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26

Plyometric Training and Drills


Anthony Cuoco, DPT, MS, CSCS, and Timothy F. Tyler, PT, MS, ATC

ChaptEr ObjECtivEs

l Explain the fundamental basis of plyometric training, its l Describe and apply important fundamentals for the use
origins, and its applications. of plyometrics as a rehabilitation tool, including pretrain-
l Describe the mechanical and neuromuscular physiologic ing assessment, application of exercise prescription prin-
processes involved in the stretch-shortening cycle and ciples, and injury prevention.
how it applies to plyometrics. l Design a basic plyometric training program at low-,
l Describe the important clinical considerations surround- medium-, and high-intensity levels.
ing the appropriate use of plyometrics in the orthopedic l Use a variety of upper and lower extremity plyometric
and sports medicine rehabilitation setting. exercises as a part of the rehabilitation process.

Speed and strength are integral components of sports that are increase measurement.4 Many studies have shown effective,
found to varying degrees in virtually all athletic movements. measurable increases in power and jumping ability via plyo-
Simply stated, the combination of speed and strength is power. metric training programs.5 However, whether improvements in
For many years, coaches and athletes have sought to improve strength and power with plyometric training directly translate
power to enhance performance. Recently, rehabilitation special- into improvements in functional outcome measures in rehabili-
ists have implemented techniques to prevent injuries and improve tation may be questioned in some cases.6 Plyometric training
power to optimize postsurgical and postinjury outcomes. is often considered the missing link between weight training
Throughout the twentieth century and no doubt long before (strength) and athletic performance (power), with particular
that, jumping, bounding, and hopping exercises have been used emphasis on the speed of activity. Plyometric training was first
in various ways to enhance athletic performance. In recent years developed in the Soviet Union for its intense and very effective
this distinct method of training for power and explosiveness has athletic development program during the 1960s. It came to the
been termed plyometrics. Plyometrics is a form of strength train- attention of the West during the 1970s and, by about 1980, had
ing designed to develop explosive power in athletics.1 Plyometric become a valuable tool in major athletic programs. The term
exercises stress the rapid generation of (maximal) force, primar- was first applied in 1975 by American track and field coach
ily during the eccentric (lengthening) phase of muscle action, Fred Wilt to describe the training methods used by Eastern
and speeding the transition between the eccentric and concentric European athletes at the time, which supposedly was the rea-
(shortening) phases. This rapid deceleration-acceleration move- son for differences between the performance of Eastern and
ment produces an explosive reaction that increases both speed Western athletes. During the 1980s, Donald Chu published
and power.2 The ultimate aim is to increase muscle performance the first articles on plyometric training methods in this country,
to absorb and move an applied load throughout its functional and he has been a leader in this area ever since.4,7,8 In the early
range of motion and allow an athlete to translate strength into 1990s, George Davies and Kevin Wilk introduced plyometrics
power more efficiently. The concentric phase of muscle activity into rehabilitation programs.9,10
during plyometric training has been estimated to result in 18% In the early years of plyometric training, most drills focused
to 20% more force than a concentric contraction from a resting on developing jumping ability. More recently, some drills have
position.2,3 been designed to develop lateral movement qualities and others
Although the actual term plyometrics is relatively new, this to improve upper body power, but plyometrics seems to have
particular form of training has been in existence for quite some been focused traditionally on enhancing lower body power.
time. Translated from its Greek origins, it literally means to In the past 10 years, plyometrics has been used not only for the

571
572 Physical Rehabilitation of the Injured Athlete

lower extremity to increase strength and conditioning but also Of course, plyometric training is not appropriate for all
for the upper extremity as a rehabilitation tool and as part of patients. For instance, an injured gymnast who is trying to
injury prevention programs. develop the shoulder strength to maintain static, slow-moving
positions on the balance beam may not require any plyometric
drills. In contrast, one study showed that plyometric training sig-
General theory nificantly improved VJH in elite volleyball players.11 Plyometric
The premise behind plyometric training is that the maximum training is not generally a favored choice of exercise for increas-
force that a muscle can develop is attained during a rapid eccen- ing muscle mass or muscular endurance. Therefore, plyometric
tric contraction. However, it should be recognized that muscles training is probably not appropriate for muscles that are pre-
seldom perform one type of contraction in isolation during ath- dominately type I muscle fibers or that act as stabilizers. In fact,
letic movements. When a concentric contraction occurs (muscle unless the athlete participates in a sport that requires explosive
shortening) immediately after an eccentric contraction (muscle movements (e.g., volleyball, baseball pitching, sprinting, bas-
lengthening), the force generated can be dramatically increased. ketball, high jump), there is no compelling reason to introduce
If a muscle is stretched, much of the energy required to stretch plyometrics into the rehabilitation program.
it is lost as heat, but some of this energy can be stored by the
elastic components of the muscle. This stored energy is avail- Applied anatomy/physiology and
able to the muscle only during a subsequent contraction. It is
important to realize that this energy boost is lost if the eccentric the biomechanics of plyometrics
contraction is not followed immediately by a concentric effort. Similar to other modes of therapeutic exercise, safe and effec-
To express this greater force the muscle must contract within tive interventions using plyometrics require that clinicians be
the shortest time possible. This whole process is usually called familiar with applied neuromuscular physiologic principles.
the stretch-shortening cycle (SSC) and is the underlying mech- Theuse of plyometrics as a training method is primarily based
anism of plyometric training. Theoretically, the SSC increases on two fundamental dynamic qualities of muscle tissue: elastic-
power production based on two proposed models: (1) mechani- ity and contractility. The capacity of working muscles to gen-
cal and (2) neurophysiologic. The mechanical model describes erate greater (or maximal) force in a minimal amount of time
the series elastic component of the musculotendinous unit as depends on these tissue qualities, along with neuromuscular
the key element of plyometric exercise, whereas the neurophysi- control, strength, and flexibility. In fact, most of the early physi-
ologic model involves potentiation of concentric muscle action ologic research relevant to plyometrics was described as a muscle
by use of the stretch reflex. The reflex component of plyomet- action termed the stretch-shortening cycle.7 Currently, the SSC is
ric exercise is based on proprioception provided by the muscle the physiologic theory that forms the basis of plyometrics.
spindles during the stretching (eccentric) action.4 Even though
these two models can be viewed as separate descriptions of plyo-
metric theory, they are in fact tightly interwoven in explaining Stretch-Shortening Cycle
the mechanisms involved in plyometric training. The SSC can be defined as a phenomenon whereby the natu-
ral pattern of lengthening of active muscle produces energy that
is stored in the musculotendinous unit for later use in a sub-
Clinical relevancy sequent shortening, or concentric, contraction of the SSC. It is
Overall, the final phase of rehabilitating an injured athlete intro- this eccentric-concentric coupling that forms the basis of the
duces functional, sport-specific components of athletic per- SSC. In an often-referenced study, Cavagna12 established that
formance. Depending on the athlete, this will typically involve concentric muscle performance in an SSC is enhanced greater
increasing metabolic capacity, strength, power, speed, and agility. than that in a pure concentric-only action. In practical terms,
It is during this final phase that the use of plyometrics is most plyometrics involves high-velocity eccentric contraction or pre-
appropriate. In earlier phases of rehabilitation, the clinician has stretching of a muscle before an immediate reciprocal concentric
presumably addressed joint and soft tissue mobility, range of contraction of that same muscle (group). The eccentric contrac-
motion, flexibility, biomechanics, balance, proprioception/kin- tion stores energy that can be used to maximize the amount of
esthesia, endurance, and strength. The challenge of the final, power produced during concentric contraction of that muscle
sport-specific phase is designing rehabilitation progression or muscle group.13,14 This storage of elastic energy in musculo-
that maximizes neuromuscular and skeletal adaptations with- tendinous tissues contributes to the increased force produced in
out adversely affecting biologic healing. Sport-specific train- the subsequent concentric contraction phase and increased effi-
ing means that the movement that the patient performs should ciency of movement.15,16 Muscles and tendons have an intrinsic
match, as closely as possible, the movements encountered dur- stiffness that resists stretch and then reciprocates with a muscle
ing competition without jeopardizing the patient's health status. contraction stimulated by the stretch reflex loop.13,17 Though an
If the patient is a basketball player practicing for rebounding oversimplification, this phenomenon can be visualized as the
or a volleyball player interested in increasing vertical jump action of a spring. Biomechanically, one can relate the SSC to
height (VJH), drop jumping or box jumping may be the right the simple action of a person attempting to improve VJH by
exercise. If, however, the patient is a quarterback 6 months instinctively performing a partial squat before jumping in place.
after a Bankart repair who is trying to increase throwing veloc- The simple act of walking or running uses the SSC with each
ity, upper body plyometrics may be far more appropriate. In the stride, which begins with the loading response through an
volleyball and quarterback cases, though, the strength and eccentric contraction of the quadriceps, soleus, and gastrocne-
power generated from both the lower and upper extremities mius muscles, followed by a concentric push-off action. Hence,
might be considered. the SSC of plyometric exercise is a natural motion, given the
C H A P TE R 2 6 Pl y o m e t r i c Tr a i n i n g a n d D ri l l s 573

Box26-1 beyond the scope of this chapter, it is important for the clinician
Important Factors in Neuromuscular Anatomy
to be aware of the metabolic systems that contribute to optimal
andPhysiology performance of muscle tissues during plyometric exercise. Type
II fibers are classified further into at least two basic types: type
Serial elastic and histologic components of muscle and IIa and type IIb. Fast-twitch type IIb fibers are those that rely
tendons, i.e., myosin and actin sliding filaments/cross- primarily on the phosphate and glycolytic energy systems and are
bridge attachments, sarcomeres, fiber types, and metabolic termed fast glycolytic fibers. Type IIa fibers are more like a hybrid
properties between the slow oxidative type I fibers and the type IIb fibers
Proprioception mediated through muscle spindles and Golgi
and are termed fast glycolytic-oxidative fibers.21-23 Plyometric exer-
tendon organs and their contribution to stretch (or myotonic)
cise should focus on adaptation of these fibers to overload with
reflex loops
anaerobic training while still taking into consideration those type
IIa fibers that use both the oxidative and glycolytic energy sys-
Gross musculotendinous architecture, tendon stiffness, tems. Both the force generation and endurance qualities neces-
andelasticity sary in functional athletic activity require that the athlete develop
Absence or presence of pathology or degenerative changes
both classes of type II fibers. Practically, consider the metabolic
inbone, ligaments, and musculotendinous units
demands imposed on a basketball player jumping for consecutive
rebounds over a 5-second period, and then consider that same
task early and very late in the same game.

