Opening
Return to play (RTP) is a unique endeavor, and there are several variables that collectively determine what this process looks like. Apart from your title (credentialing and licensing), your setting, resources, and training availability/frequency will all largely dictate this process. Now my tenth year as a strength coach, and despite never deliberately setting out to do so, almost my entire career has been centered around working with injured athletes. This includes everything from high level military personnel to general population and now professional athletes. Having been fortunate to work in high level interdisciplinary settings, I understand how this process works when you have all the professionals and resources working in tandem under one roof. I’ve also been in positions where the network is completely patchworked, rendering me a satellite to the process while being reliant on communicating and trusting others I may not even know.
Unfortunately, the latter represents the reality for most strength coaches, as they will not have that luxury of having a full interdisciplinary staff to work within. Nevertheless, whether you’re a strength coach in a highly resourceful and well-functioning professional network, or you’re the independent strength coach working remotely with others, the process for RTP athletes can be highly unpredictable, fragmented and complicated. As such, in this article, I’d like to examine how we can expand the role of the strength coach as it applies to RTP athletes and demonstrate how we can provide a tremendous value to this estuary of injuries and high level performance.
Injury Rates and Trends
Injuries are invariably a component of sport. No matter the level, the specific sport, or the preparations and preventative measures put into place, there’s no way to eliminate the assumed risk of competitive sport. Although injuries are inevitable, one would think that with the influx of data, resources, and technological advances we would at least see a mitigation of injuries across sports, but this hasn’t been the case (1, 2, 3). Despite our vastly improved tools, resources, and ability to track our athletes, we still see either consistent or rising injury rates across most sports, at least at the professional levels. And while the data is difficult to collect, anecdotal evidence may suggest that athletes at lower levels of sport appear to be experiencing injuries at a greater rate as well.
Speculating about injury rates is a difficult endeavor, given the innumerable variables that need to be factored into consideration. There is an assortment of potential culprits that have been evaluated over the years- training/sport volume, footwear and surface type, training protocols and methodologies, even analyzing the rules, dimensions, and process of play. Irrespective of what the reason may be to explain this influx of injuries, it isn’t a stretch to say we should double down on investigating and amending this rise of injury. And my suggestion is this is where strength and conditioning coaches can look to take on a bigger role and better assist with mitigating our injury crisis.
Defining Roles & Scope of Practice
Magnifying the role of the strength coach in the RTP process isn’t suggesting or implying we undermine the work of physical therapists or early phase rehab professionals. As evidenced in the opening graphic, there is a very clear hierarchy to the RTP model. The RTP process will always be governed by the physician or surgeon, directed by the physical therapist/ATC staff, and then carried out by the S&C coach and additional members of the RTP team.
Following the early phases of rehab, the S&C coach should envision their primary contribution as being a direct extension of care provided by these early phase professionals. Where the early phases of RTP are largely focused on rehabbing the localized area, I see the role of the S&C as being developed around re-integrating the injured area back to the body. This is a great foundation for carving out our role, rather than rushing or forcing athletes back to “standard training”, we want to observe how our contributions can fit in tandem with the other services and treatments being provided and meet the point of where the athlete is.
Strength coaches have historically been marginalized with RTP athletes, as everything is filtered through an ominous barricade of tampering with scope of practice. While violating scope of practice is obviously nothing to take lightly, I believe there is an overzealous nature to assuming S&C coaches can’t accommodate injured athletes. What we do is complementary to what the rehab and medical staff provides, not in place of it. Because just as S&C coaches have their limitations in practice and ability, the medical side does in their own regard as well. Having a robust S&C component in the RTP process minimizes the likelihood of athletes feeling the need to rush back to resuming “normal” training, while also perturbing the onset of delaying the athletes return and holding them in a rehabilitation phase longer than what’s needed.
Having projected timelines and protocols are a well-intended necessity, but they often lack individuality and cannot account for nuances. Collectively this can result in an incomplete rehabilitation, which then predisposes athletes to either reaggravating the current injury or making them susceptible to a consequential injury. And this is precisely where the restorative or hybrid strength and conditioning applications provide their value.
Re-Conditioning and Building the Base
The first priority for a strength coach in the RTP process is to emphasize getting the athlete conditioned to train again. As we know, rule number one for just about any team sport athlete is never show up out of shape! Without divulging into the X’s & O’s of conditioning, in this context it really is a matter of not overthinking it. I always try to parallel my conditioning work to be as close to what the athlete will be tested or evaluated on with their team and doing so with consideration for their injury.
Meaning, if the athlete’s pre-season conditioning test includes multiple 110 yd. sprints but they are coming off an ankle injury, we would start by using assault bike, rower, or Versa Climber intervals that match the metabolic equivalent. The added advantage to the re-conditioning phase is that it provides an easy opportunity to allow the athlete to focus on not being injured or limited physically. By removing the focal point (the injury itself) from the equation, we can encourage them to simply focus on the work. And for athletes who have been down for several weeks, this is typically a massive rejuvenation for them.
