What approaches come to mind when thinking about rehabilitation after an injury? Many people imagine visiting an outpatient physical therapy clinic and receiving various treatment modalities like ultrasound, needles, cups, taping, or scraping painful areas. Others might think of low-level “physical therapy exercises” like clamshells lying down on a mat or light band-resisted activities. For athletes, these methods typically fall drastically short of meeting their specific sporting demands. If an athlete is required to sprint at top speed, move a maximum load, or change direction at high speeds, there is no amount of ice, lasers, or bird-dogs that will prepare them for that level of intensity and velocity. A proper rehabilitation program must be scaled to find the appropriate entry point for an athlete, but must also explicitly progress to meet the demands they will face upon their return to sport. This article will examine our approach to scaling and progressing rehab , including power, for athletes.
Rehab exercises are often prescribed in the classic “3 sets of 10 reps” format, but this fails to define the intent or the intensity of the exercise. Competitive sports are often performed at high intensities with deliberate intentions, and rehabilitation programs should be structured accordingly. This means that the effort of an exercise must factor into how the program is scaled for the individual athlete. Effort describes how hard a task feels independent of load. Even simple exercises like isometric quadriceps sets can be performed at high effort if an injury is acute, when there may not be many other options for training. Consider the difference between “flex your quad” and “I want you to flex your quad as hard as you can and hold it for 20 seconds.”
The literature on the implementation of effort in sports rehabilitation is sparse. A review from 2022 found that exercise descriptors for determining strength gains were missing from most studies of ACL rehabilitation programs. If clinicians are not tracking metrics for improving strength, it is not surprising that only 28% of athletes meet strength goals upon return to sport, leaving them at higher risk for re-injury. Providing the best outcomes for our athletes requires us to improve our rehabilitation programming. Low-level exercises have a place in the early stages for many athletes, but if we do not account for the effort of those movements, then we are doing a disservice in preparing our athletes for their return to sport.
The scenario below illustrates three athletes. Athlete 1 is the blue line, Athlete 2 is the black line, and Athlete 3 is the red line:
Which athlete has the best rehabilitation protocol? It depends on the purpose of the task they are performing. If the goal is to get to a point as fast as possible, Athlete 1 would win. If the objective is to produce the most force, Athlete 2 would win. If the object is to perform 3 sets of 10 for its own sake with no gauge for effort, then athlete 3 would win. We can have an athlete perform a movement as fast as they can or as hard as they can, but just having an athlete perform a movement is insufficient, because it leaves out critical parameters of dosing. Simply put: we must account for effort when prescribing sports rehab.
Although there are constraints based on tissue healing timelines and symptoms when an athlete is injured, there are almost always means of training around those constraints. An athlete with a knee injury still has the other leg, a trunk, and arms that can still benefit from training. The keys are understanding the available options for training modifications, scaling, as well as determining the rate-limiting steps for the individual athlete.
Exercise modifications often consist of scaling range of motion, modifying the load being used for exercises, or limiting the amount of activities an athlete can perform as seen in many protocols. While these are all useful strategies for keeping an athlete active, they should be focused on the following goals:
- Keep the athlete as athletic as possible throughout the process
- Preparing the athlete for return to their sport in the best possible condition
Achieving the first goal involves understanding how to program around an injury. If one limb is limited to non-weight bearing, there are multiple implements that can be used to maintain work capacity. For example, a rowing ergometer can be used where the athlete is seated, non-weight bearing on the involved leg and they can work on conditioning. They may not be able to participate in bilateral loaded exercises such as squats or deadlifts, but that does not mean they cannot bench with their leg off the ground, or perform open chain knee extensions on the uninvolved side. There are countless approaches to maintain athleticism, and proper programming can help maintain a baseline.
Overall training volume also needs to be accounted for during the rehab process. An athlete who is accustomed to training 10 hours per week and is now only participating in 2 hours per week of one-on-one rehab will be grossly detrained and deconditioned upon return to sport. Programs must include activities outside of the time they spend in direct contact with a clinician in order to maintain or improve conditioning. Tailoring exercise selection to what they enjoy, equipment availability, accounting for injury-related constraints will all help with adherence.
Achieving goal 2 means including explicit power training as a component of rehab. Explosiveness, agility, and speed are all training synonyms, but the definition we will use is the ability to produce force in the shortest amount of time possible. For example, how fast an athlete can move themselves or an object such as a barbell or ball. The ability to express power may be limited by symptoms, the constraints of tissue healing, work capacity, strength, technique, or acceleration. Regardless, they can all be addressed with proper exercise implementation and scaling.
