Before becoming a strength and conditioning coach, I was pursuing a career in physical therapy (PT). While shadowing and volunteering at various PT clinics, I quickly noticed a common trend among athletes:

Rehab → Competitive sports play → Injury → Surgery → Rehab → Repeat

Over the course of a few months, I frequently witnessed a person leave the physical therapy clinic restored to “functional capacity” only to return later with the same injury on a different limb, a different injury surrounding the original site of surgery/rehabilitation, or even worse, the same injury on the same limb.

What was causing this glaring problem? Was it the incompetence of the physical therapist? The surgeon? Was the athlete making poor choices in the weight room or on the playing field? Way more often than not, it wasn't any of these possibilities. After discussing this question with the physical therapists I worked with, the answer soon became clear.

Most physical therapists are required to discharge their patients after they are restored to a particular level of function because the insurance companies won't pay for continued therapy if the patient can safely perform a pre-defined set of activities. Now the criterion to meet this “particular level of function” or “functional capacity” varies among insurance companies, and this is where the majority of the problem lurks.

Functional capacity for a retired person may simply be the ability to walk from the television to the couch and up the stairs to bed. Functional capacity for an urban businessperson may be the strength to walk ten city blocks without his hip flaring up in pain. In contrast, functional capacity for an athlete may be the ability to sprint, stop, and quickly change direction without toppling over in pain. Unfortunately, the insurance companies control how far the patient progresses in the PT clinic, and they often decide to discharge a patient once he is able to meet a minimum goal set of walking, bending, and/or reaching overhead without significant pain.

The problem and a viable solution

There exists a large gap, especially in the athletic population, between “functional capacity” and the physical demands of competitive sports play. Athletes not enrolled in a collegiate strength and conditioning program leave physical therapy with little to no direction on how to continue preparation for a successful return to competitive play. The end result is usually far from pretty.

As strength and conditioning professionals, we have an important chance to help athletes returning from injury. One way to seize this opportunity is to seek out health care professionals who appreciate a sound approach to training beyond the rehabilitative setting. Many physical therapists will gladly refer athletes (and the lay population) to a strength coach provided the PT is confident in the coach's ability to administer sound training and reduce the likelihood of future injury.

As an example, let’s take a look at how this situation may play out between an athlete, physical therapist, and a referred strength coach. In this example, I’ll use a common injury—an ACL tear.

The most important point to note during the initial weeks following injury/surgery is that the strength and conditioning coach should have little involvement until the athletic trainer or physician has determined that the athlete can begin rehabilitation. Once the doctor, physical therapist, and athletic trainer (if there is one involved) allow a controlled exercise program, (probably around the eight- to twelve-week mark) the strength coach may take a more proactive role by:

  • Helping the patient continue key exercises performed in the PT clinic (i.e. standing resisted straight leg raises with band, proprioceptive training, cone walking, retro treadmill (to assist in knee extension), cone walking for gait, step-ups, lateral step-ups, jump rope (typically around week ten), slide board, figure eights, gentle loops, core work). At this point, the strength coach should talk to the PT to see what he has been doing and gather information on any specific movement patterns he should avoid/include with the athlete.
  • Gradually progressing to low-level plyometric training drills in a straight plane and sport-specific drills (add lateral movements around week 16).
  • Incorporating open chain strengthening as tolerated.
  • Always asking the athlete if an action hurts. (This is a yes or no question. If they say yes and it isn’t a typical “muscle soreness” pain, then refrain from performing that particular exercise.)
  • Setting a goal to return to the sport at six months provided that other six-month goals have been met:
    • Full range of motion has returned
    • Joint doesn’t “give out”
    • Pivot shift is symmetrical
    • Lachman’s test is within one grade of contra lateral knee
    • Functional tests are at least 90 percent of opposite leg
    • Other scores/tests the PT/physician may use have been taken

With regards to ACL injury reduction strategies in general, Mike Boyle states it very accurately: “ACL injury prevention is just good training. The program we use for ACL injury reduction is actually the same program we use with everyone. As coaches, we have to realize we should be practicing great injury prevention concepts with all our athletes and weekend warriors.”

According to Boyle, there are some key strategies in particular that should be utilized:

  • Active warm up
  • Power and stability (eccentric strength equals landing skills)
  • Strength development (emphasis on one leg)
  • Change of direction concepts (learning how to stop)
  • Change of direction conditioning (developing conditioning)

One final point worth noting is the host of complications often found in an injured athlete returning from surgery. For example, let’s say a strength coach receives an athlete returning from an ACL injury. Often, the attentive strength and conditioning professional may notice a host of biomechanical problems during the warm up alone, all of which are more disconcerting than the newly constructed ACL. Common issues recognized include gluteal and hamstring weakness, hip flexor tightness, internal rotation of the opposing hip, poor ankle mobility, insufficient thoracic mobility, and low sense of kinesthetic awareness and proprioception. In all likelihood, these issues were the leading contributing factors in placing the athlete on the surgeon's table to begin with, and if these aren't fixed, the athlete will most likely find himself under the knife once again.

In summary

  • Seek out health professionals to set up a referral system in order to bridge the gap between rehabilitation and sport performance training. Be sure to recognize the difference between your scope of practice and that of the health professional. Having a CSCS certification isn’t the same thing as being a licensed physical therapist, and it is imperative that the strength professional always seek the PT with regards to any gray area.
  • Practice sound injury reduction strategies even with healthy athletes. The strength coach can play a significant role in keeping athletes healthy and able to enjoy their sport with a greatly reduced risk of injury.

References

  1. Boyle M (2010) Advances in Functional Training. Aptos, California: On Target Publications.

  1. Parker D (2005) “Anterior Cruciate Ligament Reconstruction Post-Operative Rehabilitation Protocol.” Commonwealth Orthopedics and Rehabilitation.

  1. Springer B, Murphy K (2003) “ACL Reconstruction.” Physical Therapy Section. Walter Reed Army Medical Center.