IJSPT

CLINICAL COMMENTARY

INTEGRATION OF STRENGTH AND CONDITIONING

PRINCIPLES INTO A REHABILITATION PROGRAM
Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS1
Daniel S. Lorenz, DPT, PT, ATC/L, CSCS2

ABSTRACT
Background and Purpose: Rehabilitation and strength and conditioning are often seen as two separate entities in
athletic injury recovery. Traditionally an athlete progresses from the rehabilitation environment under the care of a
physical therapist and/or athletic trainer to the strength and conditioning coach for specific return to sport training.
These two facets of return to sport are often considered to have separate goals. Initial goals of each are often different
due to the timing of their implementation encompassing different stages of post-injury recovery. The initial focus of
post injury rehabilitation includes alleviation of dysfunction, enhancement of tissue healing, and provision of a systematic progression of range-of-motion and strength. During the return to function phases, specific return to play
goals are paramount. Understanding of specific principles and program parameters is necessary when designing and
implementing an athletes rehabilitation program. Communication and collaboration amongst all individuals caring
for the athlete is a must. The purpose of this review is to outline the current evidence supporting utilization of training principles in athletic rehabilitation, as well as provide suggested implementation of such principles throughout
different phases of a proposed rehabilitation program.
Evidence Acquisition: The following electronic databases were used to identify research relevant to this clinical commentary: MEDLINE (from 1950June 2011) and CINAHL (1982June 2011), for all relevant journal articles written in
English. Additional references were accrued by independent searching of references from relevant articles.
Results: Currently evidence is lacking in the integration of strength and conditioning principles into the rehabilitation program for the injured athlete. Numerous methods are suggested for possible utilization by the clinician in practice to improve strength, power, speed, endurance, and metabolic capacity.
Conclusion: Despite abundance of information on the implementation of training principles in the strength and conditioning field, investigation regarding the use of these principles in a properly designed rehabilitation program is
lacking.
Keywords: periodization, program design, rehabilitation, strength, training

Duke University Medical Center, Durham, North Carolina,

USA
2
Providence Medical Center, Kansas City, Kansas, USA
No grant support or statement of the Institutional Review
Board approval.

CORRESPONDING AUTHOR
Michael P. Reiman, PT, DPT, SCS, OCS, ATC,
FAAOMPT, CSCS
Duke University Medical Center
Department of Community and Family
Medicine
Doctor of Physical Therapy Division
DUMC 104002
Durham, NC 27710 (USA)
Phone: (919) 668-3014
Fax: (919) 684-1846
Email: michael.reiman@duke.edu

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BACKGROUND AND PURPOSE

Strength and conditioning is traditionally thought to
exist only in the training of the healthy athlete, while
rehabilitation is for the athlete who has been injured.
Once the athlete completes their post-injury rehabilitation with the athletic trainer and/or sports physical therapist, they often then move onto the strength
and conditioning coaches to resume their weight
room workouts and re-integration with the team.
The strength and conditioning coach, in consultation with the athletic trainer and/or sports physical
therapist, uses an understanding of the proper technique and application of several types of exercise to
develop a program to ready the rehabilitating athlete
for competition.
Evidence supporting the implementation of strength
and conditioning principles into such a program is
currently sparse.1-6 Several authors have investigated
both conservative1-4,6 as well as post-surgical interventions.5 While each of these studies have integrated
specific strength and conditioning concepts, none
have employed the entire spectrum of strength and
conditioning as it applies to the rehabilitating athlete.
The purpose of this clinical commentary, therefore, is
to describe these strength and conditioning principles,

and provide a suggested implementation of their use

throughout the entire rehabilitation process, not just
during the return to sport phase.
Assessment of the Athlete and the
Post-Injury Training Program
Proper implementation of a post-injury training program requires assessment of the rehabilitating athlete,
their sport, and the defined training program principles themselves (Figure 1). Periodic re-assessment of
the athlete, as well as the program and its outcomes
can provide the sports physical therapist the necessary information required to manipulate the various
training program variables to achieve the desired
goals. Specific training principles (Table 1) should be
addressed when designing the athletes program. The
sports physical therapist should consider the phase of
rehabilitation that the rehabilitating athlete is in when
implementing such a program. The specific program
parameters of strength, power, endurance, and hypertrophy must also be carefully considered and targeted
when planning the program.
The requirements or demands of any given sport must
be ascertained in order to determine how to properly
manipulate the training variables throughout the

Figure 1. Program Design for the Rehabilitation Athlete.

