April 2026

Load Management

Load management is the concept of attempting to manipulate the workload volume that a patient is dealing with in order to reduce the risk of injury and optimize performance.^{(1, 2)} The load a patient is under can be divided into two categories: external load and internal load. External load is all physical work performed by the patient over the course of a day, including not only sport-related activity, but activities of daily living as well.⁽¹⁾ External load is easily measured using devices that track exercise (e.g., GPS or accelerometers).⁽²⁾Internal load is the physiological and psychological response to the external load, as well as other environmental and biological factors and life stressors.⁽¹⁾Internal load can be measured objectively using measures like heart rate variability (HRV) and blood lactate or subjectively using patient reported outcomes measures related to perceived exertion.⁽²⁾While external load is an indicator of how much work the patient has performed and the ability to perform, internal load can be used to identify patients in need of additional rest and recovery, predicting performance deficits and increased injury risk.⁽¹⁾ Risk of injury increases when patients are performing external loads beyond their ability to tolerate them, or when patients who should be capable of handling the load are getting inadequate rest.⁽¹⁾Research suggests that effective implementation of load management may reduce the incidence rate of injuries by helping to identify and eliminate surges in training load during practice or competition.⁽³⁾ There are a variety of useful ways to measure and assess workload that can be easily integrated into clinical practice in multiple settings. For example, by tracking external and internal load, and using predictive measures such as the Acute: Chronic Workload Ratio (ACWR), patients at increased risk of injury and suboptimum performance can be identified and managed accordingly.⁽⁴⁾However, these measurements should not be used in isolation, but instead, as a part of the holistic healthcare plan for a patient.⁽⁵⁾ Additionally, it has been suggested that monitoring training load, both internal and external, during therapeutic interventions would be beneficial in order to ensure that there are no large changes that could potentially affect the patient.⁽⁶⁾

"Diagnosis, Rehabilitation, and Training Load Monitoring Following Hematogenous Calcaneal Osteomyelitis in a Competitive Adolescent Soccer Player: A Level 4 Case Report." Wikstrom et al. 2025

This case study uses the session Rate of Perceived Exertion (sRPE) to monitor the patient’s ACWR to guide decisions regarding a patient’s rehabilitation intensity and conditioning volume post-surgical intervention. Monitoring internal training load and adapting the rehab plan, either by increasing or decreasing intensity, allows for greater adaptation to patient needs, easier progression of exercise, and more informed return-to-play decisions for their specific case.

“Load and Recovery Monitoring in Top-Level Youth Soccer Players: Exploring the Associations of a Web Application-Based Score With Recognized Load Measures” Anderegg et al. 2025
The use of the Load and Recovery Score (LRS), a web-based patient-reported outcomes measure, is an effective way of monitoring athlete workload. The LRS is a tool that combines subjective measures of performance capability, recovery, muscular stress, fatigue, mood, and sleep quality with HRV and ACWR. By combining each of these variables into a single measure, overall athlete workload and recovery can be summarized in an easy-to-understand score. This tool showed a significant negative correlation with training and match load measures, as well as sensitivity to daily changes, indicating that it could be a useful way to monitor athlete load and adjust accordingly.

“Training-Load Management Ambiguities and Weak Logic: Creating Potential Consequences in Sport Training and Performance” West et al. 2025
Current training-load guidelines are well-intentioned, but results should be largely considered correlative rather than causal due to the various external variables that could also be impacting the measured outcomes. Because of this, some training load recommendations are far too cautious, resulting in a lack of positive adaptation to demands that come from activities performed at or near the limit of an athlete's abilities. Suggestions for future research rely heavily on measuring causality rather than inferring it, and considering variables such as planned vs. actual workload in order to do so. Current information should be used as a guideline/suggestion, and the desired outcome for the patient should be considered prior to implementing it. Working with a statistician or sports scientist is recommended to ensure proper usage of these values in the management of patient load.

“Week-by-Week Predictive Value of External Load Ratios on Injury Risk in Professional Soccer: A Logistic Regression and ROC Curve Analysis Approach” Fousekis et al. 2025 The ACWR has been previously used as a measure for monitoring external load and injury risk. This study examined the ACWR for high-speed running and sprint distance during the weeks prior to injury in order to establish if there was an identifiable increase in ACWR in professional soccer players. The predictive values of ACWR for non-contact injury risk was evaluated using binomial logistic regression and successful models, and Low-Load, Sweet Spot, and Danger Zone cutoffs commonly used with ACWR were determined. The ACWRs for high- and moderate-speed running during weeks three and four were the best predictors for injury in this cohort.

Training Load and Injury Prevention | FIT AS A PHYSIO PODCAST |

References in introduction

1. Schwellnus M, Soligard T, Alonso J-M, et al. How much is too much? (part 2) International Olympic Committee Consensus statement on load in sport and risk of illness. British Journal of Sports Medicine. 2016;50(17):1043-1052. doi:10.1136/bjsports-2016-096572

2. Soligard T, Schwellnus M, Alonso J-M, et al. How much is too much? (part 1) International Olympic Committee Consensus statement on load in sport and risk of injury. British Journal of Sports Medicine. 2016;50(17):1030-1041. doi:10.1136/bjsports-2016-096581

3. Tsilimigkras T, Kakkos I, Matsopoulos GK, Bogdanis GC. Enhancing Sports Injury Risk Assessment in Soccer Through Machine Learning and Training Load Analysis. J Sports Sci Med. 2024;23(1):537-547. Published 2024 Sep 1. doi:10.52082/jssm.2024.537 4. Anderegg J. Brefin SL, Nigg CR, Koschnick D, Paul C, Ketelhut S. Load and recovery monitoring in top‐level youth soccer players: Exploring the associations of a web application‐based score with recognized Load Measures. European Journal of Sport Science. 2025;25(9). doi:10.1002/ejsc.70031

5. West S, Shrier I, Impellizzeri FM, Clubb J, Ward P, Bullock G. Training-load management ambiguities and weak logic: Creating potential consequences in sport training and performance. International Journal of Sports Physiology and Performance. 2025;20(3):481-484. doi:10.1123/ijspp.2024-0158

6. Kowalski T, Schumann M, Klich S, Zanini M. Equity in training load: Research Design Considerations for Intervention Assessment in Sports Science and physical therapy. European Journal of Applied Physiology. 2025;125(8):2067-2075. doi:10.1007/s00421-025-05844-9

This content was developed in part by Morgan Kocher, PhD, ATC, CSCS; Tyler Held, MS, ATC; and the NATA Foundation Educational Resources Committee.

Submit a Topic Idea!

View all past Research to Clinical Practice issues HERE.

You received this email because you subscribed to our list. You can unsubscribe at any time.

1620 Valwood Parkway
Ste 115
Carrollton, TX 75006
USA