One of the most common questions we tend to get over time is how to return athletes back to sport after an injury.
This is one of the main topics in our online Champion Sports PT Mentorship, and probably the most popular portion of the program for past students (BTW, our next cohort starts in January… click here to learn more).
In this episode, we talk about the criteria to start a return to sport progression, and then how to advance our athletes to make sure they are ready to return to competition.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 351: Building Return to Sport Programs
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Show Notes
• Champion Sports PT Mentorship
Transcript
Mike Reinold:
Welcome back everybody to the latest episode of the Ask Mike Reinold Show. I am here for a special episode with Dave Tilley, Dan Pope, here answering your questions, and the reason why we wanted to do a special episode this time was… This is probably a topic that is our number one question that I think we get in general, with emails and DMs on social media and stuff. But we started an online mentorship program in sports physical therapy, the Champion Sports Physical Therapy Mentorship Program. We started that last year.
We’re building it up a little bit and I’ll say, when we get to this module in the mentorship, this is the one that seems to pique everybody’s interest, kind of gets everybody asking the most questions. And it made us realize that, gosh, for some reason, people have a ton of questions about return to sports. I think they doubt themselves. I think they have a lot of lack of self-confidence. They’re not a hundred percent sure what to do. Why don’t we start with that, guys? Why do you think people have so many questions about return to sport? Why is it so daunting to so many people?
Dave Tilley:
Yeah, I can start for sure. I think that it’s murky. I think this is an area in school that you don’t have concrete examples for and guidelines for. Like, pain’s a great guideline. When someone obviously is approaching a new exercise in the intermediate phase, if they get a little sore or if it swells up a knee or something like that, you’re probably pushing too much. And it’s pretty clear about, okay, that was a bit too much and you back off, versus if somebody tolerates that well, there’s pretty clear cut progression lines for how to test somebody, range of motion, strength… It’s very objective. It’s very metric. You have very good concrete strength numbers to follow, but the farther you get out in the rehab, the less and less concrete it becomes, particularly because I think as a whole, one of the reasons the mentorship is positive is because people really lack strength conditioning knowledge and good programming knowledge.
So the intermediate to advanced phase is like, “Okay, now I need to know a lot about strength and conditioning and maybe I’m not as comfortable there.” But then you get past that phase and now you’re in this really deep end of advanced strength and conditioning, but now you’re talking about high-end strength work, power speed, agility, dosage of cardiovascular exercises, workload stuff. That stuff I think unfortunately is really far away from what we’re experts in, which is the acute to intermediate phase, mostly coming out of school. So that’s what I found personally, is that as I worked with more athletes, I found all right, I don’t really know a lot about how to build a running program for VO2 max or a workload program or particularly, in certain sports, throwing. I didn’t come from a throwing background. I didn’t really know a lot about interval throwing programs and I had to learn that. So that’s probably a lot of overwhelming because every sport has this weird niche part of it that you’re like, “I don’t know how to dose a rowing program.” So yeah, that’s my thought.
Mike Reinold:
Yeah, it makes sense to me too. I mean, I guess you’re right. Physical therapy school, which is what we’ve all kind of been through, it probably teaches you the basics at the beginning. And maybe that’s part of what makes specializing in sports a little different, is you have to understand these late phase concepts like the transition to strength and conditioning, the building of workloads that’s specific to the sport that you’re going to play. It’s daunting. And I think a lot of people probably, I don’t want to say outsource this, but they rely on the sport coaches for help with that, which is probably fair, but there’s got to be some baseline knowledge. And I’ve always found it crazy that we’re just like, “Okay, yeah, no, you graduate. You can just go back to football practice now.” And make sure that we’re building that. But, Dan, what do you think? But why do you think so many people have struggles with returning to sport?
