drastically. If we only treat the tendon, bone, or muscle belly without examining how that athlete is fueling and recovering, we are attempting to rebuild a structure without delivering the raw construction materials.
Stalled Strength? Check the Supply Lines
When an athlete is not seeing the gains expected from a well-structured training program, we are often too quick to blame the program. Hypertrophy, neuromuscular adaptations, and power output are metabolically expensive processes.
If an athlete is in a state of chronic Low Energy Availability (LEA) whether intentional or simply due to a hectic schedule, the body prioritizes survival over laying down new contractile tissue. If their fueling and sleep hygiene are falling short, no program adjustment will overcome that physiological ceiling. Recovery is where adaptation happens; the workout is merely the stimulus.
Reframing Food: Shifting from "Diet" to Fueling
Terminology dictates patient buy-in. Words like "diet" and "eating habits" can carry emotional baggage, body image pressure, and restrictive connotations. Instead, frame food through the lens of performance: fueling activity and fueling healing.
Athletes understand equipment performance. If you put low-grade fuel into a race car, you cannot expect high-level track times without engine failure. The same logic applies to tissue remodeling.
This framing also opens the door to screen for Relative Energy Deficiency in Sport (RED-S). RED-S does not only live at the extreme end of clinical eating disorders. Far more commonly, athletes experience unintentional under-fueling caused by high training volumes, heavy academic loads, and the logistical challenges of prepping enough food to match their daily metabolic expenditure.
To hear the complete discussion on bone stress injuries, muscle strains, and systemic recovery factors, check out Episode 31 of the Rehab & Performance Lab Podcast with Dr. Teresa Schuemann.
You can listen to the episode at the links below. If you'd like CEUs, make sure to use the MedBridge link.