If we take a set of exercises like a squat, a clean, and a jump and compare them as in the video below, they are basically the same movement performed at various speeds and external loads. While the first focuses on maximal strength development, the latter focuses more on power. This does not mean that the Olympic lifts or jumps need to be part of every athlete’s program, but the intent to move fast should be explicitly programmed. There is no best exercise for power development. Rather, it depends on the needs of the athlete and the forces they will experience.
The athlete in the video was cued to squat at RPE 8, clean the bar as fast as possible, and jump as high as possible, where this explicit prescription for intensity was the most important variable. Rehabilitation has created a paradox with their programming with the idea that we should decrease forces on joints. Cues such as “land soft” or “be quiet” under the premise that softer landings do less “damage” to joints. This fails to recognize that joints adapt to the forces to which they are exposed. “Soft” is not athletic. If an athlete spends more time on the ground during a landing or during foot strike running, they will be slower than their competitors. A good way to get dunked on in basketball is being soft in the paint.
When athletes were cued to land “soft”, land normally, or land “stiff”, there were notable differences in both degree of knee flexion in landing and peak pressure of force delivered to the ground. While landing soft still resulted in 1.3x bodyweight in force, self-selected “normal” landing resulted in 1.5x bodyweight force, and “stiff” landing 1.8x bodyweight force. During a sport, an athlete does not have time to decide if they are going to land soft or stiff, and sports often require a variety of landing capabilities. What happens if an athlete has only been preparing for soft landings, and a cornerback or power forward starts forcing stiffer landings on defense? Instead of lowering the ceiling to what an athlete is exposed to in rehab and training, perhaps we should be raising the floor by preparing them to accept larger forces as well as deliver more force to the ground. Being an exceptional athlete is predicated on being able to do things better than anyone else, why should we continue to program in a manner that decreases the likelihood of this outcome?
After an acute injury, an athlete may need to favor safety in programming. However, that does not mean that components of power development and performance cannot remain part of programming. Athletes typically do not get hurt while jumping — they get hurt while landing. This sudden absorption of force, or an inability to properly do so, can cause injuries. Exercises and drills can be scaled to mimic landing components earlier in the rehab process. Thus, when an athlete is allowed or capable to return to jumping, sprinting, or changing direction there is not a large inflection point between what they have performed and what they are trying to perform.
Let’s ask the question, what is a jump?
Even though one foot remained on the ground in this lunge, the foot stepping forward had to decelerate against the ground. Technically, it “landed”. We can scale this with how high up we pick up the foot, the external load, and how we cue the landing. In the rear foot elevated split squat example, there is an rhythmic oscillation to the movement. It can be cued for speed without either foot leaving contact with the ground. A simple exercise that would fall under the category of “lunge” now has multiple different functions, depending on the intent of the activity.
There are a host of exercises that can be scaled to meet the needs of the athlete, anchored to effort with proper constraints. An isometric mid-thigh pull can be performed early in rehab at a very high intensity. A spider stomp can mimic sprinting technique without a large ground reaction force. These can be progressed into exercises like A-skips and B-skips, jumping rope, or the oscillating split squats mentioned above. There is still a difference between working on the technique for a skip series, and attempting to make the movement as crisp as possible. At what point an athlete is safe for both feet to leave the ground after many lower extremity surgeries is still up for debate, but there is a large difference in forces between jumping rope, and attempting to perform a maximum vertical jump. Jumping rope can also be made more ankle dominant by cueing to limit knee flexion. Once again, we need to be better about working around an injury versus just shutting an athlete down altogether.
Early phases of rehab can focus on coordination, timing, rhythm, and impacts with a focus on building capacity for maximum effort. But there is almost always a small set of exercises that an athlete can perform at high effort. As an athlete returns to participation in sport and practice, building capacity is still fundamental, but exposure to higher-effort exercises must increase. Exercises like drop vertical jumps, reactive ball drills, or maximum accelerations should be a part of the program if an athlete is going to be required to land, change directions, or sprint.
How does this match protocols?
Most rehabilitation protocols are overly restrictive. At 8 weeks after ACL reconstruction, protocols are often constructed like this:
Elliptical, stair climber, flutter kick swimming, pool jogging
Leg press machine, hamstring curls, hip abductor and adductor machines, hip extension machine, Roman chair, seated calf raises, squat to chair, lateral lunges, Romanian deadlifts, step downs, step ups, seated knee extensions.
