Review Article

The Envelope of Function: Revisiting the Theory

With New Concepts—A Narrative Review
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

Iberê P. Datti, MD
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/18/2024

Renata Silva, PhD

Leandro Ejnisman, MD, PhD
ABSTRACT
Musculoskeletal injuries are a complex multifactorial phenomenon, and
several factors can contribute to their occurrence. This review aimed to
discuss some relevant and often unexpected elements involved in
musculoskeletal injuries and rehabilitation. One of the main factors
discussed is the role of physiological adaptation to training in
musculoskeletal injury susceptibility. This is probably the most
modifiable factor in preventing and treating musculoskeletal injuries.
Other factors discussed are the role of genetics in injury susceptibility;
the effect of stressors and environmental factors and the way we deal
with setbacks; anabolic steroid use as aesthetic and performance-
enhancement drugs; nutrition, sleeping, and the imbalance between
rest, energy intake, and training; anatomic and biomechanical factors;
and the role of systemic disease. Moreover, the topic of unknown
factors keeps an open door for future discoveries. This review
highlights the importance of understanding the various factors
contributing to musculoskeletal injuries and the need for an
individualized approach to injury prevention and rehabilitation, from
both a historical and a physiological point of view.

From the Grupo de Cirurgia de Joelho, Clı́nica de

H
Ortopedia e Traumatologia, Hospital do Servidor istorically, biomechanics drives the physiopathology of musculo-
Público Municipal, São Paulo-SP, Brasil (Datti), skeletal injuries. Examples include scapular dyskinesia and rotator
the Centro Universitário UniFECAF, Taboão da
Serra - SP, Brasil (Silva), Hospital Israelita Albert
cuff lesion, flatfoot and shin splints, restricted shoulder rotation and
Einstein, São Paulo-SP, Brasil (Ejnisman). epicondylitis, cavus foot and stress fracture, dynamic valgus, and anterior
None of the following authors or any immediate cruciate ligament rupture. Recently, a new approach has emerged that focuses
family member has received anything of value on the balance between the stress experienced by an individual and their
from or has stock or stock options held in a
commercial company or institution related adaptation capacity.1 Dye2 is the precursor of this way of thinking among
directly or indirectly to the subject of this article: orthopaedic surgeons after the publication of the theory of the envelope of
Dr. Datti, Dr. Silva, and Dr. Ejnisman
function. Since the publication, several other correlated concepts have
Authors’ contribution: All authors participated in
evolved in other health science areas. Unfortunately, most orthopaedic
the idea conception, literature search, and
manuscript review surgeons neglect these invaluable details necessary to offer the best care to
J Am Acad Orthop Surg 2024;00:1-12 patients.
DOI: 10.5435/JAAOS-D-23-00433 The goal of this review was to compile the thoughts about factors inter-
Copyright 2024 by the American Academy of
fering in the envelope of function. It is a narrative review of well-established
Orthopaedic Surgeons. theories on nonorthopaedic science that can tune the envelope of function.

1
-----

-----

JAAOS® Month 2024, Vol 00, No 00 © American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 The Envelope of Function: Revisiting the Theory With New Concepts—A Narrative Review

Supercompensation, functional reserve, training load, frequency is the number of events in a predefined period.
training principles, periodization, and others are new Intensity and volume are the more precise nomenclature
ideas for most orthopaedic surgeons. Most physicians for the terms involved in the envelope of function.
seldom link these aspects to the physiopathology of It is worth noting that the envelope of function is not
orthopaedic injuries and rehabilitation. However, static over time. The effects of external and internal fac-
these concepts are crucial for improving treatment tors can change it quickly. The following paragraphs
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

outcomes. detail these factors.

In particular, orthopaedic surgeons are critical in
caring for patients with musculoskeletal injuries.
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/18/2024

Although they may not be directly involved in all aspects

Functional Reserve and Aging
of training, orthopaedic surgeons frequently collaborate
with coaches, trainers, therapists, and other physicians. The concept of functional reserve, also known as physi-
Therefore, this review aims to introduce and summarize ological reserve or homeostatic reserve, is similar to the
key concepts relevant to surgeons in their interactions concept of the envelope of function—although it is more
with patients and other healthcare professionals involved widespread among physicians in other fields. Functional
in musculoskeletal care. reserve is the capacity to maintain homeostasis in the
face of stress. The relationship between functional
reserve and aging dates to the 1940s3 and has already
been adopted in gerontology, geriatrics, cardiovascular,
The Theory of the Envelope of Function cognitive, neurological, renal, pulmonary, and hepatic
In this theory, Dye compared the knee with an automo- systems.4
bile transmission, whose primary function is to absorb The natural decline in functional reserve with aging is
and transfer loads. He defined three zones: the zone of variable among individuals. This variability in deterio-
homeostasis, in which the body can handle loads without ration is related to lifestyle choices, environmental fac-
disrupting tissue homeostasis; the zone of supra- tors, genetics, and age-related disease.5 The functional
physiologic overload, in which loads exceed the limit of reserve is vital to the envelope of function.
homeostasis but do not cause macrostructural damage; Aging individuals with reduced functional reserves are
and the zone of structural failure, in which loads cause particularly susceptible to errors in controlling or pro-
macrostructural damage2 (Figure 1). Because load is the gressing training loads, even during rehabilitation. After
product between training volume and intensity, and the third decade of life, the only way to improve the

Figure 1

Graphical representation of the envelope of functional zones and the key factors in determining an individual’s performance, both for
improvement and decline, is presented.

