Rehabilitation vs. Athletic Performance Enhancement Training: Are we Asking Questions that are Already Answered?

Rehabilitation vs. Athletic Performance Enhancement Training: Are we Asking Questions that are Already Answered?

Robert A. Panariello MS, PT, ATC, CSCS
Professional Physical Therapy
Professional Athletic Performance Center
New York, New York

Throughout my career as a Physical Therapist (PT), Certified Athletic Trainer (ATC), and Strength and Conditioning (S&C) Coach I have been witness to many trends that have transpired upon these related professions. The evolution of the internet has been a significant venue for the conveyance of these trends with much of this information comprising assorted material of pertinent substance, some without; nonetheless the internet has offered many professionals their own claim of “notoriety” and in some instances financial gain. I am personally not opposed to capitalism as I am in private business myself. Like many others I also acknowledge various practitioners who evolve as “experts” in their professional field of choice and have mentors whom I very much respect. Presently there is an abundant amount of information and products available to the practicing professional where as the boundaries for the specific application of some of this information is often clouded if not altogether disregarded.

Buddy Morris

Performance Enhancement Training Trends

One current training trend appears to be the application of the principles of Sports Rehabilitation (SR) into the S&C setting. Certainly there is an “overlap” so to speak with regard to these two professions, however, it should be noted that these are two distinctly different professions. The application of various SR principles as related to the practice of S&C although practicable at times is becoming alarmingly close to providing a disservice to the training athlete.

Rehabilitation concerns often articulated include the “dreaded” type III acromion, upper trap dominance, the deep squat, disregarding bi-lateral leg exercises, the reluctance to utilize heavy weight intensities, and the list goes on and on. When pathology, anatomical abnormality or medical concerns are present; wouldn’t communication between the rehabilitation and S&C professionals take place to design a training program with all pertinent modifications? When these concerns are NOT present why is there still the intention to train the athlete as if they do exist? Is this due to the rehabilitation principles publicized for the training environment? In the S&C environment is optimal athletic performance as well as the prevention of athletic injuries best achieved with the application of rehabilitation principles or by optimally enhancing the physical qualities required for the sport of participation?

As an example the concern of the previously mentioned type III acromion appears to be commonly communicated. Is the expectation to x-ray every athlete training to confirm if the type III acromion morphology exists? Type III acromion morphology is substantiated to be present in the minority when compared to the type I and II. This evidence is often overlooked thus is the intent to have the minority manipulate the majority and prohibit overhead exercise performance? During my recent trip to the University of North Carolina at Chapel Hill to visit with my good friend Head Basketball S&C Coach Jonas Sahratian, some of his players demonstrated split jerking 100 – 100+ Kg of weight intensity overhead. These players had no complaint of shoulder, back, hip or knee pain, and demonstrated no limitations in range of motion (ROM), strength, neuro-muscular timing, or any other often stated clinical rehabilitation concerns. These basketball athletes lifted weights overhead for enhanced athletic/basketball performance as well as to survive the physical confrontations that occur under the boards during repetitive practice days and game day competition. Is there as much publically stated concern for the weaker athlete situated against a stronger opponent in the confined area under the boards? Isn’t it possible that these dominated weaker athletes are placed at risk of injury?

Why is it necessary to perform an abundant number of rotator cuff exercises when this muscle group is confirmed to be strong, neuro-muscular timing is appropriate and research attests this small muscle group has an active role during the execution of many upper body exercises? Why is there failure to mention the documented consequences due to excessive rotator cuff fatigue that transpires due to unwarranted exercise performance? When no deficiency in muscle activity nor neuro-muscular timing is noted during a pain-free technically proficient exercise execution, why is it necessary to “activate the muscles” prior to the actual exercise performance? Isn’t the most precise muscle “activation” for a specific activity an appropriately executed progression of the actual activity? This is not to imply that a warm-up isn’t warranted, however, if an athlete desires to become a better baseball pitcher wouldn’t they practice pitching? To become an improved golfer wouldn’t they golf? Therefore to become a better back squatter wouldn’t they actually have to back squat? Doesn’t form follow function? If this were not true why is practice necessary? Why not workout and just play the game?