mechanical properties of the musculoskeletal system. The SSC


has been studied by many investigators, and it is generally agreed
Neuromuscular Physiology: Muscle
that several important factors of neuromuscular anatomy and Spindles and Golgi Tendon Organs
physiology should be considered: serial elastic components of Muscle spindles function primarily as stretch receptors, as
muscles and tendons, proprioception, and gross musculotendi- observed clinically in the performance of standard reflex testing
nous architecture. The eccentric-concentric coupling of the SSC (e.g., the knee jerk). When the patellar tendon is tapped with a
stimulates the proprioceptors of the muscle spindle, Golgi ten- reflex hammer, the muscle spindles are stimulated, which causes
don organs (GTOs), and ligament receptors to facilitate recruit- an immediate concentric contraction of the quadriceps muscle
ment of the motor units required to maximize the concentric group. This minimal latency time between the quick stretch
power generated during plyometric activity (Box26-1).16,18,19 and subsequent contraction is mediated at the level of the spi-
nal cord as a monosynaptic reflex. Muscle spindles are sensi-
Histologic Considerations in Skeletal tive to changes in velocity and are innervated by type 1a nerve
fibers. These afferent nerve fibers conduct the impulse directly
Muscle to the spinal cord, where they are immediately conducted via
Histologically, the level of the fascicles is a fundamental compo- interneurons to alpha motor neurons, which stimulate muscle
nent of the serial elasticity of muscle. Although much research contraction. The brain is not involved in this spinal reflex loop,
has been conducted on the dynamics of the SSC at the histo- contributing to the speed at which the stretch-contraction cycle
logic level, the behavior of human skeletal muscle during SSC occurs.24
exercises has not been directly investigated invivo. It has been Muscle spindles are located within extrafusal (skeletal) mus-
well documented in the literature that activated muscle stretched cle fibers and consist of connective tissue surrounding intrafusal
before shortening performs more forcefully.12 However, the exact fibers in a capsular structure. Muscle spindles are innervated by
mechanisms that mediate the stretch-enhanced performance myelinated afferent nerve fibers, which enter the capsule of and
have been a source of controversy. Kubo etal examined changes spiral around the intrafusal fibers. Based on the architecture of
in fascicle length and tendon structure in humans during SSC the muscle spindle, stretching of the skeletal (extrafusal) fibers
exercises involving the gastrocnemius muscle at both fast and also stretches the intrafusal fibers. This stretch increases the fir-
slow speeds with real-time ultrasonography. They found that ing rate of the afferent fibers innervating the intrafusal fibers,
both fascicle and tendon structures are lengthened at the dor- thus "loading" the muscle spindle. When the stretch is released
siflexion phase and shortened at the plantar flexion phase.20 or lessened, the firing rate diminishes. Both primary and sec-
The stretching ability depends on many factors, but the rate ondary afferent fibers are present, and these fibers contribute to
andmagnitude of the stretch applied contribute to how much the ability of the spindle to detect small changes in length. Thus,
force a muscle can generate. the muscle spindle is sensitive to changes in muscle length, as
Though perhaps not as critical in terms of stretching dynam- well as to the speed and magnitude of the stretch.25
ics, the fiber types used for plyometrics are worth reviewing. It is Although the muscle spindle reacts to stretch, it does not
well documented that type II, or fast-twitch, fibers are capable of simply "turn off " when the muscle is no longer stretched; the
generating more force than type I, or slow-twitch, fibers can. This fibers continue to send messages when the muscle has begun
is primarily a function of the increased cross-sectional area, larger to concentrically contract and shorten. The central nervous sys-
motor units, and high glycolytic capacity associated with type II tem (CNS) regulates the loading through alpha motor neurons,
fibers.21-23 The amount of force necessary during the eccentric and which modulate spindle activity and thereby make the transi-
subsequent explosive concentric phases of SSC exercise necessi- tion from stretch to contraction smoother.25 This modulation
tates the recruitment of type II fibers. It should also be noted contributes to muscle tone and thus to the intrinsic stiffness of
that type II fibers are also readily fatigable. Although a detailed the muscle. Therefore, the muscle tends to act as a spring that
discussion of the metabolic properties of muscle fiber types is enables the SSC to produce force with precision.
574 Physical Rehabilitation of the Injured Athlete

Although the muscle spindle is sensitive to stretch, the GTOs increased musculotendinous stiffness may be more important
provide complementary information to the CNS about muscle than the ability to store more elastic energy in terms of enhanc-
activity. Specifically, length and the degree of tension are moni- ing SSC performance in activities such as sprinting.26 Given
tored by GTOs. GTOs are encapsulated collagen structures these equivocal results, the principle of specificity in terms of
typically located at the musculotendinous junction. Each GTO exercise mode and the muscles involved may be an important
is innervated by nerve fibers that wrap around the collagen distinction in determining optimal musculotendinous stiffness.
bundles. As the collagen bundles are stretched, they straighten To this point, one can see that the histologic structure of
and the nerve fibers fire more rapidly. GTOs are sensitive to muscle and tendons can both enhance and hinder movement
small changes in muscle tension. Because GTOs surround col- and force-generating capacity. Although the inherent elastic
lagen and not extrafusal muscle fibers, they are not as sensitive components of the musculotendinous unit can store energy for
to stretch since collagen has a stiffer molecular structure than use in generating force and powerful movement, gross structural
muscle fiber does. Thus, most of the stretch is absorbed by the aspects may be present that limit the ability of a muscle to maxi-
muscle fibers and the muscle spindles. This makes GTOs more mize the SSC. Neural factors and recruitment of fibers, as well
sensitive to active muscle contraction that stresses the musculo- as the metabolic capacities of muscle and the appropriate exer-
tendinous junction to a greater degree.25 cise conditioning, all have an impact on performance.
Finally, Brownstein and Bronner18 formulated a classifica-
tion system based on three types of musculotendinous units
Gross Musculotendinous Structure (Table26-1). Their theory centers around gross muscle struc-
On a gross anatomic and clinical level, muscles and tendons ture (i.e., length of the muscles and tendons).
resist stretch as force increases. Muscle stiffness can be defined
as change in force over change in muscle length. This inherent
stiffness is the resistance to stretch by the fibers of the active Fundamentals of Plyometrics
muscle and tendons before the changes in activation modulated Plyometrics is defined by the SSC and is an inherent part of
by the muscle spindles and GTOs described earlier occur. Benn the functional aspects of athletic movement. The primary basis
et al26 described this property of stiffness as the stretch work of plyometrics is to use both the serial elastic (mechanical) and
used in completion of the SSC. Several authors have studied neurophysiologic components described earlier to combine
the relationship between SSC performance and muscle stiff- speed and strength in the production of power. Plyometrics
ness. Goslow etal27 found that cat tendons with a high degree has been described as stretch-shortening drills or reactive neu-
of stiffness may transfer energy more rapidly to attached mus- romuscular training. There are basically three phases of a plyo-
cles, thereby resulting in earlier activation of the stretch reflex metric exercise and the SSC.
and thus more rapid contraction of the muscle. Wilson etal17 The eccentric phase (sometimes called the preloading or
concluded that in humans, a stiffer musculotendinous unit may setting phase) refers to the early moments in the movement
result in an increased rate of concentric contraction and more in which the muscle spindles are loaded and stretched during
rapid transmission of force to the working limbs. In another an eccentric contraction, such as stepping from a box onto the
study these authors concluded that decreased musculotendi- ground and squatting as one lands to absorb the ground reaction
nous stiffness actually enhances SSC performance in a bench force. This is when storing of elastic energy takes place. The time
press exercise because more elastic energy can be stored in a less interval for this phase depends on how much stretch facilita-
stiff musculotendinous unit. Other studies have concluded that tion is desired for the subsequent phases. For rehabilitation, this

Table26-1 Summary of Three Types of Musculotendinous Units

Type Example Characteristics


Muscles with long fascicles and Gluteus maximus This type of muscle is usually located proximally and tends to be large in size.
relatively short tendons These muscles are typically powerful movers with a large muscle fiber cross-
sectional area.
They are capable of moving the limb through a wide range of motion and can
absorb a significant amount of energy. For the gluteus maximus, stepping off
a box and into a squat position smoothly is partially a function of eccentric
contracting (lengthening) of the gluteal muscles.

Muscles with long, thick, inelastic Gastrocnemius (although this The tendons have a high degree of stiffness and provide strong control
tendons muscle type is generally located of the distal segment.
more proximally)

Muscles with short fascicles and Tibialis anterior These muscles can store large amounts of elastic energy when stretched rapidly
long, slender tendons because they are less stiff.
Such muscles shorten very little and are more efficient on the length-tension
andforce-velocity curves.
They tend to have more slow-twitch, highly oxidative fibers and are therefore
metabolically efficient.

From Brownstein, B., Bronner, S. (1997): Functional Movement. New York, Churchill Livingstone.
C H A P TE R 2 6 Pl y o m e t r i c Tr a i n i n g a n d D ri l l s 575

