Sports Medicine (2020) 50:239–252

https://doi.org/10.1007/s40279-019-01195-6

REVIEW ARTICLE

Strength and Power Training in Rehabilitation: Underpinning

Principles and Practical Strategies to Return Athletes to High
Performance
Luca Maestroni1,2 · Paul Read3 · Chris Bishop4 · Anthony Turner4

Published online: 26 September 2019

© Springer Nature Switzerland AG 2019

Abstract
Injuries have a detrimental impact on team and individual athletic performance. Deficits in maximal strength, rate of force
development (RFD), and reactive strength are commonly reported following several musculoskeletal injuries. This article first
examines the available literature to identify common deficits in fundamental physical qualities following injury, specifically
strength, rate of force development and reactive strength. Secondly, evidence-based strategies to target a resolution of these
residual deficits will be discussed to reduce the risk of future injury. Examples to enhance practical application and training
programmes have also been provided to show how these can be addressed.

suggest an interaction between injury, performance, physi-

Key Points cal outputs, and success at both team and individual levels
[2–4]. It seems logical that all staff involved should strive
Residual deficits in maximal strength, rate of force devel- to work together in an interdisciplinary fashion to prevent
opment and reactive strength are documented following injuries and to improve performance. Furthermore, several
musculoskeletal injury. studies have reported that a previous injury may increase the
Targeting these residual deficits following injury can risk for subsequent injuries [5–10]. This raises the question
reduce the risk of future injury as a means of tertiary of whether persistent deficits have been fully assessed and
prevention. targeted before athletes return to play (RTP), and if a greater
emphasis should be placed on a return to performance strat-
Rehabilitation should prepare athletic populations to egy as a means of tertiary prevention [11].
tolerate loads and velocities across the full spectrum of Following the occurrence of injury or pain onset, defi-
the force–velocity curve and this is essential for return- cits in strength [12–16], strength ratios [17], rate of force
ing injured athletes to high performance levels. development [18–23], reactive strength [24–26], leg stiff-
ness [27–31], and peak power [32–34], have all been shown
in athletic populations. Equally, these same attributes are
1 Introduction widely considered important physical performance deter-
minants in high-performance sport [35, 36]. In spite of this,
Injuries have a detrimental impact on team and individual rehabilitation programmes often adopted in research and
athletic performance, with increased player availability clinical practice are mainly focused on restoring strength
improving the chances of success [1]. The available data [37–40], which by definition, consists of high forces at low

1
* Luca Maestroni Smuoviti, Viale Giulio Cesare, 29, 24121 Bergamo, BG,
[email protected] Italy
2
Paul Read StudioErre, Via della Badia, 18, 25127 Brescia, BS, Italy
[email protected] 3
Athlete Health and Performance Research Center, Aspetar
Chris Bishop Orthopaedic and Sports Medicine Hospital, Doha, Qatar
[email protected] 4
London Sport Institute, School of Science and Technology,
Anthony Turner Middlesex University, Greenlands Lane, London, UK
[email protected]

Vol.:(0123456789)
240 L. Maestroni et al.

velocities. However, this alone may not fully prepare the II fibres (IIa/IIx) have a greater capacity to generate power
musculoskeletal system to accept and produce moderate to per unit CSA, than the relatively smaller type I fibres. Archi-
high loads at rapid velocities, which underpin most sport- tectural features such as longer fascicle length allow more
ing actions. Furthermore, maximal strength and ballistic force production through an optimal length–tension relation-
power training (which is typically advocated for the latter) ship [46]. The number of sarcomeres in series influences a
induce different physiological adaptations. There is, how- muscle’s contractility and the rate at which it can shorten.
ever, a strong interplay and overlap in both performance In regards to neural factors, the size principle dictates that
and physiological determinants between maximal strength motor unit (MU) recruitment is related to motor unit type
development and ballistic power training. Maximal strength and that MUs are recruited in a sequenced manner based on
serves as the foundation for the expression of high power their size (smallest to largest) [51]. Thus, the availability of
outputs, making the adoption of training with heavy loads high-threshold MUs and/or lower threshold of MU recruit-
advantageous, not only for relatively weaker athletes, but ment is advantageous for higher force production. Further-
also for improving physiological features necessary for more, a higher rate of neural impulses (firing frequency) and
high-velocity actions [41, 42]. Strength training with heavy the concurrent activation of multiple motor units (motor unit
loads (i.e. ≥ 80% one repetition maximum (1RM)) increases synchronisation) enhance the magnitude of force generated
neural drive, intermuscular coordination, myofibrillar cross- during a contraction. These, together with an effective inter-
sectional area (CSA) of Type II fibres, lean muscle mass, muscular coordination (i.e. appropriate magnitude and tim-
and pennation angle [43, 44]. Ballistic power training is ing of activation of agonist, synergist and antagonist mus-
more specific in increasing maximal power output, rate of cles) permit maximal force production [44, 46, 49, 50, 52].
force development (RFD), movement velocity, jump height
and sprint performance via lowered motor unit recruitment 2.1 The Importance of Maximal Strength
thresholds, improved motor unit firing frequency, and syn-
chronisation, as well as enhanced intermuscular coordina- In sport, the ability to generate maximal force is limited
tion [43, 45]. These positive physiological and performance by the time constraints of specific tasks; thus, rate of force
changes are relevant from both a rehabilitative as well as development (RFD) and power are a critical part of optimis-
performance perspective and should lead towards a uni- ing physical performance. Maximal strength can be defined
fied vision that encompasses robustness and resilience for as the upper limit of the neuromuscular system to produce
enhanced performance and reduced risk of re-/subsequent force [53], with increases in this capacity correlated with
injury. RFD and power [45, 54–56]. Current literature suggests that
This article will examine the available literature pertain- athletes who can back squat 2 × body mass are able to best
ing to strength and power development to provide a theoreti- capitalise on these associations [55], as well as changes in
cal framework, from which, clear strategies are developed endocrine concentrations (namely testosterone) in response
to indicate how these principles and training modes can be to training [57]. Furthermore, current evidence suggests that
incorporated into rehabilitation, optimising the return to play until athletes can squat at least 1.6 × body mass, maximal
and return to performance process. The aim of this article is strength training should be the dominant training modality
to give clinicians guidance with clear practical applications [43]. Specifically, Cormie et al. [43] examined the effect of
to assist with resolving persistent deficits that may be present a 10-week (3/week) training intervention of either strength
in athletic populations following injury. This information is training or ballistic-power training on jumping and sprinting
important as it will enhance sports performance and reduce performances, force–velocity profile, muscle architecture,
the risk of recurrence and subsequent injury. and neural drive in a cohort of 24 male subjects who were
proficient in the back squat. They found that despite both
groups displaying similar improvements in performance,
2 Maximal Strength relatively weak men (back squat < 1.6 × BM) benefited
more from strength training due to its potential long-term
The development of muscular strength can be broadly improvement. This occurred as a result of increased neu-
divided into morphological and neural factors [46]. The ral activation and muscle thickness, which are adaptations
maximal force generated by a single muscle fibre is directly specific to this type of training stimulus. This is in line with
proportional to its cross-sectional area (CSA) [47, 48] which the recent research performed by Comfort et al. [58] who
is determined by the number of sarcomeres in parallel, an showed that prior identification of athletic physical char-
important parameter of its force generating capacity. Greater acteristics (here using the dynamic strength index calcula-
pennation angles are more common in hypertrophied than tion) may improve the prediction of significant changes in
in normal muscles. Maximal force is also influenced by the response to a specific type of training. In particular, they
muscle fibres composition [44, 46, 49, 50]. Specifically, type emphasised the importance of increasing force production
Strength and Power Training in Rehabilitation 241