Dan Pope:
Yeah, I agree with Dave completely. It’s not something we learn in school and it’s not bad. I feel like I’m always bashing on school. I’m not. They just don’t have the bandwidth to teach folks that, plus physical therapy is such a broad profession that not everyone needs to know it. So then what happens is that some folks get a little bit more education than others, right, and they’re just kind of left guessing without that kind of, I guess curriculum you would get in a normal physical therapy school. And we just talked about this for the podcast, but I think the other one is there’s such a tremendous variety of different pathologies, even at the same joint. So there’s a ton of research on ACL reconstruction, but what always makes me laugh is that if you look at meniscus repair, the return to sport guidelines are tiny. We don’t really know from a research standpoint. So there’s a lot of questions that we do have, and the return to sport times for an ACL reconstruction are probably going to be a little different from a meniscus.
But then you start getting into, let’s say, non-op versus operative, and that changes things tremendously. So if I have a hamstring strain injury and I’m mid-season, that’s going to be treated very differently than some sort of post-op knee surgery. And then if you start getting down to, let’s say, the Achilles repair… Whole different ball game, right? And then you have to have a different set of exercises, different progression, different deficits. So I think it’s one of those things, like we said, we don’t learn about a ton in school. And then on top of that, it’s very daunting because you have to have a tremendous amount of knowledge. It changes a lot from joint to joint, muscle to muscle, sport to sport.
Demands of a field sport athlete versus, let’s say, a rower or something along those lines are tremendously different. And then a huge lack of research, Dave was just talking about the spine, right? Return to sport for spine, where do you see that? It doesn’t exist. If you go on PubMed right now and start searching around, you’re not going to find much for some of those weird pathologies. So I can see why folks are confused, scared, so on, so forth.
Mike Reinold:
And there’s just so much out there, I guess. I guess that’s the point is there’s a lot out there. I feel like to me, this is what I always tell our students at Champion is that you probably are more prepared and know how to do this than you think. You just haven’t experienced it yet. You haven’t gone through it yet. And we’re going to do some basics. So good example with us, we just released our new interval throwing program in the international general sports physical therapy, and in it, we used workload equations to try to quantify the progression. This is more modern, but we compared it to the one we published over 20 years ago, which is probably the most popular one being used around the world.
And we actually showed that we were pretty close 25 years ago. It wasn’t that bad. We could make it better, but our basic understanding of how to progress load and how to progress stress… It carries forth.
So people probably are better at it than they even realize sometimes. But let’s do this. Let’s hit this from the top and kind of progress through it. Let’s start with this. When is somebody ready to start a return to sport progression? Let’s start with that, then we’ll talk about what that means. But how do you guys determine that somebody is now at an appropriate position that they can begin return to sport? Who wants to start this one?
Dave Tilley:
Yeah, I can grab this one. I think a lot of this is what I’ve kind of picked up from you and Lenny anyway, so it’s kind of like full circle is, in any of these situations, the first thing you should do is try to find the best available evidence. So if you do have that classic fifteen-year-old soccer player with a non-contact ACL tear and she says, “Isolated ACL tear,” there’s a lot of great research out there to kind of look at what tests we could use. And then obviously there’s a little bit of an evidence-based hat you need to do to be like, “All right, what tests are valid? What things are actually measuring what we want to do?” External validity. So, hop testing is out there. There’s a lot of other things on strength indexes, LSI, stuff like that. So if you do have the available evidence, you want to try your best to do your due diligence on a Sunday morning cup of coffee and being like, “All right, what is the best current thing?”
Because you might get something that comes to you that’s not what you see all the time and maybe some new stuff has come out in the last two years since you’ve treated a SLAP tear on a baseball player or something like that. So if you do have the ability to find some things that are moderately evidence-based, I think that’s the best place first to start. And then from there though, you have to do some digging and think about, “Okay, what does the sport need?” And then how did that person do throughout the rehab process in those areas? So I think if you just do a basic needs analysis on what the sport is, you’ll see that, “Okay, I have a…” I’ll just use my example. Like, someone who was spondy fracture, I treat a lot of spondy fractures because gymnastics kind of gets them to me, but not all of them are gymnasts, right?