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Table 1. Training Program Design Principles.18,22,23,60,64

program. For example, training for a football lineman

in the latter phases of rehabilitation should emphasize
explosive power in activities performed that last 7-10
seconds with 20-60 seconds of recovery time to best
replicate the demands of the sport.7,8 In the earlier
phases of rehabilitation it may be necessary to correct
specific impairments, such as muscle imbalances, that
may contribute to injury.9-12 The inability of a rehabilitating athlete to perform a specific task can be identified using various measures (self-report, impairment
based, bio-psycho-social, and/or performance based
measures). An individuals ability to properly function
occurs along a continuum, and therefore should include

these multiple measures.13,14 The assessment continuum should include a subjective report of functional
ability, observation and examination of impairments,
and functional performance testing as appropriate.
Functional performance testing has previously been
defined as using a variety of physical skills and tests to
determine (1) ones ability to participate at the desired
level in sport, occupation, recreation, or to return to
participation in a safe and timely manner without
functional limitations and (2) ones ability to move
through as many as three planes of movement. Functional performance is assessed using nontraditional
(e.g. beyond manual muscle and range-of-motion)

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testing that provides qualitative and quantitative

information related to specialized motions involved in
sport, exercise, and occupations.13 The comprehensive
assessment approach can be utilized to not only assess
the rehabilitating athlete and their sport demands, but
the success of the implemented program as well. If
specific program parameter(s) (e.g. functional movement, strength, power, endurance, and/or hypertrophy) are determined to be deficient in the rehabilitating
athlete during testing, the program can be modified to
correct these deficiencies. Limitations demonstrated
in fundamental movement patterns15,16 would require
amelioration prior to placing emphasis on power training. Since it has recently been suggested that assessment of an individuals overall functional ability is
multifactorial14 complete description of functional
assessment is beyond the scope of this clinical commentary. For additional suggestions on the implementation of the assessment of the athlete, the reader is
referred elsewhere.13-17
Traditional Training Program Parameters
Specifically training a muscle or group of muscles to
achieve the desired goals of increased strength, power,
endurance, and hypertrophy is paramount. The reader
is advised to consult other sources18-20 for detailed
information on training of these parameters, as it is
also beyond the scope of this commentary to do so.
General parameters will be discussed here.

Training for muscle performance including strength,

power, and endurance, requires different program
design and does necessitates variability in exercise
prescription (Table 2). Strength training typically
involves a load/ intensity of 80-100% of the maximum
amount of weight that the individual can lift one repetition (1 RM), utilizing approximately 1 to 6 repetitions.18-23 Power training, on the other hand, requires a
primary component of velocity of movement. Therefore, since velocity is inversely proportional to the
amount of load lifted, the load will have to be relatively lighter than loads utilized in strength training in
order to accomplish the necessary velocity. Power
training though does require a foundation of strength.
While strength and power training can require similar
components of training, endurance training is fairly
unique. Endurance training can involve many methods (circuit training, etc.) but the common theme is
high repetitions with lighter loads.18-23 The relative
work to rest ratio is the lowest amongst the primary
three parameters of muscle performance. Endurance
training can be a method to achieve hypertrophy training since moderate loads and repetition range of 8-12
is suggested for hypertrophy training.18,22,23
Phases of Injury Rehabilitation
Regardless of the type or region of injury, basic
phases of rehabilitation have been described in the

Table 2. Repetition Maximum Continuum.18,19,21-23

Table 3. Rest Period Continuum.18,19,21-23,63

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literature.3-5,24-34 Dependent on the injury status,

whether surgery was involved, and the restrictions
associated with the recovery, the duration of these
phases will differ. There are some common characteristics, goals, precautions and criteria for progression to the subsequent phase. Described below and
in Table 4 is a general outline of the various phases of
rehabilitation based on multiple previous protocols,
literature sources,3-5,24-34 as well as opinions of the

authors. Criteria for progression, goals of each phase,

and characteristics of each phase therefore are the
authors opinions based upon available protocols and
past literature.
Phase I, Immediate rehabilitation: Characterized by tissue and/or joint inflammation and pain, disuse,
detraining, loss of muscle performance, potential
immobilization (dependent on injury), and initiation

Table 4. Utilization of Non-Linear Periodization in Different Phases of Rehabilitation.

