Train and Sustain: A Combination of Plyometrics Individualized Sport-Specific Training and Appropriate Bracing Can Help Athletes Get Back in the Game
By Jim Lundy, MPT, CSCS, and Ron Higa, ATC

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How do I Apply Plyometrics?

To apply plyometrics, advise patients to simply start jumping in place with both feet.  This is great for knee strengthening as well as testing.  Have patients jump three to five jumps with 5 to 10 seconds between jumps.  Encourage fast, explosive leg motions.  The time in contact on the floor should be as short as possible.  More rest between jumps can encourage shorter contact time with the ground.  If contact time is too long, the kinetic energy is dissipated as heat – making the exercise ineffective.  Continue to increase sets or number of jumps in subsequent treatments, still avoiding exhaustion and maintaining proper knee alignment.  Always conclude plyometrics if either is noted. 

As the patient gets a better feel for the task, progress to a more challenging level.  After establishing that form and fatigue are under control, encourage patients to jump successively higher, over an object (a low step), over a longer distance, or onto or from a raised platform.  The most advanced plyometric drills are depth jumps in which the patient initiates the jump from a 12- to 36-inch box and subsequently attempts a maximal height jump after landing.  This progression is systematic yet flexible for individual patients and sports.  Additionally, single legs jumps can be implemented at any level in place of bilateral jumps – simply continue to insure that the patient has proper from and alignment between the involved and uninvolved side.

Remember, like medications, a little can go a long way.  It is easy to overdue the number of jumps and have muscular soreness the next day.  The maximum number of jumps should never exceed 80 explosive foot contacts (beginner level with no injuries).

Proprioception in Knee Rehabilitation

Maintaining and improving proprioception and neuromuscular control is an integral part of an athlete’s training program.  For example, dynamic knee joint stability coupling of these muscles prevents excessive joint motion.  If the knee joint is unexpectedly hyperextend, the mechanoreceptors in the ligaments sense this movement and trigger a chain of events to prevent excessive motion (by facilitating the hamstrings and inhibiting the quadriceps).  These dynamic stabilizers occur at all moveable joints.  After injury, it is important that these muscles are trained not only to regain strength, but also to reclaim their proprioceptive roles.

Patients most directly comprehend proprioceptive and neuromuscular training through balance drills.  Patients can start by standing on a single leg while catching a ball for time intervals or repetitions.  Progression can include weighted medicine balls, balance pads, and rocker boards.  Additionally, proprioceptive and neuromuscular training can also be integrated into strength training techniques.  A balance pad can be placed under the feet on a leg-press machine while performing the exercise.  Squats can be performed on a physio ball (properly securing the ball first).  A baseball player can balance on one foot on a balance disc while reaching for the ball.  The exercise database is never ending and keeping the SAID principle in mind will lead to a successful strength and proprioceptive training program.

What About Bracing?

By incorporating strength training and the SAID principle with agility, coordination, proprioceptive, and neuromuscular training, higher level patients will increase their strength and power.  But is it possible to incorporate additional knee-specific tools?  With the help of functional bracing, the answer is yes.

Bracing had traditionally been used to stabilize injured or ligament-deficient knees.  Braces range widely in type, size, level of restriction, and cost.  The main concept of any brace is to minimize femoral translation over a stable tibia.  However, the research on stability in anterior cruciate ligament (ACL) injured or deficient patients has not been encouraging.  Braces that have not consistently demonstrated joint stabilization have often affected performance negatively.  Further research regarding stability and performance is definitely needed.

On the other hand, the proprioceptive components of braces are well supported by research.  For the most part, bracing has been shown to improve proprioception in isokinetic testing, walking, downhill skiing, and balance activities.  The most convincing study incorporated a neoprene sleeve with ACL reconstructed patients.  The tasks included unilateral depth jumps from a 10-cm height followed by a one-legged balance test.  This is an advanced plyometric drill, with the added difficulty of a balance challenge.  With the brace, the subjects performed well with higher ground reaction forces.  The results again consistently supported better muscular control of the knee and improved balance with the brace.  Knee braces enhanced proprioception and also provided psychological support in the unstable lower extremity.

We feel it is best to treat advanced patients with and without the brace.  The prorpioceptive feedback a brace provides is invaluable and difficult to create with tactile cues alone. Additionally, the psychological support it provides can often go further than your verbal encouragement. 

Practice several jumping situations with the brace, and several jumps without.  Continue to progress the patient with intermittent brace application while maintaining adequate and appropriate muscular knee stability.  Never compromise knee stability and alignment for muscular firing.  Use a knee brace as you would any therapy tool.  Just think if it as an extension of your hands.

Jim Lundy, MPT, CSCS, is the regional clinical manager and co-owner of Athletic Physical Therapy.  He practices in West Los Angeles, Calif, and specializes in sports injuries and spine disorders.  He can be reached via email: jim@athleticpt.com.

Ron Higa, ATC, works at Athletic Physical Therapy, a private practice in Westlake Village, Calif.  He trains athletes at high school, college, and professional levels.  He specializes in volleyball and soccer performance.  He can be reached via email:  ron@athleticpt.com.