Some are baseball players, some are hockey players, some are field sport athletes. And so I can’t give the same principle-based approach to a gymnast with a spondy fracture as I can a basketball player with a spondy fracture or a baseball player because one is bending backwards, one is jumping up and down, and one is running side to side. So you have to do a little bit of time to look at, “Okay, what does this person need from me?” And then as you progress that person through the intermediate phase, you’re like, “Okay, how did this person do with basic strength training? Did they tolerate all their strength training? Did they have any flare-ups? Did they feel okay? How did this person tolerate running? How did they tolerate box jumps? How do they tolerate broad jumps?” And if that person’s doing really well and each time they progress, there’s not any flare-ups, you’re feeling good that that person’s on the right track.
And then I think from there, the last piece of it is always a principle-based approach. And we talk about this in the mentorship is like, maybe I didn’t row in college like Lisa did, but I can look at the principles of intensity and frequency and duration and I can apply those things for throwing. Intensity is distance, but in gymnastics intensity is the surface they use, where in Olympic weight lifting, intensity is the amount of pounds on the bar or kilos on the bar. So I would say those are kind of the three things I teach people. It’s like start with the best available evidence, then look at how they progress through the rest of the other stages second, and then third is what are the principles that all sports go by to progress on.
Mike Reinold:
Dang, love it. What do you think, Dan?
Dan Pope:
I got a list of things I was just going to rattle off. Hopefully this helps folks in terms of progressing their athletes back to sport because there is kind of a checklist, and if you can hit those checklists, I think it simplifies it a little bit. I’m talking mostly about post-op patients, so I think it changes a lot with non-op. Let’s say this is a post-op knee of sorts. So first and foremost, you do have to respect some of the timeframes for return to sport. For ACL reconstruction, we know that nine-month is really important, but that’s not when you start your return to sport progression. But just keep that in mind. You can’t start jumping week three. We do need to make sure that we’re advancing people enough so we can get high level activities. Maybe we’re waiting till around month three to four to do any sort of impact or plyometrics and you can progress from there.
The first one is range of motion. So we need to make sure we have full range of motion at that joint. We also make sure that we have symmetrical strength or close. We’re always trying to bridge that gap. We’re trying to make sure that we have as close to possible 100% limb symmetry index over the course of time. And I’ve seen a lot of studies that try to dose the intensity of exercise and return to sport activities based on the LSI, which I think is pretty interesting. But that’s one of the things you can utilize to figure out if your patient is ready for higher-level stuff. We’re also looking at swelling. So we’re making sure that the knee is not swelling more over the course of time. We want to have a pretty quiet knee before we start some of these impact activities.
And then we can base our progressions on whether or not the knee is getting more painful. Swelling is starting to be more prominent. If we’re losing range of motion, those are all bad signs, but if the knee is staying quiet as we progress, that’s a really good sign. Like I said, pain is also important. That quiet knee requires it. We want to make sure that the knee is not hurting when we introduce jumping activities on top of that. Movement quality is very important. This is one of the things I see folks missing. You’ll have an athlete that’s at nine months and they can jump and they have minimal pain, but they’re not bending through the knee whatsoever. That could be a strength thing or pain thing or fear thing. So I think that movement quality has to be good before we decide someone can go back to sport.
On top of that, I think we just need to have a really well-rounded strength program for that athlete. Unfortunately, that’s super broad and Dave hinted towards that, but we are going to start with easy stuff and progress towards harder stuff over the course of time. Same thing goes with plyometrics, same kind of deal. And lastly, you just have to get kind of sport-specific. So trying to incorporate things like drills first, things that are not that dangerous, making sure that looks good, building some capacity, and slowly over the course of time, progressing that to more kind of real-time game situation activities. And I think one of the big things you probably want to ask the patients beforehand or give them is some sort of psychological readiness questionnaire. And I know that’s like a shotgun of stuff, but that’s right off the top of my head. Those are probably the most important things before you get someone back to sport.
