Reconditioning the Injured Athlete
Of course, when of the main jobs of an S&C coach is to prevent injuries. When an injury sidelines an athlete, the main goal of the strength and conditioning coach is to maintain the athlete's level of fitness, to allow for return to play to be as seamless as possible. The strength and conditioning coach must have a return to play guideline in place that can be used for every type of injury.
Now, no two injuries are the same. The athlete's response to the injury, treatment, and rehabilitation will be different for each case. However, the same basic principles will apply to each individual, which sets the groundwork for the return to play plan.
The most important aspect of the reconditioning plan is communication.
The strength and conditioning coach must have daily communication with the athletic trainer involved in the case throughout the entire process. During the acute phase of the injury, the sports medicine team should discuss all aspects of the injury. What is the approximate timetable for the injury? What limitations are present for maintaining the athlete's current fitness level? What contraindications exist for this particular case?
From here, the strength and conditioning coach can begin to develop micro phases that are appropriate for the length of the rehabilitation process. A weekly schedule should then be developed to ensure rehab exercise and treatment performed by the athletic trainer coincides with the exercise plan the strength and conditioning coach has put together.
Ice hockey is a unique sport in which the aerobic, glycolytic, and phosphagen energy systems must be optimal in order for the player to excel. When an injury strikes in-season, it is vital to maintain the efficiency of these energy systems throughout the recovery process. In fact, cardiovascular system efficiency and metabolic characteristics have a significant reduction after just a few days of inactivity and an even more severe reduction after a couple weeks (1,2,3,4,5). After the initial acute phase of the injury, which can be within the first 2 or 3 days depending on the severity, the sports medicine team should decide when the athlete can begin to exercise in order to limit these losses.
Detraining begins just a few days after an athlete goes from daily intense physical training and competition, to a period of inactivity and sometimes an almost sedentary lifestyle.
First, the resting metabolic rate will decrease as well as glucose tolerance, which could lead to body weight and fat mass gain (1,2). The strength and conditioning coach and/or nutritionist should have a conversation with the athlete about dietary needs during recovery, especially if the injury is long term.
Blood volume is also lost quickly, resulting in an increased heart rate for simple activities. This will lead to a rapid decline in the aerobic system capabilities. If nothing is done to combat this decline, a significant reduction in VO2 max is shown within 2-4 weeks(3, 4).
Finally, muscle glycogen storage decreases and lactate threshold is lowered(4, 5). The combination of these changes will be detrimental to the athlete's performance if not addressed quickly. An athlete spends countless hours trying to improve all of these qualities, it is best not to let them slip away in the middle of a competitive season.
Once exercise is approved and limitations are discussed, it is time to get the athlete moving.
In most cases, the aerobic system will be the best place to start. This low-intensity form of exercise will allow the athlete to become more familiar with the limitations of the injury. Once the athlete is comfortable with the injury and is able to progress with intensity, the glycolytic system should be targeted. As the athlete approaches a targeted return to play date and as the parameters of the injury allow, the strength and conditioning coach should focus on the phosphagen system and first step quickness.
There are significant differences in how to handle each injury, especially between injuries to the upper and lower body. The basic layout mentioned above would typically work for an upper or lower body injury. The sports medicine team may have to be creative with a lower body injury, but the same progression can be followed.
Let's take a look at how to handle a typical shoulder injury with a return to play target of 6 weeks.
The athlete has been cleared for low impact and low intensity exercise, so he starts with a steady-state upright bike ride with a heart rate target of 65-75% of heart rate max. If you can, use a heart rate monitor to monitor the athlete's workload, ensuring the correct zones are achieved for the session goal. If a heart rate monitor is not available, perceived exertion can be used as a guide. This is referred to as Zone 1, which the athlete will be able to carry on a conversation during exercise and generally will start to sweat. The length of the exercise session should start with 15-20 minutes and move up to 40-45 minutes throughout the entire rehab. This transition period usually only needs a week, but always converse with the athlete and the athletic trainer before progressing. This will be the basis of the aerobic energy system, which is essential for recovery between shifts, periods, and games.
The aerobic system can be challenged a step further. Zone 2 has a heart rate range of 76-85% of max heart rate or able to converse in phrases going by perceived exertion. Even though the intensity is higher, the athlete is capable of performing this workload without accumulating much lactate. However, the duration needs to be lower than Zone 1, especially at first. Start the athlete with Zone 1 workloads for a week, then mix in Zone 2 sessions starting with 15 minutes of duration. These two zones combined should be done 2-4 times a week throughout the entire rehab process.