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of tissue repair and/or regeneration. The primary

goals to be addressed during this phase are protection of the integrity of the involved tissue, restoration
of range-of-motion (ROM) within restrictions; diminishment of pain and inflammation, and prevention
of muscular inhibition. Major criteria for progression
to Phase II include: minimal pain with all phase I
exercises, ROM75% of non-involved (NI) side, and
proper muscle firing patterns for initial exercises.
Phase II, Intermediate rehabilitation: Characterized by
continuation of tissue repair and/or regeneration,
increased use of involved body part or region, decreased
inflammation, and improved muscle performance.
The primary goals to be addressed during phase II
include: continued protection of involved tissue(s) or
structures and restoration of function of the involved
body part or region. Criteria for progression to Phase
III include: close to full ROM/muscle length/joint play,
and 60% strength of primary involved musculature
when compared to the uninjured side.
Phase III, Advanced rehabilitation: Characterized by
restoring normal joint kinematics, ROM, and continued improvement of muscle performance. The primary goals to be addressed during this phase are
restoration of muscular endurance and strength, cardiovascular endurance, and neuromuscular control/
balance/proprioception. Criteria for progression to
phase IV include: strength > 70-80% of non-involved
(NI) side and demonstration of initial agility drills
with proper form (e.g. avoidance of medial collapse35
of bilateral lower extremities, coordinated and symmetrical movement of all extremities, controlled
movement of entire body).
Phase IV: Return to function: Characterized by activities that focus on returning the athlete to full function. The primary goals to be addressed during this
phase are successful return to previous functional
level in the athletes preferred activity, and prevention of re-injury.
Designing a Training Program with
Consideration for the Injured Athlete Needs
Analysis of Training Program
In order to properly design a patient and sports specific rehabilitation program, a needs analysis should be
performed.36 Performing a comprehensive analysis

(Recall Figure 1), investigating such factors as the

physiological and biomechanical requirements of a
sport is required when designing the program. Components of a needs analysis include a general biomechanical analysis of the sport which rehabilitating
athlete participates in, an analysis of the energy
sources utilized in the sport, and an analysis of the
common injury sites and patterns for the sport.36
Furthermore, an appropriate physiological analysis
allows the clinician to devise a program that addresses
specific strength, range of motion, flexibility, power,
endurance, and speed requirements for any given
sport. For example, an American football player
needs more muscle size and strength than a crosscountry athlete or a soccer player. Only by addressing these requirements specifically will an athlete be
successful in returning to their sport or activity. Next,
a biomechanical analysis is required to choose training activities that develop the athlete in a manner
most specific to the sport. Specificity of training is a
foundation of both functional and resistance training
programs.18 It is the authors opinion that the sports
physical therapist should be well-versed on injury
patterns that are present in the sport in which the
rehabilitating athlete is participating to ensure that
prevention strategies are included. For example,
female soccer and basketball players have demonstrated a higher risk for anterior cruciate ligament
ruptures than athletes who participate in other
sports.37-41 Likewise, American football lineman and
gymnasts are at an increased risk for spondylolysis
and spondylolisthesis compared to athletes in other
sports.42-45 Each of these examples shows how training programs for the rehabilitating athlete should be
specifically designed to accommodate each individual athletes needs to maximize performance and
avoid subsequent injury. The reader is directed to
Table 5 for an illustration of these concepts.
Assessment of Rehabilitating Athletes
Strengths and Weaknesses
Assessment of each rehabilitating athletes strengths
and weaknesses can be a complex undertaking. As
previously mentioned, proper assessment of an athletes functional capacity is multi-factorial, involving
multiple variables.14 Along with the assessment of
the rehabilitating athletes strengths and weaknesses,
knowledge of their training history/status, injury

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Table 5. Needs Analysis Comparison for a Male Football Player versus Female Soccer Player Recovering from
ACL Reconstruction Surgery.

