Today I want to start with a simple question in regards to what you would let your son or daughter do when it comes to returning to sport related activities. We are going to initially take all science out of this question and just rely on simple logic. So here it is; it has been 3 months since ACL surgery, would it be appropriate to progress their program, that up to this point has had no plyometric training involved, to an activity that requires them to complete 200 hops per leg (both injured and non-injured leg) proceeded by a ¼ mile walk and then repeat for 1-3 more rounds?
Before reading on really think about that question and decide on your answer. At this point there is no right or wrong.
OK now let me interject some information. First let’s start with “no plyometric training”. Plyometrics will use the muscles natural elastic potential to create greater force production than occurs with a simple concentric contraction, which is the type of muscle contraction that predominates the rehab programs up to this point. Also, from a plyometric progression, a jump, double leg takeoff to a double leg landing, is much less intense than a hop, single leg takeoff to a single leg landing.
Before reading on really think about that question and decide on your answer. At this point there is no right or wrong.
OK now let me interject some information. First let’s start with “no plyometric training”. Plyometrics will use the muscles natural elastic potential to create greater force production than occurs with a simple concentric contraction, which is the type of muscle contraction that predominates the rehab programs up to this point. Also, from a plyometric progression, a jump, double leg takeoff to a double leg landing, is much less intense than a hop, single leg takeoff to a single leg landing.
So hopefully with this little amount of scientific facts I have provided you enough information to change your thought process in creating your answer to the 200 hop question. Not to say that the plan of attack is wrong, but at least make you realize that if anyone deserves the right to hit every step on the “plyometric progression staircase” it should be an athlete returning from an ACL injury.
So I may have changed your answer to the 200 hop question, so don’t forget how you answered it and we will get back to it a little later. Let’s dig a little deeper into the science.
Case example: limitations of the traditional model in ACL rehabilitation
Traditional rehabilitation protocol cannot satisfactorily develop the lower extremity strength required to effectively protect the knee and enhance performance for multi directional sports, athletes must sufficiently developed their fast twitch, type two muscles. These are responsible for high intensity force production, stabilization and force reduction.
New joint injuries negatively affect neuromuscular control (AMI) of the lower extremity and specifically affect type II fast twitch muscle. The exercises used to best develop this type II neurophysiological profile are often contraindicated for 3 to 5 months to protect the healing graft (such as heavy resistance training, plyometrics, sprinting, fast eccentric and concentric training), while strength training is encouraged during this time (0 to 5 months), it is still under estimating what will be required to best protect the knee in competition. Moderate intensity functional exercises (targeting type I muscle) often predominate in the rehabilitation protocol.
So I may have changed your answer to the 200 hop question, so don’t forget how you answered it and we will get back to it a little later. Let’s dig a little deeper into the science.
Case example: limitations of the traditional model in ACL rehabilitation
Traditional rehabilitation protocol cannot satisfactorily develop the lower extremity strength required to effectively protect the knee and enhance performance for multi directional sports, athletes must sufficiently developed their fast twitch, type two muscles. These are responsible for high intensity force production, stabilization and force reduction.
New joint injuries negatively affect neuromuscular control (AMI) of the lower extremity and specifically affect type II fast twitch muscle. The exercises used to best develop this type II neurophysiological profile are often contraindicated for 3 to 5 months to protect the healing graft (such as heavy resistance training, plyometrics, sprinting, fast eccentric and concentric training), while strength training is encouraged during this time (0 to 5 months), it is still under estimating what will be required to best protect the knee in competition. Moderate intensity functional exercises (targeting type I muscle) often predominate in the rehabilitation protocol.
High intensity sport specific training is usually indicated by months five through six post-op. This usually involves sprinting, cutting, technical support skill and other plyometric training. Following this, athletes are typically cleared to return to play at six months post-op after spending the least amount of time training the muscle fiber types (Type II) that contribute the most to protecting the knee under high stress. The return to competition program would not allow an athlete to return to team training following ACL surgery without multiple months a progressive type II activation training as part of an overall plan of reconditioning. A qualified athletic development professional makes decisions from a preparation and performance perspective, not a timeline based on biological healing.
