Periodization and Physical Therapy: Bridging the Gap between Training and Rehabilitation

Abstract

Background: Exercise prescription and training progression for competitive athletes has evolved considerably in recent decades, as strength and conditioning coaches increasingly use periodization models to inform the development and implementation of training programs for their athletes. Similarly, exercise prescription and progression is a fundamental skill for sport physical therapists, and is necessary for balancing the physiological stresses of injury with an athlete’s capacity for recovery. Objective: This article will provide the sport physical therapist with an overview of periodization models and their application to rehabilitation.
Summary: In recent decades models for exercise prescription and progression also have evolved in theory and scope, contributing to improved rehabilitation for countless athletes, when compared to care offered to athletes of previous generations. Nonetheless, despite such advances, such models typically fail to fully bridge the gap between such rehabilitation schemes and the corresponding training models that coaches use to help athletes peak for competition. Greater knowledge of these training systems, also known as periodization models, can help sport physical therapists in their evaluation, clinical reasoning skills, exercise progression, and goal setting for the sustained return of athletes to high level competition.

Full text

Masterclass
Periodization and physical therapy: Bridging the gap between training
and rehabilitation
*
Donald L. Hoover
a
,
*
, William R. VanWye
a
,
1
, Lawrence W. Judge
b
,
2
a
Western Kentucky University, Bowling Green, KY, USA
b
Ball State University, Muncie, IN, USA
article info
Article history:
Received 20 January 2015
Received in revised form
13 August 2015
Accepted 14 August 2015
Keywords:
Exercise prescription
Exercise progression
Rehabilitation in sport
Clinical reasoning
abstract
Background: Exercise prescription and training progression for competitive athletes has evolved
considerably in recent decades, as strength and conditioning coaches increasingly use periodization
models to inform the development and implementation of training programs for their athletes. Similarly,
exercise prescription and progression is a fundamental skill for sport physical therapists, and is necessary
for balancing the physiological stresses of injury with an athlete's capacity for recovery.
Objective: This article will provide the sport physical therapist with an overview of periodization models
and their application to rehabilitation.
Summary: In recent decades models for exercise prescription and progression also have evolved in
theory and scope, contributing to improved rehabilitatio n for countless athletes, when compared to care
offered to athletes of previous generations. Nonetheless, despite such advances, such models typically fail
to fully bridge the gap between such rehabilitation schemes and the corresponding training models that
coaches use to help athletes peak for competition. Greater knowledge of periodization models can help
sport physical therapists in their evaluation, clinical reasoning skills, exercise progression, and goal
setting for the sustained return of athletes to high level competition.
© 2015 Elsevier Ltd. All rights reserved.
1. Introduction
Over the last half-century, preparation for athletic endeavors
has progressed in scope and complexity (Wilmore, 1988; Potteiger
& Wilson, 1989b; Potteiger & Wilson, 1989a). Successful athletes
and sport enthusiasts now typically train for competition with as
much forethought and planning as possible (Apel, Lacey, & Kell,
2011; Buford, Rossi, Smith, & Warren, 2007; Franchini, Branco,
Agostinho, Calmet, & Candau, 2014). Periodization, characterized
by the dividing of the annual training plan into smaller, distinct
phases as a means of separating the program into more manageable
segments, represents the most sophisticated method of
preparation for competition, and in recent decades periodization
has been increasingly used at all levels of athletic preparation.
Whether conceptualized and directed by coaches, or by athletes
themselves, competitors of all types use periodization as a means of
structuring their training in a cyclic fashion, enabling them to best
realize their performance capacities and goals (Bompa, 1990).
Consequently, a basic understanding of the periodization process
allows well-informed sport physical therapists to expedite the
successful return of the athlete to competition following an injury
(K. E. Wilk & Arrigo, 1993). Additionally, an understanding of
periodization theory may further help athletes remain injury-free
following return to training or competition. This paper examines
the basic premises underlying periodization. In addition, it de-
scribes foundational elements of periodization theory and
commonly used periodization paradigms as well as current chal-
lenges and controversies surrounding this topic. Finally, this paper
presents case studies illustrating how periodization theory may be
woven into the rehabilitation of competitive athletes. Collectively,
these content topics may help sport physical therapists bridge the
gaps evident between the bodies of knowledge devoted to the
preparation for competition and the rehabilitation of sport injuries.
*
This paper has not been presented previously, at a professional meeting or
otherwise, nor is it currently under review with another journal.
* Corresponding author. Western Kentucky University, 1906 College Heights Blvd,
Bowling Green, KY 42101, USA. Tel.: þ1 270 745 4378; fax: þ1 270 745 3497.
E-mail addresses: Don.Hoover@wku.edu (D.L. Hoover), ray.vanwye@wku.edu
(W.R. VanWye), lwjudge@bsu.edu (L.W. Judge).
1
Tel.: þ1 270 745 4925.
2
Tel.: þ1 765 285 4211.
Contents lists available at ScienceDirect
Physical Therapy in Sport
journal homepage: www.elsevier.com/ptsp
http://dx.doi.org/10.1016/j.ptsp.2015.08.003
1466-853X/© 2015 Elsevier Ltd. All rights reserved.
Physical Therapy in Sport xxx (2015) 1e20
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1.1. The general adaptation syndrome (GAS): foundation for
training, foundation for rehabilitation
Most healthcare and fitness professionals typically think of ex-
ercise as a universally positive activity, as well as having universally
positive effects upon the human body. However, this viewpoint is
not entirely correct. Rather, as it relates to the effects upon the
human body, any physical activity is better described as a physio-
logical stressor (Selye, 1978). In turn, stress is a state created by the
specific syndrome that consists of all non-specifically induced
changes within a biological system (Plowman, 2011). This generates
a disruption within the body and all attempts by the body to regain
its homeostatic state. Thus, when physical activity is properly dosed
in individuals who possess the physiological capacity to respond
acutely, homeostasis is restored. With repeated bouts of properly
dosed physical activity in individuals having the physiological ca-
pacity to respond over longer time frames, adaptation occurs.
Conversely, when the body's tissues and systems are overly dis-
rupted, disease and injuries occur, and even death happens when
an individual cannot respond acutely or over longer time frames.
Throughout Western civilization, people have observed and
asked questions regarding these physiological workings of the
body, and from the start they have created and tested theories as a
means of better understanding these phenomena. Periodization
theory is one such informed school of thought. At its very essence,
periodization theory is a reasoned attempt to plan and distribute
such training stressors to maximize and refine the growth that can
come with regular physical activity, while simultaneously mini-
mizing the potentially negative effects of the same activity.
The foundations of periodization theory and its application to
athletic preparation first emerged in the late-twentieth century
(Bompa, 1994). Most of the periodization theory and terminology
widely used today can be traced conceptually to the work of Hans
Seyle, a prolific scientist who conducted many landmark studies in
the area of endocrinology. More specifically, Selye conducted much
important scientific work on the non-specific endocrine responses
of tissues subjected to a wide variety of physiological and psycho-
logical stresses. Much of this work in endocrinology served as the
inspiration for his description of the GAS, which describes the
sequelae when the body is exposed to stressors, acutely and over
time (Plowman, 2011).
The GAS consists of three stages, each having distinct charac-
teristics and traits (Plowman, 2011). The first stage described by
Selye is the Alarm Reaction, in which the body responds non-
specifically to the disruption to homeostasis. The second stage in
this model is the Stage of Resistance; the stress is relatively mild
and advantageous, and in this stage the body can adjust. The final
stage is the Stage of Exhaustion. In this stage, the body cannot
adjust. The stress becomes chronic or the adaptation to the stressor
is lost.
Decades ago, sport scientists e initially in Eastern Europe and
then on a broader global basis - first took note of the GAS and began
applying its potential lessons to athletic training and competition
(Bompa, 1994; Plowman, 2011). An overview of the GAS and its
application to athletic preparation is described as follows. The fa-
tigue of physical activity is temporary and reversible if the training
load is appropriate; accordingly, factors such as proper exercise
technique, rest, and nutrition are keys to ensuring that an athlete
can recover from the stress of any given training bout. This de-
scribes the first stage within the GAS. However, an overarching goal
of effective training is to strive to not only restore homeostasis, but
to encourage “supercompensation” or increased capacities of
physiological and psychological attributes such as muscular energy
stores, strength of muscle, bone and other connective tissues,
greater muscular endurance, less anxiety during physical activity
and so on. This describes the second stage within the GAS. When
applying these axioms to athletic preparation, the goal of all
training is to alternate the individual athlete between Stages I and II
within the GAS. Stage III is to be avoided, if at all possible, as the
athlete's performance will likely regress, he or she will be more
susceptible to injury, and the like. It was within this context, then,
that the annual training calendar, or periodization, emerged as
sport scientists and coaches aimed to divide the annual training
plan into smaller, distinct phases (Bompa, 1994). The goal was to
separate the training program into more manageable components,
facilitating not only the monitoring of individual athletes but also of
the relative merits and shortcomings of the training regimens as
well.
Sport scientists were not the only professionals to apply the
lessons of the GAS to their work (Csermely, Korcsmaros, & Sulyok,
2007; Gellman & Turner, 2013; Lovallo, 2005). More specifically,
physicians and other licensed healthcare professionals also saw
Seyle's theory as quite helpful in explaining many conditions
among the individuals under their care. To illustrate, many of the
chronic diseases seen in contemporary Western society are mani-
festations of the Stage of Exhaustion of the GAS, in which the tissue
or system has become overly fatigued and/or lost its ability to adapt
to the stresses regularly placed upon it (Csermely et al., 2007).
Conditions such as congestive heart failure, kidney failure, herni-
ated disks, torn rotator cuffs, ruptured anterior cruciate ligaments
(ACL), and psychological depression are but a few examples of
diseases or injuries that may arise out of the third stage of the GAS
(Gellman & Turner, 2013). As this model directly relates to sport
physical therapy, rehabilitation specialists have long acknowledged
that therapeutic doses of stress must be re-applied to tissues
following injury or surgery in order to take the tissues first to the
Alarm Stage of the GAS, with the goals of progressing the damaged
tissue to the Stage of Resistance and simultaneously avoiding the
Stage of Exhaustion. This process is common physiologically with
athletic preparation, and through it injured or surgically-repaired
tissues are gradually strengthened as needed to help restore a pa-
tient's functional abilities.
In summary, physiological stress is a significant byproduct of
athletic training and competition. It is also a fundamental compo-
nent of therapeutic exercise used in sport physical therapy. If such
physiological stressors are not manipulated correctly in either
scenario, it may adversely affect an athlete's training and perfor-
mance, or it may negatively impact a patient's recovery of function
following injury or disease. Periodization theory and annual
training calendars thus play an important role in helping the
athlete manage the various physiological and psychological
stressors associated with training and competition (Bompa, 1994).
These principles similarly may be of great benefit when integrated
into the rehabilitation of injured athletes.
1.2. Foundational training concepts: basis for conditioning and
sport-specific development, and for therapeutic exercise prescription
High-level athletic performance hinges upon an individual's
physiological adaptation to exercise, psychological adjustment to
training, and the neurological development of sport specific skills
necessary for a high degree of sport readiness, sport form,or
competitive fitness as it has been described in the literature (Bompa,
1994; Plowman, 2011). The duration of the respective training
phases depends on the time necessary to improve the level of
performance from an athlete's baseline capacities. Moreover, the
higher the level of sport readiness an athlete may obtain, the
shorter duration he or she may maintain such a peak (Apel et al.,
2011). Consequently, the annual training calendar, or periodiza-
tion, emerges as the main method for calculating the length of each
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training phase, and the cycling of training in a sequential fashion
enhances the organization of this annual plan. Periodization rep-
resents the splitting of the annual training calendar into more
manageable segments as well as ensures correct peaking for the
main competitions of the year (Bompa, 1994). Dividing the training
calendar allows an athlete to train in a systematic manner,
enhancing the organization of training and improving perfor-
mance. Furthermore, by giving a constant supply of short-term and
long-term goals that can be met systematically, the execution of a
well-constructed periodization plan gives an athlete heightened
ability to control the peaking process (Bompa, 1994; Brown &
Greenwood, 2005; Buford et al., 2007; May, Cipriani, & Lorenz,
2010).
Foundational concepts noted in Table 1 form the basis of all
areas of physiological conditioning, whether it occur for sport
training, or as part of a therapeutic exercise within a rehabilitation
program. Intensity, duration, frequency, mode, volume, and specificity
represent the basic units of measurement associated with the
construction of such training programs (Plowman, 2011). Intensity
represents the most important component of development in
competitive athletes, and all training programs are based upon the
notion that an athlete must generate sufficient intensity to induce
training affects. Intensity may be measured in many ways. For
example, intensity is typically measured in cardiovascular training
by the individual's heart rate: the higher the intensity of activity,
the higher one's heart rate elevates. Similarly, the development and
widespread adoption of on-bike power meters over the past 15
years has afforded competitive cyclists another method of quanti-
fying intensity during training and competition (Allen & Coggan,
2010). Intensity in strength training is measured by how much
resistance is overcome in the process. Thus, it stands to reason, that
in order to improve aerobic capacity, cycling output, or gain
strength, an athlete must exercise at ever increasing levels of in-
tensity or physiological output (Bompa, 1994; Kraemer & Fleck,
2007; May et al., 2010). Each form of exercise intensity is driven
e and continually monitored e by the neuroendocrine system, a
phenomenon often not fully grasped by inexperienced athletes,
coaches, and sport physical therapists alike; however, this is a
physiological reality that underscores the theoretical importance of
the GAS noted above and the practical importance of carefully
monitoring the intensity of all physical activity throughout the
training year.
Like intensity, duration also greatly influences the training ef-
fects of the conditioning program (Plowman, 2011). For example,
The duration of the cardiovascular session typically varies from 20
to 60 min in most fitness programs, but these times can vary greatly
as an athlete moves from one period to another during the annual
training calendar, depending on his or her given sport (Zappe &
Bauer, 1989). Again, extended durations of physical activity have a
particular capacity to disrupt the neuroendocrine regulation of
homeostasis, and thus must be regularly monitored if athletes are
to remain on the desired side of the thin line existing between
positive stresses and negative stresses while training and
competing. Controlling the frequency of training sessions also
greatly impacts the overall success of the program (Buford et al.,
2007; Buford et al., 2007; Issurin, 2008; Plowman, 2011
). In order
to recuperate from a given training session, the body needs
adequate time to rebuild tissue and to replenish energy stores. The
same idea holds true for recuperation from the training bouts over
additional time frames, such as over a week, month, and even
longer periods.
Mode represents the type of training an individual completes
(Plowman, 2011), and while all athletes are encouraged to engage
in a variety of exercise types e or “cross-train” e there are wide
Table 1
Foundational concepts in periodization.
Active Rest: Low intensity, low volume physical activity used to maintain fitness during the transitive phase. The goal of active rest is to avoid a detraining effect or
substantial loss in the physiological adaptations established in the previous months of training.
Competitive Fitness: A state of physiological adaptations that underlie optimal performance. Often used interchangeably with sport form and sport readiness.
Competitive Phase: The goals of this phase include the perfection of all training factors toward the goal of enabling the athlete to compete successfully in the main
competitions or championships targeted by the annual training plan.
Distress: A negative stressor in Seyle's theory of the general adaptation syndrome.
Duration: Training session length of time.
Eustress: A positive stressor in Seyle's theory of the general adaptation syndrome.
Frequency: Refers to the number of training sessions per day, week, or month.
Intensity: The qualitative element of training such as speed, maximum strength, and power. In strength training, in strength training, intensity is often expressed in load
related to the 1 RM.
Macrocycle: A medium-term training cycle that lasts between 2 and 8 weeks.
