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What Do You Do When You Have to Program for an Athlete With an Injury?

Bennett, Scott MEd, CSCS*D

Strength and Conditioning Journal: February 2009 - Volume 31 - Issue 1 - p 65-67
doi: 10.1519/SSC.0b013e318195a247
OTHER FEATURES: College Coaches Corner
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THE STRENGTH AND CONDITIONING COACH OFTEN IS FACED WITH DESIGNING A CONDITIONING PROGRAM FOR AN INJURED ATHLETE IN DIFFERENT PHASES OF THE REHABILITATION/RETURN TO PLAY PROCESS. AS A STRENGTH AND CONDITIONING COACH, WHAT DO YOU DO WHEN YOU HAVE TO PROGRAM FOR AN ATHLETE WITH AN INJURY?

University of Southern Mississippi, Hattiesburg, Mississippi

Ron McKeeferyis the Head Strength and Conditioning Coach at the University of South Florida, Tampa Bay, Florida.

Stephanie Tracey-Simmonsis the Head Strength & Conditioning Coach, Olympic Sports, at the University of Kentucky, Lexington, Kentucky.

Greg Werneris the Head Strength & Conditioning Coach at James Madison University, Harrisonburg, Virginia.

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Scott Bennett, MEd, CSCS*D

Column Editor

It is very important as strength and conditioning professionals to have a great relationship with your sports medicine team. We strive hard to provide our injured athletes with the best care and training possible. Successful rehabilitation of injured athletes requires great communication, trust, and structure.

Communication is the fundamental component to dealing with injured athletes. We communicate with our sports medicine team every day, most days multiple times. We are provided a daily injury report that gives us what the athletes have approached the trainers with, which we use to adjust workouts before training occurs. Additionally, we meet at the end of each day to discuss anything that came up during the training groups.

To improve communication, the best thing we have done is include 2 sections on our workout card. We have one section for medical and orthopedic concerns and one for prehabilitation/rehabilitation protocols. In the medical orthopedic concerns section, the sports medicine staff writes down every injury reported and their limitations. Our strength staff is trained to look at this section before any training occurs to make sure they are training the athlete appropriately. During our meetings with our sports medicine staff, we write in any prehabilitation/rehabilitation protocols that we determine necessary for the athlete in that section. This way, we know each day the sports medicine team is training the injured area and is aware of what the athlete is doing. Finally, we make each of our athletes get their workout card signed by the trainer each day. Most athletes want to lift weights but don't always like getting treatment. This is our way of helping our sports medicine team get the athletes that need treatment in the training room. This has gone a long way with establishing the trust and respect for the 2 departments.

We must also have a relationship built on trust with the athlete. It is difficult to train when you are injured. As strength and conditioning professionals, we must be able to motivate the athlete. If an athlete does not trust you, then his or her rehabilitation will be slowed down. To provide optimal training conditions, we encourage athletes to express how they are feeling and progressing. One way we build trust and confidence is by calling and sending encouraging text messages. Additionally, we are there for a kick in the pants when they get frustrated and stressed.

When we adjust our workouts for injured, nonsurgical athletes, it is not very noticeable to someone standing by, or to the group. We try to make things as normal as possible. All of our injured athletes train. If they have a right lower-limb injury, they are doing the other limb and the upper body. Our entire inventory of machine-based equipment has independent movement arms. Athletes never stop training.

We group our athletes into groups of 4 and put a strength coach with them. This way when an exercise cannot be performed because of an injury, the strength coach simply alternates it with the exercise we predetermined appropriate. If it is a very serious injury and requires additional care, we then bring the athlete in individually between lift groups. We will also do this when an athlete is not giving one hundred percent effort.

In determining appropriate alternatives we consider modalities, execution (bilateral, unilateral), and muscles trained. Our athletes often joke and say “they are going to take our internet away” because we can always find an alternative exercise. Our trainers will usually turn the athlete back over to us at about 55-60% of his or her previous strength level. Up until that point, we trust our sports medicine team is doing everything they can to get the athlete back to us. In return they trust we will not injure the athlete from the 60-100% mark.

It is important to communicate effectively with both the student athlete and the sports medicine team. Communication often leads to the trust that is necessary to get the job done. Once we gain trust, we establish a training structure that works for the athlete, sports medicine staff and strength and conditioning professional.

At the University of Kentucky, we have a great relationship with our athletic training staff. Every week, we receive a full injury report on our athletic teams. This injury report discusses all athletes who have any type of illness or injury, as well as the considerations that should be taken during practices, conditioning sessions, and weight lifting.

The considerations of restrictions or limitations to exercise are obviously reflected by what type of injury has been incurred. The list of injuries that we have observed in the weight room is extremely broad. We've worked with every injury, from a sprained wrist to athletes who have had back surgery. The guidelines that we follow are similarly broad based and are mostly communicated by the athletic trainer. It is so vital to the success of the athlete to have an open line of communication between the strength staff and the athletic training staff. This is truly the only way we may be certain of what the athlete's particular needs are.

There are so many factors to consider when working with injured athletes, but when breaking down the areas of injuries, there seems to be 3 categories: (a) acute, (b) chronic, and (c) nonathletic-related/illness. A few examples of acute injuries would be: an ACL tear, a torn rotator cuff, or a herniated disc. These injuries, all very severe, need to be first evaluated by the athletic training staff and by the team doctors. After both of these professionals have determined the exact injury and that surgery is required, surgery is scheduled, followed by a period of rehabilitation with the training staff. When the trainer and the doctor are comfortable with the athlete's progress in therapy, he or she is then permitted to train with the strength staff given limitations. A program is then developed that takes into account the medical restrictions but still demands strength gains from the rest of the athlete's body. The program's focus is more on the use of the healthy extremities as well as the core. Once the athlete progresses in the affected area, we begin by doing light weight exercises within the limitations of the injury and gradually increase the weight over time.