via strength training in weaker athletes. This is reinforced prescription is fundamental to define the physical as well as
by James et al. [59], who revealed that the magnitude of athletic adaptations targeted.
improvement in peak velocity in response to ballistic train-
ing was significantly influenced by baseline strength levels 2.2 Strength Deficits Following Injury
in the first 5 weeks of training. Overall, the available evi-
dence suggests that achieving and maintaining a high level Increased inhibitory inputs may reduce the extent to which
of strength is of utmost importance in the athletic population muscles are voluntarily activated [84]. It is widely acknowl-
for positive adaptations. edged that in the acute phase after an injury, local phe-
Indeed, developing maximal strength has been shown nomena occurring in peripheral tissues such as swelling,
to have significant benefits on musculotendinous stiffness inflammation and joint laxity, may change the discharge
[60], neuromuscular inhibition [44, 61], and connective of sensory receptors, which causes neuromuscular inhibi-
tissue strength [62–65], culminating in decreases in the tion. This is often referred to as arthrogenic muscle inhibi-
relative force (% of maximum) applied during the loading tion after distension or damage to structures of a joint [85].
phase of running at ground contact [66–68]. Collectively, Neuromuscular inhibition can persist even in the absence of
this reduces metabolic demand for the same force output, effusion or pain [86], leading to persistent strength deficits
creating a motor unit reserve available for additional work that impair normal physical function, return to full perfor-
[67]. Normative data to ensure when a patient or an athlete is mance, and increase the risk of re-injury and subsequent
“strong enough” are available for isometric bilateral adduc- injury [87]. Mechanisms for this inhibition include complex
tor strength tests [5, 13], although strength ratios between neural adaptations from spinal reflex (affecting the group
muscle groups of the same limb [17, 69] or threshold for I non-reciprocal (Ib) inhibitory pathway, the flexion reflex
inter-limb asymmetries are more commonly reported [12, and the gamma loop) and corticomotor excitability path-
70–75]. These values may be used to examine single joint ways [86, 88–90]. Neuromuscular inhibition would, there-
strength and guide training programmes, and to determine fore, explain persistent neuromuscular alterations (e.g. shift
readiness to return to play following injuries; however, in joint torque–angle relationship, atrophy, reduction in in-
global measures of maximal strength are also warranted series sarcomeres) and limit positive muscle adaptations to
which display heightened transfer to athletic performance. training despite the return to play [91–94].
In addition to the physiological and performance advan- Knee extensor and flexor strength is significantly reduced
tages of developing maximal strength, it is not surprising after anterior cruciate ligament reconstruction (ACLR) [16],
that injury risk may be reduced by the adoption of this train- even up to 10 years post-surgery [95]. These measures have
ing modality. Lauersen et al. [76] indicated that a variety been used to guide rehabilitation status [32] and reported as
of strength training modalities can reduce sports injuries a significant predictor of re-injury [70]. Similarly, several
by one third, and overuse injuries by almost half. Further- studies have indicated that lower levels of eccentric knee
more, strength training programmes appears superior to flexor strength increased the risk of hamstrings re-injury
neuromuscular training and multicomponent programmes [12]. This may be due to the directional specificity of the
in injury reduction [76]. More recently, Malone et al. [77] hamstring complex or this persistent maladaptive feature
have shown that over two consecutive seasons, athletes who not being completely resolved in previously injured players.
are stronger, faster, and have better repeated sprint abil- In fact, Brughelli et al. [96] showed that Australian Rules
ity (RSA) times have a lower injury risk than their weaker Football players with previous hamstring injuries had sig-
counterparts. Thus, increasing strength is a key component nificant deficits in horizontal but not vertical force during
of any tertiary prevention approach and should be targeted running at submaximal velocities. Similarly, Lord et al. [97]
within injury rehabilitation to reduce the risk of re-injury demonstrated that horizontal force production decreases at a
[11]. However, while research and clinical practice promote greater rate in previously injured than uninjured hamstrings
increases in strength, this has been largely investigated in during an RSA test in football players. Charlton et al. [98]
several injury types in isolation, often with much lighter found isometric knee flexion strength deficits in semi-profes-
loads and subsequently higher repetition ranges. For exam- sional Australian Rules Football players with a past history
ple, loading schemes of < 80% 1RM are often reported in of hamstring injury for up to three seasons following injury.
research articles with a rep-set configuration of “15 × 3” Other studies investigating common lower limb injuries
or “10 × 3” without a clear indication of the load employed revealed discrepancies in the association between strength
[78, 79], or using relatively low loads, thus not targeting values and risk of injury [32, 99] as well as inconsistent pat-
higher threshold motor units to maximise strength adap- terns of strength and performance change in symptomatic
tations [80–83]. Instead, the clarity in details of exercise and asymptomatic subjects [100]. In addition, research has
242 L. Maestroni et al.

shown that muscle strength is impaired bilaterally and below option to reduce corticospinal inhibition [110], to increase
normative data in runners with Achilles tendinopathy [101]. contralateral limb strength [111] and to induce hypoalgesia
[112]. A potential progression based on the rehabilitation
2.3 Using Maximal Strength Training to Target phase and the patient’s irritability post-ACLR might be: (1)
Deficits bodyweight single leg squat performed at high volume sets
focusing on technique mastery and cross-education (2) sin-
The available data suggest that higher strength levels help gle leg squat with light load and high volume sets until fail-
to reduce the risk of sports injuries [12, 76, 102]. From a ure (with/without blood flow restriction) (3) split squat with
rehabilitation perspective, patients should be gradually progressive loading in a traditional periodization scheme
progressed to heavier loads in a periodized manner, with until reaching the recommended prescription for maximal
high-intensity resistance training being a valid and effective strength and (4) split squat performed accordingly with max-
therapeutic tool across age and gender in the treatment of the imal strength recommendations, with potential adaptations
most common musculoskeletal injuries [103, 104]. From a highlighted in Table 1.
neurobiological perspective, it may also reverse alterations
in intra-cortical inhibitory networks in individuals with per- 2.4 Using Isometric Strength Training to Target
sistent musculoskeletal pain [88, 89, 100]. Deficits
Current evidence indicates that prescription of maxi-
mal strength training should involve a load (or intensity) From a rehabilitation perspective, isometric contractions
of 80–100% of the participant’s one-repetition maximum may be employed during specific phases where dynamic
(1-RM), utilising approximately 1–6 repetitions, across 3–5 contractions may be contraindicated. Although dependent
sets, with rest periods of 3–5 min and a frequency of 2–3 on the persistent musculoskeletal condition analysed, iso-
times per week [105]. Hence, for clinicians whose specific metric contractions are capable of inducing hypoalgesia for
aim at a particular phase is to improve maximal force, they chronic hand, knee, and shoulder injuries [113], also during
should be progressively working toward this volume load in-season [114, 115]. The hypoalgesic effect is, however,
prescription. Evidence-based recommendations for an effec- variable and not always consistent [116, 117]. This may
tive stimulus for tendon adaptation suggest high intensity depend on the population analysed, the tissues properties,
loading (85–90% iMVC) applied in five sets of four repeti- the physical activity level, and the pain modulation profile
tions with a contraction and relaxation duration of 3 s each of the subjects assessed [118–122].
and an inter-set rest of 2 min [106]. However, in the initial During isometric contractions, the muscle-tendon unit
stages when they are unable to tolerate heavy loads, lower remains at a constant length. Isometric muscle actions have
intensities may be employed in multiple high volume sets been widely used due to their tightly controlled applica-
until momentary failure, to recruit the highest threshold tion of force at specific joint angles, their ability to develop
motor units and to increase CSA [107, 108]. Alternatively, greater force than concentric contractions, and their high
blood flow restriction training can be used to provide an reliability in assessing and tracking force production [123].
effective stimulus during rehabilitation for patients who are Isometric training at long muscle lengths and at high vol-
load compromised [109]. Cross-education (i.e. heavy resist- umes is more effective for inducing muscle hypertrophy
ance training of the unaffected limb) can be also a viable than at short muscle lengths [124–126], potentially due to

Table 1  Examples of different resistance training prescriptions to enhance strength

Example of targeted Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
muscle group

Quadriceps Isometric leg exten- Isotonic leg extension Split squat Eccentric single leg Contrast approach -
sion 45” × 5 reps 5 sets × until failure 3–6 reps × 2–6 sets box squat Trap bar deadlift 4RM
@60° knee flexion @85–93%1RM 3–6 reps × 2–6 sets paired with triple
and @ > 80% 1RM @110–120% 1RM hop × 4 sets
Possible performance ↑ Peak Power
gains ↑ Strength
↑ RFD
↓ Inter-limb asymmetries
↑ Horizontal force production
↑ Vertical force production