Mike Reinold:
I love it. And a good outline. And I think for the people that are paying attention here, there’s not a lot of advanced concepts that Dave and Dan just talked about. There isn’t a fancy special test that you can do. There isn’t a functional test that you can do that somebody needs to pass. It’s the basics. If you don’t have range of motion, if you’re swollen, if your strength’s not there, if you’re in pain, you’re not ready. And I think that’s an important part of it. And then the thing that I would add to it is that especially after a big injury or a big surgery, I mean, follow the rehab protocol, and the protocol is designed to gradually apply stress and load to the body over the course of time so that way you’re ready to take that next step. So a lot of people, we always say the example with us when we were down working in Birmingham with Dr. Andrews…
We’d have people fly in, they can have surgery, and we’d make them all come back at the four-month mark so we can evaluate: are they ready to start a return to sport progression? And a lot of people thought just because it was week 16 or 20 or 12 that they’re just cleared to start throwing or running, whatever it may be. And that’s not the case. If you haven’t done your plyometrics, you haven’t done your drills to do that, assuming even all orthopedic looks great, swelling, range of motion, strength, all that stuff looks great, even if you haven’t gone through the progressions before, you’re not ready. So time is just a limiting factor of when you can begin. It doesn’t mean that’s when you actually begin. That’s just the earliest you can begin. So you got to go through the rehab protocol, and I hate to say it, but that’s my most important return to sport criteria and test, is that they did the sequential phases of the rehab protocol already. Because if you count backwards and you go backwards, you should be able to build up stress to the body.
So, something to think about here. Again, I think a lot of people hopefully listen to what we just said and realize, “Hey, there isn’t a magical test for overhead athletes to begin a throwing program if they can do a certain amount of drills in a certain amount of seconds.” Sure, that’s great, but there’s a lot more impactful things that we should be focused on. All right, we’ve progressed, they’re now able to start this return to sport progression. I like what Dave said actually, I think that’s the answer to the next question. The next question is, “Okay, what do we do? How do we build this return to sport progression now that we’ve cleared them? They’re able to do it. How do we do it?” I like what Dave said, the first thing you do is probably go to PubMed and Google and you say return to sport progression for basketball player.
And you actually probably look and see what’s been published out there to look at these things because you probably will find some published materials from experts within that sport, and then you’ll have a progression. But other than that, what are some of the concepts that you guys use in terms of building a progression, workloads, making sure that we’re doing this in an appropriate fashion? We’re not spiking our acute chronic workload ratios. What are some of the fundamental thoughts here? And let’s start with Dave. Dave, you covered this in our mentorship the most, so I think you have a good module on that in the program, but why don’t you share a little bit about that? How do you build these programs?
Dave Tilley:
Yeah, so I think the biggest background is that you have to remember that there’s only a biological limit of the cycling of tissues. So bone, tendon, muscle obviously is a bit quicker, but bone, ligament, and tendon for example, those are not going to tolerate high dosage of loading every single day. So I think that that’s something Stu McGill talked a lot about on a podcast. He kind of opened my eyes like, “It’s bone and it can’t heal day to day.” So if you load somebody who has an Achilles repair, for example, with heavy plyometrics in their sport, you can’t expect that person to do five days in a row, and that’s going to limit how fast you progress. So that’s a big thing that we talk about is the actual frequency component of these things because you can only load so many days in a row.
But when you look at these things of assembling a program, I think the examples we like to use in the mentorship are like, all right, let’s talk about a baseball thrower, a gymnast with an elbow U construction, and an Olympic weightlifter that all have the same elbow UCL repair. How are we going to dose that person based on the sport? Well, they all have different components and principles that we just talked about, right? So intensity, for example, is probably the most important thing to think about… Is that you don’t want to start somebody off on an intensity that’s too high because it’s going to overload the tissue and they haven’t done it. And you’ve always said this is that, throwing is the program at one point, like the stress of throwing on the UCL, the stress of the handstands or front rack position in a clean, they are at some way, shape, or form a bit of rehab at the right context and point.
