Jan 29, 2015
Golden Opportunity

How do you turn a devastating knee injury into a positive? By treating it as an opportunity to take an athlete to new heights.

By Bill Knowles

Bill Knowles, ATC, CSCS, a Sports Performance and Sports Rehabilitation Specialist, is the Director of iSPORT Training at iSPORT in Killington, Vt. He can be reached through the group Web site at: www.isporttraining.com.

For the past 16 years I have been designing and implementing rehabilitation, reconditioning, and strength-training programs for world-class and Olympic-level alpine ski racers, freestyle mogul skiers, and snowboarders. Moving at speeds of up to 80 mph and performing flat landings from 20 feet, my athletes see their share of knee injuries. But they get back to the slopes quickly and, in most cases, in stronger competitive condition than before. The reason, I believe, is a program that integrates performance training with rehab every step of the way. In my mind, rehab and strength training are one in the same–you just need to modify the application. Thus I’ve developed an ACL rehab program that more resembles a strength and conditioning periodized plan than a rehab protocol. By treating rehab as a chance to improve performance, my approach addresses the entire athlete–the neuromuscular systems affected by the injury and the emotional and mental challenge of returning to high-level competition. Although I work primarily with skiers and snowboarders, more recently I have also worked with many ground-based sport athletes. The program I use is applicable to any sport and it has three keys: motivation, training the entire athlete, and careful program design.

OPPORTUNITY OF A LIFETIME A season-ending ACL injury can devastate an athlete, so I try to turn the emotions completely around. Very simply, I tell my athletes this: Injury equals opportunity. If you spend time thinking otherwise, you’re moving in the wrong direction. I explain that this is their opportunity to get their body in sync. It is a time when they can concentrate on becoming stronger and more athletic in every area. It is rare that professional athletes have extended time to work on their weaknesses, and this time allows them to do so. It is critical, however, that this strategy is planned. In most cases, athletes buy into the concept pretty quickly. Because they tend to be highly driven individuals who crave a motivating and stimulating environment, they love the idea of a new challenge. They also understand the importance of turning a negative into a positive. I take advantage of this trait through three motivational strategies. First, I focus on the environment. As soon as possible, I move the athlete from a treatment setting, such as the athletic training room or physical therapy clinic, to a weightroom, field house, or gym. For any athlete, getting off the treatment table and back into the weightroom or fitness center provides energy and confidence. They’re in an environment where they’re comfortable and can see themselves on the comeback trail. They’re in a place where they’ve spent countless hours getting stronger and pushing themselves to become the best. They feel less like a patient and more like the athlete they really are. And in this strength-training environment, highly athletic individuals feed off each other and provide motivational support. Second, I motivate my athletes by explaining to them the entire rehab and reconditioning plan. By showing them where we are and where we are going, I quickly gain the trust and confidence of the athlete. They feel more in control and understand their role. The third motivational tool is to exude confidence in my own ability and plan. The most important source of confidence for a rehabbing athlete is their athletic trainer’s leadership and comfort in the athletic training environment. Just like a good coach doesn’t waver in his or her directions to athletes, neither should a rehab professional. If athletic trainers are confident in themselves and their program, they will breed success through motivated athletes.