Mesocycle: In the Russian literature, a medium term training cycle that lasts between 2 and 8 weeks.
Microcycle: A short training cycle that lasts 3 e7 days.
Mode: Type of physical activity or training.
Monocycle: An annual training plan with one major peak.
Overload: A demand placed on the body greater than that to which it is accustomed.
Overreaching: A short-term period during which the athlete demonstrates a short-term decrement in performance.
Overtraining: A long-term decrement in performance that occurs in response to accumulation of training and non-training stressors.
Phase vs Stage: Phases described by Bompa as segments within the annual training calendar. Stages described by Selye as neurophysiological states in response to stressor
load.
Preparatory Phase: Establishes the physical, technical, and psychological base from which the competitive phase is developed. The adaptations that occur during the
preparatory phase are developed as a result of the increased training volume within this phase, allowing the athlete to better tolerate the increased training intensity
that occurs in the competitive phase.
Specificity: Specific adaptations to demands imposed on the body during training. Must always determine the competitive or fitness goals before developing the training
program.
Sport Form: A state of physiological adaptations that underlie optimal performance. Often used interchangeably with competitive fitness and sport readiness.
Sport Readiness: A state of physiological adaptations that underlie optimal performance. Often used interchangeably with competitive fitness and sport form.
Stress: Defined by Seyle as “the non-specific response of the body to any demand for change”.
Transition: Used to prepare the athlete for the next training cycle. Typically achieved via a transitive phase.
Transitive Phase: Follows the preparatory and competitive phases, as well as links two annual training plans. Allows for recuperation from central nervous system fatigue
that accumulates during training and competition.
Volume: A quantitative element of training that can be measured as time or duration of training, the number of sessions per week, the distance covered, the volume load of
resistance training, or the number of repetitions performed.
D.L. Hoover et al. / Physical Therapy in Sport xxx (2015) 1e20 3
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disparities in the range of activities an individual must regularly
train in order to successfully compete. Track and field provides
ample examples of this type of range in necessary training modes,
such as the wide differences between forms of training the colle-
giate 10,000-m runner and the decathlete must integrate into their
training to be reasonably keen during the competition phase of the
annual calendar. Such differences in required skills also affect the
modes of training necessary for success in team sports. For
example, the specialization in contemporary American football
fundamentally limits the necessary skills a lineman must master,
when he very likely plays only on offense or defense and may go
through his entire career without touching the ball during a game,
when compared to position players in baseball and basketball who
are required to possess basic mastery of each of the basic skills in
the respective sport (e.g. hitting, fielding, base running, and so on).
Similarly, for multi-sport athletes mode of training often shifts
substantially throughout the calendar year. For example, it is fairly
common for high school athletes to transition from soccer or
American football or volleyball in the Fall, to basketball or wrestling
in the Winter, and then to track and field or baseball/softball in the
Spring. Such transitions by athletes from sport to sport present
challenges for coaches, sport scientists, and rehabilitation pro-
fessionals intent on helping their clients maximize performance
and/or remain injury-free. Finally, training volume refers to the
total number of exercises, sets, and repetitions completed during a
training session (Plowman, 2011). Training volume typically varies
greatly as an athlete moves through the training calendar.
Specificity is another vital concept in training (Judge, 2007).
Emphasizing specific training characteristics may develop specific
physiological and/or performance attributes. Exercises must be
specifically designed for the demands of the given sport, and spe-
cific exercises are tailored so to facilitate strength, power, agility,
quickness, endurance, and so on, in a manner that further in-
dividualizes the training for the given sport. Consequently, effective
exercise prescription within a periodization plan adroitly addresses
bioenergetics, biomechanics, and motor coordination characteris-
tics unique to the athlete's chosen sport. The “mix” of these specific
training characteristics varies also throughout the training year in
well-designed training plans, as the athlete's needs change be-
tween non-competitive and competitive phases in the calendar
year.
Each of these variables e intensity, duration, frequency, mode,
volume, and specificity e as well as the interactions between each,
serves an important role in training for competition. These vari-
ables and their interactions are represented schematically in Fig. 1,
albeit in a two-dimensional and non-time-dependent manner. In
practical application, each of these individual circles fluctuates
regularly throughout the training year, resulting in an ever-
changing degree of interaction between these components, as
well as to their relative contributions to training on a given day
throughout the year. Further, balancing these variables provides
greater challenges as an athlete raises his or her level of perfor-
mance (Bompa, 1994).
Another important concept associated with periodization is the
idea that improvements in work or exercise capacity approximate
an exponential function with time (Buford et al., 2007). The
seasoned athlete improves performance at a relatively much lower
rate than does the untrained individual. The longer an athlete is in
training, the rate of improvement associated with a given type of
training diminishes. This leveling of performance is seen in all
athletes. Similarly, improvements in performance typically occur in
a non-linear fashion. The dynamic patterns theory from the motor
behavior literature helps to illustrate that behavioral changes are
typically not exhibited in a continuous and/or linear fashion; rather
individuals often make sudden and abrupt changes in behavior
over time as their nervous systems “figure out” in incremental
fashion how to excel at a given motor task or tasks (Magill, 2010).
These foundational training concepts are certainly not novel
ideas for sport physical therapists. Students are introduced to each
of these training variables seemingly the first week of physical
therapy school (if not before entering PT school), and then regularly
encounters clinical scenarios in which these training variables must
be manipulated in order to create stimulating rehabilitation pro-
grams capable of restoring function. Thus, it is necessary to point
out important differences in the ways these variables are typically
conceptualized in rehabilitation and in periodization models. One
major difference between such models is the typical time frames of
rehabilitation and periodization models. While some patients are
certainly seen for longer periods, the majority of patients partici-
pate in physical therapy programs between 6 and 12 weeks
(American Physical Therapy Association, 2003). Physical therapists
manipulate the intensity, duration, frequency, mode volume, and
specificity of activity completed in each rehabilitation session, with
the goal of stimulating increased function for the patient in ques-
tion (American Physical Therapy Association, 2003). These in-
dividuals are then typically discharged from care and in most cases
not seen again by the treating physical therapist. Conversely,
coaches and/or the competitive athletes manipulate these same
variables over much longer time frames, such as the 52 weeks that
occur each year. Moreover, it is not uncommon for coaches to
conceptualize a given athlete's development over a 4 or 5-year
period, resulting in training timelines that may be 200e250
weeks in duration. As a consequence, the coach may possess a
fundamentally broader view over time of how these training vari-
ables contribute to the outcome goals (e.g. excellence in competi-
tion), when compared with the sport physical therapist who
typically works with relatively much shorter timelines when
managing his or her caseload (e.g. discharge to resumption of
activity).
In addition to weighing these training variables against a much
broader timeline, there are arguably lesser margins for error in
prescribing these variables in competitive athletes, particularly as it
relates to dosing exercise immediately prior to important compe-
titions. The windows of opportunity are also tighter for the
competitive athlete. To illustrate, consider the rehabilitation of low
back pain and return to function for individuals who work as
Fig. 1. The foundational elements for conditioning and sport-specific development.
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plumbers, electricians, and auto mechanics; these are individuals
who typically perform in these roles for many years, if not decades.
Contrast the peak years for these skilled professionals with those of
the high school wrestlers, collegiate quarterbacks, and amateur
track cyclists who have relatively fleeting windows of opportunity
to pursue their competitive goals. In sum, a professional miscal-
culation in dosing exercise intensity or any other variable during
the week immediately preceding a major competitive event (such
as the opening of the high school state wrestling tournament) can
have profoundly negative effects if not dosed appropriately for the
high school wrestler. Such errors in exercise prescription or plan-
ned peaking cannot be rectified until the following competitive
season, if ever.
1.3. The annual training calendar: a reasoned approach to
stimulating, and predicting, performance
The periodization, or annual training calendar, plays an impor-
tant role in helping the athlete manage the physiological, psycho-
logical, and sociological stressors associated with training and
competition (Bompa, 1994; Franchini et al., 2014; Plisk & Stone,
2003). As noted in the section above describing the GAS and its
relationship to training theory, a fine line exists between the pos-
itive stress (e.g. eustress as described by Selye) that leads to growth
or improved performance and the negative stress (e.g. distress in
Seyle's model) that leads to decreased performance, disease or
injury, and even death if sustained over time (Selye, 1978). The
planning of annual training calendars represents the major tool
used to overcome the body's natural resistance to improvements
and work capacity (McBride, McCaulley, Cormie, Nuzzo, Cavill, &
Triplett, 2009). Within the annual training calendar, training vari-
ables such as intensity, duration, frequency, mode, volume and
specificity are consequently varied or “cycled” as a means of
altering the training so as to stimulate improved performance
measures in a calculated way, helping to overcome the body's
resistance to disruptions in homeostasis and improvements in
sport form. Fig. 2 depicts the variability of physiological stress levels
controlled throughout the year via periodization. The curve dem-
onstrates an almost nonexistent stress level during some phases of
the periodization plan and a variable stress level through other
phases of the year.
In most sports, the annual training calendar is conventionally
divided into three cyclic phases of training: the preparatory phase,
the competitive phase, and the transitive phase (Bompa, 1994;
Peterson, Dodd, Alvar, Rhea, & Favre, 2008; Plisk & Stone, 2003).
These three main phases of the typical periodization plan are
depicted in Fig. 3. The preparatory and competitive phases are
further divided into sub phases since the goals of training e and
subsequently the specificity of training tasks e can vary quite a bit
at different points in the annual training plan. The preparatory
phase has both general and specific
sub phases based on the
different characteristics of training, and the competitive phase
usually follows a short pre-competitive sub phase. The transitive
phase, also commonly known as either active rest or the transition
phase, allows the athlete's mind and body to recuperate from the
rigors of the competitive phase as well as to prepare for the pre-
paratory phase to follow. Additionally, each phase is composed of
smaller periods known as macro and microcycles. The specific ob-
jectives of these smaller segments are derived from the general
objectives of the annual training plan. A representative division of
the annual training calendar into phases, sub phases, and cycles are
also illustrated in Fig. 3. Building upon these concepts, by inte-
grating the training principles described in the section on foun-
dational training concepts, Fig. 4 depicts the relationships existing
between training intensity, duration, and sport form throughout
the training year.
As one might expect, the annual plans used in training are
typically constructed to meet an athlete's unique competitive needs
(Niederbracht, Shim, Sloniger, Paternostro-Bayles, & Short, 2008;
Peterson et al., 2008). Detailed discussion of annual plans used in
Fig. 2. The stress curve during a monocycle.
Adapted from Bompa, 1994.
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each specific sport is beyond the scope of this paper, but all plans
include specific skill development as well as physiological condi-
tioning. For example, one competitive phase exists for those sports
having only one major competition or limited by seasonal consid-
erations. Weightlifting, crew, and Alpine skiing may best represent
sports falling into this category. This type of annual plan is known
as a monocycle (Bompa, 1994), and it includes the three classical
phases of training: preparatory, competition, and transition, which
are depicted in Fig. 2. The preparatory phase includes general and
specific preparation, and this period may last for approximately
3e7 months. However, if the training parameters are not carefully
monitored, it is easy to see that the athlete may peak too slowly or
too quickly for the desired segment of the competitive season
(Cissik, Hedrick, & Barnes, 2008). The competitive phase consists of
smaller sub phases aimed at specific competitive goals. The
competitive phase also includes an unloading or tapering phase
prior to the most important competition of the year e both the
intensity and duration of training are reduced during this sub
Fig. 3. Schematic of the annual training plan.
Adapted from Bompa, 1994.
Fig. 4. A monocycle training plan.
Adapted from Bompa, 1994.
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phase, allowing the athlete to best regenerate prior to the target
competition such as the conference or national championships.
Allowing for the specifics of the particular sport, relatively low
intensity and high duration activity typically characterize the
training during the preparatory and beginning of the competitive
phases. The intensity of training is generally emphasized more as
the competitive phase progresses. With this in mind, it is a general
practice in most programs to keep detailed records of training pa-
rameters in order to establish individual tendencies for further
periodization cycles and eliciting the desired training responses
(Apel et al., 2011; Buford et al., 2007; Franchini et al., 2014).
The transitive phase, as its name implies is used to join the
preparatory and the competitive phases (Baker & Newton, 2008;
May et al., 2010). Transition is normally used in two ways in the
periodization system. Af ter competition, transition is used to allow
the athlete to rest mentally and physically from the rigors of the
previous competitive phase. Also known as active rest, this transi-
tion phase consists of reduced total volume and intensity in the
training program. The athlete at this time typically engages in other
forms of physical activity, or in some cases, in complete rest. The
transition phase is crucial to the restorative capabilities of the
athlete, and active rest is also used on a more limited basis
throughout the preparation and competition phases of the training
year. Active rest allows the athlete to recuperate both physiologi-
cally and psychologically as he or she begins a new, slightly more
advanced annual training calendar.
The periodization calendar possesses slightly different charac-
teristics in those sports with more than one competitive phase. Two
distinct competitive phases, or bi-cyclic phases, characterize the
periodization models for these sports. Example sports include
swimming, collegiate track and field, or increasingly high school
basketball and volleyball in the United States, with their inter-
scholastic schedules during the school year and club schedules
during the summer months. In contrast with the monocycle, a bi-
cycle periodization plan generally include two short model cycles
linked by a very short transition and preparatory phases (Bompa,
1994; Brown & Greenwood, 2005). The emphasis is typically
greater on the second half of the bi-cycle, for example, sports with
two competitive phases such as collegiate track and field where the
outdoor championships are usually more important. Fig. 5 appro-
priately illustrates the higher athletic condition planned for the
second competitive phase of the bi-cycle.
A tri-cycle is used in sports having three important competitions
during the same annual training calendar (Bompa, 1994; Campos
et al., 2002). It is not unusual for so-called “Olympic” sports such
as boxing, wrestling, or gymnastics to train for national champi-
onships, international qualifying meets, and international cham-
pionships scheduled months apart but within a calendar year. In
the tri-cycle, the athlete again typically tries to achieve the highest
conditioning level for the third cycle. Fig. 6 depicts a representative
tri-cyclic periodization model.
Well designed and executed, the overall training program is a
fairly complex entity, requiring a thorough knowledge of its
component parts if periodization is to be used to an athlete's
maximum benefit. But once an athlete understands underlying
principles of periodization, he or she assumes more responsibility
to ensure that the training cycle is developed and utilized to best
meet his or her individual training needs. If an athlete makes sound
decisions regarding periodization, the annualized periodization
plan can enable him or her to reach higher levels of performance
than is possible without the use of systematic training approaches.
In summary, the annual plan consists of the implementation of
progressively more qualitative workouts over a given period of time
(Kraemer & Fleck, 2007; Kraemer et al., 2003; Rønnestad, Hansen,
& Ellefsen, 2014
). The basic rationale underlying this principle is
that an athlete needs graded adaptation over time to acclimate to
more intense training loads. He or she also needs measured rest in
order to facilitate recovery and recuperation. In most cases, athletes
engage in training of some type throughout the entire calendar
year. The intensity of training is generally low during the beginning
of the training year, and it gradually increases until it is at its