The deep squat results in various joint(s) stresses that all professionals should be aware as isn’t this knowledge (science) required for prudent training? Investigations have established the deeper knee bend positions demonstrate the greatest lower extremity muscle activity, thus without the presence of a contra-indication why would an athlete not assume the most beneficial position during the exercise performance? If the deep knee bend position is so detrimental to the athlete why are there no noted medical community demands for the abolishment of the catcher’s position in the game of baseball?

Why is there such concern with appropriately programmed heavy weight intensities? Is it because these weight intensities exceed those utilized in the rehabilitation setting? It is documented that game day competition and practice days are the environments where the highest incidence of athletic injuries occur as weight room injuries have been noted to occur at a rate of less than 1%. There are circumstances where specific exercises and heavy weight intensities may be appropriately prohibited from the athlete’s training program design. However there are also instances at the time rehabilitation is completed and all contra-indications are resolved, yet an apprehension continues to exist with regard to these same exercises and weight intensities. Isn’t this suitable programming necessary to prepare the athlete for the stresses of repetitive team practice, game day competition and the physical confrontation of an opponent? Why on occasion does there appear to be less concern with returning the athlete to the field of competition, the initial cause of the athlete’s problem? When appropriate exercises and weight intensities are deemed prohibitive isn’t it fair to inquire if they are truly contra-indicated or are the principles of rehabilitation for a pathology which no longer exists continually being applied?

Most professionals would agree that not every exercise, principle, and application of heavy weight intensity is appropriate for every individual. However, isn’t the athlete’s exercise selection and training programming part of the “art” of both SR and S&C? Why is the “art and science” of coaching often ignored by the reader of an article or the attendee of a conference at the time the rehabilitation based questions of “what about this, what about that” arise? Is this due to the clinical rehabilitation information that is delivered via various public forums? If abnormalities and medical conditions are acknowledged why is it assumed they will not be properly addressed during training?

They are Different Professions

Ask yourself why do the majority if not all Professional Sport Teams, Colleges, and Universities have both an Athletic Training Medical Staff and an S&C Staff? Why are there two distinct departments? In most circumstances would the Athletic Training Staff be designated to Athletic Performance Enhancement Train an individual or team for a Championship? Would the S&C Staff be appointed to rehabilitate a post-operative World Class athlete or any athlete from day one? Why not just employ ONE of these professional staffs to both rehabilitate and train all athletes? Imagine all the money saved by eliminating an entire professional staff/department. This does not occur because these are two distinctly different and respected professions. This statement is not intended to be disparaging as I respect and practice both in my vocation. Many of the concerns and principles deemed appropriate and utilized in one profession may not be a concern or appropriate for utilization in another. There are certainly professionals qualified to practice both, however this is the exception and not the rule. In our 44 Orthopedic and Sports Physical Therapy clinics as well as our 20,000 square foot Athletic Performance Training Center we accept more than 180 physical therapy, physical therapy assistant, athletic training, and S&C student interns annually. In review of the curriculums of these student interns it is substantiated that they are quite different in both educational content and clinical requirements.

My good friend Hall of Fame NFL S&C Coach Johnny Parker told me a story about a former NFL Assistant and Head Coach whom I am familiar named Al Groh. Coach Groh was an assistant on Head Coach Bill Parcells coaching staff with the NFL New York Giants, New England Patriots, and New York Jets. These teams were persistently in the playoffs winning Super Bowls and Championship games. These three organizations had one thing in common; they were all not very successful prior to the arrival of Coach Parcell’s and his staff. This coaching staff was not elaborate and avoided the trends and hearsay of the “outsiders”. They just applied the fundamentals specific to the game of football and worked very hard. On one occasion Coach Groh turned to Coach Parker and stated, “You know JP I think I have this thing figured out. Get the team organized, get them disciplined, get the team in condition, have a plan, follow that plan and let the losers eliminate themselves”. During my 10 years as the Head S&C Coach at St. John’s University Hall of Fame Basketball Coach Lou Carnesecca had the same ”no outside nonsense” and work hard philosophy. Coach Carnesecca won 640 basketball games during his coaching career.