Strength training can be started during this phase as well. If there is an upper body injury, the lower body can be trained with non-traditional exercises using bands, belts, weight vests, and safety squat bars. For those that are qualified to administer, blood flow restriction is also a perfect starting point.
Once the athlete is ready to move on from steady state exercise, long duration intervals are the next step.
Zone 3 is the target heart for the work part of the interval at 85-90% of heart rate max or very difficult to speak in phrases going by perceived exertion. The active rest will be 76-85% of heart rate max or Zone 2. The intervals can be any combination of time from 2 minutes to 6 minutes, as long as the work to rest ratio remains between 1:1 and 1:2. The duration of the exercise session can range from 20 minutes to 1 hour. The strength and conditioning coach can prescribe a continuous set of intervals for the entire session or allow very low intensity active rest (walking) between sets of 3-5 intervals. The addition of active rest between sets will allow the musculature to regenerate energy stores and enable the athlete to complete more work over a longer period of time. The purpose of this type of interval is to stress the aerobic system and increase the amount work that can be done at a lower stimulus on the body. This should be done twice a week for approximately 2 weeks in this particular case. It can be stretched out to 4-6 weeks dependent on the injury timetable.
Returning to the Ice
Given the athlete is progressing nicely after 2 -2.5 weeks and the injury soreness is significantly reduced, it is time for the sports medicine team to discuss the possibility of returning to the ice for conditioning only. Once cleared, the athlete can begin to do shorter duration aerobic interval work on the ice in the form of lap skating or other simulated movements without a puck. The duration of intervals here can be anywhere from 30 seconds to 90 seconds maintaining the work to rest ratio of 1:1-1:3. The ability to maintain “skating legs” is crucial for the athlete to return to play seamlessly, making this step extremely important. This also serves as a transition to off ice training of the anaerobic system.
The anaerobic system here is referred to as the system that produces enough lactic acid within tissues, that muscular fatigue is experienced and the athlete is unable to sustain the intensity. The intervals used here closely replicate those that happen in a typical hockey game and focus on the athlete's ability to buffer lactic acid buildup in order to perform more work. The work to rest ratio used here is 1:8-1:12 and the duration should be anywhere from 20 seconds to 1 minute for the work portion. The work part is still Zone 3 at 85-90% of max heart rate, but the athlete needs to achieve this in a much shorter period of time, driving up the intensity. The rest intensity will be Zone 1 at 65-75% of max heart rate. This enables the body to use the by-product lactate as an energy source, clearing muscle and blood concentrations more efficiently. Session durations can range anywhere between 20 minutes to 1 hour, depending on continuous intervals or the addition of very low intensity active rest between sets.
A schedule must be created in order not to burn out the athlete before return to play. If the player is on the ice for interval conditioning, off ice interval conditioning is not performed on the same day. Typically, at least a day and preferably two days, should be between high intensity interval training sessions, depending on the athlete's level of fitness. At first, the focus will be more off ice conditioning, but as the return to play date approaches, more focus needs to be on ice.
The athlete is now 4 – 4.5 weeks post injury and the sports medicine team has decided the athlete is ready to begin stickhandling, passing, shooting, and first step quickness. It is important to start slow with activities involving the stick, as to not aggravate the injury. The athlete should begin to emulate normal practice drills on a daily basis. On specified training days, there should be dedicated time set aside for training the phosphagen system and getting the athlete sprinting at full speed. The beginning of these sessions should start with edge work and flow drills to allow the athlete to completely warmup.
Sprint activities should progress with some form of rolling sprints on session 1 and 2, to standstill starts on session 3, to finally stops and starts on session 4 and beyond. This progression will not only condition the phosphagen system, but it will help limit soft tissue injury to the groins and hip flexors when gearing up to a return to full team participation. The work to rest ratio for these intervals should be 1:12 to 1:30 and the duration of the work portion should not exceed 10 seconds. The rest needs to be sufficient to allow for proper energy regeneration and maximal effort each rep. The athlete's rest can be made up of full rest, very low intensity active rest, or active rest at 65-75% max heart rate. Session duration can be anywhere from 15 to 45 minutes, depending on the athlete's level of fitness. There should always be 2-3 days in between sprint sessions to allow for proper recovery.
The athlete has now reached the 6 week mark and is ready to return to play. With daily communication between the athletic trainer, strength and conditioning coach, and the athlete, a return to play plan can be executed that provides a seamless transition to full team participation.
About Kevin
Kevin Collins is the head strength and conditioning coach for the Columbus Blue Jackets. He's been with the Blue Jackets for over ten years. He was featured last March in a piece for The Athletic.
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