2
-----

-----

JAAOS® Month 2024, Vol 00, No 00 © American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Iberê P. Datti, MD, et al

Review Article
envelope of function is through supercompensation sec- and, consequently, in the upper limit of the envelope of
ondary to well-structured training plans. Several factors function.
can negatively affect the envelope of function. Training science is primarily concerned with when
and how to apply the stress at the optimal point of su-
percompensation while avoiding injuries, chronic
fatigue, or overtraining.
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

Supercompensation
Aging, injury, and comorbidities can delay the su-
Nikolai N. Yakovlev first proposed the super- percompensation process. Typically, training micro-
compensation phenomenon in the 1950s.5 Super- cycles are structured with seven-day intervals. However,
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/18/2024

compensation is the adaptative response of the body to in certain circumstances, extending this interval up to
stresses to maintain homeostasis. It is a four-step pro- 10 days may be beneficial to provide adequate time for
cess: (1) application of training stress and fatigue recovery and the supercompensation phases.
(immediate response to training stress), with a predict- Understanding supercompensation is essential for
able drop of fitness level and performance; (2) recovery orthopaedic surgeons to determine whether the training
phase, return to the baseline fitness; (3) super- program facilitates optimal tissue adaptation and
compensation phase, rebound above the baseline fitness recovery or injuries.
level; (4) detraining, if no new stress is appropriately
applied (Figure 2).
In step 3, the stress of bringing the body out of its
homeostasis is more notable than before the training Training Load
session. In other words, supercompensation is the pro- The concepts of internal and external training load have
cess responsible for the increase in the functional reserve become essential in sports science because they help to

Figure 2

Graph showing supercompensation. Supercompensation is a four-step process: 0: initial fitness; 1: drop of fitness level and
performance due to (A) training stress and fatigue; 2: recovery phase and return to initial fitness; 3: supercompensation phase, rebound
above the baseline fitness level; 4: detraining, if no new stress is appropriately applied (gray line). B: if a new stress is applied before
adequate recovery, the risk of injury may increase (red line); C: if a new stress is applied during the supercompensation phase, the
physiological adaptations add up and improve the function envelope (blue line). Aging and other factors lengthen the recovery phase.
This should be considered during the training planning phase.

3
-----

-----

JAAOS® Month 2024, Vol 00, No 00 © American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 The Envelope of Function: Revisiting the Theory With New Concepts—A Narrative Review

understand how the body adapts to different types of able psychophysiological responses (internal to the
exercise. athlete) elicited by the external training load, which the
In the early 1990s, Foster first developed the training athlete experiences during the training session6
load measurement techniques. However, Impellizzeri (Figure 3).
et al6 coined and clarified the concepts of internal and By understanding these concepts, caregivers can
external workload. External training load refers to better optimize physiological adaptation, enhance the
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

measurable aspects that occur outside of the athlete, envelope of function, prevent injuries, and improve
such as organization, volume, and intensity of the rehabilitation. Proper training load measurement is
exercise (physical work prescribed in the training plan). essential for achieving optimal performance and pre-
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/18/2024

Internal training load, contrarily, refers to the measur- venting athlete injuries. Orthopaedic surgeons should

Figure 3

Flowchart showing the theoretical framework of the training process. The internal load parameters are the lead reference for adjusting
the training plan and the external training load.

4
-----

-----

JAAOS® Month 2024, Vol 00, No 00 © American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Iberê P. Datti, MD, et al

Review Article
understand this concept because musculoskeletal at the expense of intensity while keeping high training
health is affected by external training loads, which, in variability could produce a positive adaptative response.
turn, influence internal training loads. This is especially Contrarily, increasing the workload at the expense of
important in elite sports, where athletic trainers and volume and increasing training monotony could induce a
sports medicine doctors should work closely together negative adaptative response.7 This information is
to prevent injuries. valuable for understanding how the training load is
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

Orthopaedic surgeons should understand the nuances worked matters (Figure 4).
of training load measurement better to assess patients’ Usually, a training microcycle should contain hetero-
readiness for return to activity, find possible causes for geneity among training sessions, mixing high volume,
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/18/2024

injuries, and mitigate injury risk. high intensity, interval training, and recovery sessions.
New technologies are constantly being developed to For example, three sets of 15 reps of leg extension in the
monitor internal and external training loads. Telephone machine daily is not a good strategy after anterior cru-
apps and wearables, such as smartwatches, can measure ciate reconstruction surgery.
steps, heart rate, and specific sports data like speed and Orthopaedic surgeons should recognize the role of
cadence. These data can assist coaches and healthcare training variability in promoting adaptive responses and
professionals in individualizing training plans. mitigating the risk of overuse injuries in their patients.