Rehabilitation and S&C Coaches are well respected professionals that are vital to the athlete’s and team’s success. Although there is overlap between these two professions, these are two distinctly unique vocations requiring very different knowledge and skill sets. Every athlete in training should be treated as an individual and the S&C Professional has a choice to incorporate an S&C philosophy or a rehabilitation philosophy. The performance training road paved will eventually be one of success or one of consequences as with athleticism and skill being similar it is the stronger and more powerful athlete that will usually prevail. The terms “Rehabilitation” and “Strength and Conditioning” are not interchangeable and are as different as the principles and skill sets utilized in each respective profession. If this were not true why aren’t these professional staffs/departments interchangeable?

19 Comments

  • Chris says:

    Hello!

    We had kind of a heated debate on one of your articles here on Bret´s blog. It was about unilateral and bilateral exercises. You claimed bilateral exercises are superior in several domains, whereas I was skeptical about that and provided some, (although not sufficient) indirect and direct evidence for my stance that they may be both similarly effective. http://bretcontreras.com/rehabilitation-strength-conditioning-professional-abandon-traditional-bi-lateral-leg-exercise-single-leg-exercise-performance/

    Coincidentally, with this article here, this week Bret and Chris Beardsley published another edition of the S&C review. One of the topics was unilateral vs bilateral training. Seems like this evidence supports my stance that bilateral and unilateral training can be equally effective in a number of practical outcome measures in athletes, here: rugby players. Have a look, maybe Bret and Chris´ evidence can convince you; you can read a summary by Chris B. in the research review or the original study here:
    http://www.ncbi.nlm.nih.gov/pubmed/26200193

    Looking forward to your thoughts either in this comment section or of course, if you want to keep this one only for the discussion of this article, in the comment section of the article back then (link is above).

    Regards
    Chris

    • Bret says:

      Chris, I agree with you, and I’d love to see a comprehensive study of sufficient length (say 10 weeks) and size (say 12 subjects in each group) examining volume-matched unilateral (ex: RFESS, 1-Leg RDL, Single leg hip thrust, Walking Lunge) versus bilateral (ex: Squats, Deadlifts, Hip Thrusts, Front Squats) versus combined on strength, hypertrophy, and performance. This would be a very challenging study to perform with a lot of data to collect, but that’s what’s needed to really settle this debate IMO.

      • Chris says:

        Of course, I dont see that as “case closed”, either. Just that evidence keeps coming for the effectiveness of both bilateral and unilateral training. Considering the study you suggest – wont the bucks be rolling in in truckloads once youre a PhD? So… can we expect another piece of work after the hip thrust studies that enhances traditional thinking in the S&C world? 🙂

  • Derrick Blanton says:

    Rob, this is outstanding, in the truest sense of the word.

    It stands out like a laser sharply cutting through the fog; brilliantly illuminating the murky sky.

  • Chris says:

