RTP Steps, Briefly

For starters, I’m going to drop this graphic below to give you a visual on how I see the RTP process:

As you can see, there are 6 steps that athletes need to work through, which include:

1. Optimizing Internal Tissue Environment
2. Mobility & Movement Capacity
3. Local Tissue Hypertrophy, Strength and Stability
4. Global Motor Control and Force Production
5. Power, Stretch-Shortening Cycle and Impact Management
6. Sport-Specific Reconditioning

And then over the top of all that, we have Breathing, Position and COG Management.

Your goal if you’re an athlete – or taking an athlete through this process – is to “clear” each step, in order, because they each build off each other.

Let’s use the knee as an example:

If you have swelling and fluid in your knee (ie a suboptimal tissue environment), that’s going to decrease and limit your mobility (Step 2).

And if your knee is swollen and you don’t have full mobility, that’s going to limit your ability to recruit muscle (Step 3).

Each step builds off the previous one, so if you haven’t cleared the previous step(s), you’re not going to get the best possible outcome.

Now one more caveat: This doesn’t mean you can’t TRAIN qualities that are further down the line

For example, if you’re working on reducing swelling and improving mobility around the knee, you simultaneously want to be working on local strength.

However, the goal is to build that isolated strength without compromising your progress in the steps before it.

If every time you lift your knee swells up like a balloon, then what you’re doing is actually holding back the process versus moving it forward.

Another example could be conditioning: After all, you don’t want to wait until the end of your RTP process to get your conditioning back up to snuff!

Instead, you can be doing general conditioning virtually the way, and then once you’ve built the other qualities underneath it, then you can start making your conditioning sport-specific.

As you can see there’s a lot to unpack here, so let’s start with that overarching theme first.

Step 0

Breathing, Position and Center of Gravity (COG) Management

At IFAST, we used to get slammed online for being “breathing guys.”

If you listened to our haters talk, they’d tell you all we had our athletes do was lie around, breath, and foam roll for the entire session.

Ah the good ole days… 😉

But here’s the thing: If things like breathing, posture/alignment and center of gravity (COG) management weren’t important, I wouldn’t be doing it at all!

Instead, you need to think about breathing, position and COG management as rebuilding your foundation.

World-renowned physiotherapist Karl Lewit was known for the following saying:

Whenever I train an injured athlete, I ask myself two questions:

1. HOW do we rehab the injured area, and
2. WHY did this particular joint/muscle/tissue get injured in the first place?

Too often, I see an athlete go through a fantastic rehab process, only to reinjure the same area time and again – all because they didn’t look at the big picture and truly understand how they move!

Instead of looking at injuries as a “foot problem,” “knee problem,” or “back problem,” I think of them as a SYSTEM problem.

The body works as a system to create movement, and therefore you can’t just blame one area of the body – you have to address the entire system.

So whether that’s getting someone to breathe differently, better align their joints, or shift their center of gravity back, I always ask myself WHY this athlete got injured, and how we can prevent future injury FIRST.

Now that we’re looking at the big picture, let’s dive in and look at the step-by-step process I use to get athletes back to 100%.

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Step 1

Internal Tissue Environment

The first step in our process is optimizing internal environment.

We know that swelling and inflammation are known to reduce mobility and motor output, but this quote from Erik Meira on the Jacked Athlete Podcast really put it into perspective:

So the first goal in our process should be to reduce swelling and inflammation in that irritated joint.

That doesn’t mean we can’t work on mobility.

That doesn’t mean we can’t work on motor control and low-level strength around the joint.

But what it does mean is that UNTIL swelling and inflammation are cleared, you’re not going to optimize any of the steps that come after this.

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Step 2

Mobility and Movement Capacity

As you’re working to reduce swelling and inflammation, the next step is to unlock mobility.

Sticking with our knee joint example, you’ll obviously want to get flexion and extension back at the knee.

But this is where we need to broaden our perspective, and again, look at the body as a complete movement system.

In the case of the knee, it’s actually a pretty dumb joint.

No it’s not a true hinge joint like many would have you believe, but the amount of shift and rotation it has is pretty limited.

Instead, the hip and ankle play a HUGE role in the performance of the knee, so we really need to be looking at (the very least) three areas:

1. The target joint (ie the knee),
2. The joints immediately above (the hip/pelvis), and
3. The joints immediately below (the foot/ankle).

This is where our RTP process becomes much more global in nature.

Now we’re not just “fixing” the injured area, but improving how the entire system moves.