Training Variability and Training Monotony Accumulated Training Load

While studying overtraining, injuries, and illness in ath- Accumulated training load is an essential concept in
letes, several authors found that increasing the workload sports training and performance because it helps to track

Figure 4

Graph of ACWR and injury, demonstrating the "sweet spot" for the acute-chronic workload ratio. An individual below this zone will be
undertraining and above this zone will be at risk of injury.

5
-----

-----

JAAOS® Month 2024, Vol 00, No 00 © American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 The Envelope of Function: Revisiting the Theory With New Concepts—A Narrative Review

the overall stress level placed on an athlete’s body over a or periods, to achieve peak performance at a specific
specific period. This can be useful in determining time. It involves customizing training stimuli and
whether an athlete is overtraining, at risk of injury, or fatigue in microcycles, mesocycles, and macrocycles
whether their training program is adequate to meet their according to individual conditions and sport specific-
goals. ity.11 It is a step-by-step process that balances phys-
Cumulative training load is the sum of different single- ical, technical, psychological, and tactical aspects to
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

training loads in a time frame. For example, the achieve peak performance at a preset time course12
cumulative training load for a week represents all the (Figure 5).
training loads done on a particular week. It is a good In short, periodization is a strategy to increase an in-
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/18/2024

parameter to discriminate between easy or hard weeks/ dividual’s functional envelope, often applied only to
months. athletes. It is logical to apply this paradigm to the
Several methods are available for calculating the rehabilitation process13 and pay attention to it in injury
cumulative training load. These methods can be based on prevention programs.
average heart rate, training zone, and effort perception,
among others. The chosen method should fit the speci-
ficity of each sport. Training Principles
The acute-chronic workload ratio (ACWR) is one Although the principles of physical training are widely
method used to estimate the risk of injury and over- known, they are not unanimous among authors. They
training,8 but it is still a topic of ongoing research and vary from 314 to more than 7, potentially relevant to
debate in the field.9 achieving better fitness, injury prevention, and recovery.
Patients who regularly run may challenge themselves Oddsson et al15 propounded that not following the
by participating in running events requiring greater principles of physical training is one of the major causes
fitness levels than they currently possess, such as of a failed conservative treatment to improve gait and
increasing their long session in the microcycle from balance function in the elderly. Other authors proposed
12 km to a half-marathon. Similarly, patients recov- principles of physical training apart from the ones listed
ering from injuries may be eager to resume the desired here. However, all correlate with the following list:
level of physical activity and may feel that they do not overload, reversibility, specificity, individuality, pro-
need to wait as long as recommended. When calcu- gression, periodization, and variation.
lating the acute-chronic workload ratio, it is possible
to demonstrate to the patient the rationale for grad- Overload
ually increasing their workload to reduce the risk of a Overload means exercising the organ systems or tissues
new injury. at intensities exceeding their accustomed levels to elicit
Orthopaedic surgeons can use knowledge of accu- training adaptations and enhance functionality over
mulated training load to monitor patients’ training time. Key variables contributing to the overload para-
progression and identify potential risk factors of overuse digm encompass exercise intensity, duration, frequency,
injuries. and rest.14

Reversibility
The counterpart to the overload elucidates the phenom-
Periodization enon wherein the fitness gains achieved through training
Some current sports science theories, such as periodiza- at an overload diminish rapidly when training is dis-
tion, find their roots in ancient Greece and the Ancient continued and the overload stimulus is withdrawn. This
Olympic Games (776 BC - 393 AD).10 The "milieu in- principle underscores the transient nature of physiolog-
térieur" or internal environment, homeostasis, and the ical adaptations, highlighting the importance of main-
General Adaptation Syndrome theory, proposed by taining a consistent training regimen to sustain and
Hans Selye, are the basis of modern periodization. maximize training-induced improvements.14
Subsequently, Leo Matveyev and Tudor Bompa
advanced with the application of periodization strate- Specificity
gies in Soviet athletes during the Cold War. Exercise-induced adaptations are specific to the muscles
Periodization is a training method that involves involved, the recruited fiber types, the predominant
breaking down the training plan into different cycles, energy system engaged (aerobic or anaerobic), the

6
-----

-----

JAAOS® Month 2024, Vol 00, No 00 © American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Iberê P. Datti, MD, et al

Review Article
Figure 5
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/18/2024

