What is the number one focus for a strength coach or sports performance physical therapist working with athletes and clients with the goal of reimplementing training and sport? If you answered “get them back on the field as quickly as possible,” you may be feeding into the systemic problem that we are facing as an industry, the epidemic of re-injury rates across the board in youth, amateur and professional sports and fitness.
This week we have strength and conditioning coach Chris Cooper featured on DrJohnRusin.com with his innovative and spot on view of the bridging process between rehabilitation and performance to prevent re-injury. Co-management and synergy between the sistering healthcare professions is a must if we want to start making a dent in this process, and keeping our clients healthy for the long run. It’s not about the short term, it’s all about longevity of function, health and wellbeing.
Here’s What You Need To Know…
1. Incomplete rehabilitation in athletes and the general fitness population has lead to an re-injury epidemic of massive proportion. Is your goal as a coach or practitioner to get your clients back to sport as quickly as possible, or to prevent re-injury from occurring?
2. The gray area of bridge time between rehabilitation and performance training is the most advantageous time to optimally complete the total rehabilitation process to prevent re-injury. Yes, strength coaches and personal trainers ARE finishing off the rehab process.
3. Implementing corrective and physical therapy guided exercises in the dynamic warm up routine or training program itself in the form of supersets is a highly effective way to bridge the gap between performance and therapy.
4. Tapping into the mental side of training and performance will allow athletes to gain the last few steps of a total rehabilitation process in the gym, that if overlooked, can play a key role in re-injury.
5. Like Mike Boyle says, “Injury Prevention is just good training,” which is the dual role of the rehab practitioner and coach working together to prevent re-injury.
Bridging Rehab Into Strength and Conditioning
As athletes, it’s important to be functioning as the highly skilled machines you have trained to become. No one wants to be caught up in rehab purgatory, or even worse be stuck in a re-injury scenario. The goal is to rebuild the body back to where it was before injury, without the risk of re-injury even being a thought in the back of the mind. Avoiding at all cost that cycle of an injury leading to rehab, the rehab being incomplete with early re-integration of competition, training and daily activities, and ultimately a re-injury.
“Injury prevention is just good training.” -Mike Boyle
There is an ever growing movement within the fitness industry in which a blend between rehabilitation with prevention work is fusing with strength training and performance. This has given birth to a protocol that not only works to prevent injury and re-injury, but to also build a bridge between what’s typically seen in a rehab setting and what happens on the gym floor. This is the future of fitness and sports performance, that’s if the bridge process is handled in the proper way.
A Little Disclaimer For Athletes and Coaches
If you have suffered an injury, it is your priority to seek medical treatment by a licensed practitioner. This article is in no way medical advice for you to use in lieu of professional counsel. After you have been cleared for training, seeking the proper trainer and/or coach that has experience with post-rehab clientele is a necessity. Now with that said, lets get to it!
The Road To Complete Recovery and Limiting Re-Injury
Whether you have sprained, strained, pulled, torn, broken, etc. your body is going to need a few things regardless.
Manual manipulation of soft tissue
This is the typical course of action. Once you have sought medical help and been diagnosed, it’s time to go to work. For most part, that is going to start with physical therapy. Physical therapy is where the frame work or the base of your strength is going to be built. Remember, a bigger base or foundation means a more solid structure resulting in the best results.
What happens once you have been released from PT? Physical therapy is about restoring function through building strength and developing confidence in the once injured area. However, there’s a big difference between having functional capacity to do things and be symptom free and having the requisite strength to perform like you did pre-injury. Imagine if you had rolled your ankle.
Once PT was over, you probably will not possess the strength or mentality to go back to cutting on it. That is going to take time and along with that, proper strength training.
Minding The Gap Between Rehab and Performance
There used to be a chasm between the PT field and the strength & performance training world. Progressively though, that void is slowly closing as more PT’s crossover into the world of strength & conditioning. Working in isolation on injured areas no longer makes the cut. Treating systemically and re-grooving movement patterns is the new norm to break through that aforementioned cycle of rehab purgatory. Every athlete (and we’re all athletes to some degree) has performance goals and eventually wants to get back to that previous level of athleticism and back doing what they were before various injuries.