The assigned exercises are ordered from the lowest to the highest intensity. Potential performance adaptations are also listed
RM repetition maximum, ↑ increased, ↓ decreased, → unchanged
Strength and Power Training in Rehabilitation 243

greater blood flow occlusion, rates of oxygen consumption, typical standardised rehabilitation programme and achieved
and metabolite build-up [127]. Although it may not be an nearly full recovery in the International Knee Documenta-
effective strategy for directly improving sports performance, tion Committee (IKDC), Tegner activity scale, KT1000
isometric training shows the largest improvements at the and MVIC, which are objective measures commonly used
trained angles [123]. This has connotations for athletes who to guide return to sports decision-making. Similarly, Kline
are rehabilitating following injury. For example, in subjects et al. [22] demonstrated reduced quadriceps RFD in subjects
who had previously sustained an ACL rupture, between- at 6 months post-ACLR with patellar tendon autograft.
limbs deficits in quadriceps torque were evident at angles Deficits in RFD have also been shown in other common
of less than 40 degrees knee flexion, as opposed to peak pathologies. For example, Nunes et al. [18] found reduced
torque (which does not consider the angle at which the peak RFD in hip abduction and extension in a cohort of physi-
value occurs) [128, 129]. This may reveal the potential util- cally active females with patellofemoral pain. In addition,
ity of implementing positional isometrics in a rehabilitation Wang et al. [20] demonstrated lower values in early RFD
programme for ACL-deficient patients. Similarly, isometric in the triceps surae muscle in elite athletes with unilateral
quadriceps muscle actions, using the leg extension machine chronic Achilles tendinopathy, while Opar et al. [23] showed
at 80% of the MVIC, and holding for 45 s for 5 sets, with lower rate of torque development in previously injured ham-
1 min between sets, may be employed for subjects with strings. Cumulatively, the available evidence indicates that
patellar tendinopathy when isotonic contractions are not restoration of the ability to apply high forces in short time
tolerated or during in-season [114, 115, 130]. frames is crucial from both a rehabilitative and performance
perspective.

3.3 Using Training to Target RFD Deficits

3 Rate of Force and Torque Development
The available evidence indicates that training at high velocities
3.1 The Importance of Rate of Force Development or with the intention to move loads quickly is highly effective
in eliciting marked gains in rapid force production capacity
Rate of Force Development (RFD) is defined as the ability [131, 133–135]. This includes medicine ball throws, plyomet-
of the neuromuscular system to produce a high rate of rise in rics [136], Olympic weightlifting and their derivatives [55,
muscle force per unit of time during the initial phase follow- 137] (see Table 2 for further examples). The prescription
ing contraction onset [45]; torque refers to a force that causes of these can be best appreciated by defining the mechanical
rotation. Contractile RFD is a parameter used for measur- parameters that underpin power. Mechanically, power is the
ing “explosive” strength capabilities. It is determined from work performed per unit of time, or force multiplied by veloc-
the slope of the force time curve (generally between 0 and ity. The inverse relationship between force and velocity can
250 ms), and calculated as ∆Force/∆Time. Several factors be illustrated by the force–velocity (FV) curve (Fig. 1), which
can impact RFD, particularly the early phase (< 100 ms rela- identifies that maximum strength is exerted under high loads,
tive to contraction onset), which is more influenced by intrin- and maximum speed is produced under low loads [56]. Sub-
sic muscle properties and neural drive; while the late phase sequently, the goal of strength and conditioning programming
(> 100 ms relative to contraction onset) is more respondent is to improve force capability under the full spectrum of loads
to maximal muscle strength [45, 131]. Considering that force and thus velocities. For example, emerging evidence shows
application during skills such as sprinting, jumping, throw- how different force–velocity profiles exist within individu-
ing, and kicking lasts approximately 30–200 ms [56], RFD als, thus suggesting that improving maximal strength may be
is a critical performance characteristic central to success in most beneficial for some athletes, while others may benefit
most power-based sporting events, as well as endurance run- most from improving force at high velocity [137, 138]. This
ning performance [132]. has been shown recently by Jimenez-Reyes et al. [138] who
tailored the training programme based on the Force–Velocity
3.2 RFD Deficits Following Injury profile during jumping. An individualised training programme
specifically based on the difference between the actual and
In addition to the short time frames available to execute optimal Force–Velocity profiles of each individual (F–V imbal-
sporting tasks, it has been demonstrated that non-contact ance) was more effective in improving jumping performance
ACL tears occur in a timeframe of less than 50 ms; while than traditional resistance training common to all subjects
the quadriceps, for example, requires more than 300 ms to (velocity-deficit, force-deficit, and well-balanced increased
reach peak torque during isometric testing [22]. Angelozzi by 12.7 ± 5.7% ES = 0.93 ± 0.09, 14.2 ± 7.3% ES = 1.00 ± 0.17,
et al. [19] found significant deficits in RFD at 6 months post- and 7.2 ± 4.5% ES = 0.70 ± 0.36, respectively). Furthermore,
ACLR in professional soccer players who had completed a despite being just a case report, Mendiguchia et al. found
244 L. Maestroni et al.

that the capability to produce horizontal force at low speed

contractions “as fast and hard as pos-

(FH0) was altered both before and after return to sport from a

Explosive contractions (10 isometric

hamstring injury in two professional athletes; thus, changing
the slope of the F–V relationship [139]. The data collectively
show that athletes need a well-rounded approach that prepares
them to tolerate high and low loads as well as high and low
velocities, not only from a performance perspective, but also
sible” × 4 sets) to empower resilience to different stress stimuli and to increase
musculoskeletal robustness.
Example 4

4 Reactive Strength

4.1 The importance of Reactive Strength

Single leg countermovement jump
4 × 4 sets (w/variable loads)

Eccentric actions are those in which the musculotendinous

unit actively lengthens throughout the muscle action. Eccen-
tric training has received considerable attention due to its
potentially more favourable adaptations compared to con-
centric, isometric, and traditional isotonic (eccentric/concen-
Example 3

tric) training [140, 141]. These include superior benefits for

isometric and concentric strength, preferential recruitment
of type II muscle fibres, power, RFD and stiffness, mus-
cle architecture, and increased muscle activation, as well as
Jump shrug 3 × 4 sets (30–45% 1RM

improved performance in sporting actions [44, 142, 143].

Forceful eccentric contractions may have a superior impact
in reducing intra-cortical inhibition and in increasing intra-
cortical facilitation [110, 144]. These improvements can
occur where there are high eccentric stretch loads, such as
of the Hang Clean)

landing and change of direction mechanics, and fast stretch-

shortening cycle (SSC) demands, because an athlete’s reac-
Example 2

tive strength ability is underpinned by relative maximal

eccentric strength [145]; this again reinforces the need of
Table 2  Examples of exercises aiming to enhance RFD via ballistic/power

substantial high levels of strength values before developing

SSC capabilities [59]. The reactive strength index (RSI) has
Squat jumps (start position from static

been widely employed to quantify plyometric or SSC perfor-

mance, that is the ability to change quickly from an eccentric
to concentric muscle action [146]. The factors that underpin
an efficient SSC are related to the storage and the reutiliza-
↓ Inter-limb asymmetries

tion of elastic energy. These are the result of a number of

RM repetition maximum, ↑ increased, ↓ decreased
↑ Jump Performance

↑ Running Economy
↑ CoD performance

Potential performance adaptations are also listed

pause) 3 × 5 sets

mechanisms including utilisation of intrinsic muscle-tendon

↑ Early/Late RFD

stiffness, involuntary reflex muscle activity, antagonistic

Possible performance gains ↑ Peak Power

co-contraction, and the SSC pre-stretch [147]. The latter,

Example 1

↑ Speed

referred also as pre-activation during the eccentric phase,

may allow for a greater number of motor units to be recruited
during the concentric contraction through neural potentia-
tion, thus indicating the important role of eccentric force
Example of prescriptions

production in SSC capabilities [146, 148].

