I am currently working to attain my transitional doctorate in physical therapy (tDPT) at Northeastern University. As I continue to work full time as a clinician, it has been really cool to apply the learning with my current caseload. At this time, I am in a motor control class that is both fascinating and challenging. In week three, we examined pain and the impact it has on neuroplasticity (the brain’s ability to adapt or change).

In the sports medicine realm, I generally think many practitioners solely focus on the musculoskeletal system or physical impairment. As such, interventions are developed around tissue constraints, ROM deficits, weakness, etc. Too often, we look past the power and impact of the brain and how it plays a vital role in healing and return to play. For some patients, there is a maladaptive response to injury/surgery and a hypersensitivity of the central nervous system or central sensitization that occurs. Pelletier (2015) notes that structural and functional changes can occur. (1)

Two critical concepts to consider here are:

  1. Sensory amplification – sensory and motor representations change resulting in perceptual changes in body image, motor control changes, and even a persistence or amplification of pain
  2. Experience dependent plasticity – patient’s response to pain is related to prior experience and may experience maladatpive imprinting where the pain outlasts the physical insult

Kleim (2008) gives a great lesson on experience dependent plasticity and states that learning is essential for the brain to adapt to damage self taught behavioral changes can be maladaptive or positive and specific forms of neural plasticity and associated behavioral changes are dependent on specific kinds of experience (2). While one would assume that chronic pain is rare in athletes, I would counter and say it is probably just overlooked as we tend to expect athletes to “push through the pain” because of the driven culture we live in. Coaches, parents and even teammates can affect the mindset around injury and recovery.

I am a strong believer that pain and threat detection cripple orthopedic rehab efforts, and we must treat these patients differently to be successful. Today, I am very focused on learning more about how pain thresholds and pain science impacts or alters rehab with my patients. I routinely measure kinesiophobia (TSK-11 and ACL-RSI) and work on external cues actively in all my sessions. Mental imagery and task specificity are also things I utilize at times. The patient’s mood, affect, body language and anxiety are all yellow flags I look for. I definitely see some patients after ACLR that fit in this maladaptive category with some altered cortical mapping (inhibition of quadriceps, altered pain thresholds, depression, altered body image and apprehension/anxiety about their recovery).

To illustrate how experience dependent plasticity and/or pain may impact the recovery a high level athlete, I will outline the case of  a female college soccer player from John HopkinsUniversity recovering from her second ACL tear. I rehabbed her in high school just over 2 years ago after her first injury. Her MD in Raleigh opted for an allograft reconstruction. Albeit not the common choice for a female in a level 1 sport, she did very well and made a full return to soccer her senior year.

Approximately two years later, she suffered a non-contact injury of her other knee in pre-game warm-ups for her first collegiate game. The team physician performed a bone-patella tendon bone ACL reconstruction this time. Now, she is 6 months post-op and keeps saying her knee “does not feel normal.” She has complained of anterior knee pain of some sort throughout the recovery. Of note, her college surgeon openly questioned the graft choice of her prior surgeon and this seemed to lay the foundation for a cascade of emotional and psychological issues following this second surgery.

Now, the BTB graft has presented a very different experience for her (anterior knee discomfort). Her expectations of what surgery and rehab should be like the second time were molded and impacted by her prior experience. Simply put, this surgery and recovery have been very different. While she looks structurally sound and is doing quite well objectively, her perception is different, and her pain threshold seems lower. She does not have chronic pain per se, but I do believe her pain experience has been impacted by her expectations and prior rehab experience. This illustrates how we must also treat the brain to allow an athlete to return to the prior level of performance.

How do we treat this? The key points we must remember in terms of driving neuroplasticity are:

  • Provide novel skill training that is meaningful to the athlete
  • Focus on movement quality over repetition
  • Tasks should involve a cognitive effort and be specific
  • Move in a pain free manner (non-threatening) versus no pain, no gain approach
  • Provide feedback that induces an external focus of attention

Pain is real, and we cannot pretend to know what the patient feels. It can be easy to dismiss lingering pain, especially if it does not fit the recovery timeline or mirror physical capacity. Our challenge in sports medicine is to be better at recognizing signs of maladaptive neuroplasticity, gaining a broader understanding of pain neuroscience, and devising a comprehensive rehab plan to address pain if needed to enable an athlete to reclaim the best version of him/herself.



  1. Pelletier R, Higgins J, Bourbonais D. Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskeletal Disorders. 2015.16(25):4-13.
  2. Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. 2008 Feb;51(1):S225-39.