Multidimensional speed and agility
Another very generic rehabilitation term is the return to running program. From my reconditioning perspective for multi directional athletes, we tend to avoid the use of the terms running or jogging. It is preferable to speak in terms of acceleration, deceleration, stabilization and change of direction. This approach is called multidimensional speed and agility, or MDSA. Most rehabilitation protocols used return to running as an indicator of functional restoration midway through a return to sport progression. This imparts a false sense of security for the athlete, as basic linear running requires very little strength and coordinative abilities. Yet the athlete feels a connection to function that clouds their vision of the essential athletic qualities that are still required to perform at a high-level. Typically, this quickly leads towards sport specific physical and technical skills that continue in the absence of the necessary strength and coordination required for deceleration and change of direction actions, thus potentially predisposing the athlete to re-injury or poor performance.
A performance base model understands that injury most often occurs during deceleration actions. Thus the performance team should focus on the complex movements of MDSA. Since perception, decision-making in speed in change of direction or critical factors in the performance of agility test, it is helpful to think of agility as having both motor and cognitive components. This must be trained at progressive levels throughout the entire reconditioning program. It cannot wait until that often prescribed final phase of the rehabilitation program.
If you can't slow down, don't speed it up
This is a basic message to stress the importance of delaying running until the athlete establishes significant strength to support change of direction and stopping. My experience is that, after injury, acceleration and other forms of force production are much easier to express then deceleration. This is why I support MDSA versus the return to running program for most athletes. MDSA can be implemented early and often in the reconditioning program at low intensity where it represents technical training only. In fact, the early post-operative phase is a perfect time to introduce basic running mechanics as static or slow images of the whole movement that is coming in the very near future. The static images become dynamic overtime but require a foundation of coordination and strength to protect the athlete.
Back to the 200 hop question
So based upon the information provided hopefully you see the error in starting a plyometric program with 200 single leg hops per leg with a bout of walking in between for 2-4 rounds. So you are probably think who in their right mind would start with such a program to stress these athlete returning from ACL surgery? Well let me answer that by breaking the hopping pattern down. We have 200 hops with each leg, but instead of hopping straight up let’s hop forward a little bit (enter sarcasm, not too much though, they just tore their ACL 3 months ago) and instead of doing all the hops on one leg and then the other let’s alternate legs. Next, let’s add an arm swing, maybe opposite of the leg they land on. What does that look like? It looks a whole lot like jogging, and the answer to who in their right mind would prescribe such a program is pretty much every medical protocol that has ever been written for ACL recovery! 400 total steps (hops) covers about ¼ mile in distance. Jog a ¼ mile then walk a ¼ mile repeat 2-4 times; this is a standard return to running program. Gives a false sense of security. I’m all for giving athletes returning from injury benchmarks to gauge recovery progress, but it is imperative that those skills actually relate to the sport in which they wish to return to and will build them towards the demand of that sport. Jogging is not that skill and it can lead to setbacks by increasing fatigue and taking away of building applicable skills.
Multidimensional speed and agility
Another very generic rehabilitation term is the return to running program. From my reconditioning perspective for multi directional athletes, we tend to avoid the use of the terms running or jogging. It is preferable to speak in terms of acceleration, deceleration, stabilization and change of direction. This approach is called multidimensional speed and agility, or MDSA. Most rehabilitation protocols used return to running as an indicator of functional restoration midway through a return to sport progression. This imparts a false sense of security for the athlete, as basic linear running requires very little strength and coordinative abilities. Yet the athlete feels a connection to function that clouds their vision of the essential athletic qualities that are still required to perform at a high-level. Typically, this quickly leads towards sport specific physical and technical skills that continue in the absence of the necessary strength and coordination required for deceleration and change of direction actions, thus potentially predisposing the athlete to re-injury or poor performance.
