When considering all aspects of Return to Sport, one thing the profession of physical therapy does a very poor job of (in my opinion) is addressing the fitness and training demands required of the athletic population. In fact, I would argue that the medical community in general lacks guidance in this avenue. We FAR too often tie the hands of our strength and conditioning professionals by telling them, “no cutting/pivoting,” “no lifting,” “no squatting,” “no jumping,” or things like “no lower body work at all”. Let us rehab them first, then you guys can have them. While there is merit is avoiding provocation of pain, not rushing back too soon, and allowing tissue to heal…we cannot afford simply sit back and wait.
In the mean time, athletes are getting deconditioned and worrying about losing any progress they were making in their sport. Again, all an athlete wants to do is get back to their sport. I hear all of the time,
“Well, what can I do?”
This one question is the often answered with whatever bias is held by the person the question is asked of. That opinion-based guidance with its inherent lack of clarity and collaboration with others involved in the care of the athlete becomes the source of so much frustration. The medical community seems to either use general and vague guidelines – which are nearly impossible to actually follow – OR a lot of “expert” opinions with personal experience on what has worked for them in the past to guide how best to treat an injured athlete.
While I find a great deal of value in those in the field drawing upon their own knowledge, it is most helpful to have concrete, universally-accepted objective criteria to guide these opinions. Well, you will NEVER find that level of consensus. There are too many very intelligent and capable people that feel their own methods are successful and think they are generally already utilizing the best approach. They are highly unlikely to agree to something of this magnitude…which, arguably has many too variables to appropriately account for. Still, I feel strongly that we should strive to establish some common ground that provides a baseline of utilizable guidelines. We have to speak the same language. All successful sports teams have common goals and use a common system to reach those goals. Why should the rehab community be different? We need common baselines, benchmarks, and objective guidance. These benchmark may correlate with injury risk, but our understanding is always evolving – as such, our information is also hopefully always challenged, modified & advanced as needed.
So, I feel the first step needed is to establish something tangible. Something we can track. Something everyone can follow and understand. Something that addresses the numerous facets of training. One of the first things that should be considered when attempting to categorize how to begin training is an understanding that returning to athletics has to be criterion-based as well as biology-based. Meaning, you have to meet criteria that demonstrates an ability to accomplish actual functional demands that would be asked of you to play your sport…and you need to do so at a given level of symmetry, quality and performance capacity. In other words, have the athlete prove they are ready to go back to the physical demands of sports. As far as the Biology-based element, you cannot change the time it takes your body to heal – the musculoskeletal integrity is what it is. Tissues have to heal. You have to pass given steps along the way to healing. I discussed these benchmarks in greater detail in a previous post.
Getting back to training…it is phasic. By that I mean that all injury recovery happens in phases, so the rehab/conditioning/training needs to as well. You shouldn’t walk before you can crawl, so to speak. These phases need to encompass numerous aspects. That of intensity/effort, linear (straight line) fitness/energy systems development, multi-directional movements AND sport-specific demands. Basically, trying to cover the key aspects of training. There is no way everyone will progress the same, and the phasic concept is meant to facilitate the overall process – it is not a perfect model.
Within this phasic model, rehabilitation is able to join strength and conditioning as well as sport skill/coaching elements. One major missing piece of this process is the lack of weight room criteria in this design. While I highly value the weight room and know its role in sports performance, returning an athlete to a sport (especially in-season) is not typically dependent on how much they can squat or bench press. They need to strengthen oftentimes and numerous power and strength sports will require additional strengthening. BUT, for the sake of trying to limit at least some variables, this has been excluded. See this example of a Return to Sport Soccer diagram…This return to sport training program was developed in large part from collaboration with Brian Gerlach, ATC. Brian has an extensive background with soccer and has worked with D.C. United, as well as several U.S. youth National teams. At this time, he is the head athletic trainer for the Indy Eleven professional soccer team in Indianapolis, IN. This program is currently being utilized by their organization to help guide readiness to return to team-related activities and training.
All interval work is: Jog/Accelerate x Sprint x Decelerate…ALL phases advance sprint distances at given intensity & recovery time for each phase – (Complete only one interval/day…i.e. only A, advance to only B, then only C)
- Rest is active (walk, dynamic stretch/mobilize…not just sit, stand or lie down)
- Work:Rest Ratio = A period of work followed by a rest interval (Example: 1:2 = 15 seconds of work, followed by 30 seconds of rest)
How to move through the phases:
Periodization – Days of the week should increase throughout the phases, with opposite days focusing on muscular development and rehabilitation. One day each week should be given “OFF” as a complete recovery day, with no rehab or sport specific activity.
- Phase 1: 4 days/week-Light ball work every other day; 2 Days fitness, 2 days multi-directional
- Phase 2: 4 days/week- Ball work every other day; 3 Days fitness, 2 Days multi-directional = 1 Day Combination (hard day)
- Phase 3: 5 days/week- Ball work every day; 4 Days Fitness, 4 Days multi-directional = 3 Days Combination (hard days)
- Phase 4: 5-6 days/week: Ball work, Fitness every day; 2-3 Days multidirectional, 1 day rest
*** DO NOT complete more than 3 combination days in a row. Always take at least 1 day off for every 3 days of combination work. ***
Again, the purpose is to guide. Not dictate. Accounting for intensity/effort and work:rest ratio allows this programming to be objectified. Utilizing training parameters that also account for gradual (phasic) progression in regards to directions or body movements and subsequent sport-specific ball demands within those same intensity/effort levels further allows graded response to these demands. Of course there are countless great drills, fitness ideas, programming that may differ than the one above, as well as alternative programming methods that all can be immensely beneficial to an athlete in training (like the addition of the aforementioned weight room); however, having the basics – the baseline – is still one of the most important things we can do in the healthcare and wellness fields. Being able to tell the athlete, coach, team athletic trainer, team physician, athlete’s parent in some cases, the strength coach and physical therapist:
- An overall view of the steps needed
- Which phase an athlete is currently training
- What he/she needs to accomplish to move on to the next phase
- Where/when an athlete may be able to begin part(s) of team training
This discussion allows us all to be better equipped to discuss a timeline for full return to sport. Knowing where we have been, where we need to go, and steps to help get us there can do nothing but enhance our ability to safely and appropriately return athletes to sport!