As physical therapists, we often do a great job with the early phases of rehabilitation and helping people restore motion and strength.
But many people, especially athletes, also need to develop their loading capacity to get back to advanced activities like running, cutting, and jumping.
In this episode, we talk about how we progress people and build their loading capacity.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 321: Building Load Capacity After Lower Extremity Injuries
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All right, we got Devin from North Carolina, who says, “As a new graduate physical therapist, I don’t feel comfortable with some of the advanced exercises to build loading capacity after lower extremity injuries. What are some tips for taking someone from injured to full-speed running, cutting, and jumping?”
Awesome. Another great question, Devin. I like what we’re getting for questions lately. Because I feel like the questions we’re getting are probably on a lot of people’s minds. Last episode, I think, it was very similar to that, something that a lot of people are thinking about. But as a new grad physical therapist, it’s very daunting to look at somebody in front of you five days post-op with a gigantically swollen knee, a huge scar, bloody gauze everywhere, and think that they somehow need to start running, jumping, and cutting in the very near future. And there’s a lot of steps that get into that.
So I think in PT school, look, we get the, “Let’s get range of motion. Let’s get their baseline strength.” I think from my perspective, what we focus on here for Devin here is, “Okay, you have somebody that has their motion back. You have somebody that looks good. You have somebody that is doing strengthening exercises. How do you assure you’re going from strengthening exercises to building load when you start increasing ground reaction forces and all these fun things?” I think that that was my perception of what Devin was asking.
So I don’t know. The person I go to answer these questions is always Dan Pope and fitnesspainfree.com.
So why don’t we start with Dan, and you’ve probably done a recent podcast on this. We seem to always ask or answer questions that you’ve already answered on yours too. But Dan, you want to start off with helping Devin here?
Yeah, sometimes I do it in reverse. I don’t know if you guys noticed that, but if it’s a really good question here and I’m like, “Dang, I want to just say more,” I’ll do another podcast about it. I’m addicted to podcasts.
Yeah, I guess let’s assume that someone is post-op, so we probably have to go a little bit more slow and progressive. If someone’s not post-op, then oftentimes I’m kind of going to their tolerance. But if you’re trying to protect a surgical site and you know you can’t go too quickly, I think sometimes we need to be a little more systematic.
So let’s say it’s post-op ACL reconstruction, something along those lines. So maybe somewhere between three and four months you’re starting to think about introducing some plyometrics.
I tend to think about what does the athlete need to be able to do? Let’s say it’s something like soccer. So those folks are going to have to be able to kind of jog or run. They also have to be able to accelerate, they have to be able to do top-end speed, and then they have to be able to change direction or do agility stuff. And at the end, we have to layer in conditioning, which is going to be a little bit different from basically sport to sport, position to position.
But ultimately we can reverse engineer a bit of a solution. So in the beginning stages when you introduce, let’s say, plyometric activity, I think we’re just trying to build load tolerance. You’re not thinking about power, you’re not thinking about speed. I think when a lot of strength coaches think about these activities, they’re thinking about, “We’re trying to go fast and build power.” Early on, I don’t think that’s the case. It’s kind of building tolerance.
So I think your knowledge of how to grade your exercises and progress your exercise becomes really important. Unfortunately, we don’t get this education in PT school.
I usually start folks with something nice and easy, double-legged exercise before single-legged exercise. So think about pogo jumps. Some pogo jumps a couple times per week, and we’re watching along this process to make sure that we’re not losing range of motion, getting too swollen, or going backwards. That’s going to dictate if you’re going too fast or too slow. And each time you start to ramp it up a little bit more.
And I tend to think about how much volume I’m throwing at that person. And also how much intensity. So both start slow with pogo jumps, we may end up trying to do pogo jumps in different planes. If you think that someone needs it, you can actually do a pogo jump with a band to get started. So if you’re very scared with that person and you want to go very slowly, start with easy pogo jumps with assistance, and then advance yourself to just regular pogo jumps and then maybe into different planes.
Then I start to progress into some light jog, light skip. You can also throw in some light shuffle and carioca. I know I like those a lot. And then that naturally progresses into a bit of a return to jog program. And if you want to be really cautious, you can actually count the amount of repetitions you do with your pogo jumps throughout the course of a session and then calculate how much your return to run impact has. And then you’re just being very, very slow and progressive. You know exactly what you’re doing and controlling for.
Those pogo jumps turned into box jumps, box jumps turned into a box jump with a landing, and then you’re putting it together. Once you’re tolerating double-legged jumping, you progress to single-legged jumping.
Usually this is about a month, month and a half. And then you can start introducing, let’s say, some easy acceleration drills. I’ll start with fall runs, and I basically grade them. I give them a level of difficulty based on a perceived challenge. So we’ll say 50%, and then we work up to 60%, 70%. Then we do some buildup runs. So we’re working on top-end sprinting. During this time period, you can also introduce some very low-level change in direction drills, let’s say ladder drills, which are going to progress into, let’s say, some shuffling drills.
So you can kind of see that we’re working all these buckets. So jumping, we’re working on acceleration, we’re working on our top-end sprinting, we’re working on our changing direction. We’re starting very low and we’re working our way up slowly over the course of time.
I guess one more thing I’ll say before we move on is that I don’t think we’re educated very well on this stuff, so I’m going to try to put out more information in the future, but one person was very, very helpful for me, this guy by the name of Lee Taft. There’s a lot of courses out there. He is a strength coach, and what’s funny is that he creates these amazing programs that are developed for athletes trying to improve their performance, but he breaks everything down from high level to easy level for the beginner person getting into a sport. But what’s funny is that that’s perfect for rehab. So a large majority of my knowledge about that has come from him.