history/status, and basic physical characteristics is

warranted. Training status may depend on numerous factors, including length of time playing the
sport, length of time specializing in the sport (or
position within a sport), and the level of competition
at which the athlete is accustomed to participating.
Training Program Design Principles
Once the clinician has determined the rehabilitating
athletes needs, the next step in designing the rehabilitation program is manipulation of the program
principles. As previously mentioned, it is beyond the
scope of this article to discuss all the necessities of
program design; however some discussion of these
principles is warranted especially in light of the paucity of literature regarding their implementation in
the rehabilitating athlete The program principles of

interest to the sports physical therapist for manipulation include: exercise selection, training equipment
availability, training frequency, exercise order, rest
interval and resistance/training load.
Exercise Selection
Exercise selection is a critical program principle for
which the clinician should account. Multi-joint exercises are exercises that involve many muscle groups
in one exercise.18 Examples of multi-joint exercises
include squats, deadlifts, cleans, bench presses, and
push jerks. Typically, these exercises are done first in
the training session because they are the most fatiguing, but also because they are recommended most for
increasing muscle and bone strength.18 The other type
of exercise is known as supplementary, or isolation
exercises. Examples of isolation exercises include front

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raises, lateral raises, and knee extensions. Since these

isolation exercises are primarily single joint-single
plane exercises, they are a good choice for the untrained
or inexperienced athlete.18 Ultimately, though, the
experienced athlete will require several multi-joint
exercises in their program in order to be successful.
Progression to multi-joint exercises involves more
instruction and greater time to practice in order for
the athlete to establish the necessary coordination to
properly execute the exercise safely and effectively.
Performing large muscle mass, multi-joint exercises
early in the workout has been shown to produce significant elevations in anabolic hormones.46-48 This
type of an anabolic response may potentially expose
smaller muscles (such as those in the affected area)
to a greater anabolic response than that resulting
from only performing small muscle exercises.47,48

Availability of Training Equipment

A lack of certain equipment necessitates changes or
does not allow the performance of some exercises.36
In the context of free weights, lack of floor or ceiling
space may hamper lifts that could involve dropped
weights or pushing weights overhead. For example,
many Olympic lifts performed overhead (i.e. snatch,
jerks) are performed with bumper plates that bounce
on the ground to promote athlete safety if a lift is
missed, or if maximal lifts are attempted. In any of
these cases, the bar is often dropped to the floor where
it bounces and could potentially injure others. Some
machines may not be multi-dimensional enough to
be sport-specific for the rehabilitating athlete,36 so the
clinician will need to supplement training programs
with appropriate exercises. For example, when the
rehabilitating athlete needs to perform a chest press
motion, it may be more appropriate to use the dumbbell or barbell bench press than a weight machine.
These lifts, although utilizing the same musculature,
require the athlete to make adjustments to complete
the lift given that the axis of movement is not fixed
and may follow an unpredictable course compared to
a seated chest press using a weight machine which
only has one axis of movement.

Training Frequency
Training frequency ultimately depends on the volume and load of exercises, the type of movement

(multi vs. single joint) that prevails throughout the

workout, the training level of the athlete, the goals
of training, and the health status of the athlete.36 Traditionally, resistance training on alternating days is
encouraged in the early stages of training to ensure
recovery,36 but frequency may increase with increased
training experience. Previous authors have demonstrated insignificant differences in strength gains
observed between training 1, 2, 3, or 5 days per
week if the volume was kept constant.18 When near
maximal resistances are used, more recovery time
is advocated.18,19,22,23
The sports physical therapist must also consider other
concurrent training in which the athlete is involved.
A young pitcher may not only be in season, but may
also be working with a pitching coach once or twice a
week in addition to resistance training. The frequency
of training may need to be reduced to accommodate
the athletes schedule of training in order to ensure
that proper rest and recovery is achieved. Similarly,
an increase in training frequency may be warranted
if the athlete appears to be reaching a plateau or making minimal gains in one or more of the training
parameters (e.g. strength, power, endurance).

