The Clinical Coach: Avoid These Mistakes in Post-surgical Rehabilitation

, over the last 7 years, I’ve seen a variety of post-surgical cases with beyond poor results.

And I am not talking about a few degrees lost in a range of motion following a surgical procedure.

I am talking about poor movement patterns, weak muscles, fearful mindset and fragile humans.

This is unacceptable!

I thought the world was moving forward, that new rehab based professionals were moving away from mediocre results to high level achievements for their patients.

I was dead wrong!

Just last week I had a call with a very good friend and colleague of mine, also an ex-patient and ex-student of mine. I will keep them anonymous for the remainder of this e-mail, so don’t ask.

I’ve worked with them previously on a similar issue so they have certain expectations about their recovery. Also, they are super smart!

After a 30 minute call with them, learning what they were doing at PT and what they were experiencing, I knew their PT would get them nowhere.

If anywhere, it would definitively not be back to their regular activities.

Once I had a good picture of what was going on, we made a few tweaks to their rehab. Suggested a few exercises to add to their daily routine, limitations and better progressions.

Within a week I received the following text.

I’ll toot my own horn here.

Those that have worked with me in the past, know that I take a less conservative approach to rehab.

Yes, there are timelines for tissue recovery, healing and adaptations…

But don’t forget.

The body is a living organism always adapting.

The goal is to create positive adaptations that a patient can 1) feel and observe, and 2) are building blocks to long term positive adaptations.

You can read all the rehab books, learn all the protocols out there, and have a great plan.

If you don’t understand your patients current level of health, their fitness and their skill level, you will not get the results you want.

This was exactly what was happening with my friend here.

After a 30 minute call with them, here are the top 3 mistakes their PT team was making.

Mistake #1

A conservative treatment that is too conservative.

In other words, they basically got exercises for the sake of being in PT.

Mind you, my colleague here is not new to fitness. They are nowhere near the novice realm of fitness.

While basic exercises have a time and a place into a rehab program. You need to make sure these exercises are progressed to the point of creating positive adaptations in a patient.

If your patient can perform an exercise to 50% ROM with zero to no pain that’s good. Now challenge them to get to 55-60% of ROM with 1-2 points of pain.

As long as the pain subsided within a few minutes, you are now driving cortical changes in movement and brain patterning.

This is what you want.

Being too conservative in your treatment will lead to two things:

1) poor insurance reimbursements - your patient will most likely stop showing up because their insurance is no longer paying.

2) poor patient outcomes - your patient will not meet their performance goals.

In other words… challenge your patient from day 1.

Mistake #2

Sticking to one type of modality because of EB-blinders.

Most DPT’s are very bad at this, and some DC’s are too.

Yes, exercise has continuously trumped pretty much all modalities in musculoskeletal rehabilitation when it comes to long term outcomes.

But in the short term… they all work!

Some work better than others in specific populations. For example, athletes and fitness enthusiasts who undergo surgery tend to respond better to dry needling than cupping near the area of surgery for pain management.

Sticking to one modality simply because evidence shows better long term outcomes forgets where your patient is CURRENTLY.

Don’t forget that your patient is not just a set of outcomes. They are individuals who are living through the experience… unlike you.

Thankfully my colleague is a CDNP and works at a clinic where they have access to a variety of passive modalities to treat their everyday pain and discomfort.

Does this mean they shouldn’t be doing their exercises at home? Absolutely not.

Which leads me to…

Mistake #3

Not knowing rehab is performance training in the presence of tissue injury.

Many physical therapists and rehab-based chiropractors don’t know that rehab is not very different from performance training.

Yes.

In the continuum of strength and conditioning, rehab is training in the presence of tissue injury, while performance training is training in the presence of competition.

If you don’t understand the principles of strength and conditioning, then you only understand rehab at its basic components.

This is where my colleagues DPT’s plan was heading.

Not to full return of activities, but simply to basic ranges of motion in the absence of pain.

Not under my watch.

I’ve already shared with you the 3-phase formula for rehab that I use at the office with 90% of my patients.

The 3-Phase Rehab Formula

This is not a set in stone formula. Each phase can bleed into the next, they can overlap and in some cases some exercises from one phase can stick around all the way into bridging the gap back to training.

It all just depends on your patient, their health, their fitness level, and their skills.

By implementing the 3-phase rehab formula and avoiding the mistakes outline above, your patients will never think that your rehab is not

1. Tailored to them

2. Challenging enough

3. Going to produce the results they want

Phase 1: RESET (0-2 weeks)

Goal: Reduce pain, swelling, and restore mobility

Priorities:

• Control swelling: compression, elevation, active movement

• Light weight-bearing as tolerated

Phase 2: REBUILD (1-4 weeks)

Goal: Rebuild balance, control, and ankle-specific strength

Priorities:

Proprioception (awareness and balance)

Mobility and stability

Controlled contractions and movement patterns

Phase 3: RELOAD (3-6+ weeks)

Goal: Prepare for return to running/hiking with full function and trust

Priorities:

Restore power, reactivity, and load tolerance

Simulate real-world terrain demands

Reinforce joint integrity under fatigue

Clinical Pearls

Tissue remodeling, tissue capacity, and tissue adaptations only occur through adequate stressors.

In post-surgical cases your best progressions or regressions are based on range of motion, volume, load, intensity and frequency of the stimulus.

Every patient is unique.

Make sure you take the time to understand them.

Until our next issue!

In health and strength,

P.S. If you have questions or comments, feel free to respond to this email. I reply to all emails personally.

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