Chart demonstrating periodization. A hypothetical model of classic linear periodization with a macrocycle and mesocycles for a 100-m
track and field runner. Periodization allows for predicting the workload along the season and planning the advance of the specificity of
the practice. Periodization must also consider tactical and technical aspects. The relationship between volume and intensity should be
proper for each sport. Thus, it is possible to plan reverse periodization (start with high intensity and low volume; end with low intensity
and high volume) and undulating periodization, for instance. Purple line: volume; blue line: intensity; green line: fatigue; blue line: fitness.

contraction velocity, and the type of muscle contraction Periodization

(eccentric, concentric, or isometric). Notably, the Periodization is the strategic organization of training into
training effects experienced during a particular activity distinct phases, each targeting specific physiological and
are localized and do not markedly extend to unrelated performance goals. It involves carefully planned cycles of
muscle groups.14 varying intensity, volume, and specificity. It allows for
progressive overload, adequate recovery, and prevention
Individuality of plateaus. By tailoring training protocols to individual
Training approaches should consider the characteristics needs and manipulating key variables throughout distinct
and backgrounds of each trainee, according to the in- training phases, periodization maximizes the potential for
dividual’s genetic potential, age, and pretraining phys- physiological adaptations and peak performance.17
ical activity levels on their response to a training
stimulus.16 Variation
The manipulation of training intensity, speed of move-
Progression ment, volume, and exercise selection is crucial in pro-
The necessity of incrementally escalating workloads. longing adaptations and optimizing training outcomes in
Strategic workload increments, typically ranging from continuous training programs. Strategic sequencing of
5% to 15% per week to a week and a half, allow for volume, intensity, and exercise selection, particularly
optimal adaptation while minimizing the risk of exces- incorporating speed-strength exercises, can enhance
sive strain. The cumulative training volume should be at diverse performance abilities.18
most 5% to 15% per year, with cautionary limits for While cycling in pelotons is a common and enjoyable
athletes training over 600 hours/year, suggesting no form of training for several cyclists, individual control
more than a 10% yearly increase in volume.17 over certain training principles is often diminished when

7
-----

-----

JAAOS® Month 2024, Vol 00, No 00 © American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 The Envelope of Function: Revisiting the Theory With New Concepts—A Narrative Review

riding in groups. In addition, prematurely returning an dressing coping strategies and using cognitive-behavioral
athlete in the rehabilitation process to collective training therapy is essential in rehabilitation.
can have adverse effects.

Genetics
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

Allostasis and Psychological Aspects Genetics plays a role in the injury process and sports
performance. However, it is debatable how strong of a
Parallel to the physiological foundation of the basis of the
predictor it is. At least 19 genes are linked with articular
stress study, psychology-influenced research emerged,
cartilage degeneration and changes in subchondral
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/18/2024

demonstrating that situations, individual characteristics,

bone.26 Genetic variants within genes such as tenascin-
psychological factors, and social relationships influence
C, COL1A1, COL5A1, COL11A1, COL11A2, and
the stress response.19 Psychological stress response
COL12A1 are involved in anterior cruciate ligament
studies developed the allostasis concept,20 whose core
rupture, chronic Achilles tendinopathy, spontaneous
idea is not constancy (homeostasis core idea) but
quadriceps tendon ruptures, degenerative rotator cuff
coordinated variation to optimize performance at the
tears,27 anterior shoulder instability, elbow tendon
least cost. Allostasis suggests that organisms maintain
pathology,28 and osteoarthritis.29 Other genes were
physiological stability by anticipating and preparing for
related to athletic performance.30
potential needs before they arise and by mobilizing a
Several genes have been linked to various diseases
diverse breadth of neurological, biological, and immu-
and injuries. Analyzing the effect of each gene in each
nological accommodations to counter these emerging
health condition can be challenging because of factors
challenges.21
such as polymorphism, gene interaction, pleiotropy,
Allostasis is being comfortable in discomfort. To
and epigenetics. Big-data analysis and artificial intel-
accomplish this, a complex set of integrated emotional,
ligence may aid in better understanding the role of
physiological, immunological, and psychological pro-
each gene in the physiopathology of orthopaedic
cesses intimately collaborate to establish a new set of
diseases.
internal conditions that best fit the current circum-
The increased incidence of certain injuries, including
stances. The brain coordinates and orchestrates adapta-
the anterior cruciate ligament, among twins suggests a
tions in the central and peripheral systems to anticipate
genetic contribution to injury risk.31 Thus, implementing
and respond to future challenges.22 Therefore, emotions,
personalized preventive programs may be beneficial for
psychological factors, and past experiences can affect
some individuals.
the body’s adaptations to training stresses and the
likelihood of injury.
Emerging evidence supports an association between
life stresses, psychological traits, and injuries23; others Nutrition and Sleeping
correlate psycho-emotional stresses with diminished Nutrition, rest, and sleep are crucial to sports perfor-
return to play24 and athletic performance.25 Conse- mance and injury prevention. The most recent guidelines
quently, athletes subjected to excessive stress are more from the American College of Sports Medicine provide
prone to injuries, overtraining, underperformance, an overview of the essential nutritional aspects of sports
overuse, burnout, chronic fatigue, immunosuppression, performance.32
and depression-like symptoms. A psychological Athletes with inadequate energy intake may develop a
approach integrated with the periodization and training condition known as Relative Energy Deficiency in Sport
process is crucial. This approach promotes under- (RED-S). In addition to detrimental effects on perfor-
standing and trust in the training plan, as well as a sense mance, the health consequences of RED-S include poor
of purpose, ownership, and control concerning the bone health, disruptions to endocrine-metabolic and
training plan. Trainers should implement feedback and immunological systems, and an increased risk of
feedforward processes and adopt strategies to positively injury.33 A balanced intake of carbohydrates, fats, and
influence mood, perceptions, mindsets, attitudes, risk proteins is essential for maintaining optimal body
appraisal, anxiety, trust, coping skills, and inter- composition and safely achieving a negative caloric
pretations of challenges in the training program.21 balance.
Patient management of limitations, diseases, and in- Certain micronutrients are also of particular interest.
juries is a crucial aspect of treatment. Therefore, ad- Studies have documented the relationship between