Exercise Order
The ability to perform the desired load and volume
of each exercise is dependent on proper order of
exercise.36 Proper coordination of the integration of
multi-joint and isolated strengthening exercises
requires careful planning on part of the sports physical therapist. Each individual athletes physical condition, as well as the their particular strengths and
weaknesses will require consideration when designing the training program.36 Various methods of utilization of exercise order will be described.
Because multi-joint exercises require the most coordination, skill, and proper levels of energy, it is
encouraged that they are performed first in the training session. For example, the bench press should be
performed prior to tricep extensions. Since multijoint lifts are the most fatiguing, the athlete is unlikely
to obtain the maximum benefit of these exercises if
the smaller muscle groups are fatigued from previous exercises. Pre-exhaustion is a training technique is
a training technique in which a muscle is fatigued in
a single-joint, isolated movement prior to performing

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a multi-joint exercise involving the same muscle.36

An example of pre-exhaustion training is performing
leg curls or leg extensions prior to a back squat or
deadlift. The sports physical therapist may utilize
this technique if they feel that the multi-joint movements are not completely developing the muscles in
question or to help alleviate the effects of training
boredom. To the authors knowledge, no studies exist
utilizing pre-exhaustion as a training technique.
There are various methods of pairing exercises to
challenge the athlete, alleviate boredom, and emphasize muscle endurance and hypertrophy. Super setting involves alternating agonists and antagonists
with minimal rests between exercises. For example,
a bench press followed by a seated row or a bicep
curl followed by a triceps pushdown would be examples of super sets. Compound setting is performing
two different exercises of the same muscle group in
alternating fashion with little to no rest between
exercises. Anterior lunges followed by squats or barbell bicep curls followed by alternating dumbbell
curls are both examples of compound setting. Athletes in poor physical condition may find super setting, compound setting, or pre-exhaustion techniques
too strenuous in the early stages of training.36
Other methods to manipulate exercise order are to
have an athlete perform upper and lower body exercises in an alternating fashion. The clinician can
also have the athlete perform upper body push and
lower body pull exercises alternatively, or vice versa.
Lastly, the athlete can perform a push-pull routine.
Here, the athlete can perform a front squat followed
by a deadlift. Push-pull may involve agonists and
antagonists, but may also include an upper body
push exercise coupled with a lower body pull, or
vice versa. Collectively, these methods allow more
exercises to be completed within a session and allow
greater intensity of each exercise due to extended
recovery of the each muscle group being worked.
Plus, these methods help promote balance and symmetry of agonist-antagonist training.

Rest Period & Resistance/Training Load

Manipulation of all of the above training variables are
applicable to the rehabilitating athlete, but it will
require the sports physical therapist to design athlete
specific programs, keeping the above principles in

mind. Regardless of injury, it is advised that the athlete have at least 24 hours of recovery between sessions, and 48 hours in between sessions working the
same muscle group.18,21,22 For a rehabilitating athlete
who is seen only 1-2 times per week, a total body routine is advocated to maximize training balance. If
training is done 4-5 days per week, a split routine is
advocated by the authors of this review to allow proper
recovery between muscle groups used. Regarding the
athlete who is rehabilitating 3-5 days per week, the
authors suggest activities on off days might include
flexibility training, yoga, balance and proprioceptive
exercises, or core/abdominal training.
Determining the training load and rest ratios requires
careful consideration of the rehabilitating athletes
sport and the body part or region to be trained. For
example, muscles of the trunk are primarily slow
twitch, type I muscle fibers49-51 that necessitate high
repetition, low load endurance based training. Other,
more explosive muscles that are prime movers, utilized in jumping (e.g. quadriceps and gastrocnemius)
require strength based training programs, progressing to lower loads at explosive speeds, and plyometric type training for development of power.
Training load is usually determined with 1 RM testing in strength and conditioning. The use of 1 RM
testing is often disadvantageous for the rehabilitating
athlete as it requires a systematic progressive increase
in maximum load lifting capability. Although this
method is the most advantageous and accurate
method of determining 1 RM, the use of estimating
1 RM and training load charts is advisable for these
athletes. Other methods for determining training
load include the DeLorme technique, the Daily
Adjusted Progressive Resistance Exercise (DAPRE)
technique, the OMNI-RES, or the Oddvar Holten
method.52-55 These tables are intended to be used as a
guide until the athlete has developed the neuromuscular capabilities that will allow them to safely and
effectively test with heavier loads to more accurately
determine their 1 RM.18 The use of such tables is but
one method of determining load, as other methods
have proven effective.55 Training volume is typically
prescribed in terms of the number of repetitions per
set, number of sets per session, and the number of
sessions per week.56 The importance of training volume for maximal strength and hypertrophy gains