A performance base model understands that injury most often occurs during deceleration actions. Thus the performance team should focus on the complex movements of MDSA. Since perception, decision-making in speed in change of direction or critical factors in the performance of agility test, it is helpful to think of agility as having both motor and cognitive components. This must be trained at progressive levels throughout the entire reconditioning program. It cannot wait until that often prescribed final phase of the rehabilitation program.
If you can't slow down, don't speed it up
This is a basic message to stress the importance of delaying running until the athlete establishes significant strength to support change of direction and stopping. My experience is that, after injury, acceleration and other forms of force production are much easier to express then deceleration. This is why I support MDSA versus the return to running program for most athletes. MDSA can be implemented early and often in the reconditioning program at low intensity where it represents technical training only. In fact, the early post-operative phase is a perfect time to introduce basic running mechanics as static or slow images of the whole movement that is coming in the very near future. The static images become dynamic overtime but require a foundation of coordination and strength to protect the athlete.
Back to the 200 hop question
So based upon the information provided hopefully you see the error in starting a plyometric program with 200 single leg hops per leg with a bout of walking in between for 2-4 rounds. So you are probably think who in their right mind would start with such a program to stress these athlete returning from ACL surgery? Well let me answer that by breaking the hopping pattern down. We have 200 hops with each leg, but instead of hopping straight up let’s hop forward a little bit (enter sarcasm, not too much though, they just tore their ACL 3 months ago) and instead of doing all the hops on one leg and then the other let’s alternate legs. Next, let’s add an arm swing, maybe opposite of the leg they land on. What does that look like? It looks a whole lot like jogging, and the answer to who in their right mind would prescribe such a program is pretty much every medical protocol that has ever been written for ACL recovery! 400 total steps (hops) covers about ¼ mile in distance. Jog a ¼ mile then walk a ¼ mile repeat 2-4 times; this is a standard return to running program. Gives a false sense of security. I’m all for giving athletes returning from injury benchmarks to gauge recovery progress, but it is imperative that those skills actually relate to the sport in which they wish to return to and will build them towards the demand of that sport. Jogging is not that skill and it can lead to setbacks by increasing fatigue and taking away of building applicable skills.
Summary of all 3 parts!
If a professional athlete is following the same post injury program for the first three months that an average adult would follow for the same injury, then the concept of sports rehabilitation is greatly misunderstood by the practitioner designing and/or implementing such protocol. We must continue to advance the quality of post injury protocols for athletes by having discussions and sharing experiences with the orthopedic community as they can significantly influenced the path reconditioning can follow. By ensuring we operate as an interdisciplinary team, whereby performance coaches are involved in the decision-making processes, along with medical professionals, we may further understand that for athletic preparedness is not a given just because the peripheral musculoskeletal injury was repaired.
I also want to thank you for taking this time to absorb all of this information over this 3 part series. If you have any questions in regard to any of the information please do not hesitate to comment here or on Facebook. As always we are proud to be the areas leading authority for sports performance/reconditioning programming and information.
If a professional athlete is following the same post injury program for the first three months that an average adult would follow for the same injury, then the concept of sports rehabilitation is greatly misunderstood by the practitioner designing and/or implementing such protocol. We must continue to advance the quality of post injury protocols for athletes by having discussions and sharing experiences with the orthopedic community as they can significantly influenced the path reconditioning can follow. By ensuring we operate as an interdisciplinary team, whereby performance coaches are involved in the decision-making processes, along with medical professionals, we may further understand that for athletic preparedness is not a given just because the peripheral musculoskeletal injury was repaired.
I also want to thank you for taking this time to absorb all of this information over this 3 part series. If you have any questions in regard to any of the information please do not hesitate to comment here or on Facebook. As always we are proud to be the areas leading authority for sports performance/reconditioning programming and information.
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