8
-----

-----

JAAOS® Month 2024, Vol 00, No 00 © American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Iberê P. Datti, MD, et al

Review Article
vitamin D, iron, calcium status, injury prevention, and
the risk of stress fractures;34 the female athlete triad; and
Anatomic Factors
overall bone health.35 Vegetarians; postbariatric in- Several anatomic variations correlate with an increased
dividuals; and those with bowel disease, eating dis- risk of injury. Examples include glenoid retroversion, an
orders, or restricted eating habits should receive increased Q-angle, cavus feet, and tibial slope.
particular attention. However, only orthopaedic surgery can correct most
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

of these anatomic variations. Currently, no evidence

supports the use of prophylactic surgery for injury
prevention.
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/18/2024

Anabolic Steroid Use Patients with limiting musculoskeletal disorders may

The World Anti-Doping Agency prohibits anabolic be eligible for correction of anatomic conditions. How-
steroids (AS), although both competitive and noncom- ever, the best course of action for most patients is edu-
petitive athletes’ use of AS for performance or aesthetic cation about the risk of injury.
purposes is widespread. Several studies have associated
the use of AS with increased musculoskeletal injury.36
Although AS can enhance physical performance, there is
evidence that it can jeopardize the biomechanical and
Biomechanics and Sport Gesture
morphological properties of tendons and ligaments.37 Physicians, physiotherapists, and physical trainers often
This is likely due to dysplasia of collagen fibers and focus on finding and correcting a supposed error in the
alterations in connective tissues.38 biomechanics of the sports gesture when treating or
preventing injuries.
However, the ability of an adult human being to learn
a new complex motor gesture or to modify a deep-seated
Overtraining, Female Athlete Triad, and one is debatable. Moreover, how long the new gesture
Relative Energy Deficiency in Sport can be maintained before it deteriorates into a child-
Since the 1940s, the detrimental effects of overtraining learned one or how much effort is needed to incorporate
have been described, initially in the cardiovascular sys- it must be clarified.
tem. In 1992, the American College of Sports Medicine An analysis of professional long-distance runners has
recognized the female athlete triad, which is composed of shown that even they cannot maintain the same running
eating disorders, amenorrhea, and osteoporosis in ado- form throughout the route or have a biomechanically
lescent and young-adult female athletes subjected to high perfect running form (some have a flawed one instead).
training loads and caloric restriction. In a more recent A recent meta-analysis suggested that the best approach
approach, in 2014, the International Olympic Com- for running and preventing running injuries is to
mittee introduced a broader, more comprehensive implement strategies to land softer.40
approach to the imbalance between training load and Similar thoughts apply to other physical activities and
energy intake, known as the RED-S.33 movements. Probably, only motor gestures excessively
The main modifications included recognizing men’s discordant from a biomechanically ideal one may benefit
involvement and the syndrome’s systemic effects, from movement adjustment approaches.
including impaired physiological functions such as Orthopaedic surgeons should adopt a holistic injury
metabolic rate, menstrual function, bone health, prevention and treatment approach, considering bio-
immunity, protein synthesis, and cardiovascular mechanical factors, individual variability, and functional
health.33 demands.
Similarly to the female athlete triad, RED-S can pre-
dispose athletes to injuries.39 Some tools, such as the
RED-S Clinical Assessment Tool (RED-S CAT), can
help healthcare providers identify at-risk athletes, even
Previous Diseases
those in rehabilitation. Previous diseases can affect an individual’s risk for
Individuals involved in activities requiring strict musculoskeletal disorders and injuries. Conditions such
weight control, such as ballet dancers and wrestlers, and as gout, rheumatic disease, and dyslipidemia can make
those unwilling to sacrifice their busy social lives are at an individuals more susceptible to injuries such as tendon
increased risk of developing RED-S. ruptures and ligament sprains.