So I think that intensity is the first thing you want to always think about. So intensity for baseball is the distance throwing, right? Intensity in gymnastics is the amount of percentage of your body weight you have on your elbow. And then intensity in an Olympic lifter is the pounds on the bar. Pending that, you can do a front rack and it doesn’t hurt. That’s kind of the first checklist. Dan said range of motion, whatever, but intensity is universal throughout all three of those sports, even though everyone had the same UCL tear and repair five months ago or six months ago. So that’s one. And then repetitions is always pretty universal too. So the number of throws, the number of skills on your hands, and the number of cleans you did are all exposure things you can use. So you have two pieces there, and then frequency. I think most people are probably going to fall in the bucket of two, three days per week with a nice day off in between to make sure we don’t flare anything up.
But those three things alone are universal from every sport. And everyone who has a UCL tear, whether they’re a curling athlete from Canada or they’re throwing here in the States, they’re all going to need those principle-based components. And you start with those things of distance, frequency, intensity, and then you can even play around with volume – is another piece you can put in there too as well of total weight movement or whatever. But yeah, those principles are universal regardless of what type of sport that person is going back to if they had a reconstruction.
Mike Reinold:
Yeah, I mean I think those are the big three for workload. You start with volume and frequency, that’s the quantity, but then the intensity of that really changes all of that equation. So workload progressions and workload itself is just an equation of volume, frequency, and intensity. So think about that. If you’re getting somebody back to jumping sport, you should be paying attention to the volume, the frequency, and the intensity of jumps. So you should be counting sets and reps, and you should be counting them over the course of the week. You should be looking at, I’m just making up an example, you should be looking at how high they’re jumping a box height or something if that’s what it is, or how powerful if you have a force test. You can do a partial jump to a more aggressive jump, but you should be looking at those three variables and then trying to quantify it.
So I think throwing might be one of the easiest. Maybe I’m just more comfortable with it, but you have 10 throws at 45 feet. Okay, what’s the progression? Well, you can either go 15 throws or you can go back to 60 feet. So it’s one of those two that you have. We only go by 15 feet in baseball. You can’t do anything in between, but you know what I mean? It’s that sort of thing. But I want you to take your sport and take a huge step back and think of it that way. Dan, what are some pearls on this from your perspective? How would you advise this?
Dan Pope:
Yeah, I just want to kind of reinforce what you guys are saying and then also talk about the importance of a protocol of some sort, and actually protocols for operative as well as non-operative patients as well. I know that we typically don’t think of protocols for non-op folks so much, but for example, when you were writing the newest return to throwing program, were you actually doing it in front of a patient after you’ve done the entire session and were like, “Okay, here we go. Return to throwing program.” You sit down and you think about it and you look at the variables and you calculate the intensities, the volume, so on and so forth. And you do it in a period of time where you can actually think and put a lot of thought through this.
I think folks will poo poo the idea of a protocol because they think it’s like following the standard PT mill, but if you have a certain patient you’re thinking about, and you have the time to think through everything, and every week it’s just progressively a little bit more volume, a little more intensity, that’s the best case scenario. And then when the patient comes, you apply the protocol or whatever you thought about before, but you just wiggle it around, move some of the variables based on how they’re presenting. So I just think it’s really important that you think about the sport and you try to reverse engineer a solution that’s very slow.
The slower you go, the more you respect the acute to chronic workload ratio. Obviously if you go too slow, the athlete never gets back to sport, so that’s a problem as well. But yeah, I just tend to think of it that way. Try to design a protocol that works out really well for your patient, training program, if you will. You don’t have to use the word protocol. And then try to follow that as much as possible, and then make those small adjustments over the course of time as needed.
Mike Reinold:
I love it. I think that’s great, and I think that’s a good starting point for everybody here. Again, it’s probably less daunting than you think. You probably understand these concepts more than you realize. It’s probably just going to take some reps, right, and you’re just going to have to do it. And unless you work with a specific sport, you probably aren’t rehabbing dozens of basketball players or dozens of gymnasts every time. So great stuff. Thanks, Dan. Thanks, Dave. If you’re interested in our online mentorship, you can check it out. I’ll put a link in the show notes. We’re always starting up new cohorts, so you can definitely check that out. But if you have more questions like that, just head to mikereinold.com and click on the podcast link and you can fill out a form. I was thinking, “What can we fill out?” You fill out a form to ask us more questions. Thank you so much.