    Rob, I can understand your frustration about some unnecessary PT mixing and leaning in the realm of S&C. But I think generally its a good thing. Let me explain why. Consider the bigger picture:
    Example: the external rotation exercises (or any prehab exercises in that matter). In a perfect world, you would be completely right: A healthy person starts a well-rounded strength program that balances every movement. In his work, this person also does a variety of movements. As well in his sports and in his spare time. –> No prehab exercises needed at all.
    Unfortunately, this isnt the case.
    The reality: A college baseball pitcher sits in his classes from 8 to 12. Lunch (sitting). Some more classes (sitting). After that, pitching. 100 throws. Internal rotation all the way. Then strength training (well-rounded program). After that time for dinner (sitting), some home work (sitting) and maybe a round of computer games (sitting) or TV (well, sitting, this time on a couch, though).
    So we actually have about 10 hours of a hunched forward position with internal rotation, kyphosis, shortened hip flexors. Add to that 100 high-intensity internal rotations. Do you really think 30 reps of rowing will do the trick and undo all the day´s work of internal rotation and kyphosis? Hell, the 30 reps have a hard time to counter the (habitually) more reps of bench pressing and flys that come first. In this scenario, even some external rotation exercises wont do the trick entirely. But God are they badly needed.
    My point is: Were not dealing with ideal persons in an ideal world. Sports at a high performance level are inherently “not healthy”, theyre one-sided (for the pitcher even literally so), causing imbalances. Modern daily life is not healthy and one-sided. A well-rounded program alone is too little to combat that. So maybe external rotation exercises are not needed for activation before. But theyre needed additionally after big compound exercises for our pitcher.
    Concerning “disregarding bilateral exercises”: I agree that we shouldnt completely disregard them, they have a lot to offer. But again: Were not dealing with ideal circumstances. In mid-season, there may well be times when the capacity for leg training is not exhausted in an athlete – but his lower back is. In comes the unilateral exercise: Same bang for the buck leg-wise, less strain on the spine.
    Concerning acromion type 3: Well, type 3 is not so rare as you state it is: almost a whooping 40% have it: https://en.wikipedia.org/wiki/Acromion#Variation And while some sports surely are self-selecting in that regard (you wont be a pitcher if you have one, neither will you be an olympic weightlifter – injuries stop you well before your first medal), some sports, where bench pressing or overhead movements are only means to an end, not the movement itself, are not. And as you mention we dont have preemptive x-ray scans of everyone´s shoulder, isnt it prudent to err on the safe side? And subsitute the behind-the-neck press by the classical OHP? If someone feels absolutely no discomfort in the shoulders he might even go for the BTNP. Maybe damage will show only later, maybe never. But what is the cost-benefit-ratio of doing BTNP in the first place? Almost zero advantages over the safer OHP. And dumbbell presses have even less risk while providing similar benefits as the barbell press – so theyre a good choice for athletes that are prone to shoulder problems (maybe because they have type 3 acromion, maybe because of other reasons).
    The point here is: Some exercise may appear “whimpy, or strange” for the veteran coach or athlete that is only accustomed to a dozen or so traditional exercises. Hip thrusts are a perfect example, they are still referred to by many as “unnecessary and have only a place in a rehabilitation setting” – yet evidence shows theyre also great for healthy athletes!
    The overpowering point is: In my opinion, “healthy” and “injured”, S&C training and prehab/rehab are not as black and white as you wish and demand them to be. The lines are blurry, neither one of us is completely healthy all the time.
    They are especially blurry in high performance athletes. Theyre almost never free from some small injuries here and there, some chronic problems, some dysbalances almost all year round.
    So in my opinion, it pays off greatly to react to these realities, preventing them with – yes, PT like exercises additionally to the traditional S&C exercises – instead of ranting that rehab PT – figuratively speaking – should keep their mouths shut once an athlete is deemed “not injured anymore” by the physician´s bulletin.
    Quite the contrary, I think its very advantageous if we manage to have highly specialized coaches that nevertheless know a good portion of the other profession (someone like you) and cooperate constantly with each other (as I mentioned: youre neither injured nor completely healthy all the time as a high-level athlete). You dont put the athlete into the S&C department to resume his old habits when you know that those were the habits that caused a chronic injury in the first place. No, if that athlete is prone to some kind of overuse – or even almost all athletes of a certain sport are for a body part or type of injury – then a prehab exercise should be a companion and addition to their strength training for the rest of their entire career! Even in the absence of current injuries or problems!
    Imo you think too much of acute injuries that werent the “fault” of the athlete when you try to draw the line between healthy-injured and PT-S&C. A great portion of missing game time are not catastrophic injuries like a broken leg. And even acute injuries can be caused of chronic stresses that werent adressed by what you perceive as PT-like actions (external rotation exercises, unilateral exercises) before the accident happend. That cant be seen superficially, but they build up in the background.
    Tl;dr? –>
    A case for cooperation and integrating S&C and PT instead of building walls and drawing lines. Grey instead of black and white. 🙂

  • Kind of ironic to see a picture of Buddy Morris on this article. Buddy is the epitome of a strength coach that does rehab exercises. The thing is Buddy includes enough progressive overload to help athletes develop. They aren’t missing out. I learned the concept of movement prep from buddy almost 10 years ago- no one was doing it then.