The RSI can be used to assess leg stiffness. This can be
described as the resistance to the deformation of the lower
limb in response to an applied force. Therefore, a certain
amount of lower extremity stiffness is required for effective
storage and re-utilisation of elastic energy in SSC activities
Strength and Power Training in Rehabilitation 245

Fig. 1  Concentric portion of the

force–velocity curve

[132]. Lower extremity stiffness is considered to be a key 4.3 Using Training to Target Reactive Strength
attribute in the enhancement of running, jumping and hop- Deficits
ping activities [149, 150]. Indeed, numerous studies reported
that lower extremity stiffness increases with running veloc- Attainment of an adequate strength level is fundamental to
ity and this is concomitant with increased vertical ground the development of reactive strength as discussed previously.
reaction forces (GRFs), increased ground contact frequency, In addition, plyometric training can enhance early and late
and shorter ground contact times [148, 151]. SSC activities RFD as well as optimising leg stiffness and the modula-
have been divided into fast SSC (< 250 ms) and slow SSC tion of the SSC [55, 155]. Plyometric training exploits the
(> 250 ms) accordingly with the ground contact time. rapid cyclical muscle action of the SSC whereby the mus-
cle undergoes a lengthening movement (“eccentric mus-
4.2 Reactive Strength Deficits Following Injury cle action”), followed by a transitional period prior to the
shortening movement (“concentric contraction”) and can be
Emerging evidence shows the importance of incorporating used to improve eccentric force generation capacity. Fla-
drop jumps in the evaluation of RSI as criteria for return to nagan et al. [146] suggested a 4-step progression focusing
play. King et al. [26] revealed that the single leg drop jump on the eccentric jumping action while landing (phase 1);
identified greater performance deficits between the ACL rebound spring-like actions with short ground contact times
reconstructed limb and the non-operated limb compared (phase 2); hurdle jumps with an emphasis on short ground
to the single leg hop for distance, suggesting insufficient contact while increasing intensity of the eccentric stimulus
rehabilitation status at 9 months post-surgery. Incomplete (phase 3); and finally depth jumps to maximise jump height
restoration of reactive strength and stiffness capabilities may while maintaining minimal ground contact times (phase
also be present in the periods following a range of other 4) (Table 3). Furthermore, progressive training intensities
injuries. Gore et al. [27] found that hip abductor stiffness might be an effective prescription to achieve improvements
was impaired in a cohort of subjects with athletic groin pain in change of direction ability [149, 156].
compared to controls and that this difference was no longer Alternative strategies for athletes who have attained the
significant after the rehabilitation period. In the presence of requisite level of strength include accentuated eccentric load-
Achilles Tendinopathy, several studies have shown that the ing (AEL) to increase eccentric strength via supra-maximal
tendon mechanical properties [152, 153], modulations of the loading [140, 145]. Examples include adopting weight releas-
SSC, leg stiffness, and RFD are altered [20, 28, 29]. This is ers or dumbbells dropped in the bottom position to overload
in contrast with the normal function of the tendon complex, the eccentric portion of the movement, enhancing the sub-
whose key role is to store, recoil and release energy while sequent concentric action. Following ACLR, patients who
maintaining optimal efficiency in power production [154]. have undergone a suitable period of rehabilitation and reached
246 L. Maestroni et al.

normative strength values across different ranges of motion the reconstructed knee; the latter tended to be deemed
and velocities, may benefit from AEL to further increase optimal when both Limb Symmetry Index and hop tests
quadriceps eccentric strength [157], together with progressive reach at least 90% of the contralateral limb [16]. How-
intensities of plyometric training. However, AEL by defini- ever, Ardern et al. [164] found that, despite obtaining
tion is not commonly employed in rehabilitation strategies, what was considered normal strength values, the rate of
although sports medicine professionals are now widely apply- return to sport was low. This suggests that evaluating
ing eccentric loads for the prevention and rehabilitation of maximal strength at low velocities only, as per current
hamstring injuries. The Nordic hamstring exercise has been most common criteria to return athletes to unrestricted
shown to significantly reduce the risk of hamstring injuries sports activities, is not sufficient. Indeed, a recent review
[158–160]. Furthermore, even a low training volume can [165] analysed the discharge criteria for RTS following
stimulate increases in fascicle length and improvements in primary ACLR in studies published from 2001 to 2011,
eccentric knee flexor strength [40]. Similarly, the Copenhagen revealing that 85% of studies used time based measures
adduction exercise is commonly prescribed due to its superior as RTS criterion. Strength criteria were reported in 41%
ability to increase eccentric hip adduction strength [82] and of studies, whereas physical performance-based criteria
the eccentric triceps surae exercise has been shown to increase in only 20% of studies. This may indicate a potential gap
not only maximal strength, tendon stiffness, Young’s modulus in the implementation of performance strategies and tests
and tendon CSA [60, 106, 161], but also ankle dorsiflexion in rehabilitation settings. Return to play criteria should,
[162] and the SSC behaviour. therefore, also consider multiple physical capacities and
Practically, AEL can be applied by completing the concen- assessments of maximal strength, reactive strength, RFD
tric portion of the movement with both limbs at high loading and power capabilities along the whole F–V curve and in
schemes and using only the involved limb for the eccentric por- multiple planes, in addition to vertical jumps, change of
tion, thus resulting in load above 100% of 1RM. Similarly, the directions, acceleration, deceleration and speed actions as
athlete may also be assisted during the concentric portion of the dictated by each individual’s sports demands through the
exercise while the eccentric portion is completed independently. completion of a comprehensive needs analysis.
Alternatively, the use of heavy chains allows increases of load
during both the early concentric phase of the lift as well as early
eccentric phase of the descent, due to the favourable muscle 4.5 Programme Design
leverage and the additional chain links [163].
When attempting to maximise power output, provided
4.4 Return to Play Tests and the Need to Test that a high overall level of strength has been reached, a
Multiple Physical Capacities periodized mixed methods approach, in which a variety
of loads and exercise types are used is suggested. This is
A recent review on the topic of ACL rehabilitation because it allows a more complete development of the
summarised that there is a high rate of return to sport force–velocity relationship (Fig. 1). The use of low-load,
overall (81–82%) but a lower rate for competitive high-velocity movements (such as unloaded jump squats)
sports (44–55%). These data appear to be dictated by may have a greater influence on the high-velocity area of
fear of re-injury as well as functional capabilities of the force–velocity curve; while heavier loads (e.g. used in

Table 3  Example of plyometric exercises to improve SSC capabilities

Example of prescriptions Phase 1 Phase 2 Phase 3 Phase 4

Drop lands 6 reps × 8 sets Pogo jumps 8 contacts × 8 Skipping rope 15 con- Drop vertical jumps 5 × 3
sets tacts × 5 sets sets (from a 30 cm box)
Possible performance gains ↑ Eccentric strength
↑ Peak Power
↑ CoD performance
↑ Early RFD
↑ RSI
↑ Jump Performance
↓ Inter-limb asymmetries
↑ Running Economy
↓ Ground Contact Time

The assigned exercises are ordered from the lowest to the highest intensity. Potential performance adaptations are also listed
↑ increased, ↓ decreased
Strength and Power Training in Rehabilitation 247

Table 4  Example of exercises for Football player (midfielder) with persistent Achilles tendinopathy presenting with maladaptive reduced triceps
surae capacities aiming to full rehabilitation and enhanced performance over a 12-week period
Rehabilitation phase Training aim Exercise prescription

Phase 1—Work capacity/pain reduction To increase strength endurance and reduce Unilateral seated calf raises (3 sets with man-
emphasis pain ageable load until failure)
Isometric calf raises on smith machine
(3 × 45 s)
RFESS (3 × 8RM each leg)
Phase 2—Strength emphasis To increase muscle strength and musculotendi- Eccentric heel drops (4 × 10)
nous stiffness Unilateral standing calf raises
(4 × 6–8RM)
RFESS (4 × 6RM)
Drop lands (4 × 4)
Phase 3—Power and RFD emphasis To increase power output and RFD Split squat (3 × 3RM each leg)
Pogos (3 × 15–20 foot contacts)
Drop jumps (4 × 4 from 20 cm)
Phase 4—Peak power and RFD emphasis To increase peak power, RFD and enhanced Front squat (3 × 2RM)
stiffness Drop jumps (5 × 3 from 40 cm)
Unilateral drop jumps (3 × 3 from 20 cm each
leg)

RM repetition maximum, RFD rate of force development, RFESS rear foot elevated split squat