highest during the most important part of the competitive season.
Fig. 5. A typical bi-cycle training plan.
Adapted from Bompa, 1994.
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1.4. Current challenges in periodization: linking theory to practical
application during training
Most coaches set out to construct training programs for their
athletes that consistently lead to improvements in competitive
performance measures, a goal that is often “easier said than done”.
Given the many variables involved in maximizing performance for
competition - in combination with individual response and adap-
tation to given training stimuli, this poses a substantial challenge
for any coach intent on realizing this goal. As a consequence,
training programs for most sports generally follow a periodization
method for optimal results. Ultimately, periodization is a reasoned
attempt to predict future performance based on evaluation of
previous competition and training results (Judge, 2007).
A periodization training year is divided so as 1) to meet specific
objectives, 2) to produce high levels of performance, and 3) at
designated times, such as tournaments or specific competitions.
Accordingly, Bompa recommends that a threshold of 32e36 weeks
of training (or 200 days of training) are needed for advanced ath-
letes to reach a peak (Bompa, 1994).
The timing, sequencing, and interaction of these training stimuli
over these 30-plus weeks are foundational to triggering optimum
adaptive responses in pursuit of specific competitive goals (Judge,
2007). As these training variables are weighed and adjusted, it is
essential in all cases that competitive fitness be maximized while
simultaneously managing the accumulation of fatigue. This physi-
ologic balance must be struck in order to improve sport readiness
over the course of the training year. The ultimate goal of finishing
preparation during the competition phase is to maximize fitness
and sport form, while simultaneously minimizing fatigue on the
day of the competition. Proper sequencing of these training effects
contributes to such sport readiness, and peak performance typically
occurs at the point where fitness and fatigue differences are
maximized (Judge, 20 07).
As is the case with many topics in physical therapy specifically
and rehabilitation generally, periodization is a subject that
possesses conflicting findings in the research literature. While
periodization is widely known as an excellent method of organizing
training, authors regularly debate whether it is the most effective
type of program. Similarly, many coaches of team sports mistakenly
believe that periodization theory and methodology applies only to
individual sports, thus some coaches are reluctant (or outright
resistant) to apply these theories and models to the training of their
team sport participants. Such misconceptions represent a road-
block to successfully implementing reasoned training programs on
a more widespread basis. Ironically, such misconceptions may also
serve as an impediment to the widespread eradication of risk of
serious injury among youth baseball pitchers, for example, or other
health issues raised by prominent orthopedic experts (Fleisig et al.,
2011).
When the concept of periodization was first introduced in the
United States, it involved a program that used training routines of
high volume and low intensity to improve general conditioning,
followed by a progression to lower volume and greater intensity as
a means of improving performance (Baechle & Earle, 2008). This
change in volume and intensity was linear and generally followed
the models described in the section above, while showing pro-
gressive increases in sport-related movements (Baechle & Earle,
2008). Some researchers are still using this traditional linear form
of periodization in their study designs and coaches continue to
implement such programs, and many are still having successful
results with this methodological approach (Macaluso, 2010).
However, in recent decades researchers began addressing
periodization theory from differing perspectives, and, as a result
non-linear or undulating forms of periodization have subsequently
evolved. This shift in thought has caused a general rethinking of
some basic premises in periodization theory, which in turn has
resulted in additional e and sometimes contradictory e research
findings making their way into sport science journals. Two studies
published in 2011 help to illustrate the dilemma that coaches face
when interpreting such research findings. A study by Apel and co-
investigators compared a linear model to a weekly undulating form
Fig. 6. A typical tri-cycle training plan.
Adapted from Bompa, 1994.
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of periodization, reporting that the linear model was more effective
at eliciting the performance measures used in the study (Apel et al.,
2011). Conversely, a study by Miranda and co-investigators
compared a linear model to a daily undulating form of periodiza-
tion (Miranda et al., 2011). In contrast to the first study, their results
suggested that the daily variation of the undulating model was
more effective than the linear model. Adding to the confusion,
other researchers have tested both methods, and have reported
that both are equally effective at eliciting improvement in perfor-
mance measures (Franchini et al., 2014; May et al., 2010). Thus, it
seems that there is not one single answer to the question of which
method of periodization is most beneficial. Rather, as is the case
with issues such as core stabilization training regimens, joint
mobilization models, clinical prediction rules or any number of
other topics commonly debated in rehabilitation (Niederbracht
et al., 2008), the most beneficial form of periodization often
changes from one scenario to another, depending on issues such as
the sport, length of season, athlete age and any number of other
variables coaches must consider when developing training
programs.
Such conflicting findings are common in research, and conse-
quently they pose an issue to coaches, who may have little time to
keep up with current research findings, possess rudimentary un-
derstandings of the scientific method, and little or no time to test
such findings by implementing them into the practice plans used
for their own athletes. These limitations are essentially no different
than those faced by busy healthcare clinicians (Cissik et al., 2008).
Still, large gaps exist in the current understanding of periodization
and the collective ability to apply these theories to the training of
athletes. Such gaps are partially related to the inherent tension or
“disconnect” which exists between the university settings where
the majority of the strength and conditioning research is conducted
and the coaches and athletes in the field who are reluctant to
participate in interventional training studies (Cissik et al., 2008).
A limitation of many contemporary studies on periodization is
the relatively small sample size and/or limited time frame that
characterizes the typical study on this topic, and which in turn
usually makes it more difficult for the busy coach to place such
findings into a broader context. Again, these problems are not
limited to sport science, as similar limitations exist within the
medical literature, making it more challenging for physicians,
nurses, physical therapists and other licensed providers to integrate
current research into their own practices (De Smedt, Buyl, &
Nyssen, 2006; Turner, 2011). Therefore, when faced with this
quandary, both coaches and sport physical therapists are encour-
aged to seek out review articles on periodization as the best way to
stay current on the topic of periodization and its application in
training or rehabilitation. Recent reviews by Turner et al. provide
excellent overviews on how a progressive periodization program
can increase strength or improve speed and power, as well as how
these attributes may be reconditioned during a course of rehabili-
tation (Kirby, Erickson, & McBride, 2010; Turner, 2011).
In summary, the limitations of current research on periodization
are similar to the shortcomings of scientific knowledge in many
areas within the healthcare literature, in particular given that most
research on periodization has been conducted on healthy in-
dividuals. Similarly, there are challenges for the sport physical
therapists that choose to draw connections between the current
literature on periodization theory and implementation models and
the same in topics within the rehabilitation literature. Conversely,
there are also likely many benefits for sport physical therapists that
choose to draw such connections conceptually. Such benefits likely
extend beyond the perceived practical rewards of more fully un-
derstanding the competitive mindset of coaches and their athletes
as the injured ones undergo the rehabilitation process.
1.5. Periodization and the treatment of sports injuries: a connection
between clinical and competitive worlds
Just as periodization theory and training models within sport
science have evolved in recent decades, so has the appreciation of
this topic within the rehabilitation world. Interestingly, few sources
in the 1980s and early 1990s on the rehabilitation of sport injuries
addressed directly the importance conceptually of periodization as
a functional endpoint for injured athletes, as evidenced by searches
of electronic databases such as Index Medicus (K. E. Wilk & Arrigo,
1993; Shankman, 1989). Sport rehabilitation manuscripts of that
era more typically focused instead on issues such as raising the
physical limitations of the injured tissue rather than on the
methods of returning the athlete to the proper level of readiness for
a given segment of the training year (Brewster & Schwab, 1993;K.
E. Wilk & Andrews, 1992).
In marked contrast, a current review of medical electronic da-
tabases suggests that periodization theory and application is
increasingly finding its way into contemporary sport rehabilitation
literature (Cole, Kruger, Bates, Steil, & Zbreski, 2009; Horschig, Neff,
& Serrano, 2014; Pegrum, Dixit, Padhiar, & Nugent, 2014). This
evolution in appreciation of periodization within the rehabilitation
literature parallels evolution in rehabilitation theory itself.
Contemporary rehabilitation literature appropriately continues to
acknowledge issues such as raising the physical limitations of
injured tissues. However, authors increasingly also tend to have
broader appreciation of the ways that poor movement patterns
while landing, for example, typically have upon the tissues within
the knee joint, in particular the ACL (Di Stasi, Myer, & Hewett, 2013;
Myer, Paterno, Ford, & Hewett, 2008). Such studies reinforce the
emerging consensus that musculoskeletal injuries and pain syn-
dromes typically emerge from disruptions within the human
movement system, requiring that dysfunctional movement pat-
terns need to be eradicated during rehabilitation in order to restore
normal function on a long-term basis (Sahrmann, 2011). One such
rehabilitation model, which accounts for the multiple systems
involved in the kinesiopathology of movement system injuries and
pain syndromes, is depicted schematically in Fig. 7. In sum, there
has been a widespread acknowledgment of the importance of not
only progressing the tissues but of progressing patients function-
ally from a movement perspective over the past few decades
(Sahrmann, 2011). Further, this broadening appreciation of the
contribution of poor movement patterns to the onset of injuries can
serve as a valuable asset to coaches when creating annual training
plans, provided sport physical therapists take the time to help
bridge this gap by educating coaches and athletes alike when such
opportunities arise.
Still, despite these advances, one might argue that more wide-
spread integration of periodization theory into sport rehabilitation
represents something of a “next frontier”, as it relates to pro-
gressing athletes from a functional movement perspective during
sport physical therapy. Sport physical therapists increasingly agree
that injured athletes need to restore functional movement prior to
resumption of training and/or competition (Di Stasi et al., 2013;
Myer et al., 2008). However, a higher level of rehabilitation man-
agement (for a lack of a better description) may be accomplished by
fully placing these athletes into the context of periodization
models, based simply on the view that this is the model which
athletes and their coaches are using to formulate and monitor
when training for competition. As such, greater knowledge and
embracing of these training theories may assist sport physical
therapists to further refine their evaluation, clinical reasoning skills,
exercise progression, and goal setting for the sustained return of
athletes to high level competition. By blending rehabilitation and
periodization theory, sport physical therapists can more skillfully
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progress toward return to function for a wide range of individuals,
whether in progressing a patient post-operatively following ACL
reconstruction or helping an injured worker with low back pain
return to full duty. Periodization principles should be an integral
part of sport physical therapy training and lexicon, included widely
in the discussion of exercise training principles such as progression,
overload, specificity, reversibility, and individual differences.
In practical application, sport physical therapists use periodi-
zation, a common example being post-operative “protocols” that
serve as rudimentary forms of periodization, albeit implemented
over shorter time frames than typically used in preparation for
competition. An example would be the progression of an athlete
recovering from post-operative ACL reconstruction. This brief
periodization plan initially focuses on the preparatory aspects of
rehabilitation, addressing impairments such as range of motion,
quadriceps strength, and normalized gait. These attributes of
functional limitation are typically addressed within the first 6e8
weeks following surgery. Once addressed, there is a transition
phase where the focus turns to more function-based recovery; as
an athlete reaches this transitive mesocycle, we can further divide it
into four microcycles: dynamic stabilization and core strength-
ening, functional strength, power development, and sport perfor-
mance symmetry (Di Stasi et al., 2013; Myer et al., 2008). This brief
periodization plan includes entrance criteria, regular testing and
measures for advancement, and modifications of exercise pre-
scription. This scenario assumes time to complete each microcycle
fully before the progression to the next. Ideally, this would be the
case, not only for the athlete's safety and prevention of re-injury,
but also for the potential to return to sport at higher-than-
previous levels. By fully understanding the goals of the athlete as
well as the time at which the injury falls during the training cal-
endar, one can best help the athlete return to the proper periodi-
zation sub phase. This means treatment for the athlete post-
operatively must consider more than the strength ratios of the
involved and uninvolved legs but also the state of the athlete's
aerobic and anaerobic capacities, neurological conditioning, and
physiological readiness before clearing him or her for full return to
practice or competition. This does not mean to imply that most
sport physical therapists do not consider such factors, but that they
consider these parameters for training and competition from the
vantage point of the annual training calendar of the periodization
model. As such, a better understanding of periodization theory by
sport physical therapists can only serve to facilitate better clinical
thinking skills, as well as improved communication between
therapists, athletes, and coaches, thus allowing for more effective
return to high-level activity. In this vein, case studies can be
particularly helpful in describing how periodization theory may be
applied to the rehabilitation of competitive athletes, and thus three
such cases from among the author's respective workloads in recent
years are presented below.
1.5.1. Case 1: Collegiate hammer thrower with ACL Tear
A 20-year old freshman collegiate track and field thrower was
referred to a physical therapist with the diagnoses of acute knee
pain and swelling. This international athlete arrived on campus
with an ACL-deficit right knee, the result of an injury sustained in a
team handball competition four years earlier. At the physical
therapy evaluation, she reported one incidence of instability and
swelling in her right knee since re-injury. She rated her current pain
as 5/10 and her pain at worst at 9/10. Her symptoms began a week
earlier, during the fall conditioning program, in which she was
learning the weight throw and performed numerous heavy lifts in
the weight room. The chief concern of her and the track and field
coaches was the hopes of quickly returning to full unrestricted
activity-status, in order to begin the indoor season in 6 months (e.g.
“competition”). The larger plan was for her to then “redshirt” dur-
ing the outdoor season, as she underwent ACL reconstruction sur-
gery and initiated post-operative rehabilitation to prepare for the
next indoor season.
At the initial physical therapy evaluation, the athlete was able to
ambulate to the clinic without an assistive device, but did show
signs of antalgia with decreased stance time on the right lower
extremity (LE) and decreased step length for the left LE. Disability
was scored via the International Knee Documentation Committee
Fig. 7. Kinesiopathological model of the human movement system.
Adapted from Sahrmann, 2011.
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Table 2
Rehabilitation periodization plan for collegiate track and field thrower with ACL Tear.
Phases of Training Preparatory Competitive Transition
Sub-phases General Preparatory Specific Preparatory Pre Competitive Transition
Sub-phase General Preparatory
Macro-cycles Macro I (Weeks 1e4) Macro II (Weeks 5e8)
Macro-cycle GOAL(S) Decrease pain and swelling, normalize knee
ROM and quadriceps control
Lower quarter strengthening
Micro-Cycles Week/session General Preparatory Macro I
1e4/1e3  Upright cycle ergometer, no resistance, high seat, for AROM, progress from 5 to 15 min
 Quad sets in supine, NMES to volitional 10  10 s each
 Knee flexion AROM in supine and sitting to prone with strap assist 3  30 s each
 SLR in supine with NMES to volitional with weight supine, prone, side lying 3  20
 SLR in side lying 3  20
 Add strap weight to SLR in all positions placed just distal to knee 3  20
 Elastic band terminal knee extension 3  10 s each
 SLR in prone with weight (place just distal to knee) 3  20
 SLR in side lying with weight (place just distal to knee) 3  20
 Body weight bilateral to unilateral calf raises 3  25
 Body weight squats stable to unstable 3  12
 Single-leg stance stable to unstable 10  10 s each right and left
 Ham sets in supine (multi-angle) 10  10 s each to bridging in supine 10  10 s
 Step up, 2e4 inch step 3  10 each right and left
 Ice bag to anterior knee (no barrier) in supine  20 min
 HEP of above exercises, ice bag to knee (no barrier) in supine  20 min, each 3 times per day
Micro-Cycles Week/session General Preparatory Macro II
5e8/1e2  Upright cycle ergometer, no resistance, lower seat, for AROM  15 min

