I am a strength and condition coach with experience in many different environments. From working with the general public doing personal training to working on long-term athletic development with high school athletes and now working with professional rugby league players at the Parramatta Eels.
All these environments have one thing in common – nearly all athletes will suffer an injury at some point. It has been a huge learning curve to see the lack of knowledge that many physios (and strength and condition coaches) have about rehab. It is not uncommon to see physios excel at diagnosing and treating acute injuries, but then the waters become murky once we try to return athletes to full performance and training. I believe that physios could be better equipped to help athletes and active people with their rehabilitation and return to play processes if they understood periodisation. Hopefully, this article will provide some information in these areas.
First, I’m only able to go so far in a single blog. Sam Blanchard’s Masterclass on Clinical Reasoning for Rehab is a great resource to learn how to design optimal rehab programs to help your athletes and active patients.
Periodization
If I see another athlete being given an external rotation with a green theraband for shoulder impingement, I might lose my mind! This exercise is beneficial, but the traditional rehab prescription that every corrective be done in 3 sets of 10 reps until the end of the time has no lasting benefits! Like in strength and conditioning programs, rehabilitation must include progressive overload. Although activation and capacity training are important during the acute phase, I’ve rarely seen a physio expand their corrective measures beyond this point. Or, you can live dangerously by moving to the blue theraband in two weeks.
Corrective exercises should be designed to gradually increase the load and challenge individuals as they progress in their rehabilitation. Not only should this be applied to correctives, but also to gym (speed and agility) or sport-specific requirements such as contact in Rugby League. After a person has reached a certain level of work capacity, they should focus on developing strength and power for their athletic needs. They shouldn’t hide in the corner with the theraband or in rehab purgatory. Strength and conditioning coaches as well as physiotherapists must understand what strength and power are, and how to prescribe exercises to maximize these qualities. Later in this article, I will delve into the topic a little more.
S+Cs & Physiotherapy Should Work Together
For each injury, I believe both the strength and conditioning coach and the physiotherapist need to have a good understanding of the stages in rehab, as well as exit criteria for every stage that are based on performance results, not time, and an A and B plan for returning the injured person to training. Strength and conditioning coaches and physios should work together during all rehab stages, and not separate from each other. It is not just the responsibility of the physiotherapist to care for the injured athlete. An S+C can be involved as early as the first stages of an injury to help maintain the athlete’s performance and train around it. If an athlete is injured in the MCL, S+C can still help with upper body strength and cardio/conditioning. You can also offer lower body exercises that are less damaging to the knees, such as hip thrusts and Romanian deadlifts. When an athlete returns to training, they shouldn’t be solely the responsibility of S+C coaches. A physiotherapist should check things like the pain level, swelling and integrity of the injury area using clinical tests.
The best results for athletes are achieved when a physiotherapist and S+C coach work together to make decisions and communicate openly. It’s a real shame that these practices are usually only used at the professional level.
Rehab and Return to Play Process
We usually break down the rehab of an athlete into four phases.
Phase One (physio’s bread and butter).
In this phase, we will improve range of motion and reduce pain, while introducing corrective exercises and correctives that do not compromise healing or promote the capacity of supporting tissue. The green theraband will be at its best during this phase! The load is low, but the volume of our exercise prescription is high. (Think 3-4 sets with 10-15 reps).
Phase Two (strength).
Get rid of the therabands and grab dumbbells, bars and machines. We are now looking to gradually strengthen the injured area. With your exercise prescription, think about overloading the body. The intensity should slowly increase while the volume is gradually reduced. Week 1-2 – three x eight reps. Week 3-4 – three x six. Week 5-6 – four x four. This phase should involve the athlete using loads and weights that will take them to near failure. You should only have 1-2 reps left at the end of a set.
Phase Three (power).
It’s time to lower the weight, but move the bar more quickly! Ballistic training, plyometrics and banded resistance are all good options. Also, think about complex and contrast methods, such as contrasting exercises, ballistic training and plyometrics. Superimposing a heavy exercise, like the squat with a lighter exercise that has a similar movement pattern, like the box-jump), is a great way to build global power. This phase of our exercise prescription focuses on building global power. Express the strength you have gained from the previous phase as quickly as possible! Power development is best achieved by 3-4 sets with 3-5 reps and long rest periods between sets. Power training is not 20 sets of box jumps.
Phase Four(training integration and return to sport):
RTS criteria should be set by the co-ordinating strength and conditioning and physiotherapist. The athlete must meet these RTS requirements before returning to training. As a result, it is best to gradually increase the training load over a period of several weeks. This will reduce the risk of injury for athletes who are returning to training after a short rehab. A soccer/football player returning from an ACL tear might begin by participating in warm-ups, basic passing drills, and drills that require a predetermined change of direction. They would then sit out any small-sided games or reactive exercises. During this phase of the program, we will include sports-specific drills in the gym as well as on the field to prepare athletes for their competition.
Exercise Progressions
When an injury occurs, physiotherapists will often tell you to stop all exercises that involve the injured area. Knowing exercise progressions, and even more importantly, exercise regressions will make a huge difference to maintaining a load in a particular movement pattern. This can also help an individual return faster to sports. Regressions are something we’re afraid to try. If an athlete has lumbar issues and is unable squat, knowing the four-by-four movement matrix can help you to modify your program to maintain strength where it’s needed. Can we, for example, drop the weight, change the pattern to a front-squat, or reduce the depth of the squat? This might not always be the case, but a knowledge of progressions and regressions can help to reduce muscle loss and improve strength and bulk when an individual is injured. For more info about – physio in grey lynn.
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