In addition to the conditioning work, we also want to take this time to emphasize re-establishing the foundations of performance, or what I refer to as the “support pillars”. Staying in line with emphasizing what we can while we can, this restoration phase is an opportune time to help guide them on things like nutrition, hydration, sleep hygiene, and stress-emotional management. These, while obviously fundamental to restoring injuries, are also low hanging fruit for helping the athlete feel like they can take ownership of their situation. Injured athletes often feel constrained and minimized by everything they’re being told they can’t do, so I believe a key part of our input should be highlighting what they can.
Re-Integrating the Injured Area
Where the primary goal of the early phases of rehab are almost exclusively focused on improving the localized area, the role for the S&C coach should transition towards re-integrating the injured area back to the body. With this, reintegration should solicit you to consider the neuromuscular and global kinetic demands of movement (what they do in sport) as it relates to the injury at-hand. For instance, consider an athlete coming off of a shoulder injury (i.e., rotator cuff tear), once the early phase rehab of improving localized strength, range of motion, and motor control have been completed, is the athlete fully cleared to return to sport and play? Of course not! Yet seldomly do we see this reintegration being done before athletes are being admitted back to routine practice, training, and sport demands.
To keep this simple, we’ll stick with a rotator cuff tear as the hypothetical injury here. My three pillars for re-integrating a rotator cuff tear include:
As opposed to traditional movements like BB/DB shoulder press, bench press, delt fly’s, I want to prioritize movements that are unilateral. The primary difference here is unilateral movements all each extremity to function on its own, which reduces the likelihood of the dominant side overworking. Easy options to point to include the landmine, Keiser, or single-sided DB/KB movements.
The best thing we can provide for shoulder restoration is proper core training and rib cage/thoracic work. The core quite literally represents the foundation for which the shoulders sit on, and as far as I see it, the weaker the core is, the more difficult it becomes for the shoulder to produce motion. Similarly, the more limited we are in the rib cage or thoracic spine, the harder the shoulder joint itself will have to work to produce the same or less output.
This is another subtlety to injury restoration, albeit a shoulder or otherwise, that I feel gets overlooked. Just as altering the foot position changes the kinematic sequencing of the legs for lower-body movements, adjusting hand position has the same effect for the shoulder girdle. Moreover, utilizing a variety of load types (static, perturbative, oscillatory, etc.) can be a simple way to emphasize the neuromuscular demands and soft tissue structures for the rotator cuff/shoulder girdle.
The final point I wanted to address in this article is perhaps the most significant of everything outlined, and that is redeveloping the athletes confidence and helping them reframe their perspective as they approach their return to sport. I mean absolutely no disrespect in saying this, but the medical environment, to include a lot of physical therapy settings can be dwelling for athletes. Having to be in a space where they are constantly being reminded and reinforcing that they are injured is a difficult task, especially if the athlete hasn’t sustained many injuries in the past. While practitioners of course do their best to minimize this feeling, only so much can be done given the nature of this part of rehab.
This is where strength coaches can really capitalize and make a profound impact on the athlete, simply by rejuvenating them and allowing them to train without compounding the fact that they are injured and aren’t with the rest of their team. While of course the tangible part of our work is critical, I believe this type of intangible is what sets the foundation for us to execute the tangible part. We want to establish an environment, a dialogue, and a protocol that minimizes the conscious awareness of- “I’m broken”. The primary way I’ve found success with this is first through the demeanor and dialogue, and it may seem imprudent, but I try to ask them or bring up their injury as minimally as I possibly can. Being overzealous to “how does this feel” or “what do you feel during this” can be subtly defeating, because again it forces them into thinking about what is preventing them from playing.
I will also be very committed to making them feel a part of the process and keep their personal goals and priorities at the top of my priority list. We want to tell them, and show them, that we are actively working towards what matters to you most, and by any means we will see this through. Giving them any ounce of autonomy is an indirect way of also taking their mind off the injured site. We can help them to shift their perspective from “what doesn’t work” to “what can I have ownership over right now”. Between these ends, we can generate an atmosphere that is uplifting, strenuous but not defeating, and optimistic that where they are is not where they will be for long.
References:
1.) Drakos, MC., Domb, B., Starkey, C., Callahan, L., Allen, AA., 2010. Injury in the National Basketball Association: A 17-year overview. Sports Health.
2.) Ronda-Torres, L., Gamez, I., Robertson, S., Fernandez, J., 2022. Epidemiology and injury trends in the National Basketball Association: Pre-and per- COVID-19 (2017-2021). PLoS ONE, 17(2).
Sheth, SB. Anandayuvaraj, D., Patel, SS., Sheth, BR., 2020. Orthopedic and brain injuries over last 10 seasons in the National Football League. BMJ Open Sp Ex Med:6.