phase will most likely be dictated by the range of motion and sprinting and other track and field events, all competitive athletes
amount of shock absorption that the athlete's body is capable of may be able to reduce the risk for future injury by maximizing
withstanding or the amount of eccentric loading that the agonist their dynamic restraint system. Joint stability depends on both
musculature and passive restraints (e.g., ligaments) can tolerate. passive and dynamic restraint structures. Passive structures, such
From a tissue protection standpoint, this is why so much clinical as the arthrokinematics of articulating surfaces, ligaments, joint
research has focused on the landing phase of athletic movement. capsule, menisci, and labrum, provide support to the musculo-
In this area, the primary concern is the potentially poor neuro- skeletal components. The dynamic restraints that provide joint
muscular strategies used during athletic movement. Numerous stability include the muscles and neural controls associated with
studies on prevention of injury to the anterior cruciate ligament movement. It is often the passive restraints that are damaged in
(ACL) and rehabilitation are concerned with the biomechanics sports and daily activities involving high-velocity movements and
of the landing, or eccentric, phase.11,28-31 perturbations in dynamic balance.33,34 Unfortunately, even though
The amortization phase refers to the time between the end of healing of passive restraints can be addressed through physical
the eccentric contraction and initiation of the concentric, explo- therapy, these structures are not easily modified by active con-
sive reaction force that accelerates the body or working limb in servative treatment on the part of the athlete because the heal-
the desired direction. This phase should be as short as possible ing process is more passive (modalities, passive range of motion,
because with a long interval there is a risk of losing much of the and manual therapy). Thus, protective and rehabilitative efforts
elastic energy as heat within the muscle.8 Successful performance have focused primarily on modifying the dynamic neuromuscu-
of a plyometric drill depends on the ability of the musculotendi- lar elements, including joint capsule mechanoreceptors. To this
nous unit to effectively absorb and exploit the stored elastic energy. end, proprioceptive training, active range of motion, flexibility,
The rapid stretching (eccentric loading) must be immediately fol- and strengthening interventions are typically used to empower
lowed by a rapid, explosive concentric contraction to maximize the patient to maximize the ability of the dynamic restraints to
the force generated. The quicker that an athlete can overcome the contribute to stability and prevention of injury. Any displace-
yielding eccentric force and produce a concentric contraction, the ment that occurs too quickly for reflex reactions to protect a
more power that can be produced. The concentric phase represents joint requires that the mechanical properties of the musculoten-
the cumulative effect of the eccentric and amortization phases dinous unit resist the displacement. Active muscle response to
through a powerful concentric contraction (Box26-2).4,32 any perturbation that might compromise joint stability is thus
It is important to note that many clinicians and strength/ an important consideration in rehabilitation for prevention and
conditioning coaches would suggest that most plyometric and athletic performance. Plyometric exercises can assist the clinician
athletic injuries occur on landing and not during the jumping in addressing these biomechanical demands.
(concentric) or takeoff phase. Although this might be true, espe- Generally, plyometrics involves ballistic and repetitive
cially for noncontact ACL injuries, for example, the clinician movements. Although these exercises and drills are designed
should nonetheless be cognizant of the potential for muscle, to optimize the SSC and improve athletic performance, clini-
tendon, and soft tissue injury during takeoff when designing cians need to be cautious in deciding when a patient is ready
plyometric programs for rehabilitation. for safe and effective use of plyometrics. Specifically, a patient
must have achieved a certain level of range of motion, neuro-
Clinical considerations muscular control, proprioception, balance, strength, and flex-
ibility before undertaking plyometric exercises. The evaluation
forplyometrics process should always consider the treatment goals established
Although all athletes may not necessarily need to produce explo- for a given patient at the onset of therapy (Box26-3).
sive strength to excel at a given sport, most athletes undergoing
rehabilitation need to regain strength and proprioception after an Box26-3
injury. Even though plyometrics has traditionally been used in the
realm of sports that require strength, speed, and power, such as Neuromuscular Assessment Before Initiating
Plyometrics
Sufficient resolution of pain to participate in higher-level
Box26-2 exercises and activities
Summary of the Plyometric Phases No inflammation or joint effusion before or after exercise
Normal range of motion with respect to the uninvolved side
Eccentric Phase Normal joint alignment and mobility
Preloading or setting period Soft tissue flexibility, including both contractile and
Muscle spindles loaded via stretch/eccentric contraction noncontractile structures, within normal limits
ofagonists Adequate strength for full weight-bearing activity on the involved
limb unilaterally if the lower extremity or strength for
Amortization Phase
functional use of the upper extremity, including full weight
Interval between the eccentric and concentric phases
bearing on the upper extremities if appropriate for function
Should be short enough to fully use the elastic energy stored
Normal reflexes
inthe stretched muscle-tendon complex
Normal motor control
Concentric Phase Balance and proprioception/kinesthetic sense within functional
Concentric muscle contraction of agonists limits of the uninvolved side (e.g., consider the concept
Maximal power generation with explosive movement oftime to stabilization)
576 Physical Rehabilitation of the Injured Athlete

Applications in Rehabilitation Hewett etal35 prospectively monitored two groups of female


Plyometrics is used widely in a less intense manner for the reha- athletes, one trained before sports participation and the other
bilitation of many athletic injuries. In contrast, some patients untrained, and a group of untrained male athletes through-
progress sufficiently to allow the use of medium- and high- out the high school soccer, volleyball, and basketball seasons.
intensity plyometrics before discharge from formal rehabilita- Fourteen serious knee injuries occurred in the 1263 athletes
tion. In addition to increasing conditioning, plyometrics can tracked through the study. Ten of 463 untrained female ath-
facilitate improved functional motor patterns, reflexes, and pro- letes sustained serious knee injuries (eight noncontact), 2 of
prioception, all of which are crucial in the attempt to return an 366 trained female athletes sustained serious knee injuries (zero
athlete to competition (Box26-4). noncontact), and 2 of 434 male athletes sustained serious knee
In the past 15 years or so, the use of lower extremity plyomet- injuries (one noncontact). The untrained female athletes had a
rics has received increased attention as an adjunctive modality for 3.6-fold higher incidence of knee injury than the trained female
the prevention of noncontact ACL injuries. Although research athletes did and a 4.8-fold higher incidence than the male ath-
in this area might be considered somewhat limited, it seems letes did. The incidence of knee injury in the trained female ath-
that plyometric-oriented exercise programming is an important letes was not significantly different from that in the untrained
component in reducing ACL injuries in females.28,29,35 A growing male athletes. A significant difference was seen in the incidence
body of evidence is linking ACL injuries to poor neuromuscu- of noncontact injuries between the female groups. In this pro-
lar control in injured athletes.31 It is possible that some athletes spective study a decreased incidence of knee injury was dem-
may have poor technique during jumping, landing, stopping, or onstrated in female athletes after a specific plyometric training
turning that may lead to injury. Neuromuscular control must be program.
developed in all three planes of motionfrontal, sagittal, and Although the jumping aspect of plyometric training is impor-
transverseto decrease stress on the ACL and move it to the tant for conditioning, it is the landing of each jump that is vital
muscles and tendons. Proper plyometric training can decrease in the theoretic prevention of knee and lower extremity injuries.
the force and torque placed on the knee.28,35 Proper technique Obviously, rehabilitation and conditioning that focus on land-
increases the load placed on the muscles and tendons and ing technique only do not involve the entire SSC since there is
removes it from the joint and ligaments. The principles of plyo- no concentric phase. Nonetheless, good technique on landing is
metric trainingfunctional motor patterns, reflexes, and prop- crucial to avoid a knee going into hyperextension and external
rioceptionare instrumental in the prevention of knee injuries. rotation, the point of no return. A key concept is that the athlete
These same principles can be applied to an upper extremity that should land softly and quietly while using the knees and hips as
is functionally weak and perhaps unstable for competitive ath- shock absorbers. Another is that the shoulders should be over
letic loads or has lost position sense. the knees when the athlete lands. During plyometric training at
In fact, Hewett et al examined the effects of a plyomet- any intensity, the athlete should be constantly reminded to land
ric training program on landing mechanics and leg strength softly. Another key concept for prevention of injury and condi-
in female athletes involved in jumping sports. The plyometric tioning is that hyperextension should be avoided during all activi-
program was designed to decrease landing force by helping ties such as turning, landing, stopping, cutting, or slowing down.
the athletes improve neuromuscular control over the lower When landing from a depth jump exercise the athlete should
extremity during landing. It was also designed to increase VJH. "stick" and hold the landing. This is accomplished when balance
The authors reported that peak landing force during a volley- is maintained for several seconds after landing with no additional
ball block jump decreased by 22%. Horizontal force acting on steps taken and minimal trunk sway in any direction. Ideally, no
the knee during landing was reduced by approximately 50%. foot movement should occur after landing (Box26-5).
Hamstring-quadriceps peak torque-strength ratios increased Clearly, proper execution of plyometric exercises requires
26% in the nondominant leg and 13% in the dominant leg. dynamic stabilization during the amortization phase and landing,
Hamstring power increased 44% in the dominant leg and 21% as well as during the concentric phase. Some authors have sug-
in the nondominant leg. Mean vertical jump increased by 10% gested that the components of plyometric landing be measured
overall.28 This study, as well as others since, has linked the pre- by time to stabilization (TTS).36 The intensity of plyometrics,
ventive aspect of plyometrics and therapeutic exercise.29 It sug- especially jumping modalities, has been studied via electromyo-
gests that a properly performed plyometric training protocol may graphic (EMG), kinematic, and kinetic analysis, but the specific
help prevent knee injury in female athletes involved in jumping characteristics of many plyometric exercises have not. Ebben
sports, such as volleyball, by increasing knee stabilization dur- etal36 demonstrated that TTS can be used for progression of
ing landing and teaching athletes muscular control. Plyometrics
may also help correct torque imbalances between the hamstrings
and quadriceps and can help increase VJH. Box26-5
Plyometric Concepts for Prevention of Knee Injuries
in Females
Box26-4
"Stick" the landing with minimal trunk or hip-knee sway
Proposed Beneficial Effects of Plyometrics
Hold the landing for 2 to 5 seconds (as appropriate)
Improved proprioception during dynamic movement Land softly and quietly
Improved speed, strength, and power Keep the shoulders over the knees when landing and do not allow
Improved reaction time the knees to shift anterior to the toes in the sagittal plane
Increased bone mineral density Avoid hyperextension during all activities
C H A P TE R 2 6 Pl y o m e t r i c Tr a i n i n g a n d D r i l l s 577

