Robert Panariello MS, PT, ATC, CSCS
Founding Partner, Chief Clinical Officer
Professional Physical Therapy
New York, New York
Participation in competitive athletics can be very rewarding, but a conceivable consequence of sports participation are the high stresses that are placed upon the athlete’s body. Sprinting results in ground reaction forces that are approximately five times the athlete’s body weight at ground contact time’s reaching under 0.1 seconds. Marathon runners have prolonged ground reactive stresses of approximately three times their body weight for roughly 25,000 ground impacts during race competition. Collision sports (football, soccer, boxing, MMA, etc.) include additional high external contact stresses to the body. These high stresses that are applied to the athlete during a single tragic event or accumulate over time may lead to an unfortunate sports injury. At the time the athlete is evaluated for their injury it may also be determined that an additional invasive stressor, corrective surgery, is required for their condition. Whether or not a surgical intervention takes place, a referral for physical rehabilitation is likely to transpire to assist in the athlete’s physical recovery.
When placed in the care of a rehabilitation professional, the clinician must demonstrate both clinical knowledge and skill proficiency to secure the confidence of the athlete as well as achieve the athlete’s desired outcome. A variety of treatment options are available to the athlete including: modalities, various soft tissue and joint mobilization techniques, neuromuscular techniques, and of course, progressive resistive exercise (PRE’s) to name a few. The athlete’s prescribed sports rehabilitation exercise program design should include a foundation philosophy for the process of exercise selection (closed chain, open chain, double limb, single limb), exercise volume (sets and repetitions), exercise frequency (daily, weekly, monthly and the application of exercise intensity [load, velocity, distance]) to name a few.
One rehabilitation philosophical consideration in the sports rehabilitation setting, is the adaptation of the performance enhancement training approaches utilized for the healthy competitive athlete. If specific exercises and program design philosophies create the strongest, most powerful, and fastest athletes in the world, couldn’t the rehabilitation professional, utilize these same training and program design techniques, modifying them when necessary, to ensure an optimal patient outcome? The planning for the athlete’s sports rehabilitation program design should include a proven philosophical foundation that will result in successful outcomes. The foundation of our sports rehabilitation as well as our performance enhancement training philosophy is based upon the Hierarchy of Athletic Development, also referred to as the “pyramid” in the strength and conditioning (S&C) circles. This training philosophy was established by my good friend and one of my mentors, Hall of Fame (HOF) S&C Coach Al Vermeil (figure 1).
Figure 1 Hall of Fame Strength and Conditioning Coach Al Vermeil
During his illustrious career, Coach Vermeil has worked at both the collegiate and the professional levels including the National football League (NFL), National Basketball Association (NBA), and Major League Baseball (MLB). He is the only head S&C coach to attain seven World Championship rings and world championships in two different American professional sport leagues, the NFL and the NBA. His Hierarchy of Athletic Development (figure 2a) has been recognized and utilized by S&C professionals around the world, including HOF S&C coaches who have secured national and world championships as well. We have also adapted and modified Coach Vermeil’s hierarchy in the sports performance enhancement training of our athletes, as well as our sports rehabilitation model (figure 2b) and our return to play (RTP) testing. This dialog will place emphasis on the sports rehabilitation modified model.
Figure 2a Hierarchy of Athletic Development and Figure 2b Rehabilitation Modified Model
The Phases of Vermeil’s Hierarchy of Athletic Development
There are six levels of the hierarchy that comprise the following:
1. Evaluation/Testing– Every patient and athlete, whether engaged in the sports rehabilitation or the sports performance enhancement environment, will require an evaluation and a process of testing to determine such criteria as their medical and training history, sport(s) and position(s)/events of participation, medical history exercise contraindications, etc., as well as a demonstrated presentation of all physical assets and deficits. The rehabilitation professional should incorporate a proven system of evaluation and testing where there is a comfort level for ease and confidence during implementation. The evaluation and testing process will assist to determine the valuable information necessary for the establishment of the sports rehabilitation program design.
2. Work Capacity– The second level of the hierarchy, work capacity, is the ability of the athlete to physically perform exercises with proper technical proficiency repetitively over time without the inducement of excessive physical fatigue. During the course of rehabilitation, physical fatigue will transpire as a result of the athlete’s participation and adaptation to prolonged repetitive rehabilitation exercise execution. This includes, but is not limited to, participation in daily, weekly, and monthly programmed treatment sessions over the duration of the rehabilitation period. The establishment of an ample work capacity will ease or prevent the onset of excessive fatigue as well as assist in the physical recovery necessary prior to the next scheduled sports rehabilitation session. Over time a suitable work capacity will also establish a work capacity reserve. This reserve is establish over a prolonged sports rehabilitation and return to training period so the athlete may continue to progressively increase their volume of work to continue to enhance their physical qualities, overall condition, and physical recovery to provide their best effort each sports rehabilitation/training session. An established work capacity and work capacity reserve will also assist the athlete at the time of discharge to return to play or performance enhancement training.
The next levels of the hierarchy include the specific physical qualities that are necessary for ideal development to ensure an optimal rehabilitation outcome as well as athletic performance.
