“We do chronically underload MSK conditions. Several reasons; physios often do not understand S & C principles, are unclear about the load that exercises place on structures, and for me the key thing is that they have never been in a gym themselves.” – Jill Cook

PART 2

I believe that plyometrics are one of the most undervalued treatment tools for musculoskeletal injuries. If we look at the end goal for most of our clientele, it involves some element of power, especially if we are working with athletes. I’ll often see clients who haven’t returned to their previous activities despite working with another well-intentioned rehab professional. Sometimes, these rehab cases were incomplete as the previous therapist didn’t consider and restore the rate of force development required for their activity. The SAID principle always ring true – the human system adapts to the imposed demands that we place on it, for better or for worse.

This is why I believe so strongly in the importance of doing a needs-analysis for the sport and athlete, which acts as a snapshot for what qualities need to be developed after an injury and over the long term. Our exercises should eventually reflect this needs analysis and should aim to mimic force-velocity profiles, force vectors, joint angles and actions, energy system demands, and common injury mechanisms.

Power = Strength x Speed

We have strong evidence to support the protective effects of capacity in a well-rounded rehab program (1). If we want to resolve pain and mitigate injury risk, there’s a point in time where we must build task specific load tolerance. This doesn’t mean that we should abandon the restoration of movement options and the development of movement economy; what it means is that we should focus on the relevant signals and stop chasing the noise.

In the late stages rehab and return to sport, our end goal should be to restore sport-specific power with the relevant patterns and tissues in mind. Since power is a biproduct of strength and speed, restoring foundational strength should be our first target. Once we’ve developed a solid base of isolated and integrated strength, we can use concurrent training to incorporate plyometrics. Concurrent training allows us to build multiple qualities at the same time – in this case, strength and power – with intentional programming and exercise selection.

Return to Play Framework

The framework presented in today’s article aims to use graded exposure and progressive overloading to re-introduce power. It provides a logical pathway that is governed by increasing task and tissue demands. Each level requires a greater rate of force development and ground reaction force, giving the body an opportunity to adapt in a step-wise manner.

In the context of rehab, the underlying question that needs to be answered for any exercise progression is: where is the patient at and what is the next logical step? Assessing someone’s current level of function will allow us to apply interventions at the edge of their ability with progressive overload in mind. Our understanding of exercise progressions and regressions gives us the ability to scale movements when needed. This phase of rehab should look a lot like traditional training, because it is traditional training. I have therefore categorized it under ‘general preparation’ as it seamlessly transitions into the accumulation phase.

It’s worth mentioning that the technical and tactical aspects of sport are equally as important in any return to play scenario. An athlete needs to be gradually exposed to sport-specific skills and game-like scenarios in order to feel physically and mentally prepared for their return. Details surrounding psychosocial and sport-specific return to play are beyond the scope of this article.

Additional Considerations

This framework is by no means exhaustive. For example, I didn’t include rotational plyometrics since frontal and transverse motions occur with lateral hops and bounds. I have nothing against rotational plyometrics and there are definitely times where it makes sense to use them. Re-introducing a slopestyle snowboarder to the demands of spinning and flipping would be one instance, and a rotational double leg box jump could be used to accomplish this goal. There are no strict rules and we are only limited by context and creativity.  

We can also skip steps or choose sub-categories of exercises depending who the patient is and how adaptable they are. Exercises should be selected based on the individual, sport, injury, and desired adaptations. For example, the ankle driven plyometrics could be appropriate for a tennis player who is struggling with an achilles tendinopathy. The plyoball and club exercises seen in part 2 might be appropriate for a baseball player returning to throwing after a UCL injury. Different implements can be used in different contexts, but the principles of progression should stay consistent.

Definitions

To make sure we’re on the same page, I have defined my terms below. If you’d like to see how I fit these progressions into a more comprehensive model, check out my previous article here.

• Isometrics – can be used early in rehab for positional strength, time-under-tension, and pain modulation.

• Foundational strength – a pre-requisite to power. Using heavy-slow resistance training and tempo work to train basic movement patterns.

• Level 1 – Absorption/deceleration – used as an introduction to speed qualities. Trains energy storage and eccentric control. As a general rule, you can only produce what you can absorb.

• Level 2 – Propulsion/power output – used to train power development through fast concentric actions. Correlated with athletic movements that require longer ground contact times.

• Level 3 – Elasticity/repeated power – used to train repeated power development via the stretch-shortening-cycle. Correlated with athletic movements that require shorter ground contact times.

Principles of Progressions

The exercises in this article are derived from the principles below. You could just as easily create new exercises and progressions based on the context and athletic demands. Creativity and experimentation will provide more options to meet the patient where they are at.

• Double Leg (DL) → Split Stance (SS) → Single Leg (SL)

• Vertical → Sagittal (Horizontal) → Frontal (Lateral) → Transverse (Rotational)

• Band Assisted → Bodyweight → Medball (MB) potentiated

• No Counter-movement → Counter-movement

• Low Amplitude → High Amplitude

• Stick Landing → Repeated Plyometrics

• Isolated → Integrated

• No Perturbation → Perturbation

• Predictive → Reactive

• Slow → Fast

Return to Play Progressions

In part two, I’ll be running through my upper extremity return to play progressions. Please comment or reach out if you have any questions and tune in soon for more!

References:

1. Stephenson S, Kocan J, Vinod A, Kluczynski M, Bisson L. A Comprehensive Summary of Systematic Reviews on Sports Injury Prevention Strategies. Orthopaedic Journal of Sports Medicine. 2021;9(10):232596712110357.