plyometric intensity and that it has moderate to high reliabil- muscle damage by studying serum markers for creatine kinase
ity for jumping conditions in both male and female college-aged and collagen breakdown.45 Overall, some research suggests that
athletes. Although the average clinician does not have access to plyometric exercise may cause more delayed-onset muscle dam-
the force platform equipment to precisely measure TTS, the age than concentric exercise does, but not as much as eccentric
concept is important in evaluating a patient's ability to perform exercise alone does.45
and progress through a plyometric program. Briefly, TTS has Lower extremity plyometric exercises are of particular con-
been used to evaluate ankle stability under varying conditions, cern for injury to the feet, ankles, lower part of the legs, knees,
including a jump task from bilateral takeoff to single-leg land- hips, and lumbosacral spine. As is the case during most athletic
ing, as well as step-down from a box20 cm high.36,37 An athlete's events, injuries are more likely when an individual is fatigued,
or any patient's ability to perform and progress through plyo- typically toward the end of an event or exercise session. Sprained
metric exercises should be evaluated with consideration of these ankles and knee injuries are commonly associated with lack of
concepts. control because of excessive fatigue.8 Inadequate conditioning,
With the exception of research studying ACL injuries and lack of adequate warm-up, poor-quality athletic shoes, inappro-
prevention, there is a relative dearth of controlled studies in the priate training surfaces, and low levels of skill may predispose an
rehabilitation literature on plyometrics. In contrast, many stud- athlete or patient to injury. Borkowski39 reported that a preseason
ies in the strengthening and conditioning literature have exam- plyometric training program in collegiate volleyball players did
ined the effectiveness of plyometrics in improving parameters of not cause injuries but actually significantly reduced in-season
athletic performance, especially power and VJH.5,38 Numerous muscle soreness. Thus, it is clear that proper assessment and
studies have shown improvements in VJH, but a few studies testing of athletes before a plyometric program is started and
have failed to demonstrate significant improvement in VJH.5,38 diligent application of the exercise prescription principles of fre-
Nonetheless, in terms of rehabilitation in particular, relatively quency, duration, and intensity are extremely important.
little information is available on the efficacy and evidence-based
guidelines for plyometric rehabilitation. Clinicians must there-
fore combine knowledge of basic science, the available studies Basic Pretraining Testing
on ACL rehabilitation, and outcomes of plyometrics in healthy In addition to the physical assessments and strength guidelines
subjects to optimize results in the athletic population. mentioned previously, several basic static and dynamic tests can
As most clinicians would suspect, the literature suggests be used to determine a patient's ability to begin a plyometric
that the effects of plyometric training in healthy subjects dif- training program. Voight and Tippett proposed that an indi-
fer depending on training level, gender, age, sport activity, and vidual be able to perform a 30-second one-leg stance with the
familiarity with plyometric training.5 Even in healthy athletes it eyes open and closed before starting a plyometric program.46
is generally believed that an individual should have a reasonable Involved versus uninvolved legs should be compared. Voight
amount of flexibility, strength, and agility before starting a plyo- and Draovitch recommended that the stork balance test be per-
metric training program. Though perhaps not as important as formed for 30 seconds and that a single-leg half-squat also be
for other exercise modes used in the athletic training room or evaluated before any jumping plyometric exercises are begun.47
clinic, it is critical that specific assessment and testing be con- Although it is important to consider the athlete's ability to per-
ducted before the use of plyometrics. Plyometrics is demanding form a single repetition of a dynamic movement, such as a sin-
physically and requires that the individual concentrate on con- gle-leg squat, single-leg heel raise, or standard push-up with
trolling movements both statically and dynamically. proper biomechanics, pretraining testing should closely monitor
According to some authors, the risk for injury from plyomet- multiple repetitions and sets of exercise to test for local muscle
rics is low,39 but few studies have actually addressed injury rates endurance.
associated with plyometric training in healthy individuals. Even The clinician should be creative in using functional testing
though no studies of injury rates have been performed in patients to determine whether a patient is prepared to begin a plyomet-
undergoing rehabilitation and using plyometrics, some stud- ric program. Vertical jumps in place and horizontal long jumps
ies have examined fatigue, inflammation, muscle damage, and on a shock-absorbing surface are two simple tests that may pro-
recovery times in healthy subjects after SSC exercise. Gollhofer vide feedback about a patient's status. Particular attention to the
etal40 found that repeated SSC muscle activity induces fatigue involved (injured) side with unilateral testing can prove invalu-
effects associated with a decrease in neural input to the muscle able in avoiding reinjury or progressing too abruptly by adding
and reduced overall muscle performance. It has been suggested a plyometric component to a rehabilitation or training program.
that during fatigue from SSC exercise, the repeated stretch loads Any pain or instability observed during these tests may provide
might reduce the reflex contribution to the SSC.41 Avela and clues to the patient's tolerance of plyometrics. Having the patient
Komi studied a group of experienced endurance runners and perform step-ups and step-downs from progressively increas-
concluded that fatiguing SSC exercise reduces stretch-reflex ing heights will also provide some indication of the patient's
sensitivity, which was associated with decreased muscle stiff- tolerance. Lateral shuffle and carioca (crossover) drills likewise
ness.42 The authors postulated that this would impair the ath- provide the clinician with ways of testing whether an affected
lete's ability to use the stored elastic energy in the muscle-tendon lower limb is prepared to handle plyometrics. Obviously, jog-
complex. As discussed previously, plyometric training has a sig- ging and running are perhaps the first dynamic movements per-
nificant eccentric component, and the muscle-damaging effect formed to assess the ability of the affected limb to bear full body
of eccentric exercise modalities has been well established in the weight dynamically. Before incorporating any high-intensity, or
litereature.43 A recent study demonstrated acute inflammatory shock, plyometric drills such as box jumps or depth jumps, the
responses and reduced jump performance after an intense bout reader is encouraged to consult sources to determine the height
of plyometric training.44 Other studies have shown evidence of of the box that should be used for an individual's ability.4,7
578 Physical Rehabilitation of the Injured Athlete

Concerning plyometric training in healthy athletes, five methods entire kinetic chain, from the ankles through the knees and hips,
are used by various authors to identify the optimal drop height as well as the vertebral column, needs to absorb full body weight
that will increase countermovement jump performance on an and maintain stability. As discussed earlier, the serial elastic
individual basis. The two most common methods are the maxi- component is important, but the muscle synergy and neuromus-
mum jump height and the reactive strength index.48 The clinician cular coordination required for smooth landing and subsequent
is reminded that these methods are intended for use in healthy explosive movement during athletic activity and plyometrics are
athletes and should be used as a potential guideline; there is no probably better served by enhancing closed chain strength.
substitute for sound, practical clinical judgment. Strength and power (speed strength) are intrinsically neces-
sary components of plyometric training. Chu and Cordier rec-
ommended the power squat test as a good closed chain exercise
Strength and Conditioning Level to determine whether a patient has an adequate speed-strength
In terms of strength, it is generally accepted that a patient should base for lower extremity plyometrics.8 The exercise is performed
have a sufficient base of strength-training experience. It is with 6% of the person's body weight. Five squat repetitions are
important that a sufficient base of strength training may simply done in 5 seconds, and the depth of each repetition should be
be based on movement patterns that are free of dysfunction. For close to 90 of knee flexion. If the patient cannot perform the
patients with an ankle sprain, perhaps this is simply the ability exercise in the allotted time with proper technique, the clinician
to perform three sets of 15 repetitions of unilateral heel raises should continue to emphasize strength training and delay initia-
on the involved ankle at full range of motion off the end of a step tion of the plyometric program. For the upper extremities, it has
(with the heels dipping slightly below parallel or to 10 of dorsi- been suggested the athlete be able to perform five repetitions of
flexion). When plyometrics is used for rehabilitation, a great deal the bench press at 60% of a one-repetition maximum (1RM) in
of subjective clinical judgment is necessary on the part of the cli- 5 seconds.4 For strength training to improve vertical leap perfor-
nician. The reason is that except for perhaps ACL rehabilitation, mance, Weiss etal concluded that training programs to enhance
evidence in the literature supporting the use of various plyomet- moderately fast squatting power may improve performance
ric exercises for rehabilitation is limited. Indeed, it is agreed that as long as body weight, especially body fat, is not increased.32
plyometric training principles are beneficial for healthy athletes, In a related finding, McBride etal concluded that training with
although there is much room for subjective judgment in terms light-load jump squats results in increased movement velocity
of how these drills and exercises should progress. Even though capability and that velocity-specific changes in muscle activity
plyometrics can be a form of functional training for rehabilitat- may play a role in this adaptation.52 Guidelines are not as clear
ing both the upper and lower extremities, the ballistic nature of for the upper extremity. Anecdotally, we recommend that the
most of these exercises makes them inappropriate for the early patient have full range of motion, rotator cuff strength at least
stages of rehabilitation. One major disadvantage of plyometric 75% as strong as that on the uninvolved extremity, and greater
training is that joint excursion is difficult to control because of than grade 4 of 5 for the prime movers on a manual muscle test.
the nature of the activity. According Potash and Chu, as well as other authors, for
Although it is not necessary or suggested that strength- shock- and high-intensity lower extremity plyometrics, it is
training programs focus solely on eccentric contractions, it is recommended that a healthy athlete have a 1RM squat of 1.5
important that sufficient eccentric strength be established before times body weight. For high-intensity upper extremity plyomet-
a plyometric training program is begun, especially for an injured rics, the bench press 1RM is suggested to be at least the ath-
athlete. Studies have shown that force production is increased lete's body weight for larger athletes (body weight >100 kg). For
during eccentric contractions, thus necessitating tolerance of smaller athletes (body weight <100 kg), it has been suggested
higher loads and preferential recruitment of fast-twitch fibers; that the bench press 1RM be 1.5 times body weight. Another
in addition, high eccentric loads may reduce neural inhibition method suggests that an athlete be able to perform five clap
and lead to greater generation of concentric force.49-51 During push-ups in a row.4 Clearly, this requirement is not necessary for
most athletic pursuits, as well as activities of daily living, move- plyometrics performed in the early and middle stages of reha-
ment in the opposite direction, an eccentric motion, precedes bilitation, but it underscores the diligence that is important in
movement in the intended direction. In most movements, the evaluating a patient before initiation of plyometrics. By defini-
eccentric contraction is responsible for decelerating the moving tion, plyometric training involves maximal voluntary contrac-
limb. Similarly, the eccentric phase of the plyometric exercise tions. Therefore, plyometrics should be incorporated during the
absorbs the energy by decelerating the limb and allows storage end stages of rehabilitation, when the clinician is preparing an
of elastic energy. Thus, the clinician should incorporate eccentric athlete for return to sport or for any patient to achieve maximal
work during repetitions of various therapeutic and functional functional capacity.
exercises. Emphasis on the eccentric phase of the motion just The focus on making sure that a patient has the strength
before the concentric work more closely matches true human foundation necessary to engage in plyometrics should not
movement patterns. Note that the focus on eccentric contrac- overshadow the need for proper endurance and conditioning.
tion is not intended to minimize the importance of training with Though not an endurance activity per se, a plyometric training
faster concentric contractions as well. session does require a measure of glycolytic endurance because
No discussion of strength would be complete without men- anaerobic or strength/power exercise is more likely to increase
tion of the need for establishing a strength base by using closed lactate levels in the muscle, which decreases the pH of the muscle.
kinetic chain exercises before a plyometric exercises program is Theprocess of removing lactic acid and metabolites from mus-
begun. Indeed, practically all lower extremity plyometric exer- cle tissue (i.e., recovery) is an oxidative process. Thus, an athlete
cises are of the closed chain variety, like the functional move- should have a reasonable measure of endurance to safely avoid
ments that they mimic. In the case of jumping and landing, the fatigue and risk for injury during a plyometric training session.
C H A P TE R 2 6 Pl y o m e t r i c Tr a i n i n g a n d D r i l l s 579

