Recovery Times and Recommendations for Common Sports Injuries
“Knowledge becomes power only when we put it into use.”
When it comes to pain and sport-related injuries, oftentimes the associated suffering is not a direct result of the pain itself, but rather from the circumstantial unknowns, including how long the injury will last, whether or not it will lead to prolonged time away from athletics, and what the best treatment options are in order to promote a successful recovery. For athletes, injuries can lead to a state of anxiety limbo where it becomes easy to dwell on catastrophic thoughts such as “will this ever get better?” or “will I miss the rest of my season?” or “will I ever be able to return to my prior level of performance?”
In this week’s blog, I’ve put together a list of recovery times for common sports injuries as well as some treatment recommendations from the research literature. The goal is to help our athletic community get a better idea of what their recovery timeline may look like, whether to pursue Physical Therapy treatment or to play the “wait and see” game, and if surgery can help as a last resort. This list is by no means comprehensive; our bodies are extremely complex and recovery times will vary based on injury severity, the individual athlete in question, and the sport that they are planning on returning to. I have also excluded post-surgical recovery times as well as more traumatic injuries, as the recovery times for these situations are highly variable depending on degree of tissue trauma, surgery type, and surgical protocol. This list is intended to be a starting point when trying to determine the next step in recovery.
Shoulder
Impingement (aka Subacromial Pain syndrome, rotator cuff disorders)
What is it?: a sharp pain in the top, front, and/or side of the shoulder present with lifting, reaching (especially across the body), and dressing. Typically develops gradually as opposed to other more traumatic mechanisms.
Recovery timeline: within 12 weeks for high-functioning individuals with lower BMI, within about 6 months for ~50% of individuals, and >1 year for 32% of individuals studied. Pain beyond three months is associated with poorer recovery, disability, and reduced ability to work.
Prognostic Factors: younger age, lower BMI, and higher functional capacity were all characteristics of those who recovered fastest.
Surgery?: “Surgery did not provide important improvements in pain, function, or quality of life compared with placebo surgery or other options. Frozen shoulder may be more common with surgery (1, 2).”
Bottom Line: as will be the case with most of these injuries, having a lower BMI and higher health baseline impacts prognosis favorably. Additionally, addressing this issue EARLY by improving function with Physical Therapy can drastically improve prognosis and accelerate recovery time.
Elbow
Epicondylitis (lateral epicondylitis [tennis elbow], medial epicondylitis [golfer’s elbow], tendinopathy)
What is it?: most commonly a gradual onset injury caused by repetitive actions of the elbow, wrist, and/or shoulder. Pain is typically present at the outside or inside of the elbow where the forearm musculature attaches to the bone.
Recovery timeline:
With Physical Therapy: “Conservative treatment [of medial epicondylitis] is typically effective in symptom alleviation in 88-96% of cases” within 3-6 months
Without Physical Therapy: 6-18 months or longer.
Prognostic Factors: forearm (pronator) strength, degree of tissue damage,
Surgery/injections?: “If symptoms persist after 3-6 months of conservative treatment, operative intervention is considered.” “Steroid injections may provide short term symptom relief, yet fail to display significant long term benefits when compared with control patients (3,4).”
Bottom Line: there are many first-line conservative treatments that can help to resolve this type of elbow pain within the first 3-6 months, including physical therapy, braces, NSAIDS, and even some alternative treatments. Surgery is currently only reserved as a last resort measure.
Back
Spondylolisthesis/Spondylolysis
What is it?: stress injury and/or fracture of the Pars Interarticularis portion of the vertebrae, common in adolescent athletes such as gymnasts and dancers.
Recovery timeline: “Generally, conservative management (physical therapy) is the mainstay for treatment for spondylolysis and low-grade spondylolisthesis in fine athletes. Early diagnosis of an acute pars fracture leads to excellent results with non-operative treatment, with the majority of athletes returning to sporting activities within 3-6 months.” “The percentage of athletes who were successfully treated with conservative or operative treatment was 85 and 87.8%, respectively.”
Prognostic Factors: “The current findings show no difference in pain or function indexes with the degree or progression of slip….The onset of slip, whether in childhood or adolescence, did not occur with pain in those years, nor was it associated with pain in adulthood.”
