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Columns: Flexibility and Rehab Tips

Facilitating Power Development in the Recovering Athlete

Triple Extension in Rehabilitation

Lorenz, Daniel DPT, PT, ATC/L, CSCS, USAW

Editor(s): Reuter, Ben PhD, CSCS*D, ATC

Author Information
Strength and Conditioning Journal: February 2016 - Volume 38 - Issue 1 - p 48-50
doi: 10.1519/SSC.0000000000000192

Abstract

Athletes recovering from an injury typically follow a progression through the rehabilitation process ultimately leading to return to play. Functional testing algorithms have been proposed to ensure that every athlete is tested along the continuum of rehabilitation to address each physical quality of performance (8). For the strength and conditioning as well as the rehabilitation professional, restoration of strength and power is paramount to a successful outcome and optimal performance. Several studies have demonstrated that power differentiates elite from nonelite athletes in the same sport (3,4,6,10,15,19,20). Therefore, integration of power-based exercises should be the focus of the terminal phases of rehabilitation as the athlete transitions back to the weight room. Without a proper strength base, however, optimal power cannot be achieved.

Athletes recovering from injury, particularly in the lower extremities, have specific considerations that need to be addressed in rehabilitation. For example, Neitzel et al. have shown that athletes recovering from anterior cruciate ligament (ACL) reconstruction “unconsciously unload” their involved limb up to a year after surgery (14). In other words, athletes do not realize that during bilateral lower limb tasks, they are shifting weight to the uninvolved limb. Furthermore, Paterno et al. (17) and Chmielewski (7) found that athletes unload their involved limb up to a year after surgery during performance of a depth jump. Another study found avoidance of high vertical impact forces and compensation during bilateral movements in 50 ACL-reconstructed patients (5). Finally, a study by Angelozzi et al. (1) found that it took a year after surgery before the rate of force development in the involved limb was equal to the uninvolved one. From these studies, it is evident that unilateral deficits present after lower extremity injuries exist and need to be a focus of rehabilitation and strength and conditioning. Without appropriate loading of the involved limb, an athlete will struggle to change direction properly, may leave the uninvolved limb at risk of overuse injury, or may cause reinjury of the involved limb when the athlete eventually must fully load it during athletic competition.

“Triple extension” is a combination of ankle plantarflexion, knee extension, and hip extension. It is the synergy of these 3 individual components that allows an athlete to run, jump, sprint, and change direction to perform their sport movement. Deficits in ankle plantarflexion have been found after Achilles tendon reconstruction (12) and knee extension after ACL reconstruction (23). Therefore, it is plausible that deficits along the kinetic chain will have a detrimental effect on power through triple extension. Depending on an athlete's individual impairments and functional limitations, components of triple extension are addressed in rehabilitation, but rarely together. For example, a common step-up exercise involves hip and knee extension but lacks ankle plantarflexion. Another example is the heel/calf raise exercise. With this exercise, the athlete commonly has the hips and knees already extended while they perform ankle plantarflexion. It is well documented that, particularly after an injury or surgery, the athlete may demonstrate deficits in neuromuscular coordination (9,13,16,18,24). The lack of neuromuscular control may lead to several deleterious effects including aberrant movement patterns that can exacerbate the current injury or potentially cause a new injury. Furthermore, deficits in neuromuscular control may cause inefficient movement through improper mechanics of sport activities. Intuitively therefore, these movements can and should be addressed in earlier phases of rehabilitation to eventually help maximize return to sport activities such as running, jumping, and cutting.

Triple extension is maximized most by the use of Olympic-style movements such as the clean, jerk, and snatch (2,11,21). Although the recovering athlete may not be appropriate for high loading and/or complex movements like these in the early and middle phases of the rehabilitation process, the movements can be facilitated in a safe manner. The following are suggested interventions to facilitate power development and triple extension in the terminal phases of rehabilitation.

ELEVATED SQUATS

See Video 1, Supplemental Digital Content 1, https://links.lww.com/SCJ/A166.