A plyometric program uses successive sets/repetitions and rest their very nature and are perfectly normal for healthy children.
periods, but as the duration of the routine increases (e.g., to 15 Although it is generally considered inappropriate for children
to 30 minutes), the athlete will encounter fatigue. Similar to younger than 12 to engage in formal plyometric training, any
what occurs during an athletic event, there is a need for anaero- activity that includes jumping activities on safe surfaces is prob-
bic endurance. Specifically, the athlete encounters short bouts ably healthy for growing bones and muscles as long as over-
of explosive anaerobic activity, with short rest periods, and then use injuries are avoided. The fact that many young children
must continue to attempt to achieve that performance level for (<12 years) participate in organized sports such as gymnastics,
several minutes or even hours. Take as an example a tennis match soccer, hockey, basketball, and football speaks to the safety of
or a basketball or football game. The same explosive movements low-level, informal plyometric activity. In terms of rehabilita-
are required at the end of the match or game as are necessary in tion, we have used low-intensity plyometric drills at low vol-
the beginning of the competition. Gollhofer etal found reduced ume for gymnasts, dancers, soccer players, swimmers, and other
EMG activity during the eccentric phase of SSC exercise with childhood athletes who intend to return to their sports follow-
fatigue in healthy subjects.40 Similarly, Nicol et al concluded ing physical therapy.
that the EMG response of calf muscles to passive stretch was In terms of strength and conditioning, properly designed and
a smaller after submaximal SSC exercise.41 Strojnik and Komi supervised plyometric training programs have been used in the
also found that fatiguing submaximal SSC exercise on a sledge adolescent population with safety and effective results. Potdevin
jump apparatus decreases the contractile characteristics of the etal trained pubescent swimmers for 6 weeks with a plyomet-
quadriceps femoris muscle.53 ric program and observed improved swimming performance as
a result of improved dive and turn movements.55 Rubley et al
recently conducted a low-frequency, low-impact plyometric
Special Clinical Considerations program in female soccer players and observed increased lower
body power in terms of kicking distance and VJH.56 Other stud-
Anthropometrics ies have also used plyometric training in high school basketball
Simply because a patient is an athlete does not mean that the players and soccer players.57,58
rehabilitation program should progress to high-intensity or Weight-bearing exercise with high load intensity is known to
even high-volume plyometrics programming. In general, high- have osteogenic effects.59,60 Children who participate in activi-
intensity drills and high-volume plyometric programs may not ties associated with higher loads have been shown to exhibit
be appropriate for larger athletes (>100 kg),4 particularly if the higher bone mass than have children who participate in activi-
athlete's body fat level is high. A football lineman, for example, ties with lower loads.61 Witzke and Snow investigated the effects
may be at increased risk, especially because his role in competi- of 9 months of plyometric jump training on bone mineral con-
tion does not require jumping and leaping movements as much tent, performance, and balance in adolescent girls. They found
as the role of a running back or wide receiver does. By the same that moderate- to high-intensity plyometric training improved
token, an endurance athlete with a low body fat level but low trochanteric bone mineral content, leg strength, and balance in
muscle mass might also be at risk for injury with high-impact these adolescent girls.62
plyometric exercises. Ugarkovic et al studied anthropometric In summary, pubescent athletes can engage in low- to
and strength variables as predictors of jumping performance medium-intensity plyometrics, although it is critical that they
in elite junior basketball players and concluded that these mea- have the strength and coordination to tolerate these drills safely
sures alone are not the best predictors to assess movement per- without incurring injuries to the epiphyseal (growth) plates and
formance in homogeneous groups of athletes. They suggest overuse injuries to tendons and other soft tissue. High-intensity
that these factors and especially sport-specific movements and (shock) plyometrics such as box jumps are not generally rec-
power be used in a comprehensive evaluation.54 Nonetheless, ommended for adolescents. Although sequential age should be
body structure, body fat measures, and particularly structural considered in terms of maturity, each child should be evaluated
abnormalities and previous injuries must be considered. If body for maturity in terms of strength, flexibility, balance, and coor-
fat measurements are not readily available, it is suggested that dination. Finally, pediatric participants must be psychologically
the body mass index (BMI) be considered as a starting point. mature enough to follow the instructions of the supervising cli-
The reader is also advised to keep in mind that the BMI is a less nician or strength and conditioning coach.
appropriate measure in the athletic population because it is not
a measure of body fat; that is, it does not take into consideration Gender
lean body mass. Vertebral abnormalities, as well as problems Regarding gender differences, Aura and Komi found that female
with the knees, hips, and ankles, are of special concern for lower subjects better use the prestretch phase of SSC at low intensity
extremity drills. Previous shoulder, elbow, wrist, hand, and cer- levels whereas men show greater potentiation of elastic energy at
vical or thoracic injuries should be considered when contemplat- higher prestretch levels. However, males exhibited higher work
ing the use of upper extremity plyometrics. because of elasticity. They suggested that there may be funda-
mental differences in neuromuscular function between males
Age and Gender
and females.63 In a more recent study, an SSC index derived
Pediatric athletes from upper extremity tests showed significantly higher values in
Prepubescent children (<12 years) and adolescent athletes men than in women, although individual differences were more
(12 to 17 years) represent a special population regarding ply- variable in women. The authors concluded that men may have
ometrics. School-age children play games such as leap frog, superior ability to use the SSC in the upper extremities.64 Based
hopscotch, and jump rope to their own level of comfort with- on the work of various authors,28,29,31 it is clear that the neuro-
out any formal instructionthese activities are plyometric by muscular patterns exhibited by females during jumping tasks
580 Physical Rehabilitation of the Injured Athlete

make a strong case for the clinician to use diligence in designing maximal concentric contraction, it seems important that athletes
and supervising female athletes during both rehabilitation and should possess a level of flexibility conducive to handling the
training programs involving plyometrics. demands of the specific plyometric exercises being performed.
For plyometric warm-up, whole-body movements should be
Masters athletes (middle aged and older) used to raise the heart rate, increase muscle and soft tissue tem-
Generally speaking, middle age begins at 35 years, and most perature, decrease the viscosity of synovial fluid, and increase
sports organizations offer "masters" athlete categories beginning overall body temperature enough to generate mild perspira-
at approximately 40 years of age. Whether one is working with tion. The warm-up and stretching should be activity specific
a weekend warrior or a competitive amateur masters athlete, it and incorporate the dynamic movements associated with that
is important to evaluate the patient's functional status and goals activity. Assuming that no joint structures are limiting range
for rehabilitation. When one considers the anatomic and physi- of motion, improved flexibility through appropriate stretching
ologic changes that are inherent in the aging athlete, the use of of muscles and soft tissues should aid in the safe performance
plyometric exercises comes with special clinical considerations. of demanding plyometric exercises. Prolonged static stretch-
First, a through medical history is critical in determining how ing before and during a plyometric routine may have a negative
previous injuries, surgeries, and medical conditions might have impact on performance, so this should be considered carefully.
an impact on design of the program. Second, it is important to Dynamic, ballistic stretching is probably warranted since plyo-
consider the decrease in muscle fiber cross-sectional area, pref- metric activity is ballistic by definition. Additionally, propriocep-
erential loss of type II muscle fibers, reduction in the number tive neuromuscular facilitation stretching may be an appropriate
of motor units, changes in neuromuscular recruitment, and the adjunct to improvement in flexibility as well. Detailed discussion
subsequent reductions in strength and especially power that of stretching and flexibility is beyond the scope of this chapter,
accompany the aging process. Rates of skeletal muscle protein and the reader is encouraged to review Chapter6.
synthesis and therefore rates of recovery decline with age.65,66
In addition to changes in skeletal muscle and muscle strain Balance and Proprioception
injuries, the clinician needs to consider the potential for dam- Proprioception describes the collection of sensory afferent nerves
age to articular cartilage, knee menisci, intervertebral disks, and that enhance awareness of posture, movement, joint position,
tendons, which is more likely in this population. As with plyo- limb velocity, changes in equilibrium and weight, and resistance
metric programming for any age group, attention to appropri- of objects in relation to the body. Kinesthesia is also important
ate levels of exercise intensity, frequency, duration, and volume and represents the ability to perceive the extent, direction, and
are especially important in older athletes. Again, understanding weight of movement.70 Conscious and unconscious perception
each patient's goals in the context of the plyometric program is of these factors is critical fore safe and effective return of the ath-
important. For instance, a 50-year-old man or woman with a lete to competition. Research has shown that during jumping,
history of meniscus injury who would like to improve running the leg extensor muscles are activated before the feet contact the
performance in a 5-km event might benefit more from hop and ground.71 Komi described this phenomenon as the preactivation
bounding-type exercises than from 24-inch box jumps and high- or preinnervation phase.19 Melvill-Jones and Watt suggested that
impact plyometrics. this preactivation is mediated by higher CNS processes before
the person lands and that the correct timing and sequence of the
(eccentric) contractions to absorb the force have been learned
Warm-Up, Stretching, and Flexibility from previous experience.71 According to Avela and Komi,
The importance of warm-up is well documented in the litera- many studies have confirmed this theory, and a clear relation-
ture, and it is related to many positive effects on athletic per- ship exists between the duration and amount of preactivation
formance, including faster relaxation and contraction of both and the height of the drop as a result of the person's jumping.72
agonist and antagonist muscles, improved rate of force devel- Komi etal showed that preactivation rises with increasing run-
opment, and improvement in strength, power, and reaction ning speed.73 Despite these studies, there is evidence that the
time.67 In contrast, stretching has recently come under scrutiny vestibular and visual systems also play a role in this process.42
in the literature. Specifically, static stretching has been associ- Finally, it has been shown that the preactivation phase is impor-
ated with acute negative effects on muscle power, torque, force, tant in preparing the muscle to resist the high impact force and
and maximal strength, as well as jump, sprint, and agility perfor- in preparing for the subsequent push-off after contact.74 These
mance.67,68 Dynamic stretching, however, has not been shown to studies suggest that plyometric training and the motor learning
elicit decrements in performance and has, in fact, been shown to that takes place as a result of repetitive practice can play a criti-
improve running peformance.67 It is important to also note that cal role in developing proprioception. The speed-strength com-
a metaanalysis of stretching studies concluded that the evidence ponents of the drills should better prepare a patient to handle
is not sufficient to recommend eliminating preexercise stretch- these circumstances during functional activity.
ing and that no studies have examined populations who are at As discussed earlier, the concept of TTS is important to
increased risk for injury.69 Overall, the evidence that warm-up consider in plyometric programming, especially with bilateral
and stretching reduce risk for injury is equivocal because stud- versus unilateral SSC exercise. For example, plyometric drills,
ies often combine warm-up, stretching modes, and prestretching especially in rehabilitation, should progress from bilateral to
and poststretching practices.69 Ultimately, it is probably impor- unilateral modes. There is evidence that the feet touch down at
tant for athletic activities that require increased range of motion different times, thus suggesting an asymmetry in the landing,
(e.g., high hurdles, gymnastics) or high-intensity SSC move- with one leg absorbing more energy than the other.75 In fact,
ments to include appropriate flexibility regimens. Because of the these authors have found bilateral differences in both average
eccentric, or lengthening, nature of the SSC and the subsequent and maximum force when drop jumps are performed at less than
C H A P TE R 2 6 Pl y o m e t r i c Tr a i n i n g a n d D r i l l s 581

