Monitoring & Managing Training Load for a Safe Return to Sport OSET Orthopaedic Summit 2017 Las Vegas, NV December 6-9, 2017 Darin A. Padua, PhD, ATC Professor & Chair
Load Management: A Missing Piece of the Safe RTS Puzzle? Training Load • Cumulative stress from Stability Strength multiple training sessions Mobility / Power over time • Combination of frequency, intensity, and duration Load Function and Is pt. ready for load Tolerance Perception Movement upon RTS? Quality / Has pt. experienced enough not typically Biomechanics load to tolerate RTS loads? considered
Training Load & Injury Risk • Training load spikes precede injury Cross et al, Int J Sports Physiol Perform, 2016; Hulin et al, BJSM, 2014; Hulin et al, BJSM, 2016 • Weekly load changes ≥15% injury risk Gabbett et al, BJSM, 2016 • Doubling weekly training load 50% likelihood of injury Gabbett et al, BJSM, 2016 Large increase in acute load (past 1 week) relative to chronic load (past 2-4 weeks) 100 90 Total Weekly Load 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Acute to Chronic Training Load “Spikes” and Injury Likelihood • Acute to Chronic Load 25 Spike > 1.5 – Acute = Past 1week Likelihood of Injury (%) 20 – Chronic = Past 4 weeks 15 • 53% of injury likelihood variance in following week is 10 explained by acute to chronic load ratio 5 Latent Effect of Loading Spike 1.00 1.50 2.00 .00 Injury risk for next 4-weeks Acute to Chronic Load Ratio Orchard et al, Am J Sports Med, 2009 Blanch & Gabbett, Br J Sports Med, 2015
Does load management play a role in secondary ACL injury? RTS Time Risk of Knee Re-Injury • RTS < 5 mos 100% re-injury • Sustained within 2 mos following RTS • RTS ≤ 9 mos 39.5% re-injury • RTS ≥ 9 mos 19.4% re-injury • 51% decrease in knee re -injury for each month delaying RTS up to 9 mos RTS Time Chronic Load Base Grindem et al, Br J Sports Med, 2016 Increased Likelihood of Loading Spike Upon RTS
Does load management play a role in secondary ACL injury? 30.4% second ACL injury < 20 AEs 45.5% second knee injury 52.2% second ACL injury < 72 AEs within 2 months (short as 3 mos ) Grindem et al, Br J Sports Med, 2016 Paterno et al, Am J Sports Med, 2014
Does load management play a role in secondary ACL injury? 30.4% second ACL injury < 20 AEs 45.5% second knee injury 52.2% second ACL injury < 72 AEs within 2 months (short as 3 mos ) Greatest increase in acute loading occurs likely occurs in first 2-3 months following return to sport Increased Likelihood of Loading Spike Upon RTS Need to Monitor and Manage for Safe RTS
Record loads (in & out of rehabilitation) Systematic Approach to Establish a chronic Understand load load base ≥ sport demands upon Return to Sport demands unrestricted RTS Load Monitoring & Management Minimize week-to- Establish moderate week fluctuations chronic load base (acute load spike) prior to RTS initiation
Monitor load 4-6 weeks Record loads prior to RTS testing (in & out of rehabilitation) • Establish chronic training load at RTS testing • Chronic Training Load = Establish a chronic Understand load load base ≥ sport demands upon average training load demands unrestricted RTS over past 4-weeks Minimize week-to- Establish moderate week fluctuations chronic load base (acute load spike) prior to RTS initiation
Establish a floor & ceiling Record loads of safe loading (in & out of rehabilitation) • Understand the typical load demands during unrestricted RTS Establish a chronic Understand load load base ≥ sport demands upon • Frequency of training / demands unrestricted RTS games • Duration of training / games • Intensity of training / games Minimize week-to- Establish moderate week fluctuations chronic load base (acute load spike) prior to RTS initiation
Chronic moderate to high Record loads training loads are (in & out of rehabilitation) protective • Minimize risk of acute load spike upon RTS Establish a chronic Understand load load base ≥ sport demands upon • Is the athlete’s chronic demands unrestricted RTS load (4 weeks prior to RTS) at or near the load demands of sport? • Within 10% Minimize week-to- Establish moderate week fluctuations chronic load base (acute load spike) prior to RTS initiation