Returning from injury isn’t and shouldn’t be a quick process. It’s not going to be one of those “beach ready in six weeks,” kind of programs. It’s far better to train smarter so you can continue training harder. Progressing from rehab to strength starts with taking what was developed in PT, and building on it daily. Improving on that functionality and adding strength behind it can ensure long term success. It may involve regressing, substituting, and/or even just slowing down movements until we own them.
The All Important Transition Phase
Once you’ve gotten the “all clear” from physical therapy, you want to keep the rehab exercises, but within the confines of a strength program. This will ensure that you stay on top of the PT’s program, but it’ll also allow you to progress it.
Programming your workouts after injury can be a tricky thing to do. On the one hand you want to get better, to continue the healing process, but you also want to integrate your previous exercises. Two possible solutions to your problem, programming rehabilitation type movements into supersets during the training session itself, or implementing these strategies into the warm up.
The most ideal way is to superset rehab exercises with your main exercises pending those are restriction free. With injury often comes movement restrictions which requires attention via SMR, activations, and maybe stretching.
1A Primary Exercise
1B Rehab Drill #1
2B Rehab Drill #2
The warm up is a great place to implement rehab exercises once your body is healed. This will be your precautionary warm-up to go along with anything else you do in your warmup. Say for a rotator cuff injury, you may add in internal/external rotation or other shoulder exercises that were prescribed from the therapist for continued homework.
The last thing you want to do is end up devoting an entire half hour or longer just to your rehab exercises. That’s not the point of going from rehab to strength. Limiting the time spent on rehab and devote more time towards strength is one of the main aspects to focus on.
During our Rehab to Strength program we want to be able to test, regress, or progress through several key skills. Lets go over these skills one by one:
Re-establishing and more importantly maintaining functional range of movement is the first key piece on your path from rehab to strength. Included in this would be SMR, stretches and range of motion exercises. Movements that will restore your ability to move within the ranges you need for your sport and training.
Static Stability and the next bullet point go hand in hand in terms of regaining proprioception and awareness. You want to stress the area in need of rehab through challenging other joints to move all while the affected area stays static. A great example would be single leg stance on the floor to an airex pad, to catching a ball in single leg stance. You end up using the core and hips while trying to maintain a neutral ankle.
Once again, it’s about regaining proprioception. But in this case its moving the affected joint while keeping control of the movement.
Part of rehabbing injuries is learning how to move again and correctly. In the case of low back pain, McGill says re-grooving patterns, namely the squat is important to get out of movements of pain. You want to focus on functionality here. In the case of an upper body injury, its regaining the rhythm of the shoulder and scapula.
Now we’re where we want to be. All the way back to strength training. This is where we can start to load those movements we’ve re-grooved in the last phase or skill. You may want to go all out right away, but start slow and avoid overloading your body. Initially focus on high volume hypertrophy work before progressing into max strength.
Explosive strength may be the last element that fully proves that you’re back. Think something along the lines of box jumps or other plyometric exercises for lower body injuries.
Getting back on the field, court, ice, or even just life. Eventually we need to perform the way we used to. This is really the final step. Once you feel you have mastery of this, you’re really back from your injury.
Objectifying Gains with a Test and Re-Test Protocol
One thing to note is that you’ll want to follow this protocol, “Test, Assess & Retest.” Figuring out what movements and exercises work and don’t work is going to be vital in not suffering a setback. Avoid movements that create pain, and if necessary, regress a step in order to progress your programming.
If you’re looking for a great “catch-all” assessment, look no further than the overhead squat. From this one drill, it’s possible to learn a lot about your movement ability and quality. Two other go to assessments are standing one leg and getting up and down from the floor.
Common Sites of Injury and Dysfunction
From a programming standpoint, you want exercises that target the muscles/joints you are rehabbing. However, you may also want to add some prehab drills to the other side if you’re working on a unilateral injury. Below are common areas that get injured, whether it’s through a trauma, or just wear and tear. From the ground up:
The Foot and Ankle
Sprained ankles the most common injury, therefore it’s important to continue with stability exercises like single leg movements or just balancing on one leg. Give unloaded split squats, step-ups, and single leg deadlifts a go as well. Add in dorsi/plantar flexion for mobility and strength using bands, as well as inversion/eversion depending on the injury.