0.40 m, which suggests that the feet are placed on the ground they might actually extend the amortization phase and reduce
at different times; interestingly, symmetry of landing was better efficient use of the stretch reflex for the SSC. Again, these sur-
with a higher depth jump (0.6 m). Clinicians should, at least faces are not specific to the surface on which the athlete will
grossly, monitor TTS, landing, and takeoff asymmetry when be competing.
implementing balance and proprioception training as it relates Obviously, the amount of space needed for the lower extrem-
to plyometric exercise even when the intensity is low, as might ity is a function of the type of plyometric drills being per-
occur in the rehabilitation setting. formed. Some drills may require as much as 100 m, although
Joint stability depends partially on proper neuromuscu- most bounding and running drills require only about 30 m of
lar control. Presumably, the clinician has addressed proprio- straightaway.4,7,8 If plyometric exercises are performed indoors,
ception during the intervention leading up to initiation of a ceilings must be high enough to accommodate vertical leaps
plyometric training program. Nonetheless, the plyometric and in-depth jumps even though a small floor surface area is
program should be viewed as a higher-level extension of this needed.
component in rehabilitation for a patient to achieve return
to maximal functional status. It should be noted that heal- Equipment
ing and strengthening of the static and dynamic restraints do
not necessarily prepare a patient for the demands of athletic Footwear
endeavors. Indeed, the unanticipated changes in joint positions The flooring or playing surface is probably the most important
encountered during athletic events are something that the ath- "equipment" needed for plyometric training. Similarly, the foot-
lete must be prepared to tolerate. Plyometric training is the wear worn by the patient/athlete is very important. Footwear
next logical step in properly preparing the athlete for return should provide good cushioning and sturdy support. A standard
to sport. Although running and changing direction are impor- cross-training shoe is probably best suited for the performance
tant aspects of proprioception, these conditions in the athletic of lower extremity plyometric exercises, especially if lateral
training room or clinic do not adequately mimic the functional movements will be included. Running shoes are not typically a
requirements during competition or even practice drills. Besier good choice for plyometric training because the sole is gener-
etal studied anticipatory effects on knee joint loading during ally narrower and affords minimal lateral support for the ankles.
running and cutting maneuvers. They concluded that perfor- Abasketball or tennis shoe might also be a good choice because
mance of cutting maneuvers without preplanning may increase they typically provide good support for lateral activities, as well
the risk for noncontact knee ligament injury. The authors sug- as for changes in direction and stop/go activity.
gested that training should involve drills that familiarize ath- In contrast, our rehabilitation programs for gymnasts,
letes with making unanticipated changes in direction and that swimmers, and dancers have included a significant amount of
plyometrics should be included, as well as helping athletes barefoot low-intensity plyometric drills. In addition, recent
focus on visual cues to increase the time available for preplan- work with a mogul skier was performed with the patient actu-
ning a movement.76 ally wearing her ski boots during the plyometric jumps. For all
these athletes, we believed that it was important to establish
balance, proprioception, strength, and power in ways specific to
Programming the demands of the sport.
and implementation
Boxes or Platforms, Hurdles, and Other
LowerExtremity Items
Exercise Surface and Environmental Boxes have always been a staple of lower extremity plyomet-
Considerations ric training. The top or landing surfaces of the boxes should
Depending on the rehabilitation location, it is likely that only be covered with solid rubber, nonslip covers. Typically, these
low-level plyometrics will be conducted in the clinical setting. boxes are constructed of 34-inch plywood or pressboard (pulp)
Whenever possible, low-intensity plyometric jumps in place, wood. The boxes can vary from 6 to 24 inches or more in
hops, bounds, and in-depth jumps (>12 inches) should height. Plastic cones, hurdles, and physioballs are also useful
be performed on yielding or shock-absorbing surfaces such as pieces of equipment. Plyometric or weighted balls are very use-
hardwood or spring-loaded flooring. Bounds and hops can be ful for both upper extremity, core, and lower extremity train-
performed outside on level, well-groomed grassy surfaces or ing. A slide board and strength/jumping/plyometric shoes are
artificial turf. Rubberized indoor and outdoor tracks may also likewise useful pieces of equipment. Kraemer et al44 recently
be safe surfaces. The typical flooring in an athletic training studied the effects of one type of strength shoe and concluded
room or clinic, even if carpeted, is not appropriate for lower that sprint and plyometric training with the shoe along with
extremity plyometrics that involve full body weight. Wrestling weight training significantly increased VJH in young, healthy
or gymnastics mats might also be a good choice, especially for men who were experienced in both resistance and plyometric
landings involving full body weight. However, these surfaces training.
should not be so thick, soft, or cushioned that they increase the
risk for knee or ankle sprain or soft tissue injury. In addition, Medicine Balls, Pads, and Rebounder
it is preferable that the athlete perform the plyometric exercises forUpperExtremity Tools
on a surface similar or specific to a given sport. Because of greater reliance on open kinetic chain activi-
Although minitrampolines or excessively thick exercise ties, the upper extremities require a different set of equip-
mats might seem appropriate surfaces for lower extremity ment for implementing safe and effective plyometric drills. A
plyometrics in the early, low-intensity stages of rehabilitation, rebounder or adjustable minitrampoline enables the patient to
582 Physical Rehabilitation of the Injured Athlete

perform unassisted medicine ball throws and allows the clini- Box26-6
cian the ability to observe the activity from a variety of angles. Dynamic Warm-Up
The foam pads typically used for balance activity can func-
tion as cushioning for the hand/wrist when performing closed Jogging or light running for 5 to 10 minutes
chain upper extremity plyometric exercises such as clap push- Full body weight squats for 15 to 20 repetitions
ups and upper extremity hops. Again, these pads should not Lateral and oblique lunges for 15 to 20 repetitions
be so soft that they interfere with the intended SSC exercise Carioca for 50 to 100 feet
performance. Lateral shuffles for 50 to 100 feet
High-knee marches with appropriate reciprocal arm swing
Warm-Up and Cool-Down (elbows in 90 of flexion) three times for 30 feet
Butt-kickers three times for 30 feet
Similar to any other exercise session or higher-level therapy regi-
Submaximal high knee (power) skips three times for 30 feet
men, proper warm-up and stretching are important components
Upper part of body:
for a safer and more effective and efficient plyometric training
l Upper body ergometer exercise for 5 minutes
session. Especially for lower extremity plyometric exercises, a
l Push-ups, three sets of 5 to 10 repetitions
comprehensive warm-up routine might include the following
l Walking on hands in a protracted scapular position/trunk
principles:
onphysioball
l Jogging for 5 to 10 minutes raises the heart rate, increases l Basketball or volleyball two-handed chest and overhead passes
respiration, and raises body temperature (especially with
respect to soft tissue and synovial fluid viscosity). Although
some stationary biking might be used as an adjunct to warm-
up, full weight-bearing activity is absolutely critical to the
warm-up for lower extremity plyometric activity. Frequency
l All appropriate muscle groups, both primary agonists, antag- As for principles of traditional exercise prescription, frequency
onists, and stabilizer muscles (e.g., quadriceps, hip flexors, is defined as the number of times per week that plyometric exer-
gluteals, hamstrings, and triceps surae, as well as the internal/ cises are performed. Typically, one to three sessions are held
external hip rotators, peroneals, tibialis anterior, and lum- each week. However, the frequency is primarily a function of the
bar spine), should be dynamically engaged in closed chain intensity and duration of the workouts and hence the amount of
movements and stretching (if indicated) for 5 to 10 minutes. recovery that a patient needs between workouts. For example,
Dynamic stretch positions that mimic the specific plyomet- the clinician may choose to have a patient perform low-intensity
ric movements to be performed are clearly indicated here plyometric exercises three times a week while in the athletic
(Box26-6). training room or clinic. As the patient's condition improves, the
l After the plyometric routine has been completed, a 3- to sessions would become more intense and last longer (duration)
5-minute walk/light jog or light stationary bike ride for cool- but take place only twice per week.
down is warranted. Stretching for 5 to 15 minutes after a For comparison, plyometric programming in healthy athletes
workout is probably an important activity when considering varies during off-season and in-season periods according to the
the rehabilitation of specific soft tissue structures. demands of other conditioning, especially practice sessions and
actual competition. For most sports, off-season plyometric rou-
For upper extremity plyometrics, a brief 5-minute full-body
tines are performed twice per week, although certain athletes
warm-up followed by upper body ergometer exercise for 5 min-
(e.g., track and field) may perform them two to three times per
utes can precede specific dynamic stretches and movements of
week. During the season, one session per week is appropriate for
the upper part of the body in preparation for the program.
most sports, whereas track and field athletes may maintain the
two- or three-per-week schedule. Regardless of the frequency
used, it is recommended that plyometric drills for a given muscle
Exercise Frequency, Intensity, group or groups and joint complex not be performed on 2 con-
andDuration secutive days.4
In addition to considering the clinical appropriateness of ply-
ometric exercise in the rehabilitation of an individual athlete, Intensity
other conditioning activities such as formal sport practice ses- Intensity is the amount of stress placed on the individual during
sions, strength training, and aerobic activity must be taken a training session. In cardiovascular exercise, intensity is most
into account in designing the plyometric training program. often measured via the training heart rate, the percentage of
As return to sport approaches, the athlete might be engaged maximum oxygen consumption, or a rating of perceived exer-
in complex training, which describes a combination of resis- tion.78 In strength training and anaerobic sports, intensity is typ-
tance exercise followed by biomechanically similar plyometric ically measured in terms of the amount of resistance or weight,
exercise during the same exercise session. It is believed that speed, or the amount of recovery allowed between exercises used
power (e.g., VJH) is increased after a heavily loaded resistance for a given routine. The amount of work performed in a given
exercise because of a postactivation potentiation effect.77 period, or power, may also be used to describe intensity in any
Although programming of this type is not typically associ- type of exercise.
ated with rehabilitation, the clinician might implement a low- For plyometrics, intensity can mean the amount of stress
intensity version of this technique to enhance preparation for placed on muscles, joints, and connective tissue or the complex-
return to sport. ity and amount of work necessary to complete the exercise.4,8
C H A P TE R 2 6 Pl y o m e t r i c Tr a i n i n g a n d D ri l l s 583