Table 5  Example of exercises for a soccer player (midfielder) at 6 months post-ACLR presenting with maladaptive reduced quadriceps capaci-
ties

Rehabilitation phase Training aim Exercise prescription

Phase 1—Work capacity emphasis To increase strength endurance of the quadriceps Unilateral leg extension (3 sets
with manageable load until
failure)
Single leg squat (3 sets until
failure)
Phase 2—Strength emphasis To increase quadriceps muscle strength Front squat (4 × 6RM)
Split squat (4 × 6RM)
Romanian deadlift (4 × 6RM)
Phase 3—Power and RFD emphasis To increase power output and RFD Split squat (3 × 3RM each leg)
Squat jumps (3 × 4)
CMJ (3 × 4)
SL hop (3 × 4 each leg)
Phase 4—Peak power and RFD emphasis To increase peak power, RFD and enhanced stiffness Front squat (3 × 2RM)
Drop jumps (5 × 3)
Repeated hurdle jumps (5 × 5)
SLCMJ (5 × 3 each leg)

The aim is to complete rehabilitation fully and to enhance performance over a 12–16 weeks period
RM repetition maximum, RFD rate of force development

the back squat) improve to a greater degree the high-force rehabilitation as dictated by their ability to load safely in
portion [50]. Training modalities may, therefore, include the context of their injury and also as the athlete transi-
weightlifting exercises and/or derivatives, unilateral and/ tions towards a return to sports performance [167, 168].
or bilateral training with a range of loads, and plyometric Examples of potential rehabilitation programmes are out-
or ballistic exercises in an appropriately periodized man- lined in Tables 4 and 5.
ner [55, 131, 166]. Optimal levels of maximal strength
are the foundation for the development of efficient SSC 4.6 Conclusion
properties, as well as for ballistic sport-specific move-
ments. Furthermore, volume and intensity will be manip- This article has examined persistent deficits in fundamental
ulated to maximise physical capabilities throughout their physical qualities, such as strength, rate of force development
248 L. Maestroni et al.

and reactive strength following injury. Training strategies to predict groin injury in Gaelic football players. Phys Ther Sport.
target these deficits have also been discussed to increase an 2017;23:1–6.
14. O’Neill S, Watson PJ, Barry S. A Delphi study of risk factors
athlete’s readiness to return to sport. The concepts expressed for Achilles tendinopathy-opinions of world tendon experts. Int
in this article may help clinicians to reduce the gap between J Sports Phys Ther. 2016;11(5):684–97.
rehabilitation and sports performance, while providing a 15. Neal BS, Lack SD. Risk factors for patellofemoral pain: a system-
means of tertiary prevention following injury. Rehabilitation atic review and meta-analysis. Br J Sports Med. 2019;53:270–81.
16. Anderson MJ, et al. A systematic summary of systematic
should aim to optimise physical performance, not only return reviews on the topic of the anterior cruciate ligament. Orthop
athletes to participation. To achieve this, a strong coopera- J Sports Med. 2016;4(3):2325967116634074.
tion among health professionals, coaches and strength and 17. Thorborg K, et al. Eccentric and isometric hip adduction
conditioning specialists is essential. Furthermore, imple- strength in male soccer players with and without adductor-
related groin pain: an assessor-blinded comparison. Orthop J
mentation of the best available evidence of strength and con- Sports Med. 2014;2(2):2325967114521778.
ditioning and exercise physiology is required to maximise 18. Nunes GS, Barton CJ, Serrao FV. Hip rate of force develop-
training adaptation. ment and strength are impaired in females with patellofemo-
ral pain without signs of altered gluteus medius and maximus
morphology. J Sci Med Sport. 2017.
Compliance with Ethical Standards 19. Angelozzi M, et al. Rate of force development as an adjunctive
outcome measure for return-to-sport decisions after anterior
Conflict of interest Luca Maestroni, Paul Read, Chris Bishop and An- cruciate ligament reconstruction. J Orthop Sports Phys Ther.
thony Turner declare that they have no conflict of interest. 2012;42(9):772–80.
20. Wang HK, et al. Evoked spinal reflexes and force development
Funding No financial support was received for the preparation of this in elite athletes with middle-portion Achilles tendinopathy. J
manuscript Orthop Sports Phys Ther. 2011;41(10):785–94.
21. Cobian DG, et al. Knee extensor rate of torque development
before and after arthroscopic partial meniscectomy, with analy-
sis of neuromuscular mechanisms. J Orthop Sports Phys Ther.
References 2017;47(12):945–56.
22. Kline PW, et al. Impaired quadriceps rate of torque devel-
opment and knee mechanics after anterior cruciate ligament
1. Drew MK, Raysmith BP, Charlton PC. Injuries impair the chance
reconstruction with patellar tendon autograft. Am J Sports
of successful performance by sportspeople: a systematic review.
Med. 2015;43(10):2553–8.
Br J Sports Med. 2017;51(16):1209–14.
23. Opar DA, et al. Rate of torque and electromyographic
2. Hagglund M, et al. Injuries affect team performance negatively in
development during anticipated eccentric contraction is
professional football: an 11-year follow-up of the UEFA Champi-
lower in previously strained hamstrings. Am J Sports Med.
ons League injury study. Br J Sports Med. 2013;47(12):738–42.
2013;41(1):116–25.
3. Williams S, et al. Time loss injuries compromise team success in
24. Doherty C, et al. Coordination and symmetry patterns during
Elite Rugby Union: a 7-year prospective study. Br J Sports Med.
the drop vertical jump, 6-months after first-time lateral ankle
2016;50(11):651.
sprain. J Orthop Res. 2015;33(10):1537–44.
4. Windt J, et al. Does player unavailability affect football teams’
25. Doherty C, et al. Recovery from a first-time lateral ankle sprain
match physical outputs? A two-season study of the UEFA cham-
and the predictors of chronic ankle instability: a prospective
pions league. J Sci Med Sport. 2018;21(5):525–32.
cohort analysis. Am J Sports Med. 2016;44(4):995–1003.
5. Esteve E, et al. Preseason adductor squeeze strength in 303
26. King E. et al. Whole-body biomechanical differences between
Spanish Male Soccer Athletes: a cross-sectional study. Orthop J
limbs exist 9 months after ACL reconstruction across jump/
Sports Med. 2018;6(1):2325967117747275.
landing tasks. Scand J Med Sci Sports. 2018.
6. Hägglund M, Waldén M, Ekstrand J. Risk factors for lower
27. Gore SJ, Franklyn-Miller A. Is stiffness related to athletic groin
extremity muscle injury in professional soccer: the UEFA injury
pain? Scand J Med Sci Sports. 2018;28(6):1681–90.
study. Am J Sports Med. 2012;41(2):327–35.
28. Debenham JR, et al. Achilles tendinopathy alters stretch shorten-
7. Arnason A, et al. Risk factors for injuries in football. Am J Sports
ing cycle behaviour during a sub-maximal hopping task. J Sci
Med. 2004;32(1 Suppl):5s–16s.
Med Sport. 2016;19(1):69–73.
8. Hagglund M, Walden M, Ekstrand J. Previous injury as a risk
29. Maquirriain J. Leg stiffness changes in athletes with Achilles
factor for injury in elite football: a prospective study over two
tendinopathy. Int J Sports Med. 2012;33(7):567–71.
consecutive seasons. Br J Sports Med. 2006;40(9):767–72.
30. Pruyn EC, et al. Relationship between leg stiffness and lower
9. Fulton J, et al. Injury risk is altered by previous injury: a system-
body injuries in professional Australian football. J Sports Sci.
atic review of the literature and presentation of causative neuro-
2012;30(1):71–8.
muscular factors. Int J Sports Phys Ther. 2014;9(5):583–95.
31. Lorimer AV, Hume PA. Stiffness as a risk factor for
10. Toohey LA, et al. Is subsequent lower limb injury associated
achilles tendon injury in running athletes. Sports Med.
with previous injury? A systematic review and meta-analysis.
2016;46(12):1921–38.
Br J Sports Med. 2017;51(23):1670–8.
32. O’Malley E, et al. Countermovement jump and isokinetic
11. Jacobsson J, Timpka T. Classification of prevention in sports
dynamometry as measures of rehabilitation status after
medicine and epidemiology. Sports Med. 2015;45(11):1483–7.
anterior cruciate ligament reconstruction. J Athletes Train.
12. Bourne MN, et al. An evidence-based framework for strengthen-
2018;53(7):687–95.
ing exercises to prevent hamstring injury. Sports Med. 2017.
33. Pratt KA, Sigward SM. Detection of knee power deficits follow-
13. Delahunt E, Fitzpatrick H, Blake C. Pre-season adductor squeeze
ing ACL reconstruction using wearable sensors. J Orthop Sports
test and HAGOS function sport and recreation subscale scores
Phys Ther. 2018;48:1–24.
Strength and Power Training in Rehabilitation 249