    Buddy is an advocate for “rehab” exercises as some people may say. His offensive linemen do cuff exercises, and Y’s and T’s every time they bench press. They do TKE’s and unweighted bridges every time they squat. Their warm-ups for speed work are exhaustive. Buddy also doesn’t overhead press, deadlift, or olympic lift his athletes due to his beliefs about their cost to benefit ratio. He uses careful application and programming of plyometrics to develop speed-strength.

    Buddy is a great strength coach, he keeps his guys healthy, and when you’re working with D1 and NFL level athletes, sometimes that’s the most important thing. Those guys get strong by just looking at the weights. Buddy might not agree with all this, I’m sure we all know there is a little room for movement prep in the S&C world… but I do enjoy the tone and agree with the gist of the article. Well spoken, go lift some damn weights.

    -Teddy Willsey PT,DPT,CSCS

  • Rob Panariello says:

    Teddy,

    I just provide the article Bret determines/provides the pictures. That said Buddy Morris certainly has earned his reputation through the years as an S&C Coach. I am familiar with some of his methods as I am close friends with one of his former assistant S&C coaches. As I clearly stated in this article there is overlap between the two professions, as they do need to work together, not a black and white separation as some may have perceived I am implying. I also stated that “This is not to imply that a warm-up (movement prep; whatever you would like to call it) isn’t warranted” as that should be also incorporated during training. I also have little concern with performing an appropriate number of rehab exercises with applicable exercise volumes and intensities during training. As you mentioned Buddy Morris does utilize cuff exercises and if you re-read my rotator cuff statement I said “Why is it necessary to perform an ABUNDENT number of rotator cuff exercises” meaning “excessive”.

    If we’re going to be so concerned about incorporating all our rehab principles and exercises into training, when, as you also stated, are we going to “lift some damn weights? Isn’t training time a significant concern that is especially true in the environments where the time for training is very limited i.e. the present day NFL with the new CBA and in the University setting where the NCAA institutes restricted weekly training time? These D1 and NFL strength coaches aren’t in private practice where they would have unlimited daily, weekly, and monthly training time available. Aren’t the exercises of the training program’s foundation the ones that will make the greatest contribution to enhance the physical qualities for optimal performance as well as injury prevention? As a fellow PT I’m certain you can also recognize the consequences of excessive exercise execution and inherent risk of overuse type injury. In conclusion I also very much appreciate that you get “the gist of the article”.

    Best,
    Rob Panariello

  • Rob,
    Thank you for your thoughtful response. This was a great article. I appreciate all critical thought and discussion on these topics and think it is paramount for the responsible growth of our field. I look at you as a pioneer in the realm of understanding and melding the tenets of strength & conditioning and rehabilitation.

    Respectfully,
    Teddy

  • Tony Ricci says:

    Excellent article, thanks for providing it, Bret. I have know Rob for years and he is a superior PT, Performance Coach, and Individual.

    Tony R

  • Drew says:

    This is a poorly written article with an unclear thesis. Borderline incoherent, stream-of-consciousness, rambling question sequences, capped off this with gem: If PT and S&C were the same, why aren’t the staffs interchangeable? Wow, really ground-breaking stuff there.

    Ironic that the title of the article is regarding questions already answers when the body is just one big question with no answers. How about taking a clear stance and defending it? This author forces the reader to imply the author’s thesis through the use of the Socratic method. Just bad.

    • Bret says:

      Drew, do you have a single friend in the world? You seem like a serious dickhead!

      • Chris says:

        Wow, didnt expect you to react like that.

        Even if Drew was wrong, thats a big disappointment. Try to be neutral as if Rob wasnt a good friend of yours (Im neither a friend of Drew´s nor of Rob´s, so I can relate…) and youll see that he makes a good point.