MORE THAN THE KNEE For many athletic trainers and physical therapists, the focus of a rehab plan is on the injured knee, and often the physician’s protocol reflects this. For me, however, it’s about the athlete, not the injury. From a management perspective, I focus on the entire athlete–what I call the athlete’s system. The knee is just a part of this. The system represents the athlete’s physical, social, psychological, and professional interests. If these are in good working order, then rehabilitation and reconditioning are much more effective. If not, they must be addressed. For example, sometimes the athlete is not psychologically ready for a major rehab and the rehab professional needs to delve into why. In some cases, there are too many distractions in their life and they need a more secluded atmosphere. Other times, they need a lot of support from family and friends, who should then be included in the process. Managing the athlete’s physical qualities, however, is the primary focus of the program. Maintaining joint stability while progressing the athlete as quickly as possible is the key to any high-level rehab. Two critical objectives are maintaining joint homeostasis within the envelope of function, and strengthening and conditioning around the knee. “Envelope of function” is a phrase coined by Scott Dye, MD, author of a 1999 article in the Journal of Bone and Joint Surgery on factors contributing to post-injury knee function. As I progress an athlete through the many phases of rehab and reconditioning, I carefully adhere to the indicators of functional restoration, which are the absence of warmth, swelling, pain, and functional instability. Dye described this as staying within the envelope of function. World-class athletes can work at the upper limits of this envelope, and I design programs that encourage pushing the limits. With this approach, my program relies less on the number of weeks post-op and more on the individual’s own specific envelope of function. If you manage them individually, respect their ability, and progress them accordingly, you will achieve better results. While addressing the injured joint, I am also developing the athlete’s other physical qualities. Concentrating on the system, I develop an individualized plan that focuses less on the knee and more on the athlete’s overall physiological profile. Of course, there are limitations from the surgery that require special strategies to make appropriate strength gains, but nonetheless the focus is always holistic. I like to think of it as training around the knee. This means focusing on movements that stay within the envelope of function, yet offer excellent conditioning and motor learning opportunities for the joint through total body movements. Often the knee is looked upon as a limitation for progress, when in fact it could, and should, be included in the training session. For example, an upper-body cycle ergometer and traditional upper-body weightlifting (seated of lying positions) is often done far into the rehab process. This is training without the knee. You do need to be careful to not push the knee past its limitations, but you also don’t want to ignore the knee. For example, water training within two to three weeks post-op can address core strength endurance and anaerobic conditioning very effectively. With my athletes, the movements are coached with ski specificity to achieve proper technique and speed. This program’s hidden agenda is hundreds of repetitions to improve knee joint ROM and reduce post-op edema. By five weeks post-op, the athlete is working as hard in the water as a non-injured athlete. By the third or fourth month post-op, athletes are well conditioned off-snow and will require less of this training in the later stages of reconditioning. Now they can focus more time on skiing, advanced weight training, and various movement-specific qualities. Water training also helps the athlete follow a good progression of loading and unloading the joint. I typically use the pool every other day to unload with motion. I also use the pool for muscle recovery following heavier strength sessions. Remember, it is easy to stress the joint while strength training to get the neuromuscular response you’re after, but recovering the joint is where confidence is maintained and quality work continues. Spinning bike programs are also developed for every phase of the comeback. The emphasis here is on cardiovascular training, strength endurance, and lactate tolerance. Because it stresses the joints less than other exercises, it can be done during the first few months post-op. Standing core training is also implemented consistently. Ski-specific core training is best performed in a standing position through pulls, presses, and overhead movements. I keep this program going during all levels of rehab and reconditioning to offer core-specific strength, total stability development, and motivation. The third aspect of managing the athlete’s physical qualities is to focus on multidimensional training. The idea is to apply many different and necessary movements to best train the athlete for the next phase of the program. I’ve been inspired to develop this aspect of my program by these words from Vern Gambetta: “Multidimensional training is accomplished by training movements, not muscles. Neurologically, the brain does not recognize individual muscles. It recognizes patterns of movements.” I also think of it this way: An exercise is something you do, while a movement is something you feel. The more the movements replicate alpine ski racing, the more focused, motivated, and stimulated the athlete will likely be. For example, seated hamstring curls are a nonfunctional exercise to strength-train the hamstrings. Forward lunge walking with a medicine ball rotation, on the other hand, is an athletic movement that requires coordination, timing, concentration, and strength of the hamstrings (along with the glutes, quads, and core). When coached with ski racing vocabulary, the athlete relates the movement to past experiences and feels a connection to their sport. This dynamic movement is difficult to achieve on a weight machine. Next, I take these movements and apply variable resistance in many planes, at different loads, and at different speeds to achieve a multidimensional training regimen. Not all athletes can handle this well, so this is where I very carefully focus on the athlete as an individual. Different athletes progress at different rates due to greater pain tolerance, previous conditioning level, and faster healing, and all this must be taken into account. I am constantly trying to take advantage of the opportunity to improve athleticism throughout the rehab and reconditioning process by respecting athletes’ inherent athletic abilities. This means giving them constant multi-joint and multi-plane challenges. In essence, I am coaching them to get better, not just to perform the exercises. At the same time, I’m always respecting the envelope of function and advancing the athlete only when he or she exhibits functional control. One Olympic ski racer I recently worked with was unsure of his physical potential many months after surgery. I realized he was guarding his knee mainly through conscious muscular stiffness. There was no flow in his movements and his ability to express himself athletically was hampered. So, I decided to use a trampoline to simulate ski-specific movement patterns and coached him with the same vocabulary he hears on the slopes. This allowed me to pull the athlete out of the injury. Not surprisingly, the stiffness and apprehension associated with his other training diminished as well. I have found that movement training allows one to see the athlete within. You learn to trust the athlete’s inherent athletic ability and design a program that challenges their strength instead of prescribing exercises that underestimate their potential.