Step ups and step downs, 6e10 inch step 3  10 each right and left
 Lateral step down 4e8 inch step 3  10 each right and left
 Leg press bilateral to unilateral 3  12 repetition max (RM)
 Single-leg bridging 3  10 right and left
 Side-lying clam shells with elastic band flat to plank position 3  10 right and left
 Body weight to weighted calf raises unilateral 3  25 right and left
 Body weight to weighted split squats 3  12 right and left
 Quadruped lifts (arms, legs, alternating arms legs) with bracing 30  8 s hold right and left
 Side support with knees extended 3  10  8 s hold right and left
 Single-leg stance eyes open and closed on foam, 10  10 s each right and left
 Ice bag to anterior knee (no barrier) in supine  20 min
 HEP of above exercises and ice bag to knee (no barrier) in supine  20 min, daily
Sub-Phase Specific Preparatory
Macro-Cycles Macro I (Weeks 9e12) Active Rest (Week 13) Macro II (Weeks 14e16) Active Rest (Week 17)
Macro-Cycle GOAL(S) Dynamic stabilization Active Rest Functional strength Active Rest
Micro-Cycles Week/session Specific Preparatory Macro I
9e12/1e2  Upright cycle ergometer, no resistance, lower seat, for AROM  15 min
 Step ups and step downs, 10e12 inch step  12 right and left
 Lateral stepping with increasing elastic band resistance  20 steps right and left
 Walking lunges 2  16 steps
 Deep squat holds, stable to unstable with perturbations 5  5 s hold
 Single-leg balance stable to unstable (knee flexed 10e30

