In the increasingly competitive fitness industry today, an emerging client is the injured athlete. Whether discussing an adolescent soccer player recovering from a knee injury or the middle-aged adult golfer with lower back pain, it is important to recognize and meet the needs of this client as they want to return to functional levels.
Most experts today agree that using split body part routines and traditional body-building methods simply does not work well for athletes. Thus the idea of functional training came to prominence in the 90s, and the profession began to look more closely at how to relate training to sport and performance.
The tricky part lies not so much in training the healthy athlete but in how to handle the injured one. Uniting my background in sports medicine and certification and developing relationships with athletic trainers has allowed me to play an integral role in the rehab and return to sport progression for many. There is a sequential and predictable pattern of events that must take place to ensure a safe and effective return to sports. While this process may often move faster in the youth population, it still must play out in its entirety.
The Post-Rehab Client
This functional progression presents a great opportunity for fitness professionals seeking to work in the strength and conditioning arena, as well as those interested in post-rehab programs. This client base has very specific needs and is extremely motivated to get back to 100%. The injury may be fully resolved with traditional medical treatment; however, in most cases, the athlete is still in need of additional sport-specific conditioning that is beyond the scope of normal rehab. This is where the post-rehab link becomes critical.
Many athletes tend to return too quickly to their sport for a number of reasons. First, insurance companies often limit the rehab and use basic guidelines for when function has returned that fall short of true performance demands. Secondly, coaches and parents do not have the knowledge and experience to progress an athlete back to game play. Finally, athletes can not be trusted to provide honest and accurate feedback in regard to pain, soreness or fatigue after they resume full activity as they typically want to get back in the lineup as soon as possible.
This all too common scenario leaves a significant void in the marketplace for experienced, skilled trainers who can bridge the gap successfully between post-injury and return to play. It is important for trainers to understand: common injury patterns for specific sports, specific healing time frames, basic rehabilitation principles, the relationship between stress and healing and the impact of the sport on the injured tissue.
As the industry grows, trainers will likely play a bigger role in the area of physical recovery and healing. With that said, it is important for fitness professionals to align themselves with MDs, physical therapists and athletic trainers who can mentor, guide and teach them how to better handle rehab clients. Trainers must
understand they are not replacing the health professionals; instead, they should help complete the end stage recovery and prevent further injury in the athletes as well as maximize their performance.
The Three R's of Rehab
There are three critical phases that take place during the injury and recovery process. I refer to these as the three R's of return to play programming:
1) Recognition — It is often easy to recognize an acute injury such as a fracture, ACL tear or dislocated shoulder. However, the subtle overuse injuries like tendonitis, stress fractures and muscle strains may be much harder to detect. Athletes often ignore early warning signs of an impending injury to avoid lost playing time.
Being able to note differences in effort level, fatigue and performance will often help prevent more significant injuries and allow for a faster recovery process.
2) Response to injury — The response to injury typically involves physician intervention (evaluation, medication and surgery, if indicated) followed by rehab. The rehab plan is further defined by the following healing time intervals:
a. Acute: the first 24-72 hours after injury. This period is marked by inflammation. Treatment should focus on ice, rest, compression, elevation (as indicated) and minimizing stress and stretch on the tissue.
b. Sub-acute: days 4-21, post-injury. The body begins to resolve the inflammation and lays down new collagen fibers to repair the
damaged tissue. The muscle is still very weak in this phase. Treatment focuses on gentle stretching, strengthening and appropriate functional progression based on the extent of the injury. Some athletes may be able to return to sport in this phase, while others will be continuing to focus on resolving pain, swelling and inflammation.
c. Chronic: days 22 and beyond. This is considered the functional rehab portion of most rehab plans. The focus shifts to more aggressive activity simulation, including running, cutting, agilities, jumping and sport-specific activities to begin to prepare the athlete for return to play.
3) Return to play — This process may last weeks or even months. This phase is the most important one because it restores the athlete's confidence in their affected tissue and allows them to work up to 100% capacity again without fear of re-injury. Training now focuses specifically on specific movement patterns and energy systems vital to the specific sport or activity.
Proper exercise selection, application and progression will directly impact the pace of progression and end result. At times, trainers move through the phase too quickly and do not adequately stress the recovering tissue in a linear fashion prior to sending the athlete back to full competition. This uneven approach gives the athlete a false sense of security and often leads to re-injury as the affected tissue has not been sufficiently stressed to predict whether it will withstand the volume and intensity of forces applied to it during the athletic event.
Stages of Recovery
I have witnessed first-hand the results of a failed recovery when athletes, parents and coaches choose to ignore my advice. Although no perfect program or approach exists, I have developed a systematic way of managing this process that has worked well for most of my clients. Moving from one stage to another requires meeting exact physical criteria to advance. It can be divided into the following seven distinct and sequential categories:
1. Mobility — Regaining full excursion of dynamic movement is essential to ensure a full recovery. That is not to say static stretching is of no benefit, but focusing on regaining dynamic active mobility is a must to perform at a high level again.
2. Functional strength — Evaluating the uninvolved side (if applicable) provides the best measure of native functional strength. Emphasizing single- to multi-planar progressions for the upper and lower extremity is the best approach to avoid compensation in many cases. Beyond this, integrating multi-joint exercises and movement specific patterns of resistance training with progressive loads will elicit maximal gains. Train the whole body, and never compromise form for additional load.
3. Proprioceptive training — Many think of this in terms of dynamic balance and stability in the presence of environmental change or stress. Find the areas of weakness, and train them while forcing the athlete to adjust and respond to predictable and then random stress in different positions with safe loads that mimic sport-specific conditions.
4. Power development — Once full mobility and strength has been restored, low-level plyometrics and explosive strength work can be initiated. For lower extremity injuries, running begins in this phase as well. Plyometrics should begin in the sagittal plane and then progress to the frontal and transverse planes. It is best to achieve moderate to higher volume at low intensity prior to moving to higher intensity loading with lower volume.
5. Athletic movement drills — Many refer to this as speed, agility and quickness (SAQ). Again, the drills should be deliberate and move from simple and predictable to random and complex with linear intensity progression. Emphasis should be on submax agility drills and acceleration/deceleration to ensure that there is proper neuromuscular control before moving to higher output levels. Faulty movement patterns must be identified as they reveal a deficiency or compensation that indicates a need for
6. Sport-specific progressive loading — It is imperative to systematically progress and measure how increasing load affects the healing tissue. A common belief in rehab is that gradual increases in load actually stimulate healing (Wolff's Law). The key to success is measuring the ongoing response of the body to this load during and after activity to accurately determine if the stress was too little, appropriate or too much.
7. Recovery — Communicating closely with the athlete is a must, and the performance specialist must be able to elicit honest feedback to avoid overtraining or improper amounts of stress. Ideally, athletes should not experience any discomfort during the activity or any post-exercise soreness that goes beyond 24 hours after the latest session.
Combining the right amount of stress and recovery is the key to mastering the recovery process. Pushing too fast may re-aggravate the injury, and moving too slow may delay healing and hurt the athlete's confidence. Staying healthy requires a heightened awareness of the body and its response to high levels of physical stress moving forward. Qualified fitness professionals who possess a sound understanding of these progression principles will be able to successfully help athletes restore function and prevent re-injury issues through proper conditioning for as long as they compete.
Brian Schiff, PT, CSCS, is a nationally respected physical therapist, author and fitness professional, and he is the owner of Fitness Edge, a personal training and sport-specific conditioning facility in Dublin, Ohio. Brian's passion lies in helping clients prevent and overcome injuries while maximizing sports performance. For more information, visit www.BrianSchiff.com.