Surgery?: “Conservative treatment including physiotherapy and bracing is the mainstay in the treatment of symptomatic spondylolysis and low-grade isthmic spondylolisthesis in fine athletes. If consequent treatment fails, the operative treatment (pars repair and short fusion) is decided.”
Bottom Line: “We suggest that a child with spondylolysis or spondylolisthesis can be permitted to enjoy a normal childhood and adolescence without restriction of activities and without fear of…disabling pain (5,6).”
Lumbar disc herniation (aka Radiculopathy)
What is it?: symptoms include low back pain accompanied by numbness, tingling, burning pain, and/or weakness traveling down the back and or front of the leg, sometimes all the way down to the toes. This can develop gradually or suddenly with an injurious event.
Recovery timeline: “The clinical course of the radiculopathy varies as well as the efficacy of conservative treatment. In some patients the symptoms decline after a week or two; in others the pain may continue for many months or years.”
Prognostic Factors: "The probability of spontaneous regression [of disc herniations] was 96% for disc sequestrations, 70% for extrusions, 41% for focal protrusions, and 13% for disc bulges.” "Most spontaneous disc regression happened within the first year, however disc regression could be observed within the first two or three months." That being said, "the sole factor of 'disc regression' cannot predict or be well correlated to better clinical outcome. Conversely it was observed that the clinical outcome can improve even without disc size regression."
Surgery?: “Compared with conservative [physical] therapy, surgical treatment [ie discectomy] provided faster relief from back pain symptoms in patients with lumbar disc herniation, but did not show a benefit over conservative treatment in midterm and long-term follow-up (7,8)”
Bottom Line: The clinical consensus is that these symptoms may improve naturally within the first few weeks after injury onset and can especially be accelerated with conservative treatments such as physical therapy. In the absence of natural improvement, surgery and physical therapy have both been shown to be more effective than placebo, with surgery providing the more drastic short-term symptom relief.
Nonspecific (generalized) Low back pain (LBP)
What is it?: pain or discomfort localized to the low back without any radiating pain, numbness, or tingling into the legs.
Recovery timeline: “90% of people with LBP will recover in 3-4 months with no treatment. 70% of people with LBP will recover in 1 month with no treatment. 50% of people with LBP will recover in 2 weeks with no treatment. 5% of the remaining 10% will not respond to conservative care (such as physiotherapy).” However, 3-6 month recurrence rate of LBP among all people with low back pain is high, around 60%.
Prognostic Factors: biological factors (BMI, physical fitness), psychological factors (anxiety and depression, beliefs about pain), social factors (work and home environment).
Surgery?: surgery is considered to be the last line of defense for nonspecific low back pain and is currently not recommended in the literature. The first line of defense is education and analgesics, followed by conservative treatments such as physical therapy, chiropractic, and/or massage (9).
Bottom Line: low back pain is a complicated disorder that impacts many Americans and is not strongly correlated with anatomical dysfunctions. The natural history is generally favorable but it has a high recurrence rate, thus making conservative treatments like physical therapy, chiropractic, and massage a more desirable option to improve long-term results.
Hip
Impingement (Femoral Acetabular Impingement)
What is it?: gradual onset of pinching sensation in the front of the hip with a variety of movements, especially deep squatting.
Recovery timeline: the timeline for recovery for this condition is variable based on an individual’s anatomy as well as biopsychosocial factors, although the consensus is that “In patients who are treated for FAI syndrome, symptoms frequently improve, and they return to full activity, including sports. Without treatment, symptoms of FAI syndrome will probably worsen over time. The long-term outlook for patients with FAI syndrome is unknown.”
Prognostic Factors: hip anatomy, early treatment, biopsychosocial factors (anxiety/depression, beliefs, environment).
Surgery?: “Hip arthroscopy surgery had a small positive benefit compared with a physiotherapist-led intervention at 8-12 months. At 24 months, the level of evidence was limited indicating no difference between the hip arthroscopy surgery and physiotherapist-led interventions (10).”
Bottom Line: FAI is a condition that seems to require physical therapy or surgery to experience improvements. Surgical treatments can also lead to slightly greater benefits than PT in the short term but not after 1-2 years.