)4 10 s hold right and left
 Single-leg bend over dead left stable to BOSU (balance focus)  12 right and left
 Single-leg reach anterior to posterior stable to unstable 4  10 s hold right and left
 Single-leg reach lateral stable to unstable 4  10 s hold right and left
 Athletic position PT ball toss stable to unstable 3  20 s hold
 Unstable body weight squats at increasing speeds  8
 Unstable bilateral to unilateral knee balance 20 s hold right and left
 Unstable alternate arm and leg lifts Supermans  15
 Unstable double to single leg pelvic bridges  12
 Unstable drop off deep-hold 8  5s
13 Specific Preparatory Active Rest
Micro-Cycles Week/session Specific Preparatory Macro II
14e16/1e2  Upright cycle ergometer, no resistance, lower seat, AROM  15 min
 Box (12e18”) drop off to deep hold 10  5e10 s
 Step ups and downs 8e12 inch step stable and unstable  12 right and left
 Double straight leg dead lift 3  10
 Sumo squat with dumbbell 3  10
 Single-leg hop stable to unstable 3  30 right and left
 Single-leg hop front and back stable to unstable 3  30 right and left
 Single-leg hop lateral stable to unstable 3  30 right and left
 Single-leg  hop stable to unstable  3 right and left
 Split squats 3  20 right and left
 Line jump to deep hold forward 8 
5e10 s right and left
 Line jump to deep hold lateral 4  5e10 s right and left
17 Specific Preparatory Active Rest
Sub-Phase Pre-Competitive and Competitive
Macro-Cycles Macro I (Weeks 18e20) Macro II (Weeks 22e24) Macro III (Week 26) Active Rest (Weeks 21 & 25)
Macro-Cycle GOAL(S) Power development Sport-specific symmetry Return to Sport Active Rest
(continued on next page)
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(IKDC) subjective evaluation form, which has been shown to be
reliable and valid for patient's rating of their ACL injury related to
symptoms, function, and sport participation (Irrgang et al., 2001).
The athlete's IKDC score was 31 where 100 equals no limitation. The
athlete presented with 2þ/5 joint effusion (Sturgill, Snyder-
Mackler, Manal, & Axe, 2009). Right knee active range of motion
(ROM) was lacking five degrees of extension with knee flexion to
91

and passive ROM was lacking four degrees of extension with
knee flexion AROM to 97