Continue monitoring Record loads following RTS (in & out of rehabilitation) • Maintain acute to chronic load ratio < 1.5 • Avoid load increases Establish a chronic Understand load load base ≥ sport demands upon >10% from week to demands unrestricted RTS week • In case of load spike: • Monitor closely • Reduce weekly load increases over next 4- Minimize week-to- Establish moderate week fluctuations chronic load base weeks (acute load spike) prior to RTS initiation
Gradually increase load Record loads demands above the avg. (in & out of rehabilitation) loads in sport • Chronic load base equal to the average load Establish a chronic Understand load load base ≥ sport demands upon demands in sport may not demands unrestricted RTS be adequate • Only prepared to tolerate 50% of the actual load in unrestricted sport Minimize week-to- Establish moderate week fluctuations chronic load base (acute load spike) prior to RTS initiation
Case Example - Training Loads in Soccer Projected Acute Load at RTS Daily Load Avg (SD) • 4 practices + 1 game during week Duration (min) 75 (26) • 6.25 training hours / week • 19 miles / week Total distance (miles) 3.8 ( 1.14) • 0.75 miles high speed running / week High speed distance (miles) 0.15 ( 0.14) Heart Rate Max (%) 65.7 ( 5.7) Consider the individual’s loading history since ACLR until time of RTS? Session RPE (0 - 10 scale) 4.7 ( 2.5) Malone et al, Int J Sports Physiol Perform, 2015 Chronic Load = 4 weeks prior to RTS
Case Example - Training Loads During Rehabilitation Until RTS Weeks 1-6 Weeks 7-12 Weeks 13-20 Weeks 20+ Increasing intensity of Low to moderate intensity Increase intensity of plyometric, agility, & NM Minimize pain & swelling strengthening, endurance, strengthening, endurance, control exercises (multi- & NM control exercises & NM control exercises planar) Low to moderate intensity Full symmetrical knee Single leg stability plyometric & agility Perform sport specific drills extension exercises Normal gait Multi-planar loading Cardiovascular fitness Restore voluntary RTS Testing quadriceps activation 0% 5-10% 20-30% 40% Relative to Training Loads in Soccer 6.25 hrs/wk; 19 miles/wk; 0.75 miles high speed running/wk; 4.7 RPE
Case Example - Training Loads During Rehabilitation Until RTS Weeks 1-6 Weeks 7-12 Weeks 13-20 Weeks 20+ Increasing intensity of Low to moderate intensity Increase intensity of plyometric, agility, & NM Minimize pain & swelling strengthening, endurance, strengthening, endurance, control exercises (multi- & NM control exercises & NM control exercises planar) Low to moderate intensity Full symmetrical knee Single leg stability plyometric & agility Perform sport specific drills extension exercises Normal gait Multi-planar loading Cardiovascular fitness Restore voluntary RTS Testing quadriceps activation 0% 5-10% 20-30% 40% Relative to Training Loads in Soccer Prior to Injury (RTS loads) 6.25 hrs/wk ; 19 miles/ wk ; 0.75 miles high speed running/ wk; 4.7 RPE
Unable to Train Meters of High Velocity Running (90-100% of Maximum Velocity) Recovering from Injury
Unable to Train Meters of High Velocity Running (90-100% of Maximum Velocity) Recovering from Injury Return to Sport
Unable to Train Meters of High Velocity Running (90-100% of Maximum Velocity) Recovering from Injury X X X X X X X X X X X X X Return to Sport X X X X X X X
Unable to Train Meters of High Velocity Running (90-100% of Maximum Velocity) Recovering from Injury X X X X X X X X X X X X X Return to Sport X X X X X X X
Unable to Train Loading Meters of High Velocity Running (90-100% of Maximum Velocity) Recovering from Injury Spike X X X X X X X X X X X X X Return to Sport X X X X X X X
Unable to Train Loading On-Field Load Meters of High Velocity Running (90-100% of Maximum Velocity) Recovering from Injury Spike Reduction (Fatigue) X X X X X X X X X X X X X Return to Sport X X X X X X X
Secondary Unable to Train Loading On-Field Load Meters of High Velocity Running (90-100% of Maximum Velocity) ACL Recovering from Injury Spike Reduction Injury (Fatigue) X X X X X X X X X X X X X Return to Sport X X X X X X X
100 Secondary Injury Case Secondary Injury 90 No Secondary Injury Case 80 Manage the Load Upon RTS % of Healthy Control Athlete 70 External Training Load 60 2 Months Prior to RTP 50 40 30 20 10 0 RTP
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