Because of unloading of the involved limb during double-leg tasks found in previous studies, it is common for the recovering athlete to struggle with performing squats correctly. Under the skilled eye of a rehabilitation or a strength and conditioning professional, tilting of the pelvis or side flexion of the lumbar spine can be observed in an athlete who is not symmetrically distributing weight. Therefore, the rehabilitation or strength and conditioning professional can facilitate weight shifting to the involved side by putting the uninvolved limb on a small step. Once the athlete can squat with proper form, the step can be removed. Ultimately, this exercise helps ensure that the athlete is ready for more complex movements like back/front squats and Olympic-style lifts.

TRIPLE EXTENSION HEEL RAISE

See Video 2, Supplemental Digital Content 1, https://links.lww.com/SCJ/A167.

Here, the athlete triple flexes, then triple extends. The subject is shown barefoot in the video only to illustrate even distribution of weight among the metatarsal heads during the activity. Shoes are encouraged during performance of the exercise. The athlete may have their hands on the wall for either safety or to help ensure proper performance of the exercise. Any athlete who lands from a jump or decelerates before changing direction needs to triple flex before triple extending (23). Common errors in performance include frontal plane tilting of the pelvis, “hiking” the hip to compensate for weak hip extension, inability to maintain ankle dorsiflexion at the start of the movement, and inability to fully extend the hip, knee, and ankle.

TRIPLE EXTENSION LUNGE

See Video 3, Supplemental Digital Content 1, https://links.lww.com/SCJ/A168.

The athlete completes a walking lunge, then plantarflexes the ankle after the concentric hip and knee extension. Common errors with this movement include lack of frontal plane control of the pelvis and knee, lack of transverse plane control of the knee, or loss of balance in the triple extension position. Additionally, the lunge can be modified based on the subject's diagnosis. For example, an athlete with patellofemoral pathology can perform less knee flexion and more hip flexion (knee behind the toes) to reduce patellofemoral compressive forces. However, when trying to facilitate a more quadriceps-dominant lunge, more knee flexion (knee over the toes) may be performed.

TRIPLE EXTENSION STEP-UP

See Video 4, Supplemental Digital Content 1, https://links.lww.com/SCJ/A169.

The athlete performs a step-up, but adds ankle plantarflexion to the movement. Dumbbells or barbells can be used for resistance. The rehabilitation or strength and conditioning professional should be mindful of the athlete being able to maintain proper balance during this movement.

“POWER” STEP-UP

See Video 5, Supplemental Digital Content 1, https://links.lww.com/SCJ/A170.

Weyand has previously stated that the most explosive athletes put the most amount of force into the ground and spend the least amount of time on the ground (22). Here, the athlete “punches” the step to elevate the amount of force. Although this is not a triple extension movement, it encourages single limb force. This punch into the ground is similar to the bilateral tasks involved in Olympic-style lifts.

Before adding these modifications into a program, the athlete should demonstrate proficiency with the more “standard” heel raise, lunge, and step-up. Furthermore, the athlete should be able to maintain the fully extended position without a loss of knee extension, hip extension, or maintenance of erect trunk posture. Adding these modifications is a simple way to “begin with the end in mind” and facilitate athletic movements before the athlete returns to more complex movements in the weight room and ultimately, back to sport.