34. Lee DW, et al. Single-leg vertical jump test as a functional 57. Crewther BT, et al. Baseline strength can influence the ability of
test after anterior cruciate ligament reconstruction. Knee. salivary free testosterone to predict squat and sprinting perfor-
2018;25(6):1016–26. mance. J Strength Cond Res. 2012;26(1):261–8.
35. Morin JB, Samozino P. Interpreting power-force-velocity pro- 58. Comfort P, Thomas C. Changes in dynamic strength index in
files for individualized and specific training. Int J Sports Physiol response to strength training. Sports. 2018;6:176.
Perform. 2016;11(2):267–72. 59. James LP, et al. The impact of strength level on adaptations to
36. Lorenz DS, Reiman MP. Performance enhancement in the termi- combined weightlifting, plyometric, and ballistic training. Scand
nal phases of rehabilitation. Sports Health. 2011;3(5):470–80. J Med Sci Sports. 2018;28(5):1494–505.
37. Macdonald B et al. The single-leg Roman chair hold is more 60. Bohm S, Mersmann F, Arampatzis A. Human tendon adaptation
effective than the Nordic hamstring curl in improving hamstring in response to mechanical loading: a systematic review and meta-
strength-endurance in Gaelic footballers with previous hamstring analysis of exercise intervention studies on healthy adults. Sports
injury. J Strength Cond Res. 2018. Med Open. 2015;1(1):7.
38. Beyer R, et al. Heavy slow resistance versus eccentric training 61. Kidgell DJ, et al. Corticospinal responses following strength
as treatment for achilles tendinopathy: a randomized controlled training: a systematic review and meta-analysis. Eur J Neurosci.
trial. Am J Sports Med. 2015;43(7):1704–11. 2017;46(11):2648–61.
39. Lack S, et al. Proximal muscle rehabilitation is effective for 62. Watson SL, et al. High-intensity resistance and impact train-
patellofemoral pain: a systematic review with meta-analysis. Br ing improves bone mineral density and physical function in
J Sports Med. 2015;49(21):1365–76. postmenopausal women with osteopenia and osteoporosis: the
40. Presland JD, et al. The effect of Nordic hamstring exercise train- LIFTMOR randomized controlled trial. J Bone Miner Res.
ing volume on biceps femoris long head architectural adaptation. 2018;33(2):211–20.
Scand J Med Sci Sports. 2018;28(7):1775–83. 63. Magnusson SP, Kjaer M. The impact of loading, unload-
41. Newton RU, Kraemer WJ. Developing explosive muscular power: ing, ageing and injury on the human tendon. J Physiol.
implications for a mixed methods training strategy. Strength 2019;597(5):1283–98.
Cond J. 1994;16(5):20–31. 64. Goodman CA, Hornberger TA, Robling AG. Bone and skeletal
42. Kawamori N, Haff GG. The optimal training load for the muscle: key players in mechanotransduction and potential over-
development of muscular power. J Strength Cond Res. lapping mechanisms. Bone. 2015;80:24–36.
2004;18(3):675–84. 65. Grzelak P, et al. Hypertrophied cruciate ligament in high perfor-
43. Cormie P, McGuigan MR, Newton RU. Adaptations in athletic mance weightlifters observed in magnetic resonance imaging.
performance after ballistic power versus strength training. Med Int Orthop. 2012;36(8):1715–9.
Sci Sports Exerc. 2010;42(8):1582–98. 66. Ploutz L, et al. Effect of resistance training on muscle use during
44. Suchomel TJ, et al. The importance of muscular strength: training exercise. J Appl Physiol. 1994;76:1675–81.
considerations. Sports Med. 2018;48:765. 67. Stone M, Stone M, Sands W. Principles and practice or resistance
45. Rodríguez-Rosell D, et al. Physiological and methodological training. New York: Human Kinetics; 2007.
aspects of rate of force development assessment in human skel- 68. Ploutz LL, et al. Effect of resistance training on muscle use dur-
etal muscle. Clin Physiol Funct Imaging. 2018;38(5):743–62. ing exercise. J Appl Physiol (1985). 1994;76(4):1675–81.
46. Cormie P, McGuigan MR, Newton RU. Developing maximal 69. Baroni BM et al. Hamstring-to-quadriceps torque ratios of pro-
neuromuscular power: part 1—biological basis of maximal fessional male soccer players: a systematic review. J Strength
power production. Sports Med. 2011;41(1):17–38. Cond Res. 2018.
47. Hornsby WG, et al. What is the impact of muscle hypertro- 70. Grindem H, et al. Simple decision rules can reduce reinjury
phy on strength and sport performance? Strength Cond J. risk by 84% after ACL reconstruction: the Delaware–Oslo ACL
2018;40(6):99–111. cohort study. Br J Sports Med. 2016;50(13):804–8.
48. Taber CB, et al. Exercise-induced myofibrillar hypertrophy is 71. Bourne MN, et al. Eccentric knee flexor strength and risk of
a contributory cause of gains in muscle strength. Sports Med. hamstring injuries in Rugby Union: a prospective study. Am J
2019;49(7):993–7. Sports Med. 2015;43(11):2663–70.
49. Hughes DC, Ellefsen S, Baar K. Adaptations to endurance and 72. Kyritsis P, et al. Likelihood of ACL graft rupture: not meeting
strength training. Cold Spring Harb Perspect Med. 2017;8(6). six clinical discharge criteria before return to sport is associ-
50. Haff GG, Stone MH. Methods of developing power with ated with a four times greater risk of rupture. Br J Sports Med.
special reference to football players. Strength Cond J. 2016;50(15):946–51.
2015;37(6):2–16. 73. Adams D, et al. Current concepts for anterior cruciate ligament
51. Henneman E, Somjen G, Carpenter DO. Excitability and reconstruction: a criterion-based rehabilitation progression. J
inhibitability of motoneurons of different sizes. J Neurophysiol. Orthop Sports Phys Ther. 2012;42(7):601–14.
1965;28(3):599–620. 74. Ardern CL, et al. 2016 Consensus statement on return to sport
52. Clark BC, et al. The power of the mind: the cortex as a criti- from the First World Congress in Sports Physical Therapy,
cal determinant of muscle strength/weakness. J Neurophysiol. Bern. Br J Sports Med. 2016;50(14):853.
2014;112(12):3219–26. 75. Grindem H, et al. How does a combined preoperative and
53. Stone MH, et al. The importance of isometric maximum strength postoperative rehabilitation programme influence the outcome
and peak rate-of-force development in sprint cycling. J Strength of ACL reconstruction 2 years after surgery? A comparison
Cond Res. 2004;18(4):878–84. between patients in the Delaware–Oslo ACL Cohort and the
54. Aagaard P, et al. Increased rate of force development and neural Norwegian National Knee Ligament Registry. Br J Sports Med.
drive of human skeletal muscle following resistance training. J 2015;49(6):385–9.
Appl Physiol (1985). 2002;93(4):1318–26. 76. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of
55. Haff GG, Nimphius S. Training principles for power. Strength exercise interventions to prevent sports injuries: a systematic
Cond Res. 2012;34(6):2–12. review and meta-analysis of randomised controlled trials. Br J
56. Taber C, et al. Roles of maximal strength and rate of force devel- Sports Med. 2014;48(11):871.
opment in maximizing muscular power. Strength Cond Res.
2016;38(1):71–8.
250 L. Maestroni et al.