9
-----

-----

JAAOS® Month 2024, Vol 00, No 00 © American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 The Envelope of Function: Revisiting the Theory With New Concepts—A Narrative Review

Healthcare providers must identify and treat these as analgesics, anti-inflammatories, and physiotherapy.
comorbidities to decrease the risk of injury and tailor an A magnetic resonance image confirmed bilateral patellar
individualized training program considering any ob- and quadricipital tendinopathy. Despite the chronic
stacles caused by previous diseases. pain, the patient was unwilling to forgo participating in
the upcoming State Championship finals games sched-
uled for the following month.
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

Unknown Factors When working with adolescents engaged in team

sports, it is crucial to recognize the individual variations
Several factors capable of interfering with musculo-
in these developmental stages; the beginning and end of
skeletal injuries are still unknown. The physiopathology
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/18/2024

puberty are unique among people. These stages markedly

behind musculoskeletal injuries is a multifactorial phe-
affect the augmentation of the functional reserve inherent
nomenon. Although someday we might know all factors,
to this period.
the odds of being able to correct the weighting of every
In this case, a substantial reduction in the training load
element for each person and situation are extremely low.
was deemed necessary, a decision the patient found
challenging to embrace fully. In collaboration with the
head coach and the physical trainer, it was decided to
Clinical Cases limit the player’s involvement to tactical practices and
Clinical Case 1: Training Load Progression low-intensity drill exercises. Low-volume therapeutic
A 17-year-old female artistic swimming athlete pre- exercises replaced high-intensity activities, game simu-
sented with intermittent buttock and proximal thigh lation training, and rigorous physical exercises. This
pain. The onset of pain coincided with the commence- tailored approach allowed the patient to participate in
ment of the national squad training camp, typically the season’s final games and subsequently enjoy a
emerging on the first or second day and subsiding a few month of rest before the next preseason, during which
weeks after the camp concluded. Over the past he remained asymptomatic.
18 months, she experienced this pain 4 to 5 times,
consistently occurring during her participation in the Clinical Case 3: Periodization
training camp. Magnetic resonance imaging confirmed A 43-year-old jiu-jitsu fighter faced challenges main-
the presence of semitendinosus tendinopathy. Despite taining the desired year-round fitness level for partici-
previous treatments involving NSAIDs, cortisone, and pation in high-level tournaments, primarily because of
physical therapy, symptoms persisted during the train- pain and restricted motion stemming from advanced
ing camp. A colleague recommended exploring regen- arthritis in his left shoulder. Besides his competitive
erative and orthobiologic medicine procedures. aspirations, he also had commitments to teach in private
Given the recurrent symptoms, she expressed con- sessions, group classes, and seminars. Despite unsuc-
cerns about her ability to perform at the desired level cessful attempts with interventions such as supra-
during the training camp. Her regular training volume scapular nerve block, platelet-rich plasma, and
averaged 15 hours per week but surged to over 30 hours prolotherapy, surgical treatment was not a preferred
per week during the training camp, revealing a marked option because of personal reasons.
increase in training load. To address these limitations, the patient implemented
In response to this, beyond the standard treatment a periodization program that focused on achieving peak
recommendations, her physical trainer and artistic performance for only 1 month within the year. Through
swimming coach were consulted to develop a plan to meticulous control of training loads and a cautious
gradually increase her training volume over 4 to 6 weeks approach to progressive overload, he managed to sustain
before future training camps. After the implementation his teaching commitments and participate in selected
of this plan, she completed subsequent training camps tournaments while mitigating the effect of his shoulder
with only minor reports. condition.

Clinical Case 2: Training Load Clinical Case 4: Psychological Aspects

Individualization A 45-year-old postbariatric patient grappled with vari-
A 15-year-old basketball player presented with pro- ous musculoskeletal issues over an extended period.
gressively worsening bilateral knee pain over the past Balancing a demanding full-time job as an attorney,
few months, unresponsive to standard treatments such marriage, and mothering two children, she maintained a

10
-----

-----

JAAOS® Month 2024, Vol 00, No 00 © American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Iberê P. Datti, MD, et al