Single-limb balance with perturbation training
While these exercises could be performed at a sufficient RPE to increase strength and power, it often leads to athletes going through the motions. It also leads to programs that look like the one below that was seen for an athlete 8 months after ACL surgery:
It meets the limits of the protocol, but there is no mention of sets, repetitions, or intensity. There is also nothing that facilitates power development. This program may be safe, but it fails to prepare the athlete to return to sport. There are multiple ways to approach the development of power in athletes, but it is necessary that any exercise be scaled to the capabilities of the athlete and dosed at sufficient intensity to elicit adaptation.
There is no universal “optimal load”. It is dependent on an athlete’s training history, current limitations, and goals. Someone striving to meet physical activity guidelines benefits from a different degree of loading than an athlete trying to return to national level competition. As an athlete progresses from rehabilitation, to participation, to practice, to play, the level of intensity and complexity of training should increase. There is a large difference between being able to perform a 45 degree cut in front of a cone and being able to perform the same task with a defender who is actively trying to prevent that from happening.
What might a better program look like for the athlete mentioned above? For example:
The athlete should still be performing activities outside of this programmed training as well, if there is a need to meet work capacity. Low intensity steady state activities could be performed on off days to meet the demands of the athlete’s particular sport. Once again, this is a way, not the way. What is more important is that the exercises are explicitly dosed in sets, reps, and power development, with explicit attention to the intensity and goal of the task.
What about the Lifter?
What about the powerlifter, where there is no sprinting or jumping, and the only change of direction involves going from eccentric to concentric? It is likely the case that these athletes do not need the same volume of athletic “power” training, but it should not be completely scrapped from a program. The lifter might want to occasionally play another sport like basketball, golf, or try skiing or hiking. They should be exposed to general athletic demands. Overall, the title of “powerlifter” often carries an implied excuse to not do power or cardiovascular training. Adding 2 kg to your competition total is great, but if it comes at the expense of being winded when ascending a flight of stairs, or being physically unable to sprint, is that an adequate tradeoff to stand on the podium at a local or regional meet?
Well-designed powerlifting programs emphasize intensity and often instruct to move the load as fast as possible. That does not mean athletes should only be power training in a manner that so closely resembles their sport. Even powerlifters are athletes and can benefit from exercises besides the squat, bench press, and deadlift. General physical preparation should prepare you for a variety of physical demands. If both of an athlete’s feet have not simultaneously left the ground in years, it should not be surprising when they have difficulty with activities that require jumping. A task as simple as going out to shoot basketball includes running, changing directions, and both feet leaving the ground. If an athlete has not played in a while they are going to be running even more after all of their missed shots. Power training does not need to be a specific set of drills, and there is no magic “set” that will add to your competition total. If there are components of coordination, timing, rhythm, and some maximal effort it benefits with power.
There will of course be caveats to these recommendations depending on where in the course of a season an athlete is participating. If there is a meet of high importance on the horizon, specificity will be the primary focus. If an athlete has no competitions lined up, or they are in their offseason, then general power training should comprise a part of their program. General physical preparation is not just going through the motions on a cardio machine and catching a biceps pump. It serves to develop a well rounded athlete, capable of doing more than just picking things up and putting them down. That does not mean the program needs to focus on increasing maximum vertical jump, decreasing 40 m dash time, or any other metric that fits nicely into an excel sheet. Moving in different ways, moving fast, and being able to react to the environment are skills that need exposure just like a squat or deadlift.
There is no one optimal dose for power training. Loads from bodyweight all the way to 1 repetition max for a specific lift can be used with the intent to move fast. Ultimately, both weight selection and exercise selection is dependent on the athlete’s goals, training history, and where they are in the rehabilitation process. Low-level coordination, timing, and rhythm movements have a place in preparing athletes for maximum effort, but at some point the governor needs to be removed and the intent to be as fast, or as hard as an athlete can move. The caveat is that absolute maximum effort should not comprise the majority of a program. There is too much of a good thing, and “hard for the sake of being hard” is not a wise training strategy either.
Options for training almost always exist after an injury. Even if an athlete cannot perform max sprints, max lifts, or jump there are numerous exercises they can perform with intent. The role of a rehab professional is to manage that intensity, keep an athlete as athletic as possible, and find means of helping them increase their potential in spite of being injured. Exercises can be scaled to still work on maximizing force production or moving faster and there are countless means of accomplishing this task. For the lifting community in particular, introducing movements that work to develop power, and develop a foundation of athleticism would help produce individuals who are capable of doing more than just picking things up and putting them down.