A common example of a chronic injury is tendonitis. With this type of injury, it is extremely important to communicate with both the athletic trainer as well as the involved athlete. Tendonitis is an injury that has varying degrees of pain from day to day due to repetitive movements. We try to keep the athletes as mainstream as possible in these types of cases by having them do the same exercises as their teammates but with small changes. For example, on a squat exercise for someone who may have patellar tendonitis, we'll try to have the athlete decrease weight being used or change the range of motion to prevent painful stimuli. If these changes don't help, then we may try bodyweight exercises or remove the affected leg from all movements by doing one leg squats instead.

In cases of nonathletic-related injuries and illnesses, we usually work with these on a case-by-case basis. For instance, if an athlete has a condition like epilepsy, he or she would probably be cleared for most lifting activities, but may have some limitations during conditioning. For illnesses such as the flu, most of the time we talk with the training staff to get a better idea of how severe of a case it is before we make a decision as to whether or not the athlete would participate in that day's workout. If the athlete has a fever or is termed contagious by a physician, then he or she is excused from that particular day.

When programming for an injured athlete, it's also important to realize that this can be a time of frustration for everyone involved because of the emotional impact and mental challenges it can present. By communicating with both the athlete and the athletic training staff, we're able to get a better grasp on the issues at hand and better serve the athlete. When the athlete understands that the strength staff, the sport coach, and the athletic trainer are all working together on a program that gives direction to his or her recovery, it gives a sense of stability as well as inclusion with the team. Ultimately, it is the goal to help athletes who have suffered injuries or illnesses return to normal workouts with their teammates.

Today's competitive athletes are more involved in comprehensive strength and power development than ever before. To maintain the competitive edge, athletes can rarely afford to take time off from resistance training, even when they are injured. Yet some athletes are still receiving misinformation and are told to avoid certain lifts to prevent damaging their weakened tissue during recovery or, even worse, some athletes are advised to stop weight training all together during the injury rehabilitation period.

When an athlete is sidelined with an injury, it is critical that he or she follow the directions of the sports medicine team and adhere to proper therapy and treatment to help assure a successful and timely return to practice and competition. The sports medicine team should be composed of many of the following professionals, including the team physician, physical therapist/athletic trainer, strength and conditioning specialist, and the sport coach.

The athlete's physician should be ultimately responsible for deciding when the athlete is ready to return to practice and/or competition. That decision should be based on collective input from the entire sports medicine team and the athlete. The athlete must understand that he or she ultimately holds the key to return to practice and competition. The athlete must communicate openly and honestly with everyone involved in the recovery.

An athlete's communication with the strength and conditioning coach and subsequent return to strength and conditioning activities after injury should be immediate. A time lapse in an athlete's strength and conditioning program due to injury will adversely affect gains the student athlete made in training. To optimize return to play, an athlete must continue training.

The key areas that should be addressed in strength and conditioning training while injured are:

  • general total body conditioning;
  • maintenance of sport-specific cardiorespiratory fitness;
  • maintain/gain/regain muscle strength, power and/or endurance;
  • maintain/regain proprioception and balance; and
  • prevention of new tissue disruption

Maintaining cardiorespiratory fitness is perhaps the single most neglected component of a rehabilitation program. Creativity and cross-training are the keys to fitness success while one is injured. Ideally, one should progress from general nonimpact exercises to more sport-specific functional exercises with the goal of returning to full activity at or near 100% of preinjury conditioning level.

  • Upper-extremity injury (cannot run): use a stationary bike, stepping machine, elliptical runner, or pool
  • Upper-extremity injury (can run): use your sport's natural surface or, if needed, a treadmill
  • Lower extremity injury: use an upper body ergometer, bike, or pool

As far as strength training is concerned during the rehabilitation process, let the trainers and therapists work with the injured area and the strength and conditioning coach can work with the rest of the body.

A common observation in rehabilitation and in strength training is that chronic manipulation of one side of the body can cause adaptations to the other side. This is referred to as cross education or the cross-over effect. When one limb is injured, athletes should train unilaterally, using dumbbells or machines, with the uninjured limb.

Unilateral training of uninjured limbs:

  • Upper extremities: use the assistance of a spotter to help get the weight (dumbbell or machine) into its starting position. If possible, move the injured limb through the active range of motion, either unloaded or with a very light load, while the uninjured limb performs the exercise with a substantial load, this will increase neural drive and the cross-over effect to the injured limb. When possible, use manual resistance to spot load the injured limb in a pain free range of motion (i.e., with a wrist injury you can manually apply resistance at the forearm, and with a elbow injury you can apply resistance at the upper arm for chest, shoulder, back and arm exercises)
  • Torso (core): Train within the athlete's tolerance, paying attention to weight bearing activities, but it's extremely important to maintain strength in these areas to allow for faster progression once weight bearing activities are resumed.
  • Lower extremity: generally isolate the unaffected leg with single leg, multijoint movements, particularly exercises that target single leg hip extension.
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In summary, the design and implementation of a rehabilitation program after injury or surgery requires communication between an athlete's entire sports medicine team and coach(s), and complete cooperation and communication from the athlete.

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© 2009 National Strength and Conditioning Association