Management & Decision Making Frameworks and Models

“Horseshoes, hand grenades, and exercise prescription are three things where close enough works.” -Scot Morrison

The final three presentations from the Tendon Summit revolve around one central theme: decision making. A strong foundation of factual knowledge is non‑negotiable for any coach or clinician. But without a model to organize and apply that knowledge, even the best information produces inconsistent or ineffective care.

Scot Morrison leads off this section by expertly tackling the concept of intellectual frameworks from a 1,000-foot view. Instead of dissecting his process using a narrow scope, he explores successful commonalities across all conditions and the features that truly move the needle.

Scot touches on concepts such as specificity of adaptations, exercise progression, needs analyses, and the importance of accurate and complete testing. Some of these will be expanded upon in our next two installments of The Debrief, but today we want to break down Scot’s final topic: Satisficing. 

“There are hundreds of ways to create an exercise salad. All you need is sufficient load, sufficient frequency, and for a sufficient length of time in order to get adaptation”

This sets up a useful contrast between what actually drives adaptation and what often receives the most attention. If we were to use popularity as a proxy for importance, you’d probably believe exercise selection is one of, if not the most, vital consideration in the training process. Many individuals have risen to fame by flagplanting specific exercises and advocating for their unique contributions to successful outcomes.

Scot makes the argument that this aspect is possibly the least important step if we have a process in place to hold ourselves accountable.

There are many frameworks that likely serve this purpose, but the one discussed in this lecture is the OODA loop made famous by Air Force Colonel John Boyd. In brief, this is an iterative cycle where decisions are made by the process of Observing, Orienting, Deciding, and Acting.

Applying OODA to Tendinopathy Management

Observe 

Collect data regarding the patient’s current state and their deficiencies relative to their required demands.

Orient 

Organize and interpret the information gathered. This part of the process is highly influenced by our baseline knowledge as well as our guiding philosophies. This translates to our understanding of the pathoanatomy of tendinopathy, the determinants of adaptation, and the relevant physical and personal constraints modifying any individual encounter.

Decide 

This is a relatively simple part of the process. We combine the prior two points to make an informed decision regarding the future course of action.

Act 

Where rubber meets pavement. Carry out the intervention(s) and include tests that reliably generate new observations. Act begins the next iteration by producing the data that drives the following loop.

Navigating Uncertainty in Tendon Rehabilitation

This is how the OODA loop, and other agile approaches, shine in clinical and performance environments. No matter how much information we gather, there will always be black boxes in tendon rehabilitation. Our process must be designed to anticipate variability and respond to it rather than collapse under it.

We collect as much information as possible about the loading and recovery environment of our athletes, including their injury history, training logs, sleep records, and psychosocial confounders. But there will always be a countless web of determinants influencing their current state.

We try to record and control every aspect of their exercise prescription: total volume load, exercise intensity, length-tension relationships, loading rate, etc. But these are all merely surrogates. We almost never have real-time feedback regarding the internal loads experienced by the tendons themselves.

Perfect is the enemy of good. In situations where there will be inevitable unknowns, attempting to create a perfect plan is simply an exercise in futility. It is far more effective to make an informed choice that satisfices the conditions, observe the results, and move closer to the target through feedback. In using this loop, we’re able to act quickly while remaining flexible to adjust course when deemed necessary. 

Accountability and Staying on Target

Returning to the accountability discussion from the Summit Insider: the essential element in this model is “anchor(ing) our process to our predetermined goals rather than assumptions or impressions.”

Scot emphasizes the danger of basing decisions on irrelevant or invalid information. It is our responsibility to ensure the inferences guiding our process are sound.

We cannot assume change in a specific quality or capacity if we have not explicitly tested it in a consistent manner. Improved rep performance on a heel raise endurance test can be a useful signal, but without controlling range of motion and rep tempo, it tells us little about strength‑endurance and nothing about absolute strength or tensile stiffness.

When our tests are controlled and repeatable, they give us reliable feedback. That feedback alerts us quickly when our chosen exercise series is ineffective, which removes the burden of designing a “perfect” plan. When expectations and reality diverge, we can quickly adjust course.

Conclusion:

A coach or clinician may achieve positive outcomes in spite of their process. If we aim to maximize our chance for success, we need a framework capable of navigating noise associated with clinical care. The OODA loop is one of many tools which can fill this role. Regardless of the exact procedure you follow, the transcendent principles remain the same:

• Allow for an unbiased examination of the athlete in front of you

• Anchor to the qualities or capacities that matter

• Allow for frequent and accurate accountability checks

When these elements are consistently applied, the entire decision process becomes more stable and less dependent on perfect initial choices. We can stop fixating on exercise parameters and simply allow “good enough” to be good enough. From there, we can focus on more consequential aspects of care.

Next up, we review the lecture from Jarred Boyd — the reactive strength paradox of the healthy Achilles tendon.

Debrief written by: Jason Eure, PT, DPT, OCS, CSCS