77. Malone S, et al. Can the workload-injury relationship be mod- 97. Lord C, et al. Greater loss of horizontal force after a repeated-
erated by improved strength, speed and repeated-sprint quali- sprint test in footballers with a previous hamstring injury. J Sci
ties? J Sci Med Sport. 2019;22(1):29–34. Med Sport. 2019;22(1):16–21.
78. Holden S, Barton CJ. ‘What should I prescribe?’: time to 98. Charlton PC, et al. Knee flexion not hip extension strength is per-
improve reporting of resistance training programmes to ensure sistently reduced following hamstring strain injury in Australian
accurate translation and implementation. Br J Sports Med. Football athletes: implications for Periodic Health Examinations.
2018;53:264–5. J Sci Med Sport. 2018;21(10):999–1003.
79. Holden S, et al. How can we implement exercise therapy for 99. Rathleff MS, et al. Is hip strength a risk factor for patellofemoral
patellofemoral pain if we don’t know what was prescribed? A pain? A systematic review and meta-analysis. Br J Sports Med.
systematic review. Br J Sports Med. 2018;52(6):385. 2014;48(14):1088.
80. Murphy M, et al. Rate of improvement of pain and function 100. Rio E, et al. Tendon neuroplastic training: changing the way we
in mid-portion achilles tendinopathy with loading protocols: a think about tendon rehabilitation: a narrative review. Br J Sports
systematic review and longitudinal meta-analysis. Sports Med. Med. 2016;50(4):209–15.
2018;48(8):1875–91. 101. O’Neill S, Barry S, Watson P. Plantarflexor strength and endur-
81. Malliaras P, et al. Achilles and patellar tendinopathy loading ance deficits associated with mid-portion Achilles tendinopathy:
programmes: a systematic review comparing clinical outcomes the role of soleus. Phys Ther Sport. 2019;37:69–76.
and identifying potential mechanisms for effectiveness. Sports 102. Thorborg K. Why hamstring eccentrics are hamstring essentials.
Med. 2013;43(4):267–86. Br J Sports Med. 2012;46(7):463–5.
82. Ishoi L, et al. Large eccentric strength increase using the 103. Kristensen J, Franklyn-Miller A. Resistance training in muscu-
Copenhagen Adduction exercise in football: a randomized con- loskeletal rehabilitation: a systematic review. Br J Sports Med.
trolled trial. Scand J Med Sci Sports. 2016;26(11):1334–42. 2012;46(10):719.
83. Yousefzadeh A, et al. The effect of therapeutic exercise on 104. Booth J, et al. Exercise for chronic musculoskeletal
long-standing adductor-related groin pain in athletes: modified pain: a biopsychosocial approach. Musculoskelet Care.
Holmich protocol. Rehabil Res Pract. 2018;2018:10. 2017;15(4):413–21.
84. Sonnery-Cottet B, Saithna A. Arthrogenic muscle inhibition 105. American College of Sports Medicine position stand. Progression
after ACL reconstruction: a scoping review of the efficacy of models in resistance training for healthy adults. Med Sci Sports
interventions. Br J Sports Med. 2019;53(5):289–98. Exerc. 2009;41(3):687–708.
85. Hopkins JT, Ingersoll CD. Arthrogenic muscle inhibition: 106. Mersmann F, Bohm S, Arampatzis A. Imbalances in the devel-
a limiting factor in joint rehabilitation. J Sport Rehabil. opment of muscle and tendon as risk factor for tendinopathies
2000;9(2):135–59. in youth athletes: a review of current evidence and concepts of
86. Rice DA, McNair PJ. Quadriceps arthrogenic muscle inhibi- prevention. Front Physiol. 2017;8:987.
tion: neural mechanisms and treatment perspectives. Semin 107. Schoenfeld BJ, et al. Strength and hypertrophy adapta-
Arthritis Rheum. 2010;40(3):250–66. tions between low- vs high-load resistance training: a sys-
87. Pietrosimone BG, et al. Neural excitability alterations after tematic review and meta-analysis. J Strength Cond Res.
anterior cruciate ligament reconstruction. J Athl Train. 2017;31(12):3508–23.
2015;50(6):665–74. 108. Schoenfeld BJ, Grgic J, Krieger J. How many times per week
88. Roy JS, et al. Beyond the joint: the role of central nervous should a muscle be trained to maximize muscle hypertrophy?
system reorganizations in chronic musculoskeletal disorders. A systematic review and meta-analysis of studies examin-
J Orthop Sports Phys Ther. 2017;47(11):817–21. ing the effects of resistance training frequency. J Sports Sci.
89. Chang WJ, et al. Altered primary motor cortex structure, 2018;37:1–10.
organization, and function in chronic pain: a systematic review 109. Hughes L, et al. Blood flow restriction training in clinical muscu-
and meta-analysis. J Pain. 2018;19(4):341–59. loskeletal rehabilitation: a systematic review and meta-analysis.
90. Te M, et al. Primary motor cortex organization is altered in per- Br J Sports Med. 2017;51(13):1003.
sistent patellofemoral pain. Pain Med. 2017;18(11):2224–34. 110. Kidgell DJ, et al. Increased cross-education of muscle strength
91. Fyfe JJ, et al. The role of neuromuscular inhibition in ham- and reduced corticospinal inhibition following eccentric strength
string strain injury recurrence. J Electromyogr Kinesiol. training. Neuroscience. 2015;300:566–75.
2013;23(3):523–30. 111. Cirer-Sastre R, Beltrán-Garrido JV, Corbi F. Contralateral effects
92. Brockett CL, Morgan DL, Proske U. Predicting ham- after unilateral strength training: a meta-analysis comparing
string strain injury in elite athletes. Med Sci Sports Exerc. training loads. J Sports Sci Med. 2017;16(2):180–6.
2004;36(3):379–87. 112. Vaegter HB. Exercising non-painful muscles can induce
93. Roig M, et al. The effects of eccentric versus concentric resist- hypoalgesia in individuals with chronic pain. Scand J Pain.
ance training on muscle strength and mass in healthy adults: 2017;15:60–1.
a systematic review with meta-analysis. Br J Sports Med. 113. Naugle KM, Fillingim RB, Riley I. A meta-analytic review of the
2009;43(8):556–68. hypoalgesic effects of exercise. J Pain. 2012;13(12):1139–50.
94. Silder A, et al. MR observations of long-term musculotendon 114. Rio E, et al. Isometric contractions are more analgesic than iso-
remodeling following a hamstring strain injury. Skelet Radiol. tonic contractions for patellar tendon pain: an in-season rand-
2008;37(12):1101–9. omized clinical trial. Clin J Sport Med. 2017;27(3):253–9.
95. Bourne MN, et al. Eccentric knee flexor weakness in elite female 115. Rio E et al. isometric exercise to reduce pain in patellar tendi-
footballers 1–10 years following anterior cruciate ligament nopathy in-season; is it effective “on the road?”. Clin J Sport
reconstruction. Phys Ther Sport. 2019;37:144–9. Med. 2017.
96. Brughelli M, et al. Contralateral leg deficits in kinetic and kin- 116. O’Neill S, et al. Acute sensory and motor response to 45-s
ematic variables during running in Australian rules football heavy isometric holds for the plantar flexors in patients with
players with previous hamstring injuries. J Strength Cond Res. Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc.
2010;24(9):2539–44. 2018;27(9):2765–73.
Strength and Power Training in Rehabilitation 251