REFERENCES

1. Angelozzi M, Madama M, Corsica C, Calvisi V, Properzi G, McCaw ST, Cacchio A. Rate of force development as an adjunctive outcome measure for return-to-sport decisions after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 42: 772–780, 2012.
2. Arabatzi F, Kellis E. Olympic weightlifting training causes different knee muscle-coactivation adaptations compared with traditional weight training. J Strength Cond Res 26: 2192–2201, 2012.
3. Arnold JA, Brown B, Micheli RP, Coker TP. Anatomical and physiologic characteristics to predict football ability: Report of study methods and correlations, university of Arkansas, 1976. Am J Sports Med 8: 119–122, 1980.
4. Baker DG, Newton RU. Comparison of lower body strength, power, acceleration, speed, agility, and sprint momentum to describe and compare playing rank among professional rugby league players. J Strength Cond Res 22: 153–158, 2008.
5. Baumgart C, Schubert M, Hoppe MW, Gokeler A, Freiwald J. Do ground reaction forces during unilateral and bilateral movements exhibit compensation strategies following ACL reconstruction?. Knee Surg Sports Traumatol Arthrosc 2015. Epub ahead of print.
6. Burr JF, Jamnik RK, Baker J. Relationship of physical fitness test results and hockey playing potential in elite-level ice hockey players. J Strength Cond Res 22: 1535–1543, 2008.
7. Chmielewski TL. Asymmetrical lower extremity loading after ACL reconstruction: more than meets the eye. J Orthop Sports Phys Ther 41: 374–376, 2011.
8. Davies GJ, Zillmer DA. Functional progression of a patient through a rehabilitation program. Orthop Phys Ther Clin North Am 9: 103–118, 2000.
9. Delahunt E, Sweeney L, Chawke M, Kelleher J, Murphy K, Patterson M, Prendiville A. Lower limb kinematic alterations during drop vertical jumps in female athletes who have undergone anterior cruciate ligament reconstruction. J Orthop Rel Res 30: 72–78, 2012.
10. Farlinger CM, Kruisselbrink LD, Fowles JR. Relationships to skating performance in competitive hockey players. J Strength Cond Res 21: 915–922, 2007.
11. Hori N, Newton RU, Nosaka K, Stone MH. Weightlifting exercises enhance athletic performance that requires high-load speed strength. Strength Cond J 27: 50–55, 2005.
12. Mullaney MJ, McHugh MP, Tyler TF, Nicholas SJ, Lee SJ. Weakness in end-range plantarflexion after Achilles tendon repair. Am J Sports Med 34: 1120–1125, 2006.
13. Myers JB, Wassiner CA, Lephart SM. Sensorimotor contribution to shoulder stability: Effect of injury and rehabilitation. Man Ther 11: 197–201, 2006.
14. Neitzel JA, Kernozek TW, Davies GJ. Loading response following anterior cruciate ligament reconstruction in the parallel squat exercise. Clin Biomech 17: 551–554, 2002.
15. Newman MA, Tarpenning KM, Marino FE. Relationships between isokinetic knee strength, single-sprint performance, and repeated-sprint ability in football players. J Strength Cond Res 18: 867–872, 2004.
16. Nyland J, Wera J, Klein S, Caborn DN. Lower extremity neuromuscular compensations during instrumented single leg hop testing 2-10 years following ACL reconstruction. Knee 21: 1191–1197, 2014.
17. Paterno MV, Schmitt LC, Ford KR, Rauh MJ, Myer GD, Hewett TE. Effects of sex on compensatory landing strategies upon return to sport after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 41: 553–559, 2011.
18. Pollard CD, Stearns KM, Hayes AT, Heiderscheit BC. Altered lower extremity movement variability in female soccer players during side-step cutting after anterior cruciate ligament reconstruction. Am J Sports Med 43: 460–465, 2015.
19. Sawyer DT, Ostarello JZ, Suess EA, Dempsey M. Relationship between football playing ability and selected performance measures. J Strength Cond Res 16: 611–616, 2002.
20. Sierer SP, Battaglini CL, Mihalik JP. The national football league combine: Performance differences between drafted and non-drafted players entering the 2004 and 2005 drafts. J Strength Cond Res 22: 6–12, 2008.
21. Tricoli V, Lamas L, Carnevale R, Urgrinowitsch C. Olympic weightlifting training causes different knee muscle-coactivation adaptations compared with traditional weight training. J Strength Cond Res 19: 433–437, 2005.
22. Weyand PG, Sternlight DB, Bellizzi MJ, Wright S. Faster top running speeds are achieved with greater ground forces not more rapid leg movements. J Appl Physiol 89: 1991–1999, 2000.
23. Xergia SA, Pappas E, Zampeli F, Georgiou S, Georgoulis AD. Asymmetries in functional hop tests, lower extremity kinematics, and isokinetic strength persist 6 to 9 months following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 43: 154–162, 2013.
24. Yosmaoglu HB, Baltaci G, Kaya D, Ozer H. Tracking ability, motor coordination, and functional determinants after anterior cruciate ligament reconstruction. J Sport Rehabil 20: 207–218, 2011.

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