Credit to my friend Tom Farrow for inspiring this blog post. If you are unfamiliar with him and his work, click here to read a recent blog post I wrote about the time he spent consulting with us in Tokyo. This particular post pertains to rehabilitation and Tom’s approach to returning injured athletes to elite level competition. This is informed by his experiences of working with both track and field athletes at Speedworks and Olympic kayakers at the English Institute of Sport. I liked the idea so much I decided to write about it here.
The problem with rehab
Rehab is a problem area for many clubs and athletes, even at the elite level. The reason for this is it lies in the grey zone between acute treatment of injuries (icing, soft tissue therapy, extremely low level exercise) and high level performance (sprinting, lifting, jumping, throwing etc.). Athletes have to be carefully guided along the progression from injury to performance, and there can be a decent amount of pain and discomfort along the way either from the very initial stages of the injury or as the athlete works their way back.
Unfortunately the standard response to pain and discomfort for most programmes is a knee jerk removal of ALL elements of the programme that could potentially irritate the injury. Do you have pain running? Ok, no more on-feet work. Does your back hurt when you squat a heavy barbell? No more lower body weights. The problem with this approach is two fold. Firstly it removes any potential stimulus to the body that would help to retain physical development or slow the rate of detraining associated with injury. And secondly it doesn’t help move the athlete any closer to return to play. Sooner or later, an injured athlete must master the activities that once injured them. If they cannot do this, they have no business coming back.
The most important rehab question to ask
“What can you do?”
Imagine performance as a pyramid: at the top lies the most demanding activity we can ask of the injury site in sport. This is typically the type of activity that causes the injury in the first place. For example in the context of a hamstring tear, this would be repeat sprint ability in a game context: maximal effort sprinting, under fatigue, with a variety of other stimuli distracting the athlete from thinking about proper running mechanics (ball, opposition, weather etc.). See the diagram below:
This represents the apex of rehabilitation and the goal that we should strive for before we consider our athletes fit to return to play- we cannot be rehabilitated until we master the thing that broke us in the first place.
As we work our way down the pyramid, we place those activities which represent less stress or less risk to the injury site. Typically these activities will entail less force, speed and unpredictability within the environment. Again using our sprinting example, some middle of the pyramid activities may include straight line sprinting when in a fresh state, extensive and intensive tempo, or intensive plyometric bounding. All easier on a recovering hamstring than the example listed above.
At the very base of the pyramid lies basic function in the absence of load, speed, or any unpredictability of the environment. For me this means full range of movement, basic stability and muscle activation.
When faced with pain and discomfort, our job as coaches, rehabilitation specialists and athletes should not be to avoid anything that hurts and remove vast chunks of the programme. Rather it should be to ask “what can you do?”, to find the level on the pyramid that you can perform at, and work at that level until we have earned the right to progress.
This pyramid concept has two important implications for injury rehab:
1. It provides a framework that allows us to progress rehabilitation in a logical manner. In order to progress to a certain activity, we first have to master the activities that lie underneath it on the pyramid. You have no business doing sprinting if you can’t even touch your toes or squeeze your hamstring without feeling pain. This framework also provides a useful “end point” for coach and athlete to work towards before return to play can take place.
2. It can save a lot of time and frustration in the rehab process. Rather than just adhering to arbitrary protocols or timelines that call for x weeks of a particular activity, y weeks of the next most intense activity etc. the athlete can be quickly progressed to the level of activity that is most productive for their recovery, ensuring the least detraining and the fastest return to play.
For example, Dan Pfaff and coaches within his network have spoken about how athletes with a high hamstring strain are capable of performing low amplitude dribbles two days after an injury. By focussing on what the athletes can do, they are able to retain some technical elements of high speed running in the programme and get in a little overspeed high frequency work whilst not aggravating the injury or interrupting recovery.
If we don’t like the answers we are getting, perhaps it is time to start asking some different questions. For rehab, let’s begin by asking what our athletes CAN do.