, all measured in supine. The athlete
displayed laxity indicative of an ACL-deficient knee via Lachmann's
test with all other special tests negative. Her pain worsened with
increased weight bearing.
Based on the athlete's goals, and the information gathered from
the initial evaluation and in consultation with the athlete and her
coaches, her physical therapist was able to develop a linear peri-
odization rehabilitation program. This periodization plan is depic-
ted in Table 2. The physical therapist worked with the track and
field coach to integrate the rehabilitation program into the athlete's
regular sport specific training program, once she had progressed
through the acute stage of the injury-tissue healing continuum. The
physical therapist estimated the program would take 24e26 weeks,
allowing the athlete to peak at the ideal time for full return to
competition in January for the beginning of the indoor season. Her
plan was progressed using established frameworks previously
published and altered as needed to address her specific needs for
returning to full active participation and timed to align with qual-
ification meets for the NCAA Championships (Di Stasi et al., 2013;
Hurd, Axe, & Snyder-Mackler, 2009; Myer et al., 2008).
The preparatory phase was broken down into two sub-phases, a
general preparatory phase and a specific preparatory phase, as
depicted in Table 2 and Addendum 1. The general preparatory
phase was 8 weeks in length, broken into 2 macro-cycles. The first 4
weeks (Macro I) consisted of 3 sessions per week for a total of 12
sessions (micro-cycles) with goals of: 1) decreasing the athlete's
pain, 2) reducing joint effusion, 3) progression to full knee ROM,
and 4) quadriceps muscle activation. Pain and swelling was
addressed with cryotherapy for 20 min at least 3 times per day
using a mixture of crushed or cubed ice with water in a sealable
plastic bag and placed directly against the skin. This has been
shown to result in the greatest thermal conduction for reducing
pain and swelling (Michlovitz, Bellew, & Nolan, 2011). Early quad-
riceps activation was augmented with neuromuscular electrical
Table 2 (continued )
Phases of Training Preparatory Competitive Transition
Micro-Cycles Week/session Pre-Competitive Macro I
18e20/1e2  Upright cycle ergometer, no resistance, lower seat, AROM  15 min
 Wall Jumps 2  15 s
 Tucks jumps 2  10
 Line jumps laterally, anterior to posterior for speed  10
 Line jump max vertical four way  3
 Broad jump to deep hold 8  3 s hold
 Broad jump max vertical  6
 Unstable jump up single-leg 5  10 s hold right and left
 Unstable drop off single-leg 5  5 s hold right and left
 Unstable drop off sub-max vertical  8
 Single-leg 90

hop hold 8  3 s hold right and left
 Bounding in place 2  15 s
 180

jumps for height 2  10 s
 Single-leg X hop for reaction  4 right and left
 Cross-over hop, hop, hop for distance 4  3 s right and left
 Barbell back squats 2  8
 Dumbbell bent leg deadlift pick-up 2  8
 Swiss ball crunch  12
 Swiss ball trunk extensions  12
 Unstable gluteal balance with feet up PT ball toss 2  25 s hold
 Unstable single-leg hold PT perturbations 4  10 s hold right and left
21 Pre-Competitive Active Rest
Micro-Cycles Week/session Pre-Competitive Macro II
22e24/1  Upright cycle ergometer high intensity  5 min
 Active warm-up (knee to chest, retro hip ER, lateral shuffle, high knees, glute kicks) 2  20 ft each
 Tuck Jumps 2  10 s
 Wall jumps 2  15 s
 Box drop (12e18”) off to athletic position  5
 Box drop (12e18”) off to max vertical  10
 Box drop (12e18”) off to 180

reaction ball toss  5
 Box drop (12e18”) off to max broad jump athletic position  6
 Box drop (12e18”) off lateral max vertical  6 right and left
 Lunge jump 2  10 s
 Bounding for distance  6
 Forward barrier jumps  6
 Lateral barrier jumps  6 right and left
 Forward barrier hops staggered cone  6
 Lateral barrier hops staggered  4 right and left
 Hop, hop, hop distance hold 4  3 s right and left
 Cross over hop, hop, hop for distance  5
 Dumbbell overhead squat 2  8
25 Pre-Competitive Active Rest
Sub-Phase 26 Competition/Return to Sport
AROM ¼ active range of motion, SLR ¼ straight leg raise, NMES ¼ Neuromuscular Electrical Stimulation.
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stimulation utilizing a symmetrical biphasic pulsed current. Fre-
quency was set to 60 pulses per second, pulse duration of 600
microseconds, and an amplitude set to 50e70% of maximal
voluntary contraction. Duty cycle utilized was 10 s on, 30 s off
without ramp up or down times, which resulted in 20 contractions
over 14 min) (Michlovitz et al., 2011 ). Lower extremity cycling and
supine exercise were implemented to increase range of motion and
muscular activation of the knee.
The second 4 weeks (Macro II) consisted of 2 sessions per week
for a total of 8 sessions (micro-cycles) with the goal of progressing
the athlete to more advanced lower quarter strengthening exer-
cises focusing on the force couples of thigh, gluteal, and trunk
musculature with progressively more challenging therapeutic ex-
ercise. This phase included the continuation of stationary cycling
for AROM. The athlete could not tolerate aggressive walking or
running without re-aggravating her symptoms. However, as this
athlete does not require aerobic power for sport performance (i.e.
track and field weight thrower), this was not a concern for the
treating physical therapist and was viewed as unnecessary physi-
ological stress and could have hindered the athlete's recovery.
Once the athlete achieved the goals set in the general prepara-
tory phase the athlete was progressed to the specific preparatory
phase. This phase was 9 weeks in length and broken into 2 macro-
cycles. Emphasis during this phase was placed on having the
athlete complete progressively more challenging and higher vol-
ume core and lower extremity strengthening exercises conducted
during closed kinetic chain movements (Myer et al., 2008). The first
5 weeks (Macro I) consisted of 4 weeks of 2 sessions per week for a
total of 8 sessions (micro-cycles) with goal of improving dynamic
stabilization, ending with one week of active rest. The next 4 weeks
(Macro II) consisted of 3 weeks of 2 sessions per week for a total of 6
sessions with the goal of improving functional strength, ending
with one week of active rest.
The athlete entered the pre-competitive stage with the goals of
1) improving power development and 2) sport-specific symmetry.
The pre-competitive phase was 9 weeks in length and broken into 2
macro-cycles. The first 5 weeks (Macro I) consisted of 4 weeks of 2
sessions per week for a total of 8 sessions (micro-cycles) with goal
of improving muscular power, ending with one week of active rest.
The next 4 weeks (Macro II) consisted of 3 weeks of 1 session per
week for a total of 6 sessions with the goal of improving sport-
specific symmetry, ending with one week of active rest.
The thrower was able to progress through all sport-specific
training stages as planned passing return to sport testing based
on previously published criteria (Hurd et al., 2009). Her IKDC score
improved to 90 out of 100. She competed throughout the indoor
season and finished 9th in the NCAA Division I Championships.
After the indoor season she underwent ACL reconstructive surgery,
electing to “redshirt” during the outdoor track and field season as
originally planned.
1.5.2. Case 2: US Army soldier with low back pain
A 28-year old soldier was referred to a physical therapist with
the diagnoses of acute low back pain (LBP). At the evaluation, he
reported experiencing severe LBP, rating it at worst 9/10 with his
current pain at 6e7/10. His symptoms began one-week prior, when
he was lifting numerous heavy items. He had no prior history of
LBP. His chief concern was returning to full active duty in order to
begin Army Ranger School (“competition”) in 6 months. His
Modified Oswestry Low Back Questionnaire score was 26/50 which
equates to 52% disability.
At the initial evaluation, this soldier lacked full trunk range of
motion (ROM) in all directions, and was most limited in extension.
His trunk AROM was measured in degrees via goniometry as fol-
lows:
flexion 0e70 pain with thigh climb on return to standing,
extension to 0 limited by pain and muscle spasm, side bending was
0e20 bilaterally; rotation was 0e25 bilaterally. He noted his worse
pain was with trunk flexion, which prevented any bending,
stooping, or lifting as needed for his work. His core strength was
measured via prone plank hold for time. The soldier was able to
hold the prone plank for 12 s before discontinuing due to pain.
Therefore he displayed poor core muscular endurance as normative
data athletic men is 90e115 s (Schellenberg, Lang, Chan, &
Burnham, 2007). Based on the soldier's goals and the information
gathered during the initial evaluation, his physical therapist was
able to develop a linear periodization rehabilitation program. This
periodization plan is shown in Table 3.
The preparatory phase was broken down into two sub-phases, a
general preparatory phase and a specific preparatory phase, as
depicted in Table 3 and Addendum 2. The general preparatory
phase was 8 weeks in length, broken into 2 macro-cycles. The first 4
weeks (Macro I) consisted of 2 sessions per week for a total of 8
sessions (micro-cycles) with goals of: 1) decreasing pain, normal-
izing trunk ROM, and initiating aerobic conditioning and core sta-
bilization exercise. This was accomplished with initially using a
combination of grade I-II PA glide spinal mobilizations and elec-
trical stimulation (i.e. biphasic pulsed current, 100 pulses per sec-
ond, 50 microseconds, amplitude to highest soldier could tolerate
for 20 min) to assist with pain control and facilitate early use of
specific exercise with an extension directional preference (Fritz,
Cleland, & Childs, 2007; Michlovitz et al., 2011). Individuals with
acute LBP and no symptoms distal to the knee have shown signif-
icant improvement with lumbopelvic high velocity-low amplitude
(HVLA) spinal manipulation, which was initiated once the soldier's
pain was more manageable and which further helped to reduce his
symptoms (Fritz et al., 2007). The patient noted 50% reduction in
pain during prone press-up extension following HVLA technique
targeted to the lumbopelvic spine. The soldier was engaged in
active exercise sessions by the fourth week. The second 4 weeks
(Macro II) were dedicated to addressing impairments in his core
muscle endurance, including progressively higher volume core and
hip strengthening (Hicks, Fritz, Delitto, & McGill, 2005). This phase
also included aerobic conditioning in accordance with ACSM
guidelines for improving cardiorespiratory endurance.
The specific preparatory phase was 8 weeks in length and
broken into 2 macro-cycles. The fi rst 5 weeks (Macro I) consisted of
4 weeks of 2 sessions per week for a total of 8 sessions (micro-
cycles) with goal of improving dynamic stabilization ending with
one week of active rest. The next 3 weeks (Macro II) consisted of 2
weeks of 2 sessions per week for a total of 4 sessions with the goal
of improving functional strength ending with one week of active
rest. His treatment plan was progressed using established period-
ization frameworks previously published and altered as needed to
address his specific needs for returning to full active duty and
Ranger School (Kell, Risi, & Barden, 2011).
The solider then entered the pre-competitive stage with the goals
of improving power development and sport-specific symmetry. The
pre-competitive phase was 8 weeks in length and broken into 2
macro-cycles. The fi
rst 4 weeks (Macro I) consisted of 3 weeks of 2
sessions per week for a total of 6 sessions (micro-cycles) with goal of
improving muscular power ending with one week of active rest. The
next 4 weeks (Macro II) consisted of 4 weeks of 1 session per week
for a total of 4 sessions with the goal of improving sport-specific
symmetry ending with one week of active rest.
Twenty-five weeks following the original injury and onset of
symptoms, the soldier reported 0/10 pain and a disability rating via
the Modified Oswestry Low Back Questionnaire score of 0/50. He was
able to progress through all stages and entered Army Ranger School
as planned. A one-year follow-up revealed the soldier was able to
complete school and did ultimately become a U.S. Army Ranger.
D.L. Hoover et al. / Physical Therapy in Sport xxx (2015) 1e20 13
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Table 3
Rehabilitation periodization plan for U.S. Army soldier with low back pain.
Phases of training Preparatory Competitive Transition
Sub-Phases General Preparatory Specific Preparatory Pre Competitive Transition
Sub-Phase General Preparatory
Macro-Cycles Macro I (Weeks 1e4) Macro II (Weeks 5e8)
Macro-Cycle GOAL(S) Decrease pain, normalize trunk ROM, initiate core
stabilization exercise
Initiate aerobic conditioning and progress core stabilization exercise
Micro-Cycles Week/session General Preparatory Macro I
1e4/1e2  Electrical stimulation with ice for pain control  20 min (week 1)
 Spinal PA mobilizations grade IeII to L4-5 and L5-S1 3  30 s each (week 1)
 Prone press-up extension 5  10
 Supine lumbopelvic spinal manipulation bilaterally  2 (week 2e3)
 Prone press-up extension with PT overpressure PA mobilization, grade IV, 10  10 s hold to L4-5 and L5-S1 each
 Standing back bend trunk extension 3  10
 Abdominal bracing (“bracing”) in supine, quadruped, and standing each 30  8 s hold
Micro-Cycles Week/session General Preparatory Macro II
5e8/1e3  Upright cycle ergometer  15 min in target heart rate range (week 1)
 Treadmill walking  15e20 min, intensity set to highest tolerated walking speed, 0e5% incline, within target
heart rate range
 Standing back bend trunk extension 3  10
 Bracing with bridging 30  8 s hold
 Bracing with heel slides 10e30  4 s hold right and left
 Bracing with unilateral leg lifts 10e 30  4 s hold right and left
 Quadruped arm lifts with bracing 10e30  8 s hold right and left
 Quadruped leg lifts with bracing 10e30  8 s hold right and left
 Side support with knees flexed 3  10  8 s hold right and left
Sub-Phase Specific Preparatory
Macro-Cycles Macro I (Weeks 9e12) Macro II (Weeks 14e15) Active Rest (Week 13 &16)
Macro-Cycle GOAL(S) Dynamic stabilization Functional strength Active Rest
Micro-Cycles Week/session Specific Preparatory Macro I
9e12/1e2  Treadmill walk-run progression .1 walk, progress from .2 to .5 run  1 mile, target heart rate range
 Deep holds 5  5 s hold
 Body weight squats with elastic band around knees 3e5  12
 Side lying clam shell in side support with knees flexed 3  10 right and left
 Side support with knees extended 3e5  10  8 s hold right and left
 Side support with knees extended trunk rotation anterior and posterior 3  10 right and left
 Lateral stepping with elastic band resistance  20e40 steps right and left
 Bracing with gluteal set standing row exercise 20  6 s hold
 Bracing with gluteal set unilateral limb support row exercise 15  6 s hold right and left
 Standing hip abduction isometric against wall 10  10 s right and left
 Single-leg squat (knee flexed 10e30