Knee
Patellofemoral pain syndrome (pain around the kneecap)
What is it?: pain behind and/or around one or both kneecaps (patellas). More common among youth athletes, especially females, although it is also prevalent across the adult US population.
Recovery timeline: the natural history of patellofemoral pain syndrome (PFPS) varies considerably. According to one study, “between 71 and 91% of individuals report ongoing pain up to 20 years following initial diagnosis.” Physical therapy has shown to accelerate recovery to within a 3 month time period and reduce the risk for chronic pain, although success rates with Physical Therapy decreases if treatment is not sought within the first 3 months.
Prognostic Factors: physical therapy within the first 3 months of injury likely results in the quickest and best outcomes.
Surgery?: Surgery is not indicated for this condition at this time.
Bottom Line: PFPS can happen to anyone, especially young female athletes. While many people deal with this issue for many years, starting Physical Therapy care early on after the start of injury can significantly decrease the likelihood of long-term pain (11,12,13).
Foot/ankle
Ankle Sprains
What is it?: micro-tearing of the surrounding ankle ligaments after a traumatic injury, typically a rolling of the ankle.
Recovery timeline: “Following an acute LAS (lateral ankle sprain), pain decreases rapidly within the first two weeks after injury. However, a substantial proportion of patients report long-term unresolved injury-associated symptoms. At a follow-up of 1-4 years, 5%-46% of patients still experience pain, 3%-34% of patients experience recurrent sprains and 33%-55% of patients report instability.” Physical therapy starting within the first 2 weeks after injury to address balance, strength, and sport-specific control has been shown to greatly reduce long-term pain and instability.
Prognostic Factors: “Some of the known unfavorable prognostic factors identified for the development of CAI (chronic ankle instability) were an inability to complete jumping and landing within 2 weeks after a first-time LAS, deficiencies in dynamic postural control, altered hip joint kinematics and lack of mechanical stability/increased ligament laxity 8 weeks after an ankle sprain.” “For the time being, injury grade (rupture or no rupture) does not seem to be a strong predictor for the course of lateral ankle sprains.”
Surgery?: surgery is only indicated as a last line of defense for ankle sprains after all other options have been exhausted.
Bottom Line: ankle sprains can have a very straightford and quick recovery if treated with Physical Therapy early on. If left unchecked, athletes can develop a higher likelihood of chronic pain and ankle instability (15,16).
Tendons
Patellar and Achilles Tendonopathy (formerly known as “tendonitis”)
What is it?: these are some of the most common overuse injuries in runners, weightlifters, and crossfit athletes caused when the cumulative loading of the tendon fibers exceeds the tendons’ capacity over time.
Recovery timeline: “Patients can expect their symptoms to improve between 3 and 12 months after commencing treatment… Chronic symptoms persist in approximately a quarter of patients 10 years after treatment, and tendinopathy impairs both quality of life and physical activity.” Treatment recommendations to accelerate recovery include a progressive physical therapy program to improve load capacity of the injured tendon and therefore decrease pain with activity. “Based on the findings in this study, we advise against recommending wait-and-see therapy as a treatment strategy.”
Prognostic Factors: prognostic factors include severity of injury and whether or not treatment has been pursued, particularly one that includes a progressive loading program and return-to-sport protocol (17).
Surgery?: surgery is not indicated for these conditions.
Bottom Line: tendinopathy is an extremely common condition among endurance and strength athletes and can lead to long-term pain. The good news is that it responds extremely well to a progressive sport-specific physical therapy program and doesn’t require surgery.
This list, while not comprehensive, should serve as a quick and dirty overview of common sources of pain in athletes and, more importantly, a guideline for potential courses of action to take when injured. By staying up to date with sport-injury literature, we may reduce the ambiguity surrounding sport-related pain and injury and improve the efficacy of care so that athletes are no longer stuck in the vicious cycle of pain and reinjury.