Step 3

Local Tissue Hypertrophy, Strength, and Stability

Okay now we’re starting to get to the fun stuff!

While there’s nothing sexy or exciting about decrease swelling and inflammation, or unlocking the mobility in the joint, most athletes are excited to start getting stronger and rebuilding the area.

And especially when you look at longer-term rehabs (ACL’s, Achilles tears, etc.) you are often left with a ton of atrophy around the joint.

After all, look at the quad of an athlete coming off an ACL, or the calves of an athlete coming off an Achilles tear, and you’ll realize quickly that there’s work to be done!

So this is where we can go back to our old-school bodybuilding roots and build some muscles.

Isolation and machine-based work has been vilified for years, but I think this is a great time to work it into a program.

After all, if you try and load a squat WITHOUT rebuilding the quad, the body will find a way to squat – it may just not be the way you’d like!

The athlete will shift to offload that weak quad or leg, and asymmetries between sides will often get magnified.

So let’s not confound any of this – the goal here is simple:

I want to recapture muscle size and strength first!

We know – all things being equal – a bigger muscle is a stronger muscle.

So we have to get muscle size back, and this can be done with standard bodybuilding-style protocols:

• Isolation and/or machine-based work
• More reps per set,
• Longer time under tension, and
• Incomplete rest/recovery.

A great adjunct here is blood-flow restriction (BFR) training. Without giving you a full dissertation on BFR, essentially you can “trick” the body into thinking the work is challenging using less mechanical loading.

As we start to rebuild and recapture muscle size, we can slowly shift to more strength-based protocols, with the ultimate goal of getting strength back to ~10% of the healthy side¹.

One of my favorite tools in this phase is what I call a “Reverse Workout.”

In a normal training session, you’d order your exercises from big to small. A simple example might look like this:

But in the case of a RTP athlete, I’ll flip that structure on its head:

In a reverse workout, we work on rebuilding the targeted muscle(s) first, and then re-integrate them into movement patterns as we go.

(MR Note: The above is a VERY general example, and I’d definitely choose different exercises in a true RTP scenario!)

Now one final thing I’m chasing in this training block is stability on the injured side.

Let’s say you’re rehabbing an ACL and muscle size is coming back great, and they’re killing the strength side of the program.

At the same time, I’d also be placing a HUGE emphasis on ground-based stability and control.

It’s great if that quad is coming back, but if you can’t stabilize and control your leg from the ground-up then you’re not tying all those pieces back together.

So get that muscle size and strength back, but don’t forget to rebuild the entire athletic chain while you’re doing it!

Step 4

Global Motor Control and Force Production

Now that we’ve rebuilt the individual pieces, it’s time to start putting the entire athlete back together.

This is where things get fun – and you really start to see the hard work come together!

The goal here is simple: We want to rebuild strength, but do so in an intelligent way.

I like to think of these programs as big-bang lifts, but with restrictor plates.

Sure we want to squat, deadlift, etc., but we need to be conscious of how those lifts are being performed.

For instance, when an athlete is coming back from injury, it’s not uncommon to see them shift away from the affected side to reduce load on the injured joint.

OR you could see a totally different movement strategy between sides based on the athlete’s strength and confidence!

Even if you’ve done everything right up to this point, this can still be an issue – so you need to have it on your radar.

Depending on your situation, you can use any number of strategies to evaluate movement technique:

• 1The coaching eye. Don’t make this harder than it needs to be - just load the athlete and see what happens. Are they balanced and symmetrical? Or are they shifting, twisting and rotating to complete the lift?
• 2Record and review. I’m a big believer in using video. Not only does this give the coach multiple opportunities to review the lift (both in and out of the session), but it can also show the athlete what you’re seeing as well.
• 3Biofeedback via force plates. I realize not every facility will have force plates, but I think this is a fantastic tool for helping athletes understand weight distribution between sides, and how to better load and control their body.

So yes, we want to get strong – but we want to do it the right way.

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Step 5

Power, Stretch-Shortening Cycle and Impact Management

Too often, strength is the only end-goal for a RTP process.

And while strength is an absolutely critical step, it’s definitely not the last step.

Think about it like this: The athletes that try to muscle everything are often slower than their more bouncy and elastic counterparts.

Let’s use a vertical jump as an example – if I make you squat down and hold for 5-10 seconds before jumping, it’s going to limit your performance.

But if I let you bend your legs and give you that little “dip” before you jump, jump height increases – all thanks to the stretch-shortening cycle (SSC).