) with trunk forward lean and bracing, hold 6e10  5 s right and left
 Quadruped alternate arm and leg lifts with bracing 15e30  8 s hold
 Quadruped elastic band fire hydrants with bracing  25 right and left
 Swiss ball wall squat 3  12
 Swiss ball Mcgill crunches 3  20
 Swiss ball trunk extensions 3  12
 Swiss ball alternate arm and leg lifts Supermans 3  15
 Swiss ball double leg pelvic bridges 3  12
 Swiss ball unilateral ½ wall squat 3  10 right and left
 Deep holds with trunk rotation 5  10 s hold right and left
 Unstable single-leg balance knee flexed 10

3  20 s hold right and left
 Unstable squat hold with bracing knee flexed to 30

6  8s
 Single-leg squat, knee flexed to 10

, fire hydrants with elastic band around knees 3  12
 Prone plank with knees extended 15  8s
 Unstable deep-hold PT perturbations 3  20 s
 Unstable athletic position PT ball toss 3  20 s hold
 Unstable quadruped fire hydrants with bracing 10  10 s right and left
 Single-leg bend over dead left (balance focus)  12 right and left
13 Specific Preparatory Active Rest
Micro-Cycles Week/session Specific Preparatory Macro II
14e15/1e2  Treadmill jog-run  1e2 miles, within target heart rate range
 Single-leg hop in place, anterior posterior and lateral 1e3  30 right and left each
 Single-leg X hop  3 right and left
 Lateral step down 10e12
00
step 2  12 right and left
 Lateral step down with foam 8
00
step  10 right and left
 Split squats with body weight 3  12 right and left
 Sumo squat with dumbbell 2  10 repetition maximum (RM)
 Lateral shuffling with elastic band  6e12 passes right and left
 BOSU (flat) athletic position PT ball toss 3  20 s hold
 Pull ups to fatigue
 Push-ups to fatigue
 Sit-ups to fatigue
 Box drop (12e18
00
) off to deep hold 10  5s
 BOSU (flat) athletic position PT ball toss 3  20 s hold
16 Specific Preparatory Active Rest
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1.5.3. Case 3: High school baseball pitcher with rotator cuff
tendonitis.
A 17-year-old high school baseball pitcher was referred to a
physical therapist with the diagnosis of right shoulder rotator cuff
tendonitis, confirmed via magnetic resonance imaging. His symp-
toms began two weeks prior to the end of the season during his
junior year. He was able to finish the year, but his pitching perfor-
mance suffered. He rested for 4 weeks prior to trying to throw
again. He continued to experience pain and therefore sought
treatment. His goal was to return to pitching for his senior year. At
the time of the initial evaluation he had 30 weeks to prepare for the
beginning of his senior season.
At the physical therapy evaluation, the pitcher reported pain
when throwing a baseball, rating it 7/10 and rating his pain at rest
at 3/10. Disability was measured via the Kerlan-Jobe Orthopedic
Clinic Shoulder and Elbow (KJOC), which was found to be more a
sport-specific performance assessment for throwing athletes as
compared to the American Shoulder and Elbow Surgeons Stan-
dardized Shoulder Assessment Form (ASES). Neri et al. found the
KJOC was 85% accurate compared to the ASES 70% accuracy in re-
turn to pain-free pre-injury levels for elite throwing athletes (Neri,
ElAttrache, Owsley, Mohr, & Yocum, 2011). The athlete's KJOC score
was 66.3 out of 100 with higher scores equating to a greater level of
performance (Alberta et al., 2010).
The athlete h ad limited and painful AROM and PROM of
shoulder abduction and external rotation. His AROM/PROM for
right shoulder abduction was 0e150/0e157

(compared to
0e175/0e180

on the left) and his external rotation was 0e80/
0e82

(compared to 0e90/0e102 on the left). His right shoulder
displayed 15-degre es less in total shoulder rotation motio n
{external rotation (ER) plus interna l rotation (IR)} in the 90

abducted position. His total rot ation PROM on the left was 174

and 135

on the right. Pitchers with a difference of 5

or more are
at a higher risk for injury (Kevin E. Wilk et al., 2011). Therefore,
the PT d etermined that the athlete needed to improve his right
shoulder ER PROM to at least 116

in order to achieve this desired
symmetry.
Bilaterally his shoulders presented with global capsular laxity
with the exception of right shoulder inferior (caudal) glide in 90

abduction. The athlete did however present with posterior shoul-
der musculature tightness on the right as compared to the left. This
is consistent with previous findings that throwers exhibit posterior
musculature tightness yet have a higher likelihood of posterior
capsular laxity (Borsa et al., 2005; Reinold et al., 2008).
He displayed weakness with pain of his right shoulder ER with a
manual muscle test (MMT) score of 3þ/5, compared to 5/5 of each
on the left. The MMT for the ER was performed with the patient in
prone and his right shoulder abducted to 90

. The patient remained
in prone to test the lower and middle trapezius muscles with the
arm in full ER (thumb up position) and elevated to 135

and 90

respectively. The right lower trapezius was rated as 3þ/5 and
middle trapezius was rated as 4-/5, compared to 5/5 for each on the
Table 3 (continued )
Phases of training Preparatory Competitive Transition
Sub-Phase Pre-Competitive and Competitive
Macro-Cycles Macro I (Weeks 17e19) Macro II (Weeks 21e23) Macro III (Week 25) Active Rest (Week 20 & 24)
Macro-Cycle GOAL(S) Power development Sport-specific symmetry Ranger School Active Rest
Micro-Cycles Week/session Pre-Competitive Macro I
17e19/1e2  Treadmill jog-run  3 miles, 8 min mile
 Treadmill speed training 8 e10 MPH, 5% incline, 3  10 s
 Wall Jumps 2  15 s
 Tucks jumps 2  10
 Line jumps laterally for speed  10
 Line jumps front to back for speed  10
 Line jump max vertical four way  3
 Power pull ups  4e 8
 Power push ups  4e8
 Sit ups to stand up  4e8
 Broad jump to deep hold 8  3 s hold
 Broad jump max vertical  6
 Burpees 2  15 s
 Back pack squats 100lbs. 2  12
 Bounding in place 1  15 s
 180

jumps for height 1  10 s
 Single-leg X hop for reaction  4 right and left
 Cross-over hop, hop, hop for distance 4  3 s right and left
 Unstable jump up single-leg 5  10 s hold right and left
 Unstable drop off to sub-max vertical  8
 Single-leg 90

hop hold 8  3 s hold right and left
 Unstable single-leg hold PT perturbations 4  10 s hold right and left
20 Pre-Competitive Active Rest
Micro-Cycles Week/session Pre-Competitive Macro II
21e24/1  Active warm-up (knee to chest pull, retro hip ER, lateral shuffle, high knees, glute kicks) 20 feet  2 each
 Treadmill jog-run  4e5 miles, 8 min mile
 Box drop (12e18
00
) off to 180

reaction ball toss  3
 Box drop (12e18
00
) off to max broad jump athletic position  3
 Box drop (12e18
00
) off lateral max vertical  3 right and left
 Burpees  15 s
 Sit ups  59 reps in 2 min
 Pull ups  12
 Push-ups  49 reps in 2 min
 Back pack squats 50e100 lbs.  8e12
 Treadmill walking at terminal speed with 50 lb. back pack  1e2 mile
24 Pre-Competitive Active Rest
Sub-Phase 25 Competitive/Ranger School
D.L. Hoover et al. / Physical Therapy in Sport xxx (2015) 1e20 15
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Table 4
Rehabilitation periodization plan for high school baseball pitcher with rotator cuff tendonitis.
Case 3: High school baseball pitcher training program
Phases of training Preparatory Competitive Transition
Sub-Phases General Preparatory Specific Preparatory Pre Competitive Transition
Sub-Phase General Preparatory
Macro-Cycles Macro I (Weeks 1e4) Macro II (Weeks 5e8)
Macro-Cycle GOAL(S) Improve ROM, rotator cuff and scapular musculature
strength and aerobic fitness
Improve isotonic strength
Core and lower quarter muscle performance
Micro-Cycles Week/session General Preparatory Macro I
1e4/1e2  Schwinn
®
Airdyne
®
with UE and LE in target heart rate range  10e15 min
 Inferior glide joint mobilizations to decrease pain grades IeII to right shoulder 3  30 s each (week 1e2)
 Wand AAROM scaption in supine 3  10 with 10th rep held for 30 s stretch
 Wand AAROM scaption in sitting 3  10 with 10th rep held for 30 s stretch
 Wand AAROM 90/90 ER overhead stretch in sitting 3  10 with 10th rep held for 30 s stretch
 Elastic band elbow flexion and extension 1 e 3  12 each right and left
 Elastic band wrist flexion, extension, supination, pronation 1e3  12 each right and left
 Isometrics, manual resistance, elbow at side, towel roll under axilla, ER, IR, scaption in 30