Box26-7 and there are safety issues related to slipping on the bottom of
the pool's surface and stumbling on any boxes that are placed
Factors That Determine the Intensity of Lower in the water. Water depth is probably the most important con-
Extremity Plyometric Exercises
sideration since buoyancy is the key element separating aquatic
One versus two feet in contact with the surface from land-based plyometrics. For example, studies have shown
Vertical versus horizontal direction of jump approximately 50% of a person's body weight is supported by
Horizontal and vertical speed of movement water when submerged to the waist.80,81
Height to which the center of gravity is raised In addition to the buoyancy factor, plyometrics in water
Body weight also provides different sensory input for proprioception and
Landing surface kinesthetic awareness because of the hydrostatic pressure.
As discussed in the next section, intensity can be manipulated in
various ways. The key advantage of aquatic plyometrics is prob-
ably that an athlete might be able to perform a typically high-
The intensity of plyometric drills is typically classified as low, intensity plyometric drill in a low-intensity manner.
medium, or high. As a general rule in any exercise prescrip-
tion, volume decreases as intensity increases. However, in an Classification of plyometric drills by intensity
effort to improve conditioning and endurance, the early stages There are basic categories of plyometric movements. It
of plyometric exercise (or any exercise) can involve increases is important for the clinician to recognize opportunities
in both volume and intensity. When high-intensity levels are to design and implement low-, medium-, and high-inten-
reached by the athlete, volume should decrease. The intensity sity exercises in each of the basic categories. For instance,
of plyometric drills for the lower extremities has been related although depth jumps are considered a high-intensity drill,
to foot contact, direction of jump, speed, jump height, and body working on neuromuscular control with a 6-inch box is a low-
weight (Box26-7). intensity drill in the rehabilitation setting. The critical dif-
From an exercise physiology perspective, it has been shown ference between plyometrics in rehabilitation and traditional
that a plyometric jump-training protocol whereby participants plyometrics in healthy athletes is that exercises are not always
perform 8 sets of 10 repetitions from a 0.8-m (31.5 inches) performed with maximum effort. However, rehabilitation ply-
platform elicits oxygen consumption equal to 80% Vo2max and ometric drills can be performed with maximum power output
increased blood lactate to levels that one would expect from an in the latter stages. In addition, a patient might concurrently
aerobically paced 400-m run. Furthermore, this level of inten- perform maximal-effort ankle plyometric drills while working
sity included 3 minutes of passive rest between sets.79 Although on low- to medium-intensity submaximal jumps for the entire
no other studies have directly examined the metabolic or energy lower chain.
systems involved during plyometric training sessions, the clini- As a general rule, any unilateral version of a plyometric drill
cian should be cognizant of intensity from a metabolic perspec- is more intense than its bilateral counterpart. Jumps in place are
tive as well. Indeed, many sports-related injuries occur as a result probably the most basic lower extremity drill and tend to be low
of fatigue. intensity (e.g., ankle plyometrics), although squat jumps and tuck
Generally speaking, bilateral upper extremity and lower jumps should probably be considered medium to high intensity,
extremity exercises are less intense than unilateral or isolat- depending on the athlete's rehabilitation progress. By definition,
eral varieties. Raising box jump and hurdle heights, increas- this exercise is repetitive with no rest between jumps.4 Although
ing the resistance of elastic bands, increasing vertical leap many see obtaining maximum vertical height as the basic objec-
height and horizontal distance, using a heavier plyometric tive of jumps in place, the clinician is advised to use such jumps
(medicine) ball, and increasing the number of hurdles are all as a diagnostic for how well the patient tolerates repetitive SSC
examples of manipulating intensity. Chu and Cordier8 and exercise early in rehabilitation. Standing jumps are probably the
others classified the types of plyometric exercise into groups next level of plyometric activity. These exercises can be for both
according to increasing intensity; however, low- and high- vertical and horizontal components and are generally viewed as
intensity variations exist for each type of drill. For instance, maximal jump attempts.4 A clinical example is the single-leg hop
although in-place jumps are generally a lower-intensity activ- test for return to sport. Forward and lateral hurdle jumps are
ity, a single-leg power vertical jump in place is a high-intensity also examples.
variation. Similarly, lateral hops over a 6-inch hurdle are of As the athlete approaches return to athletic activity, it is
lesser intensity than when the drill is performed with a 12- or important to incorporate multiple jumps and hops. A hop is a
18-inch hurdle. movement that is initiated and completed with a one-foot or
two-foot landing.82 Hops are not maximal-effort jumps and are
Aquatic plyometrics repeated for a specific time, fixed height (e.g., a 6- or 12-inch
Aquatic plyometric exercises represent an interesting option hurdle), or distance. When compared with the maximal-distance
in rehabilitation, strengthening, and conditioning. As opposed or vertical jumps that are used to train for explosive power, hops
to an explosive workout for power that involves high levels of are typically focused on speed and agility. Clearly, the clinician's
impact force, plyometrics in water allows increasing intensity objective with plyometric hops (and bounds) is to establish the
with low impact and low risk for injury to healing tissues. In readiness of the athlete in terms of neuromuscular recruitment,
addition, there may be the opportunity for plyometric workouts dynamic balance, and proprioception for repetitive loading with
of longer duration and greater frequency. Several studies have speed and agility. Excellent examples of unilateral tests/exercises
observed increased VJH, muscle power, and torque with aquatic are the figure-of-eight test, lateral hop test, 6-m crossover hop
plyometrics programming.80,81 Clearly, this is a specialized area, test, and square hop test.83
584 Physical Rehabilitation of the Injured Athlete

Bounds usually represent a series of movements whereby the Box26-8


athlete lands on alternating feet, but single-leg and bilateral bound- Categories of Plyometric Drills by Intensity
ing is also an option.4,82 The focus on these drills is both horizon- WithExamples
tal distance and speed for greater repetitions.4 In strengthening
and conditioning, bounding drills are typically measured over Low Intensity
distances greater than 30 m (100 feet). The clinician is strongly Lower extremity: squat jump, jump to box, ankle bounces,
recommended to incorporate low- and medium-intensity bound- lateral low hurdle/cone jumps, standing bilateral vertical
ing drills in the clinic over short distances to monitor the patient's leapand reach, aquatic drills
response to this type of loading before return to sport. Many Upper extremity: medicine ball chest pass, bilateral overhead
sports require the ability to bound in varying degrees, whether throw
it is a basketball player's drive to the hoop or a soccer or football
Medium Intensity
player leaping over a tackling defender.
Lower extremity: split squat jumps, bilateral hurdle jumps,
High-intensity plyometric exercises such as depth and box
lateral hops, lateral box jumps, double- and single-leg
jumps are sometimes referred to as shock response. Naturally, the
pike jump, double-leg tuck jump, standing triple jump,
height of the box, weight of the athlete, landing surface, and the
zigzag cone hops, double-leg hop, alternate leg bounds,
clinician's instructions to the patient determine just how intense
combination bounds, aquatic drills
the exercise ultimately becomes. Box jumps can be performed
Upper extremity: medicine ball push-up, standing or kneeling
unilaterally or bilaterally and, like hurdles, incorporate multiple
side throw, backward throw
jumping movements. Depth jumps, in contrast, are more intense
box jumps in that the landing from a box is followed by an imme- High Intensity
diate jump vertically, horizontally, or to another box.4,82 They are Lower extremity: in-depth jumps, box jumps, single-leg vertical
typically performed repetitively, in sets and repetitions just as one power jump, single-leg tuck jump
might design a basic strength-training program. As with any plyo- Upper extremity: drop push-up, medicine ball push-up
metric exercise, the volume of both box and depth jumps is critical
to monitor and calibrate, depending on the individual's ability and
the established goals of the rehabilitation program.
Generally speaking, low-intensity drills will be performed in was planned. This could be an indication that the current pro-
the athletic training room or clinic. They might include jumps gram is too intense for the patient, that the patient needs to do
in place, standing jumps, low-intensity/short-distance hops, more cardiovascular conditioning work, or that the patient is not
and low-height box jumps. Chu and Cordier8 recommended anaerobically fit enough to tolerate this level of training volume
that low-intensity depth jumps, known as jump or drop-downs, or intensity. If the latter is the case, perhaps this patient needs
be performed in the athletic training room or clinic to improve to participate in more high-volume, moderate-intensity strength
eccentric strength. The patient simply steps off (does not jump) training to improve oxidative-glycolytic capacity, or strength-
and lands on the ground without rebounding with a jump. endurance.
In other words, this amounts to performing the first two Traditionally, plyometric sessions are geared toward healthy
phases of the SSC (i.e., preloading/eccentric and amortiza- athletes with adequate strength-training backgrounds and good
tion), although the amortization phase is purposely too long motor skills. Thus, the sessions are intense and focus on power-
and elastic energy is being lost as heat in the musculotendinous ful, speed-strength movements. Accordingly, sessions might last
unit. As condition improves, the athlete progresses to complet- 15 to 30 minutes, but it is important to realize that for healthy
ing the concentric phase (e.g., depth jumps) while attempting athletes, plyometric training sessions are often periodized and
to decrease the amortization phase and increase the height or performed with strength training sessionsplyometrics pro-
distance achieved by the concentric phase jump. grams are often not standalone exercise sessions. For the athlete
The listing in Box26-8 is a sample of some low-, medium-, undergoing rehabilitation, this can still be a useful duration for a
and high-intensity plyometric drills. More important than the plyometric session. However, the duration could be lengthened
exercise per se is how the intensity of an exercise is implemented to accommodate the need for lower-intensity exercise and lon-
(e.g., jump to a 6-inch versus an 18-inch box). The reader is ger recovery periods. Duration is a programming variable that is
encouraged to consult the referenced sources and other works highly specific to the status of the patient and the goals estab-
for a more complete presentation of the many exercises and lished during the rehabilitation process.
drills for both the upper and lower extremities.4,8,84
Exercise Volume and Recovery
Duration
Duration describes how long an exercise session lasts. Although Volume
on the surface this would seem appropriate only for cardiovas- The volume of plyometric drills is a key component in that it
cular conditioning, it is useful for plyometric sessions as well. is inherently related to the intensity and stress to which bones,
It is true that volume and intensity will ultimately determine articular cartilage, ligaments, muscles, and tendons are exposed.
the duration of a session; however, duration is an excellent This is an especially important factor for avoidance of overuse
indicator of the patient's conditioning level. Specifically, if the injury in a patient who has progressed well in rehabilitation.
patient's plyometric sessions are taking 30 minutes instead of Specifically, this patient has presumably reached all the goals for
the 20 minutes planned, the clinician should examine the recov- range of motion, strength, and flexibility in the athletic training
ery times between exercises. For example, perhaps the patient room or clinic and has begun to tolerate plyometric drills at some
needs 5 minutes of rest between drills when only 2 to 3 minutes level. Although the patient may be prepared to tolerate both
C H A P TE R 2 6 Pl y o m e t r i c Tr a i n i n g a n d D r i l l s 585