117. Riel H, Vicenzino B. The effect of isometric exercise on pain 138. Jiménez-Reyes P, et al. Effectiveness of an individualized training
in individuals with plantar fasciopathy: a randomized crossover based on force–velocity profiling during jumping. Front Physiol.
trial. Scand J Med Sci Sports. 2018;28(12):2643–50. 2016;7:677.
118. Lemley KJ, Hunter SK, Bement MK. Conditioned pain modula- 139. Mendiguchia J, et al. Field monitoring of sprinting power-force-
tion predicts exercise-induced hypoalgesia in healthy adults. Med velocity profile before, during and after hamstring injury: two
Sci Sports Exerc. 2015;47(1):176–84. case reports. J Sports Sci. 2016;34(6):535–41.
119. Naugle KM, et al. Physical activity behavior predicts endogenous 140. Aagaard P. Spinal and supraspinal control of motor function dur-
pain modulation in older adults. Pain. 2017;158(3):383–90. ing maximal eccentric muscle contraction: Effects of resistance
120. Naugle KM, et al. Isometric exercise as a test of pain modulation: training. J Sport Health Sci. 2018;7(3):282–93.
effects of experimental pain test, psychological variables, and 141. Nishikawa K. Eccentric contraction: unraveling mechanisms
sex. Pain Med. 2014;15(4):692–701. of force enhancement and energy conservation. J Exp Biol.
121. Sluka KA, Frey-Law L, Hoeger Bement M. Exercise-induced 2016;219(2):189.
pain and analgesia? Underlying mechanisms and clinical transla- 142. Wagle JP, et al. Accentuated eccentric loading for training and
tion. Pain. 2018;159(Suppl 1):S91–7. performance: a review. Sports Med. 2017;47(12):2473–95.
122. Coombes BK, Tucker K. Achilles and patellar tendinopathy dis- 143. Harden M, et al. An evaluation of supramaximally
play opposite changes in elastic properties: a shear wave elastog- loaded eccentric leg press exercise. J Strength Cond Res.
raphy study. Scand J Med Sci Sports. 2018;28(3):1201–8. 2018;32(10):2708–14.
123. Oranchuk DJ, et al. Isometric training and long-term adaptations; 144. Tallent J, et al. Enhanced corticospinal excitability and volitional
effects of muscle length, intensity and intent: a systematic review. drive in response to shortening and lengthening strength training
Scand J Med Sci Sports. 2019;29(4):484–503. and changes following detraining. Front Physiol. 2017;8:57.
124. Alegre LM, et al. Effects of isometric training on the knee exten- 145. Beattie K, et al. The relationship between maximal strength
sor moment-angle relationship and vastus lateralis muscle archi- and reactive strength. Int J Sports Physiol Perform.
tecture. Eur J Appl Physiol. 2014;114(11):2437–46. 2017;12(4):548–53.
125. Kubo K, et al. Effects of isometric training at different knee 146. Flanagan EP, Comyns TM. The use of contact time and the reac-
angles on the muscle-tendon complex in vivo. Scand J Med Sci tive strength index to optimize fast stretch-shortening cycle train-
Sports. 2006;16(3):159–67. ing. Strength Cond J. 2008;30(5):32–8.
126. Noorkoiv M, Nosaka K, Blazevich AJ. Neuromuscular adapta- 147. Pedley JS, et al. Drop jump: a technical model for scientific appli-
tions associated with knee joint angle-specific force change. Med cation. Strength Cond J. 2017;39(5):36–44.
Sci Sports Exerc. 2014;46(8):1525–37. 148. McBride JM, McCaulley GO, Cormie P. Influence of preactivity
127. de Ruiter CJ, et al. Knee angle-dependent oxygen consump- and eccentric muscle activity on concentric performance during
tion during isometric contractions of the knee extensors deter- vertical jumping. J Strength Cond Res. 2008;22(3):750–7.
mined with near-infrared spectroscopy. J Appl Physiol (1985). 149. Asadi A, et al. The effects of plyometric training on change-of-
2005;99(2):579–86. direction ability: a meta-analysis. Int J Sports Physiol Perform.
128. Huang H, et al. Isokinetic angle-specific moments and ratios 2016;11(5):563–73.
characterizing hamstring and quadriceps strength in anterior 150. Lum D, et al. Effects of intermittent sprint and plyometric train-
cruciate ligament deficient knees. Sci Rep. 2017;7(1):7269. ing on endurance running performance. J Sport Health Sci.
129. Eitzen I, et al. Anterior cruciate ligament-deficient potential 2019;8(5):471–7.
copers and noncopers reveal different isokinetic quadriceps 151. Butler RJ, Crowell I, Davis IM. Lower extremity stiffness:
strength profiles in the early stage after injury. Am J Sports Med. implications for performance and injury. Clin Biomech.
2010;38(3):586–93. 2003;18(6):511–7.
130. Rio E, et al. Isometric exercise induces analgesia and 152. Child S, et al. Mechanical properties of the achilles tendon
reduces inhibition in patellar tendinopathy. Br J Sports Med. aponeurosis are altered in athletes with achilles tendinopathy.
2015;49(19):1277–83. Am J Sports Med. 2010;38(9):1885–93.
131. Maffiuletti NA, et al. Rate of force development: physiologi- 153. Obst SJ, et al. Are the mechanical or material properties of the
cal and methodological considerations. Eur J Appl Physiol. achilles and patellar tendons altered in tendinopathy? A system-
2016;116(6):1091–116. atic review with meta-analysis. Sports Med. 2018;48(9):2179–98.
132. Brazier J, et al. Lower extremity stiffness: considerations for test- 154. Turner AN, Jeffreys I. The stretch-shortening cycle: proposed
ing, performance enhancement, and injury risk. J Strength Cond mechanisms and methods for enhancement. Strength Cond J.
Res. 2019;33(4):1156–66. 2010;32(4):87–99.
133. Andersen LL, et al. Early and late rate of force development: 155. Maloney SJ, et al. Unilateral stiffness interventions augment ver-
differential adaptive responses to resistance training? Scand J tical stiffness and change of direction speed. J Strength Cond Res.
Med Sci Sports. 2010;20(1):e162–9. 2019;33(2):372–9.
134. Tillin NA, Pain MT, Folland JP. Short-term training for explosive 156. Maloney SJ, et al. Do stiffness and asymmetries predict change
strength causes neural and mechanical adaptations. Exp Physiol. of direction performance? J Sports Sci. 2017;35(6):547–56.
2012;97(5):630–41. 157. Lepley LK, Palmieri-Smith R. Effect of eccentric strengthen-
135. Balshaw TG, et al. Training-specific functional, neural, and ing after anterior cruciate ligament reconstruction on quadriceps
hypertrophic adaptations to explosive- vs. sustained-contraction strength. J Sport Rehabil. 2013;22(2):150–6.
strength training. J Appl Physiol (1985). 2016;120(11):1364–73. 158. van der Horst N, et al. The preventive effect of the nordic
136. Butler RJ, Crowell HP 3rd, Davis IM. Lower extremity stiffness: hamstring exercise on hamstring injuries in amateur soc-
implications for performance and injury. Clin Biomech (Bristol, cer players: a randomized controlled trial. Am J Sports Med.
Avon). 2003;18(6):511–7. 2015;43(6):1316–23.
137. Suchomel TJ, Comfort P, Lake JP. Enhancing the force–velocity 159. Arnason A, et al. Prevention of hamstring strains in elite soccer:
profile of athletes using weightlifting derivatives. Strength Cond an intervention study. Scand J Med Sci Sports. 2008;18(1):40–8.
J. 2017;39(1):10–20.
252 L. Maestroni et al.

160. Petersen J, et al. Preventive effect of eccentric training on acute 164. Ardern CL, et al. Return to sport following anterior cruciate liga-
hamstring injuries in men’s soccer: a cluster-randomized con- ment reconstruction surgery: a systematic review and meta-anal-
trolled trial. Am J Sports Med. 2011;39(11):2296–303. ysis of the state of play. Br J Sports Med. 2011;45(7):596–606.
161. Geremia JM, et al. Effects of high loading by eccentric triceps 165. Burgi CR, et al. Which criteria are used to clear patients to return
surae training on Achilles tendon properties in humans. Eur J to sport after primary ACL reconstruction? A scoping review. Br
Appl Physiol. 2018;118(8):1725–36. J Sports Med. 2019;53(18):1154–61.
162. Aune AAG, et al. Acute and chronic effects of foam rolling vs 166. Comfort P, McMahon JJ, Suchomel TJ. Optimizing squat tech-
eccentric exercise on ROM and force output of the plantar flex- nique—revisited. Strength Cond J. 9000. (Publish Ahead of
ors. J Sports Sci. 2018;37:1–8. Print).
163. Ghigiarelli JJ, et al. The effects of a 7-week heavy elastic band 167. Kiely J. Periodization theory: confronting an inconvenient truth.
and weight chain program on upper-body strength and upper- Sports Med. 2018;48(4):753–64.
body power in a sample of division 1-AA football players. J 168. Cunanan AJ, et al. The general adaptation syndrome: a foundation
Strength Cond Res. 2009;23(3):756–64. for the concept of periodization. Sports Med. 2018;48(4):787–97.