,3 10 s each
 Isometrics with shoulder in 90

scapular plane ER and IR, scaption in 80

,3 10 s each
 Posterior shoulder musculature stretch (cross body horizontal adduction with PT assist to stabilize and
apply overpressure as needed, 3  30 s each
 Ice bag to R shoulder  20 min post exercise
Micro-Cycles Week/session General Preparatory Macro II
5e8/1e2  Schwinn
®
Airdyne
®
with UE and LE in target heart rate range  20e25 min
 Active warm-up:
 Swiss ball up the wall flexion  20
 Small arm circles backward  20
 Standing scaption full AROM  20
 Shrug, scarecrow, field goal, overhead  5
 Push-up plus off wall  10
 Seated Russian twist  10
 Grip pull-apart isometrics 3  10 s
 Doorway row (squat arm row)  10
 Cross body horizontal adduction stretch with scapula stabilized 3  30 s
 Bent knee prone plank, WB on forearms, full scapular protraction hold 10  10 s
 Side lying shoulder external rotation manual resistance, towel roll under axilla, 3  12
 Quadruped middle trapezius unilateral arm lifts (“T”), contralateral UE WB in full scapular protraction
5e10  10 s hold right and left
 Quadruped lower trapezius unilateral arm lifts (“Y”), contralateral UE WB in full scapular protraction
5e10  10 s hold right and left
 Elastic band bilateral external rotation with scapular retraction and posterior tilting 3  10
 Elastic band dynamic hug exercise for the serratus anterior 3  10
Sub-Phase Specific Preparatory
Macro-Cycles Macro I (Weeks 9e12) Macro II (Weeks 14e16) Active Rest (Week 13 & 17)
Macro-Cycle GOAL(S) Dynamic stabilization Functional strength Active Rest
Micro-Cycles Week/session Specific Preparatory Macro I
9e
12/1e2  Schwinn
®
Airdyne
®
with UE and LE in target heart rate range  30 min
 Active warm-up
 Elastic band and Bodyblade
®
diagonal patterns four-way  10 each right and left
 Elastic band and Bodyblade
®
dynamic hug exercise for the serratus anterior  10
 Elastic band bilateral external rotation with scapular retraction and posterior tilting  10
 Shoulder scaption with weight and Bodyblade
®
,0e90

,  10 right and left
 Bodyblade
®
unilateral external rotation at 30

abduction, 45

abduction and 90

abduction 2  15 s
each right and left
 Body weight push-up plus off treatment Tables 1e3  12
 Straight knee prone plank plus, WB on forearms, scapular protraction and retraction 1e3  20
 Elastic band elbow flexion and extension  12 each right and left
 Elastic band wrist flexion, extension, supination, pronation  12 each right and left
13 Specific Preparatory Active Rest
Micro-Cycles Week/session Specific Preparatory Macro II
14e16/1e2  Schwinn
®
Airdyne
®
with UE and LE in target heart rate range  15 min
 Active warm-up
 Elastic band bilateral external rotation with scapular retraction and posterior tilting 3  10
 Elastic band diagonal patterns in tall kneel four-way  10 right only
 Unstable elastic band diagonal patterns standing four-way  10 right only
 Unstable quadruped I,Y,T in full ER, contralateral UE WB in full scapular protraction each 10  10 s
hold right and left
 Unstable quadruped prone row with weight, contralateral UE WB in full scapular protraction
each  10RM right and left
 Unstable triceps press up  12
 Body weight push-up plus off fl oor 1e3  12
 Elastic band elbow flexion and extension  12 each right and left
 Elastic band wrist flexion, extension, supination, pronation  12 each right and left
 Tennis ball throws, 35 feet throws, 1e3  25 reps
17 Specific Preparatory Active Rest
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left. Right shoulder special testing revealed a positive Hawkins and
Kennedy impingement sign and a painful arc. All other provocation
tests were negative. Based on the athlete's goal and the information
collected during the initial evaluation, his physical therapist was
able to develop a periodization rehabilitation program. This peri-
odization plan is detailed in Table 4 and Addendum 3.
The preparatory phase was broken down into two sub-phases, a
general preparatory phase and a specific preparatory phase, as
depicted in Table 3. The general preparatory phase was 8 weeks in
length, broken into 2 macro-cycles. The first 4 weeks (Macro I)
consisted of 2 sessions per week for a total of 8 sessions (micro-
cycles) with goals of: 1) normalizing right shoulder ROM without
increasing resting pain, 2) early rotator cuff and scapular muscu-
lature activation without increasing resting pain, and 3) aerobic
fitness. The patient's ROM was addressed with a combination of
inferior glide shoulder mobilizations using grades I-II to stimulate
joint mechanoreceptors and for neuromodulation of pain (Mangus,
Hoffman, Hoffman, & Altenburger, 2002). This was followed by
wand active assistive ROM, cross-body horizontal adduction with
scapular fixation first by the patient and then with PT assist. Iso-
metrics for shoulder ER, IR, and abduction with arm at side were
also initiated. This phase included upper and lower extremity aer-
obic conditioning using a Schwinn
®
Airdyne
®
in accordance with
ACSM guidelines for improving cardiorespiratory endurance.
The second 4 weeks (Macro II) consisted of 2 sessions per week
for a total of 8 sessions (micro-cycles) with the goals of 1) Main-
taining full symmetrical ROM, 2) improving isotonic external ro-
tator and scapular stabilizer strength, 3) core lower and quarter
muscle performance, 4) continued aerobic conditioning. The
objective of this macro-cycle was to progress the athlete to more
advanced upper and lower quarter strengthening exercises using
progressively more challenging therapeutic exercise. The concept
for exercise selection has been previously published (Reinold,
Escamilla, & Wilk, 2009).
The specific preparatory phase was initiated once the pitcher
was pain free with daily tasks, negative for provocation testing,
maintenance of full symmetrical ROM as well as sufficient rotator
cuff and scapular musculature strength. Once the athlete achieved
the goals set in the general preparatory phase the athlete was
progressed to the specific preparatory phase. This phase was 9
weeks in length and broken into 2 macro-cycles. Emphasis during
this phase was placed on having the athlete complete progressively
more challenging and higher volume strengthening exercises. The
first 5 weeks (Macro I) consisted of 4 weeks of 2 sessions per week
for a total of 8 sessions (micro-cycles) with goal of improving dy-
namic stabilization, ending with one week of active rest. The next 4
weeks (Macro II) consisted of 3 weeks of 2 sessions per week for a
total of 6 sessions with the goal of improving functional strength,
ending with one week of active rest.
The athlete entered the competitive phase in week 18. This
phase is made up of two sub-phases, the precompetitive and the
competitive. The pre-competitive phase was 9 weeks in length and
broken into 2 macro-cycles. The goals of this sub-phase were: 1)
improve power and 2) return to throwing. During this sub-phase
the return to throwing interval program was initiated using an
established framework previously published (Reinold, Wilk, Reed,
Table 4 (continued )
Case 3: High school baseball pitcher training program
Phases of training Preparatory Competitive Transition
Sub-Phase Pre-Competitive and Competitive
Macro-Cycles Macro I (Weeks 18e21) Macro II (Weeks 23e25) Active Rest (Week 22 & 26) Macro III (Week 27)
Macro-Cycle GOAL(S) Power development Full return to throwing Active Rest Return to Sport
Micro-Cycles Week/session Pre-Competitive Macro I
18  Initiate Interval throwing program (Reinhold 2002)
 Criteria to start throwing:
 No pain with ADLs
 <10

deficit (5 or less preferred) side to side total rotation PROM
 Negative provocation/clearing, impingement, instability testing
 MMT 5/5 for RTC and scapulothoracic muscles
 Near normal scapulohumeral rhythm (no shrug sign/Type III Kibler)
 Grip Strength >40 kg
 Symmetrical posterior shoulder mobility
 Pain free throwing with tennis ball
 Perform every other day (non PT days), up to three times per week
 Pain free thrower's ten prior to throwing
18e21/1e2  Schwinn
®
Airdyne
®
with UE and LE in upper limit target heart rate range  10 min
 Active warm-up
 Double arm plyometric chest passes 3  8
 Double arm plyometric wood chops on rebounder 3  8
 Double arm plyometric overhead soccer throw 3  8
 Single arm 90/90 plyometric toss at rebounder  8
 Elastic band ER in 90

of abduction end range rhythmic stabilization 3  15 s
 Ball on the wall dribbling in 90

abduction and 90

ER 3e5  15 s
22 Pre-Competitive Active Rest
Micro-Cycles Week/session Pre-Competitive Macro II
23e25/1  Continue Interval Throwing program
 Schwinn
®
Airdyne
®
with UE and LE in target heart rate range  10 min
 Active warm-up
 ER flips in side lying 2  10
 Prone ball flip in T position 3  10
 Single arm 90/90 plyometric toss at rebounder 3  8
 Eccentric catching and deceleration from kneeing position 3  8
 Biofeedback elastic band throwing in tall kneel 3e5  10 reps
 Biofeedback hockey puck toss against wall or trampoline 3e5  10 reps
26 Pre-Competitive Active Rest
Sub-Phase 27 Competitive/Return to Sport
D.L. Hoover et al. / Physical Therapy in Sport xxx (2015) 1e20 17
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