3. The Physical Quality of Strength – Strength is the foundation from where all other physical qualities evolve. Therefore, the optimal development of this physical quality is essential during initial phases of the athlete’s rehabilitation. The human body was created for movement, yet how is movement possible without the application of force? Enhanced strength qualities will improve the athlete’s ability to apply and accept various levels of force. Enhancing strength levels will also result in improved rate of force development, impulse, joint stability, as well as soft tissue and joint stiffness, a requirement for an optimal stretch shortening cycle (SSC). Sprint times, jump heights, and change of direction abilities also have a direct correlation to the athlete’s relative strength levels. Weaker athletes also tend to rely more on ligaments for joint stability in high intensity situations when compared to stronger athletes, a phenomenon known as ligament dominance. During athletic competition, with skill and athleticism deemed equal, it is the stronger athlete who will usually prevail.
4. The Physical Quality of Explosive Strength– This is the first physical quality to introduce a high velocity component during the exercise execution. Explosive strength or power is defined in figure 3.
Figure 3 The Formula for Power
Time is now a factor during exercise execution, requiring the athlete to perform at higher velocities compared to strength type exercises. It is important to note that the execution of explosive strength type exercises requires the athlete and/or an external exercise resistance to be displaced from one position to another at a high velocity (short period of time) while maintaining proper technical exercise proficiency. Optimal athletic performance requires the physical quality of strength in combination with explosive strength and/or elastic strength abilities.
5. The Physical Quality of Elastic/Reactive Strength – This physical quality relies upon the SSC and the ability to exert force during a high velocity movements. The SSC is the basis of plyometric type exercises and is a natural musculotendon function where a soft tissue complex is stretched immediately prior to an active concentric muscle contraction. This eccentric/quasi-isometric/concentric muscle contraction results in a very high forceful output. Elastic/reactive competences are dependent upon the established physical quality(s) in association with the athlete’s ground reaction abilities. To optimize an elastic energy contribution, there must be a brief transition or amortization period between eccentric and concentric contractions. Dr. Dietmar Schmidtbleicher has classified the SSC as either slow, a >0.25 second ground contact time, or fast, <0.25 second ground contact time.
6. The Physical Quality of Speed – The achievement of an ideal high movement velocity such as sprinting, jumping, throwing, etc., relies on the athlete’s genetics and optimal enhancement of all of the aforementioned physical qualities in combination with their demonstrated exceptional and economical technical movement proficiency. High velocity movement skills are also attained and re-enforced via coaching and repetitive high velocity movement skill practice.
Figure 4 presents a 100-meter sprint demonstrating the interrelationship of the physical qualities of the hierarchy.
Figure 4 Relationship of the Physical Qualities During a Sprinting Task
(Courtesy of Derek Hansen)
In a review of figure 2, observed is the interrelationship of all the physical qualities of the hierarchy during a 100 meter sprint. At the initiation of the sprint, the physical quality of strength plays a significant role in the athlete’s forward propulsion/movement from a dead stop position. Explosive strength then evolves as acceleration is incorporated into this athletic task. Higher sprint velocities continue as elastic/reactive abilities come into play as the race concludes with the athlete achieving optimal maximal speed velocities. Notice how the ground contact times (amortization) decreases as sprint velocity increases.
If figure 2 is reviewed in reverse, the athlete will likely not achieve peak speed velocities without the optimal development of the physical quality of elastic/reactive strength. Ideal levels of elastic/reactive strength will require the optimal enhancement of the physical quality of explosive strength. Finally, the athlete will not achieve the desired levels of explosive strength (or any physical quality) without the optimal development of the physical quality of strength, the foundation of all physical quality development. This review demonstrates the interrelationship and rationale for the optimal enhancement of each physical quality as well as the dependence of each physical quality upon its predecessor in the athletic development hierarchy.
The Hierarchy, Rehabilitation Modified
The injured and/or postsurgical athlete will likely present with very specific physical deficits and anatomical insults as compared to a “deconditioned” athlete. Therefore, additional modifications are made to the hierarchy to accommodate for this special rehabilitation classification of athletes. Our modification of the rehabilitation hierarchy has been published in sports medicine journals and includes two additional criteria. These two additions include:
Mobility/Movement – This added level of the rehabilitation hierarchy requires the athlete to re-establish the joint mobility, soft tissue compliance, and movement skill patterns required for activities of daily living and serve as a segue for advanced sports rehabilitation programs. Over time, mobility and movement patterns will progress to the eventual elimination of assistive devices when resuming a normal lower extremity gait pattern on all surfaces. Sit to stand, acyclical and cyclical activities, and other additional patterns of movement are also required to be restored. Suitable sports rehabilitation technical exercise performance cannot transpire without the athlete’s ability to demonstrate appropriate mobility and movement patterns while maintaining and, when necessary, appropriately alter precise exercise postural positions.
Muscle Re-education – After the incidence of injury and/or surgical intervention, a muscle and/or muscle group(s) may “shut down,” so to speak. An example would be the arthrogenic muscle inhibition of the quadriceps muscle group after ACL reconstructive knee surgery. This inhibition may be due to noxious accumulative factors, including, but not limited to, the episode of injury, the invasive feature of surgery, anesthesia block procedures, and the requirement of a tourniquet (length of time) during surgery. Once a strong active muscular contraction is restored, this achievement, in association with the restoration of mobility and movement, will allow for the performance of suitable rehabilitation exercises and the progression to the work capacity phase and subsequent physical quality phases of the hierarchy.
The hierarchy of athletic development provides a strategic platform for the development of a sports rehabilitation program design for the athletes placed in our care. It should also be noted that not all athletic patients are required to progress through the hierarchy. A 75 year old golfer S/P total knee replacement will have different life requirements and goals when compared to an 18 year old high school football player. The hierarchy should be applied, as with any rehabilitation model, on a case by case basis.
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