That’s great, Dan. And I think not a lot of people understand how much information you just presented right there. That was a lot of information that took you years to put together. And what I would suggest for you, Devin, for this, is figure out the loads that you’re specifically trying to get them back to. Dan kind of mentioned this at the beginning, it’s almost like starting with the end in mind. Where do they need to get to? So you know how to build towards it.
But what Dan just did there is he just took years and years and years of him going through research on ground reaction forces and contact stress and how certain exercises build on one another from both stress and eccentric control and all those sorts of things. So it’s a slow, slow accumulation over your career of that information that you apply.
And I couldn’t agree with Dan more. I’ve learned so much from the strength coach world on these progressions. A lot of times, they’re saying it’s from easy to hard, but for us, that’s less stressful to more stressful. Sometimes it’s the same thing. It’s just a different way of thinking about it.
So why don’t we shift gears and go to the strength coaches a little bit here. I know this is something that we do a ton of here. Maybe Diwesh, start off with you a little bit here, but I know at Champion, we spent a lot of time building out systems of progressions for our drills just so that way our interns can help, that way our new strength coaches can learn how we think of things. But what sort of advice would you give somebody, Devin, on how to build out those progressions?
Yeah, that’s a good way to think about it. What we tend to do is categorize stuff so that we have a specific way of talking about a quality that we need to develop. So if we’re talking about someone that needs to get back to high-level sport like Dan mentioned. A soccer player needs to be able to cut, sprint, and decel, accel, all those things at a high-speed, high-velocity model. So we got to reverse engineer and figure out how do we bring back high velocity? How do we bring back high force? How do we combine the two together so that we have high power output?
So we tend to categorize a lot of our jumps as forceful jumps or contractile jumps, mixed jumps, which is kind of a combination of contractile and a little bit of elastic. And then the other end, which is very elastic. And then even within that elastic realm, we kind of have what we call a slow stretch-shortening and a fast stretch-shortening.
So like Dan mentioned, pogo jumps. So pogo jumps would be classified under a fast stretch-shortening, meaning you’re getting in and out of a jump quickly. You have a very short amortization phase, whereas a slow stretch-shortening is going to be a longer amortization phase, longer ground contact time, where you’re probably going to have a little bit of a higher amplitude, meaning jump height.
So we tend to come up with drills that are easy, medium, hard for each of these categories. So easy, medium, hard for contractile drills. Easy, medium, hard for our mix drills. Easy, medium, hard for our fast stretch-shortening and slow stretch-shortening elastic drills. And then from there, we just kind of start layering in whatever they’re ready for. We give them that next progression up.
And then from there, what we start to think about is a lot of these drills happen in isolation. They’re not really, truly what the sport looks like. They’re a piece or component of the sport, but now how do we layer it all together, make it look like the sport? And for us, that looks like change in direction drills that have some reactivity to them, some really high-end sprinting for acceleration and top-end speed that requires a lot of that fast stretch-shortening, as well as that slower stretch-shortening if you’re talking about acceleration. So that’s kind of how we tend to progress.
And then lastly, Dan mentioned this as his last bucket of performance, which was the conditioning. We know that conditioning governs your ability to repeat all your efforts. So at the very beginning of even the rehab process, or if we’re talking about someone that’s even healthy, we got to make sure that they have a good aerobic base, and then we tend to expand out from that aerobic base. And while we’re developing that power and that high-velocity work, we’re also building out some of the more robust and high-demanding energy systems like our phosphocreatine system, our glycolytic system, and all that stuff.
That’s great stuff. And I really liked what you said here too. So you notice what Diwesh just mentioned there is when we’re building our progressions, let’s come up with an easy, a medium, and a hard. He didn’t say, “Let’s come up with 10 exercises.” It’s easy, medium, hard, and start there.
And over the course of your career, as you learn new things, you say, “Where does this slide into that progression?” Like, “Oh, I really love this drill. Or this one is a really good sport-specific one for this athlete. Where does it slide in that continuum?” But you don’t have to have a hundred exercises. It could just be easy, medium, hard, and that is a great place to start.
Jonah, anything else from your perspective? I want to make sure the strength coaches jump in on this one because I think you guys are really good at this sort of stuff and have a lot to share with the PT world.
Yeah, I think first off, those two guys absolutely nailed it. Just talking about all the different variables to have in mind. So they took most of the stuff I would’ve said.
Now, the one thing I will add is I think it’s important to consider what the injury is that the athlete is dealing with, and what the variables are that are most likely to aggravate them. So say it’s something like a patellar tendinopathy. Landing might be something that’s more problematic for them, so something like a broad jump might be the worst option we can go to. But they might be able to do a max effort box jump. And since they’re landing on an elevated surface and there’s way less landing force, that might actually be pretty well tolerated for them.
Another example would be, say it’s a hamstring and you’re trying to return to sprinting, top end speed for hamstrings tends to be much more problematic than acceleration. So we might actually be able to do some really good acceleration work, whether it’s some resisted sprints or very short sprints, things like that. So just trying to really look at what are the variables that’s going to aggravate this person’s injury the most, and trying to find ways to take those away while continuing to work on the variables that they will be able to tolerate well.
That’s great. And work in conjunction. You could still work on the areas that are safe or that are outside of that sort of thing. There’s so many things you can do to build as you’re optimizing or normalizing some of those other things. So that’s a really good perspective.
Devin, I hope that helped. I hope that was a good progression here. I think there’s going to be a future episode of the Fitness Pain Free podcast on this, so check it out. I mean, I’m just assuming, Dan, but I could be wrong. But great question. If you have questions like that, please head to mikereinold.com, click on that podcast link, and fill out the form to ask away. And we will see you on the next episode. Thanks again.