        Return to your smart Bret-self! 🙂

      • Rob Panariello says:

        Bret,

        I appreciate your response to those you may deem inappropriate to this or any other post on your blog but if I may, I’d like to provide you with some advice that I’ve learned during my 35 years of practice. You are never going to make everyone satisfied with your work. You will always have your fans as well as your critics and that’s a good thing as CONSTRUCTIVE AND APPROPRIATE CRITICISM is part of how we continue to educate and learn. There is no one individual that knows everything.

        My current position is that unless a respondent reveals their full name and profession to demonstrate their full identity and qualifications/experience they will not elicit a response from me as that’s only fair as I (and yourself as well) have revealed mine. Without this information I would simply ignore their comments (notice I only responded to Teddy Willsey). I personally don’t need to acknowledge “Joe” who may be an accountant (nothing against accountants) informing me about rehabilitation or S&C just like “Joe” doesn’t require my advice on accounting as I am not an accountant. More often than not the responses from those “anonymous” evolve into a verbal confrontation vs. a constructive discussion, nothing ever is accomplished and all that is achieved is a waste of time. We are too busy to waste our time. Did you ever notice the difference in the discussions with those who provide full disclosure vs. those who do not?

        It’s easy to hide behind the curtain of the internet and be critical and at times even rude when you do so anonymously. So again my advice to you is unless there is full disclosure i.e. a full name posted as well as their profession/experience i.e. Teddy Willsey PT, DPT, CSCS, I would neither respond nor take the comments seriously. Did you also ever notice that the most critical “experts” like “Joe” never post an article thus exposing themselves to the same community criticism?

        Just continue with your career Bret and you’ll find that over time the world gets smaller and the people that really matter personally and professionally will be there as well.

        Have a great weekend.

        Rob Panariello

        • Drew says:

          Basically unless you are allowed to engage in fallacious reasoning (i.e., your credentials aren’t as good as mine!) you refuse to debate. Note that none of my criticism involved anything that you are allegedly an expert in. It involved a criticism of your writing.

  • Matt says:

    Nice work Rob. I see both the benefits and disadvantages of blending the two models. I’ve been blending myself when appropriate, but I think the key here is “when appropriate”. If a patient gets better, and their sport is outside my area of expertise, I’d rather refer them to someone who can get the job done better than I can.

    The corrective exercise phase had led many to fall for memorization traps like tight hip = stretch hip flexors. Without a proper assessment, it’s obviously tough to confirm that, and in some cases, may make a problem worse. I think that’s part of what you were getting at. S&C coaches spend much time avoiding issues and working to correct problems that may not have been confirmed. It’s obviously tough to refer for confirmatory radiology when there is no documented “reason”, so the possibility, no matter how remote, is still out there in their minds. That said, I’m not sure which is worse: the overly-careful S&C coach, or a trainer who doesn’t really think about this stuff at all.

    While I know there are some great strength coaches and personal trainers out there who are able to incorporate a treatment-based model, even then, it’s just part of the continuum. And, I see it being a tough transition for most depending on many factors, to include experience levels, education, and of course, legality.

    I think it’s much easier for a healthcare professional to move toward training. From a licensing/scope standpoint, that’s pretty obvious. Also, after a course of care, the patient should be cleared of any issues, and most likely, though not always, any underlying anatomical variations should be detected during the course of treatment. That is, unless the anatomical variant had nothing to do with the patient’s presentation. Healthcare professionals are also taught to take a history, perform an exam, and document everything. It’s very tough to move into the corrective realm without this information, and with some training certifications, I don’t know if that’s enough. My bet is no.

    On the flip side, many healthcare professionals seem a bit afraid to let their patients work hard! Obviously, this is a key to sports performance, and holding patients back from actual work may delay their growth.

    I think the key is finding a niche and becoming an expert in that niche. It’s a bit easier to take a patient through a course of rehab and then into performance if you’re an expert in a certain area. Otherwise, navigating the no man’s land between rehab and performance can be a bit tricky.

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