Review Article
rigorous gym exercise routine of approximately factors, the physiopathology of musculoskeletal injuries is
20 hours per week. a complex and multifaceted phenomenon. It is paramount
Postbariatric patients commonly contend with mental that orthopaedic surgeons are aware of these various ele-
health challenges, including depression, anxiety, or ments to improve their practice and provide better care for
compulsive behaviors. Unfortunately, healthcare pro- their patients. This review provides a general overview of
viders often overlook these issues after surgery. While these considerations and is a starting point for additional
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

patients successfully shed excess weight, the underlying exploration and understanding.
pathological mental states persist. Individuals sometimes
transition from binge eating to engaging in excessive
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/18/2024

physical exercise. References

This particular patient underwent a comprehensive 2- 1. Hamstra-Wright KL, Huxel Bliven KC, Napier C: Training load capacity,
cumulative risk, and bone stress injuries: A narrative review of a holistic
year psychological and psychiatric follow-up. The approach. Front Sports Act Living 2021;3:665683.
treatment plan included mindfulness practices; partici-
2. Dye SF: The knee as a biologic transmission with an envelope of
pation in yoga classes; cognitive behavioral therapy; and function: A theory. Clin Orthop Relat Res 1996;325:10-188.
the use of anxiolytic, antidepressant, and anticonvulsant 3. Cowdry EVAE: Problems of ageing; biological and medical aspects.
medications. Only after this extensive intervention did Baltimore, Williams & Wilkins, 1942.
the patient begin to experience a subsiding of symptoms. 4. Romero-Ortuño R, Martı́nez-Velilla N, Sutton R, et al.: Network
physiology in aging and frailty: The grand challenge of physiological reserve
in older adults. Front Netw Physiol 2021;1:712430.
Clinical Case 5: Training Load
5. Silverstein JH, Rooke GA, Reves JG, McLeskey CH. Geriatric
Individualization anesthesiology. Springer; 2008.
A national wheelchair basketball team has a few one-
6. Impellizzeri FM, Marcora SM, Coutts AJ: Internal and external training
week training camps during the year. Form levels are load: 15 Years on. Int J Sports Physiol Perform 2019;14:270-273.
heterogeneous because players play in different states or
7. Foster C, Florhaug JA, Franklin J, et al.: A new approach to monitoring
countries and have different competition schedules. exercise training. J Strength Cond Res 2001;15:109-115.
Modifying the Confederation schedule is impracticable 8. Griffin A, Kenny IC, Comyns TM, Lyons M: The association between the
for the health staff. In addition, the physiological answer acute:chronic workload ratio and injury and its application in team sports: A
systematic review. Sports Med 2020;50:561-580.
to exercising in spinal cord–injured patients and persons
with disabilities does not strictly follow the known 9. Andrade R, Wik EH, Rebelo-Marques A, et al.: Is the acute: Chronic
workload ratio (ACWR) associated with risk of time-loss injury in
answer for healthy persons. professional team sports? A systematic review of methodology, variables
To contour the high incidence of overuse injuries and and injury risk in practical situations. Sports Med 2020;50:1613-1635.
traumatic events in this specific population, coaches and 10. Morente Montero Á. Sports training in Ancient Greece and its
health staff instituted a daily medicine ball–throwing supposed modernity. J Hum Sport Exerc. 2019;15(1):163–176. doi:https://
doi.org/10.14198/jhse.2020.151.15.
performance evaluation and a routine of self-assessment
11. Plisk SS, Stone MH: Periodization strategies. Strength Conditioning J
for the psychological state, tiredness, and relative effort
2003;25:19-37.
perception, aiming an early recognition of athletes at
12. Turner A: The science and practice of periodization: A brief review.
risk, with good results. Strength Conditioning J 2011;33:34-46.
13. Keytsman C, Van Noten P, Verboven K, Van Asch P, Eijnde BO:
Clinical Case 6: Training Individualization Periodized versus classic exercise therapy in multiple sclerosis: A
A 23-year-old college volleyball player experienced a randomized controlled trial. Mult Scler Relat Disord 2021;49:102782.
metatarsal stress fracture. Running, chosen initially for 14. Powers SK, Howley ET: Exercise physiology: theory and application to
improving her aerobic capacity, was deemed to lack fitness and performance, ed 10 ed 1.

specificity for volleyball playing. After the treatment of the 15. Oddsson LIE, Boissy P, Melzer I: How to improve gait and balance
function in elderly individuals—compliance with principles of training. Eur
stress fracture, she was advised to opt for a complementary Rev Aging Phys Activity 2007;4:15-23.
activity that would entail lower foot impact while also
16. Adams WC, McHenry MM, Bernauer EM: Long-term physiologic
engaging the upper extremities. Options such as an air bike adaptations to exercise with special reference to performance and
or stationary rower were suggested for consideration. cardiorespiratory function in health and disease. Am J Cardiol 1974;33:
765-775.
17. Madden CC, Putukian M, McCarty E, Young C. Netter’s sports
medicine. ed 2. Elsevier; 2010:794.
Conclusion
18. Stone M, Plisk S, Collins D: Training principles: Evaluation of modes
From the understanding of biomechanics and sporting and methods of resistance training--a coaching perspective. Sports
gestures to the influence of previous diseases and unknown Biomech 2002;1:79-103.