PROGRAM DESIGN When it comes to designing the nuts and bolts of the rehab program, I always start from the finish and work my way back–from the first competition to the first week post-op. This allows me to inventory all the physiological qualities that must be addressed along the way. It also creates a clear vision of how the athlete needs to look at each stage. And, as mentioned above, it provides the athlete with a motivational roadmap. In the case of my athletes, I know that alpine racing is an intensely skilled sport that requires tremendous lower-extremity eccentric strength and core stabilization to maintain control and upper-body direction from turn to turn. During the eccentric loading there are also significant proprioceptive demands, such as ice, ruts, and bumps attacking the athlete’s stability. The giant slalom, for example, may have fifty turns, and athletes are pulling up to three times their body weight for many of them. This is like performing more than 20 500-pound squats on each leg. Those loads are often felt for .5 to 1.5 seconds, so time under tension is an issue. The heart rate is typically at 90 percent or higher for the duration of the race, which can run from 55 to 120 seconds. These are the kinds of demands a rehab program in skiing needs to be designed for. Armed with this knowledge, I design the program. When it comes to implementing a world-class program, however, the key is monitoring where the individual athlete stands and what’s needed next in terms of returning to skiing. I must decide the modes of exercise during each stage of rehab that best prepares the individual for success on snow. This often means avoiding certain types of training that may be counter-productive to keeping the knee healthy. An example of this is avoiding running and advanced plyo’s before the first on-snow camp. Many successful ski racers with a history of knee injury have stopped stressful joint loading exercises off-snow because it interferes with their skiing quality. This is where creative programs come into play. During the rehabilitation process, strength, power, speed, and quickness training is developed specifically to meet the demands of their first on-snow experience. After this time, a more intense three to four week off-snow training program must be implemented to prepare for the next, more intense on-snow camp. This cycle continues until competition. The idea is to blend sport-readiness with an awareness of what the knee is capable of at any given moment. For example, full strength is required for aggressive gate training and competition, but it is not necessary to ski or to strength-train like a skier. Therefore, our progression aims to get the athlete to ski again by focusing on ski-specific movement patterns while staying away from unnecessary loading. I will work hard to get them back on the slope even though they will not be allowed to ski at full strength. Then I will continue to increase strength gains so that, even while they are working on their ski movements, they are getting ready for the intense training and competition to come. My reasoning is that an elite athlete should get back to his or her sport as soon as feasible. In my sport this runs counter to most physicians’ time frame of keeping skiers off-snow for five months or longer, but I believe low- to medium-intensity skiing and snowboarding requires very little strength and instead depends on special skills. Multiple machines and exercises mimic these sports, but they can never duplicate the unique demands. For skiing and snowboarding, as for any sport, it’s not a matter of getting back to competition sooner, but giving the athlete a longer opportunity to train the body and build confidence. As Jim Taylor, PhD, notes in his book, Psychological Approaches to Sports Injury Rehabilitation, “Fear of re-injury is often a consequence of the time and distance that injured athletes experience during rehabilitation. This separation can create a lack of physical and psychological connectedness with their sport.” Finally, I always keep in mind the ultimate goal: to make the individual a better ski racing athlete, with the potential to become a better ski racer. As a rehabilitation and performance specialist, that is all I can hope for. The rest is up to the athlete, coach, and opportunities. It is easy to follow a standard rehab protocol and get an athlete back to their sport. But it takes a more complex approach to make an individual a better athlete through their rehab process.

Sidebar: Pre-Olympic Rehab Two weeks before departing for the Olympics, one of my athletes, Hannah Teter, suffered a knee injury. A world-class athlete with a chance for a gold medal in the half-pipe snowboard, she was willing to do whatever it would take to get ready to compete. First, we worked on unloading to achieve joint homeostasis. While pool work and light bike spinning were indicated to reduce edema in the knee, strength development was critical to prepare the entire system for competition. Select strength movements that did not unduly load the joint but provided excellent training of the lower extremity were implemented. One in particular was the standing backward cycle. Placing her heels on the pedals and cycling backward while in a forward leaning position attacked the quads without increasing joint effusion. The cadence was medium and the resistance was high. Cardiovascular and core strength endurance were addressed in the pool. All training was set up as reps of 25 seconds, the length of a run in the half pipe. A massage therapist was brought in, Hannah’s diet was excellent, her surroundings were comfortable, and the music was how she liked it: “crankin’.” All this coupled with the will to win and a sound medical and coaching staff provided an excellent opportunity for her to perform. She came home with gold.

Sidebar: Ten Key Points The following are some of my general practices when working with an ACL rehab: • All ROM training takes place in the pool, using active movements. • For the first three months, the cardiovascular emphasis in the water is both anaerobic and aerobic. • From weeks one to eight, I emphasize artificial instability training. Then we progress to more ground-based stability work. • At two weeks post-op and beyond, we attack the gluteus medius via open- and closed-chain training with bands and hurdle work. • There is an early emphasis on eccentric stabilization and time under tension training, including resistance cord work in ski-specific positions. • We use standing core training with ankles and knees flexed in a ski-specific stance. • By six weeks post-op, we conduct rhythm, agility, and coordination training on a gymnastics floor. By eight weeks, we do ski-specific trampoline training. • By four weeks, we use a ski simulation machine. At eight weeks, we do ice skating (if they already have the skill). • We eventually progress to jump training, with an emphasis on lateral drop and hold (single leg), and moderate-amplitude drop jumps. • At three and a half months, we begin to get athletes back skiing with a Phase One Return to Ski program.

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