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during early phases of resistance training has previously been demonstrated.57-59 Untrained, normal individuals were shown to experience maximal strength
gains with a mean training intensity of 12 RM, while
trained individuals demonstrated these gains with a
mean training intensity of 8 RM.59
The length of the rest period is dependent on the
training goal, the relative load lifted, the sport in
which the athlete participates, and the training status of the athlete. The rest period is a primary determinant of the overall intensity of a workout, as rest
period length is strongly related to the load lifted.18,21,60
The rest period length not only determines how
much of the adenosine triphosphate-phosphocreatine (ATP-PCr) energy source is recovered,60 but
also how high post exercise lactate concentrations
become in the blood.47,61-63
Other training principles were outlined and defined
in Table 1. Additionally, Tables 2 and 3 provided
descriptions of training load and rest period suggestions. Utilization of concepts and suggestions given in
these tables, as well as the outline provided in Figure
1 will provide the sports physical therapist the necessary framework to design a proper training program
for the rehabilitating athlete. Integration of these
principles into a specific program is the next step.
Integration of Training Principles and
Parameters into a Rehabilitation Program for
the Injured Athlete
The previous sections offered suggestions regarding
multiple parameters and the opportunities for their
manipulation of these training principles for the
rehabilitating athlete, based on current evidence and
principles used with normal (uninjured) athletes.
Additionally, Table 1 defines periodization, as well
as the difference between linear and non-linear periodization. The rehabilitating athlete may need to be
considered similar to the untrained category initially
with respect to the injured body part. Therefore, as
outlined in Table 4 the initial non-linear periodization phase for the injured body part or region should
be an emphasis on higher repetitions and muscle
endurance/hypertrophy with a later initiation of
strength-based training. As the patient progresses
further in their rehabilitation, additional progression
into more aggressive strength training and power

training should be incorporated. Unlike linear periodization, where the emphasis is on only one parameter (endurance, hypertrophy, strength, endurance),
non-linear periodization allows the clinician the ability to train more than one of these parameters at a
time, while still emphasizing one of them in a particular phase. Although the literature is lacking regarding the utilization of types of periodization with the
rehabilitating athlete, the opinion of the authors of
this review is that the non-linear form of periodization would most likely fit the rehab process in most
instances. Additionally, it is the authors suggestion
that the rehabilitating athlete continue with some
form of training with their team. Table 4 also offers
ideas on how to integrate the rehabilitating athlete
into team training components. This is a general
framework upon which the reader can build and
individualize a program specific to the needs of each
rehabilitating athlete.
As an alternative to non-linear periodization previously described, a rehabilitation program could be
constructed using short duration linear periodization. Utilizing a short duration linear program would
require initial emphasis on high volume and low
intensity (endurance and/or hypertrophy phase).
Progression into the strength/power phase and
eventually to the power phase at end stage rehabilitation would then occur. Once again, the authors of
this commentary assert that non-linear periodization may prove to be a more advantageous method
of program design for the rehabilitating athlete as it
affords implementation of multiple variables into
the different phases throughout the rehab program.
CONCLUSION
Strength and conditioning principles and training
parameters are a necessary component of the decision making and tailoring of any rehabilitation program. This is especially important in the rehabilitation
and full return to function of an injured athlete. The
sports physical therapist implementing such programs should be cognizant of each the components
and variables for the rehabilitation program of an
athlete. Currently the literature has little to offer
regarding of the integration of strength and conditioning concepts into the rehabilitation of the injured
athlete. The benefit of integration of these training
principles during the rehabilitation of an injured

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athlete, although intuitive for best practice, remains

elusive. Future studies should investigate the extent
of the relationship between strength and conditioning principles and their integration into a rehabilitation program for the rehabilitating athlete. Determining
how integral a role these training principles play for
athletic rehabilitation is long overdue.
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