Ligament and meniscus injuries are the most common things to be rehabbed. Continuing isolation exercises like TKE and leg lifts for the quads to regain extension is important, but also rebuilding strength in the hamstrings is equally important. Re-grooving how to squat is also essential in avoiding a re-injury or pain. Single leg exercises like split squats and step ups are great ways to build stability and strength as well.
The Hip Complex
Labral tears and joint replacement are the most common injuries that need to be worked with so along with the single leg exercises above, it’s important to strengthen the hips with exercises like clamshells and band walks, but also hip thrusts, deadlifts and squats.
The Shoulder Complex
Rotator cuff injuries and dislocations are usually the injuries that send you to a physical therapist. While you may have been treated for one of those aforementioned injuries, it’s also important to take a look at what may have caused it in the first place. Dislocations are traumas, but rotator cuff injuries are usually wear and tear. Shoulder stability exercises are a like kettlebell bottoms up presses or holds can help rehab such an injury. Landmine Presses are a great way to reintroduce pressing without having to go directly overhead. Lastly, it’s important to incorporate mobility drills so the shoulder works optimally.
The Low Back
Typically disc herniations are what you would see in back injuries, however it’s worth noting that it’s possible to have pain without any structural damage. Dr. McGill contributes back pain to a weak It’s all about mastering core control and stability when overcoming back injuries. Exercises that focus on the glutes and core like deadbugs, glute bridges, hip thrusts and side planks are amazing. Progress to RKC planks, suitcase carries, and Sorenson Planks to take your gains up a notch.
With most of these injuries that develop over time, there is likely a breakdown in the chain of movement. Meaning it could be that you are performing that movement with sub optimal technique or perhaps a main muscle is not firing or an opposing muscle firing too much or in some cases, both. However, the goal is the same; to make the movements more efficient, more stable, and stronger.
When programming your strength based exercises, be aware that your body acts as a whole. So one area is certainly going to affect joints above and below. By going through what was listed in the transition phase, you’ll ensure that you’ll be back to your “normal” in no time.
It’s All Mental
The last thing that you are going to have to deal with, and it often goes overlooked is the mental aspect of returning from injury, especially when it is sport related. Making hard cuts off an injured ankle is going to have you hesitate a split second. Yet, in competition, those split seconds are huge. If you’re mindful of your programming, are still doing your prehab homework, and take proper precautions, you’ll be a rock star in life, on the court, or on the field. Years to come athletes will still deal with the mental aspect, unconsciously guarding and favoring their injury long after it has physically healed.
Sometimes injuries force you to slow down and concentrate on things you may have taken for granted before. Building proper tension or doing homework. In the end you’ll come out stronger and better for it by dialing back, and building back from nothing.
In order to be confident that injuries do not become problematic, it is important to take the rehab exercises and implement them as “prehab” exercises to maintain injury free status and prevent re-injury. This starts with a solid warmup that includes some of the PT driven exercises like a TKE for the knee or internal/external rotation drills for the shoulder. This may also be something to consider even if you’re not coming off an injury. You don’t think you have a problem, till you do.
Like Mike Boyle said, injuries can largely be avoided with good programming. Listen to your body and protect it from an injury long before signs begin presenting, your performance is affected, or you suffer the injury.
About The Author
Chris Cooper, NSCA-CPT, LMT is a personal trainer with 10 years of experience in the fitness profession. He is co-owner of Active Movement & Performance, a training facility on Long Island. In addition to being a trainer, he is also a New York State Licensed Massage Therapist, which has allowed him to blend the two worlds to not only get his clients stronger and in better shape, but to also fix dysfunctions to make them better movers overall. His firm belief in education is manifest as an educator for Fitness Education Institute, presenting at their yearly convention. He is an expert contributor to Watchfit.com and his work has been featured on Movement Resilience, Men’s Health, TonyGentilcore.com & Stack.com.