11
-----

-----

JAAOS® Month 2024, Vol 00, No 00 © American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 The Envelope of Function: Revisiting the Theory With New Concepts—A Narrative Review

19. Mason JW: A re-evaluation of the concept of "non-specificity" in stress 31. Magnusson K, Turkiewicz A, Hughes V, Frobell R, Englund M: High
theory. J Psychiatr Res 1971;8:323-333. genetic contribution to anterior cruciate ligament rupture: Heritability 69.
20. Sterling P, Eyer J, in Fisher S, Reason J, eds:. John Wiley Sons, 1988. Br J Sports Med 2020. [Online ahead of print]
Handbook of Life Stress, Cognition and Health. 32. Thomas DT, Erdman KA, Burle LM. Nutrition and Athletic Performance.
21. Kiely J: Periodization theory: Confronting an inconvenient truth. Sports Med Sci Sports Exerc. 2016;48:543–568. doi:10.1249/MSS.
Med 2018;48:753-764. 0000000000000852. 26891166.
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A

22. McEwen BS, Gianaros PJ: Stress- and allostasis-induced brain 33. Mountjoy M, Sundgot-Borgen J, Burke L, et al.: The IOC consensus
plasticity. Annu Rev Med 2011;62:431-445. statement: Beyond the female athlete triad--relative energy deficiency in
23. Ivarsson A, Johnson U, Andersen MB, Tranaeus U, Stenling A, Lindwall sport (RED-S). Br J Sports Med 2014;48:491-497.
M: Psychosocial factors and sport injuries: Meta-analyses for prediction 34. Ruohola JP, Laaksi I, Ylikomi T, et al.: Association between serum
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/18/2024

and prevention. Sports Med 2017;47:353-365. 25(OH)D concentrations and bone stress fractures in Finnish young men.
24. Ardern CL, Taylor NF, Feller JA, Webster KE: A systematic review of the J Bone Miner Res 2006;21:1483-1488.
psychological factors associated with returning to sport following injury. Br 35. Petkus DL, Murray-Kolb LE, De Souza MJ: The unexplored crossroads
J Sports Med 2013;47:1120-1126. of the female athlete triad and iron deficiency: A narrative review. Sports
25. Stults-Kolehmainen MA, Lu T, Ciccolo JT, Bartholomew JB, Brotnow Med 2017;47:1721-1737.
L, Sinha R: Higher chronic psychological stress is associated with blunted 36. Kanayama G, DeLuca J, Meehan WP 3rd, et al.: Ruptured tendons in
affective responses to strenuous resistance exercise: RPE, pleasure, pain. anabolic-androgenic steroid users: A cross-sectional cohort study. Am J
Psychol Sport Exerc 2016;22:27-36. Sports Med 2015;43:2638-2644.
26. Chou CH, Lee CH, Lu LS, et al.: Direct assessment of articular cartilage and 37. Seynnes OR, Kamandulis S, Kairaitis R, et al.: Effect of androgenic-
underlying subchondral bone reveals a progressive gene expression change in anabolic steroids and heavy strength training on patellar tendon
human osteoarthritic knees. Osteoarthritis Cartilage 2013;21:450-461. morphological and mechanical properties. J Appl Physiol 2013;115:
27. Kluger R, Burgstaller J, Vogl C, Brem G, Skultety M, Mueller S: Candidate 84-89.
gene approach identifies six SNPs in tenascin-C (TNC) associated with 38. Michna H: Tendon injuries induced by exercise and anabolic steroids in
degenerative rotator cuff tears. J Orthop Res 2017;35:894-901. experimental mice. Int Orthop 1987;11:157-162.
28. Alakhdar Mohmara Y, Cook J, Benı́tez-Martı́nez JC, et al.: Influence of 39. Thein-Nissenbaum JM, Rauh MJ, Carr KE, Loud KJ, McGuine TA:
genetic factors in elbow tendon pathology: A case-control study. Sci Rep Associations between disordered eating, menstrual dysfunction, and
2020;10:6503. musculoskeletal injury among high school athletes. J Orthop Sports Phys
29. Zhu Z, Zhong L, Li R, et al.: Study of osteoarthritis-related hub genes Ther 2011;41:60-69.
based on bioinformatics analysis. Biomed Res Int 2020;2020:2379280. 40. Alexander JLN, Culvenor AG, Johnston RRT, Ezzat AM, Barton CJ:
30. La Montagna R, Canonico R, Alfano L, et al.: Genomic analysis reveals Strategies to prevent and manage running-related knee injuries: A
association of specific SNPs with athletic performance and susceptibility to systematic review of randomised controlled trials. Br J Sports Med 2022;
injuries in professional soccer players. J Cel Physiol 2020;235:2139-2148. 56:1307-1319.

12
-----

-----

JAAOS® Month 2024, Vol 00, No 00 © American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.