In part one of two, I proposed a rehab-training continuum that has helped organize my methods in a coherent and scalable way. This model provides a wider perspective that includes injury through to athletic development. It’s also generalizable as it broadly covers the spectrum of function from low to high levels.

In today’s article, I’ll be demonstrating the utility of this framework using an athletic needs analysis and two case studies.

NEEDS ANALYSIS / ATHLETE PROFILE

The goal of a needs analysis is to identify the biomotor abilities required for a sport. As seen in the images below, this analysis can be individualized by profiling an athlete based on our assessment. This acts as a snapshot for what qualities need to be developed after an injury and over the long term.

During rehab, there is often a temporary drop in athletic qualities due the inability to load painful tissues. This is predictable since pain alters movement variability, efficiency, and capacity. During training, we are looking to develop deficient qualities that are relevant to the sport and individual. In both cases, we are trying to give the athlete what they don’t have compared to what is needed for optimal health and performance.

With regard to rehab and training, our metrics might include variability, efficiency, capacity, and specificity. Variability, efficiency, and capacity maintain the same definitions as discussed in part one. Specificity stands in opposition to variability since it requires intentionally narrowing movement options so that all resources can be pushed towards raising an output (1).

For the athlete profiles, ‘100 units’ indicates the maximum amount available for a given quality compared to top performers in each area. For example, an elite power lifter is the purest expression of absolute strength, therefore specificity will rate very high in this circumstance . In contrast, a soccer player requires a more broad distribution of athletic qualities in order to be successful. They aren’t pigeon holed into a high degree of specificity and need to be more balanced in the capacities that they express.

CASE STUDIES

Let’s use the rehab-training continuum to address a grade 2 lateral ankle sprain in a soccer player. Please refer to the first image for context.

1. The acute nature of this injury would place us on the left side of the graph in the variability category. Our initial focus would be pain and swelling management, tissue healing, mobility restoration, and optimal loading. In this scenario, manual therapy to improve dorsiflexion could be thought of as a regression to loading the lower extremity into triple flexion like we see during a cut, deceleration, or squat.

2. As we transition into the sub-acute phase, we could work on movement efficiency through basic bodyweight patterns. Appropriate interventions could include single leg squat progressions and lunging drills that load into triple flexion. Specific attention should be placed on the set-up and end-points of these movements to ensure we are respecting attractors. For example, we might cue a tripod foot and joint stacking of the hip, knee and ankle. Graded exposure through low-threshold activities will drive progress.  

3. During the later stages of rehab, we should have weaned off passive therapies and lower-level drills to transition into more training scenarios. This is where we re-build capacity. Depending on the end goal, this could include plyometric progressions and change of direction drills. Progressive overload through high threshold activities will drive further adaptation.

4. The training side of the continuum consists of a long-term plan aimed at improving performance and mitigating injury risk. This could consist of further multi-directional drills that intend to build robust tissues and patterns in the context of sport.

This framework can also be applied outside of an acute injury. I believe it’s particularly useful for long-standing pain with an insidious onset and no obvious mechanism. Let’s use chronic shoulder pain in an elite power lifter as an example:

1. The athlete of interest has been experiencing left shoulder pain for 2 years associated with overhead activities and horizontal pressing. They are a wide ISA with flexion, abduction, and external rotation limitations on the left side more than the right. They also have restrictions with left cervical rotation, left MSR and increased tone of the left UFT, latissimus dorsi, and pectoralis major. From a variability standpoint, we may work on manual therapies and activities that promote left dorsal-rostral expansion. If we think we’ve optimized axial skeleton position, we can shift our focus to more traditional mobility interventions. This could include manual therapies to areas with increased tone or joint mobilizations as necessary.

   It may also be helpful to incorporate more unilateral/reciprocal activities to promote alternating expansion and compression while maintaining the ability to turn the torso. We might introduce incline and decline reaches and pulls while creating a ‘stack’ of the thorax on top of the pelvis – this could be appropriate as part of a warmup or as accessory exercises. Temporarily removing patterns that are feeding the problem could be a great adjunct strategy. In this example, bilateral/symmetrical pushes and pulls and activities with the scapula pinned down and back may be exacerbating the issue by creating more dorsal-rostral compression.

2. In terms of efficiency, it makes sense to optimize the athletes movement strategy based on archetypal shape and known attractors. Relatively lighter loads would be used in this phase. We want to ensure the athlete has good motor control and movement economy in relation to their competition lifts. With a barbell bench press, we might focus on an efficient bar path, joint stacking of the elbow and wrist, adequate torque through the shoulder complex, strong leg drive, and hyper-irradiation.

3. During the capacity phase, we can start to re-build strength with bilateral/symmetrical pushes and pulls, assuming the athlete is still able to maintain enough variability to stay pain free. This should transition nicely into a long-term training plan aimed at improving performance and mitigating injury risk.

This concludes my article series on the rehab-training continuum. Any feedback is much appreciated. I am still working through these ideas and it’s by no means complete. Post in the comments below or send me a private message and let me know what you think!

References:

1. Hartman B. The Intensive IX. Presentation presented at IFAST; 2019.