References
Vandvik P O, Lähdeoja T, Ardern C, Buchbinder R, Moro J, Brox J I et al. Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline BMJ 2019; 364 :l294 doi:10.1136/bmj.l294
Ertan S, Ayhan E, Güven MF, Kesmezacar H, Akgün K, Babacan M. Medium-term natural history of subacromial impingement syndrome. J Shoulder Elbow Surg. 2015 Oct;24(10):1512-8. doi: 10.1016/j.jse.2015.06.007. Epub 2015 Jul 23. PMID: 26212760.
Chung KC, Lark ME. Upper Extremity Injuries in Tennis Players: Diagnosis, Treatment, and Management. Hand Clin. 2017;33(1):175-186. doi:10.1016/j.hcl.2016.08.009
Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev. 2017;1(11):391-397. Published 2017 Mar 13. doi:10.1302/2058-5241.1.000049
Bouras T, Korovessis P. Management of spondylolysis and low-grade spondylolisthesis in fine athletes. A comprehensive review. Eur J Orthop Surg Traumatol. 2015 Jul;25 Suppl 1:S167-75. doi: 10.1007/s00590-014-1560-7. Epub 2014 Nov 14. PMID: 25394940.
Beutler WJ, Fredrickson BE, Murtland A, Sweeney CA, Grant WD, Baker D. The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Spine (Phila Pa 1976). 2003 May 15;28(10):1027-35; discussion 1035. doi: 10.1097/01.BRS.0000061992.98108.A0. PMID: 12768144.
Benoist M. The natural history of lumbar disc herniation and radiculopathy. Joint Bone Spine. 2002 Mar;69(2):155-60. doi: 10.1016/s1297-319x(02)00385-8. PMID: 12027305.
Gugliotta, Marinella, et al. “Surgical versus Conservative Treatment for Lumbar Disc Herniation: A Prospective Cohort Study.” BMJ Open, vol. 6, no. 12, 2016, https://doi.org/10.1136/bmjopen-2016-012938.
Barton CJ, Lack S, Hemmings S, Tufail S, Morrissey D. The 'Best Practice Guide to Conservative Management of Patellofemoral Pain': incorporating level 1 evidence with expert clinical reasoning. Br J Sports Med. 2015 Jul;49(14):923-34. doi: 10.1136/bjsports-2014-093637. Epub 2015 Feb 25. PMID: 25716151.
Collins NJ, Bierma-Zeinstra SM, Crossley KM, van Linschoten RL, Vicenzino B, van Middelkoop M. Prognostic factors for patellofemoral pain: a multicentre observational analysis. Br J Sports Med. 2013 Mar;47(4):227-33. doi: 10.1136/bjsports-2012-091696. Epub 2012 Dec 13. PMID: 23242955.
Gabriel Peixoto Leão Almeida, Helena Larissa das Neves Rodrigues, Bruno Augusto Lima Coelho, Carlos Augusto Silva Rodrigues, Pedro Olavo de Paula Lima,
Anteromedial versus posterolateral hip musculature strengthening with dose-controlled in women with patellofemoral pain: A randomized controlled trial, Physical Therapy in Sport, Volume 49, 2021, Pages 149-156, ISSN 1466-853X, https://doi.org/10.1016/j.ptsp.2021.02.016.
Vuurberg G, Hoorntje A, Wink LM, van der Doelen BFW, van den Bekerom MP, Dekker R, van Dijk CN, Krips R, Loogman MCM, Ridderikhof ML, Smithuis FF, Stufkens SAS, Verhagen EALM, de Bie RA, Kerkhoffs GMMJ. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018 Aug;52(15):956. doi: 10.1136/bjsports-2017-098106. Epub 2018 Mar 7. PMID: 29514819.
van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. 2008 Apr;121(4):324-331.e6. doi: 10.1016/j.amjmed.2007.11.018. PMID: 18374692.
van der Vlist AC, Winters M, Weir A, Ardern CL, Welton NJ, Caldwell DM, Verhaar JAN, de Vos RJ. Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. Br J Sports Med. 2021 Mar;55(5):249-256. doi: 10.1136/bjsports-2019-101872. Epub 2020 Jun 10. PMID: 32522732; PMCID: PMC7907558.
Dr. Brooks Kenderdine
PT, DPT, CSCS, USAW-1
Co-owner | The PATH Rehab & Performance