Simply being strong isn’t enough – we need to rebuild that fast, SSC piece of the equation that makes athletes great.

Now HOW we do this is tricky – and again, probably goes beyond the scope of a single-article.

But here are some things I think about when I’m moving athletes into this phase of the program:

• What movement vectors does this athlete need access to: Horizontal? Lateral? Vertical?
• What are the momentum demands of their sport?
• What body shapes and positions do they need to acquire?
• Are they doing these movements on one-leg? Two-legs? Or both?

Again, lots to unpack here but hopefully it gives you some food for thought!

Now one thing that I’ve always tried to do is make the transitions from one-phase to the next as smooth as possible.

Let’s take something as simple as a vertical jump – if you’ve got a healthy athlete you may have them come in one day one and perform a box jump with no issues.

But what if that athlete is coming off a calf strain or Achilles tear?

Then we might want to really smooth out the steps before we get there.

To really tease it out, our progression might look more like this:

(Obviously your progression might be different, but I’m just trying to show you how many steps you CAN take if necessary.)

The goal here isn’t necessarily to take 55 steps to get someone back to an activity, but to make sure the athlete feels confident every step of the way.

This was highlighted years ago when Ed was coming off that Achilles tear.

We were working step-by-step through a progression like the above, and when he got back on the court, he said something like this:

This is the goal of RTP – to not only prepare them physically for the sport, to make sure that psychologically matches physiology every step of the way.

Step 6

Sport-Specific Reconditioning

Okay kiddos, here’s a little story to finish off this article…

…want to know the single WORST year I had in my high school basketball career?

Easy – my junior year.

And it’s strange because I’d worked so hard that off-season.

I’d dialed in so many elements of my game and been in the gym for hours every day.

I’d gotten into the weight room and built my body physically as well.

But that year, our coach stated that everyone who played basketball was going to run cross country to “get their legs in shape.”

And me being the stubborn competitor that I am decided I was going to be THE BEST cross-country runner that I could be!

I made some huge improvements in my cardio and 5k times over the course of that season, and really thought I was going to crush it when basketball started.

But I couldn’t have been more wrong!

Remember this: There’s a huge difference between “being in shape” from a cardio or running perspective, and being conditioned to go out and hoop at a high-level.

Distance running is all about economy and consistency in stride – and I won’t tell you you can’t get fit or build some-level of foundation on top of it.

But if you want to be in elite basketball shape, you need to train and condition like a hooper.

Basketball isn’t mindlessly running up and down the court. Instead, it’s:

• Sprinting down the court on the fast break.
• Jogging back.
• Playing lock down man-to-man defense for 10-15 seconds, all while holding a defensive stance.
• It’s jumping up to get a rebound, and then sprinting down the floor again.
• It’s being able to set-up a defender, then explode out to receive the ball and get downhill to the rim.

Obviously my explanation can’t do it justice, but if you’ve ever hooped before, you know exactly what I mean.

And this is why the final phase of your RTP process is so important – because it’s not jumping high or cutting explosively for a single-rep that matters.

It’s being able to do that for 20-, 30-, or 40-minutes repeatedly, at a high-level, that an athlete really needs to finish the process in peak condition.

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A Word on the Psychology of Injury

Like I said it up top, but there’s nothing worse than an athlete getting injured.

But after it happens, a big part of the rehab process is psychology.

How an athlete approaches rehab can be a huge differentiator between who comes back better than ever, and someone who decides it’s time to hang ‘em up.

So one thing I always try to help athletes understand is that sometimes injuries are actually opportunities.

Does this suck in the moment? Absolutely.

Do you wish it never happened? Of course.

But the fact of the matter is it DID happen, and now it’s time to use this as an opportunity to get your body right.

So don’t just think about fixing your ankle, your knee, or your hip.

Instead take this opportunity to rebuild your entire movement foundation to try and make sure nothing like this ever happens again.

It’s a key shift in mindset, and I find when athletes buy into this, it unlocks something in their psyche and helps them make the most out of a bad situation.

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Summary

Whew! A lot of ground to cover here, but I really hope it helps.

It doesn’t matter if you’re an athlete, parent or coach reading this – I hope you’ll take the framework I’ve provided here to better manage the return to play process.

It might not be smooth.

It definitely won’t be easy.

And just respect the fact that there WILL be some bad days along thew ay.

But having a real system to guide your decision-making can make all the difference in the world.

Now go out there, get healthy, and get ready to DOMINATE when you come back!