Table26-2 Recommended Volumes and Intensity There is a threshold of anaerobic or glycolytic endurance
forEach Plyometric Training Session Based on required for an athlete to tolerate a full plyometric training ses-
PatientStatus and Plyometric Experience sion. Generally speaking, the more intense a workout is, the more
rest the athlete needs between sets, exercises, or drills during a
Number particular training session. As the athlete gets fatigued during the
Patient/ of session, the plyometric drills will be perceived to be more intense
Athlete Contacts Intensity Suggestions or difficult. Fatigue also increases the risk for injury. It is very
Patient in an 20-60 Low Increase the
important that recovery periods during the session be appropri-
orthopedic/ number of ate for the conditioning and skill level of the athlete, as well as
sports contacts before for the prescribed volume/intensity of the program. One of the
medicine increasing primary reasons for this is that plyometric drills are designed for
clinic intensity; developing functional speed-strength, not for improving overall
increases of 10% conditioning. Moreover, as mentioned previously, type II fibers
to 20% are more easily fatigued despite their force-generating capacity
Beginner 80-100 Low Primarily low,
for plyometrics. Nonetheless, it is important to match the level
medium increase to of conditioning accompanying these drills to the specific meta-
medium during bolic demands of the sport. For example, a hurdler must be
the midportion of anaerobically conditioned enough to complete hurdles over a 10-
the workout when to 30-second interval. A basketball player must be conditioned
not fatigued well enough to jump repetitively, as well as to run, cut, pivot, and
Intermediate 100-120 Low Attempt high
leap intermittently, over the course of several minutes at a time.
medium when not fatigued Depending on the height of the box, platform, or hurdle, high-
high intensity drills such as in-depth jumps and box jumps might
require as much as 5 to 10 seconds of recovery between repeti-
Advanced 120-140 Low Primarily medium tions and 2 to 3 minutes between sets. In addition, the work-
medium and high to-rest ratio should be dictated by the goals of the drill and the
high
volume and intensity being used.4
As mentioned previously, muscle groups and joint complexes
should not be subjected to plyometric drills on consecutive days.
low- and medium-intensity plyometric drills, the ability to toler- Two to 4 days between plyometric workouts is a general guide-
ate the repetitive stress from volume may not be evident until an line, but this is mostly dictated by the intensity and status of the
overuse injury, such as patellar tendinitis, has developed. patient.4,8 It is assumed that the athlete is performing strength-
Volume in plyometrics is typically expressed as the number ening and conditioning workouts on other days. An athlete
of foot contacts or throws of the medicine ball; the total distance may be able to perform some strength and endurance training
jumped might also represent volume. Volume is also an expres- on the same day as the plyometric workout, but use of body
sion of the amount of work performed. The analogue of volume parts should be alternated. For example, one might perform
in weight training is the product of the number of repetitions upper body strength training on the same day that lower body
times the number of sets performed; repetitions and sets are plyometric exercises are performed. Alternatively, one might do
appropriate terminology for most upper body plyometric exer- a light-intensity endurance workout as part of the warm-up or
cises. Foot contacts are defined as the number of times that a cool-down on a plyometric training day.
foot, or both feet together, make contact with the surface during According to Chu and Cordier, the work-to-rest ratio should
each workout session. be 1:5 to 1:10 to be certain that the intensity and proper execu-
Again, it is important to consider whether the patient has tion of the movement are preserved.8 Thus, a 10-second repeti-
regained endurance and glycolytic-oxidative capacity, in addi- tion of jumps should be followed by 50 to 100 seconds of rest
tion to musculoskeletal integrity, during the rehabilitation. before the next repetition is begun. If the set is composed of
The metabolic demands of plyometric training have been 10 repetitions, this would yield about 100 seconds of actual
established in at least one study.79 As always, the status of the work for the set, and 500 to 1000 seconds of rest would need
patient dictates how much volume (and intensity, duration, to be included in the set. Stone and Bryant, as cited by Chu and
and recovery) is appropriate. Table26-2 provides general rec- Cordier, suggested that about 1 to 5 minutes of rest is needed
ommendations for volume and intensity in a plyometric train- between plyometric exercises, depending on the intensity and
ing session.4,7,8,84 volume of the workout.8 Metabolically, high-intensity plyomet-
rics uses the phosphagen and anaerobic energy systems, depend-
Recovery ing on the duration of a given drill. Recovery periods that are too
Because plyometric drills tax the musculoskeletal system in a short for adequate recovery limit athletes' ability to develop their
novel way during rehabilitation and might involve maximal phosphagen and anaerobic metabolic systems.
effort on the part of the patient, recovery is extremely important. In contrast, as stated earlier, a basic level of endurance is
Recovery can include both rest between repetitions, sets, or drills needed to perform plyometric exercises and to perform in a
within a given exercise session and the amount of rest that a given sport or activity. In the early stages of rehabilitation it is
patient needs between actual sessions (in days). As mentioned often necessary to incorporate an endurance component within
previously, recovery between drills during the session is an impor- the plyometric training program. In this case, the rest period
tant factor in dictating the metabolic intensity of a workout. needs to be shorter because the activity must also tax the aerobic
586 Physical Rehabilitation of the Injured Athlete

or oxidative metabolic processes of the muscle. The clinician can For the upper extremity, two-arm throws with a light ball
monitor aerobic intensity via the training heart rate. It is well are a good starting point. Cordaso etal used EMG recordings
documented that training at 60% of the maximum heart rate is to determine muscle activity during the two-arm plyomet-
a minimum level of intensity to generate aerobic improvement.78 ric ball throw in 10 healthy males.86 In the cocking phase, the
In practical terms, this would indicate the need for a work-to- upper trapezius, pectoralis major, and anterior deltoid muscles
rest ratio of perhaps 1:1 or 1:2 to stress the oxidative and fast showed high activity (>40% to 60% maximum manual test), and
glycolytic energy systems. the rotator cuff muscles had moderate activity (>20% to 40%).
In summary, if it has been determined that the patient is Inthe acceleration phase, five of the muscles demonstrated high
capable of tolerating maximal power exercise, longer rest periods levels of activity (>40% to 60%), and the upper trapezius and
can be implemented. To improve anaerobic power, more rest is lower subscapularis muscles had very high levels of activity
needed. During the earlier stages of rehabilitation, it is probably (>60%). Analysis of the deceleration phase revealed high activity
more appropriate to use low- to medium-intensity plyometrics in the upper trapezius muscle and moderate activity in all other
with longer intervals of recovery. Despite the fact that plyomet- muscles except the pectoralis major. The authors concluded
rics has traditionally been reserved for healthy athletes attempt- that their findings support the use of medicine ball training as
ing to maximize power and speed-strength, there is a place in the a bridge between static resistive training and dynamic throwing
clinical setting for low-level plyometrics that stresses both the in the rehabilitation process. Fortun etal observed increases in
oxidative and glycolytic systems as a precursor to more aggres- both internal rotation strength and power following an 8-week
sive plyometrics as the patient's condition improves. Indeed, low- plyometric program.87 It should be acknowledged that rehabili-
intensity plyometrics can be focused on improving the patient's tation specialists often use open chain plyometric exercises with
eccentric strength, coordination, and agility; promoting normal a medicine ball and rebounder. Closed chain plyometric exercises
myotatic reflexes; and restoring functional ability.8 are an additional option when working on shoulder stabilization
exercises. Although "clap" push-ups might be a high-intensity
drill, clinicians should consider bilateral upper extremity hops
Muscle Fatigue, Muscle Damage, and jumps in place on an appropriate, padded surface.
andPlyometrics In most cases, the athlete progresses from two-arm throws to
Plyometrics incorporates a significant amount of eccentric mus- one-arm throws. A progression of upper extremity exercises is
cle activity, and unaccustomed eccentric anaerobic exercise has shown in Figures26-13 to 26-20 (see pp. 590-592).
been associated with an immediate decrease in tension-generating
capacity, a shift in the optimum muscle length, and changes in
excitation-contraction coupling.85 Eccentric resistance exercise has
also been associated with increased delayed-onset muscle sore-
ness, muscle tenderness, and weakness in healthy individuals.43
Exercise-induced muscle damage and injury have been stud-
ied by many investigators.42 Kyrolainen etal investigated muscle
damage after strenuous SSC exercise in power and endur-
ance groups of athletes who performed 400 jumps andfound
elevated serum levels of creatine kinase, myoglobin, and car-
bonic anhydrase.74 Levels of these blood proteins are often
measured as an indication of skeletal muscle damage. Even in
these athletic groups, the authors observed differences in physi-
ologic responses between endurance and power athletes that
they attributed to differences in muscle fiber type distribution,
differences in the recruitment order of motor units, or differ-
ences in response to power-type strength exercises. Again, the
importance of closely monitoring the volume, intensity, dura-
tion, and recovery time of plyometric training programs cannot
be overemphasized.

Progression of Plyometric Exercise


Training
Patients begin with low-intensity lower extremity drills and Figure26-1 Squat jump (low intensity). With the feet shoulder
progress to medium- and high-intensity exercises only when width apart, the athlete begins by squatting down to approximately
they have regained enough strength, range of motion, and 90 of knee flexion while simultaneously maintaining lumbar
joint integrity and have mastered the basic plyometric move- lordosis and the weight equally distributed on the heels and
ments. Chu and Cordier recommended that patients spend 12 forefeet; the hands should be behind the head with the fingers
to 18 weeks performing low- and medium-intensity plyomet- interlocked. With no arm movement, the athlete performs a
ric drills.8 Two-legged drills are a good starting point for lower maximal vertical jump and, on landing, immediately repeats the
extremity plyometrics, with progression to single-leg jumps and squat and jumps again. One set of 5 to 10 repetitions is performed.
hops. A progression of lower extremity exercises is presented in The amortization phase is slightly longer for this exercise to absorb
Figures26-1 to 26-12. the landing force until skill and strength improve.
C H A P TE R 2 6 Pl y o m e t r i c Tr a i n i n g a n d D ri l l s 587

Figure 2 6 - 4 Lateral hurdle hops (low to medium intensity).


Using a short cone or low 6- to 8-inch hurdle and keeping the
feet together, the athlete jumps laterally over the hurdle as
quickly as possible and repeats in the opposite direction. Most
Figur e 26- 2 Ankle bounces (low intensity). With the feet 6 of the work should come from ankle action, but natural flexion of
to 10 inches apart, the athlete jumps in the shape of a V, then the knees and hips should be used to clear the hurdle. Three sets
laterally, and then forward/backward. Ten jumps in each direction of 10 to 15 repetitions are performed.
should be performed for a total of 30 repetitions in 60 seconds;
reduce the time allotted to increase agility and speed.

Figur e 26- 3 Standing jump and reach (low to medium


intensity). Standing close to a target on the wall or near an object Figur e 2 6 - 5 Thirty-second lateral box drill (low to
suspended overhead and the feet shoulder width apart, the athlete medium intensity). Standing next to a 4- to 8-inch-high box
performs a half-squat using double-arm action (extension or step with the feet shoulder width apart, the athlete jumps
flexion) and jumps to maximal height while reaching with one laterally with both feet onto the box, then off to the ground
hand for the target each time. On landing, the athlete repeats on the opposite side, and continues without stopping for
the slight squat and jumps without taking any steps before 15 to 30 seconds. The ankles, knees, and hips should be
jumping. The amortization time is slightly longer for beginners; used to absorb the force of landings. Progress to reducing
progress to reducing amortization time. Three sets of 5 to 10 amortization time or increasing the height of the step/box to
repetitions are performed. increase intensity.
588 Physical Rehabilitation of the Injured Athlete

A B
Figur e26- 6 A and B, Double-leg tuck jump (medium intensity). Standing with the feet shoulder width apart, the athlete performs a
half-squat with double-arm action, then immediately explodes vertically while pulling both knees to the chest and grasping the knees
with both hands, and quickly releases them as descent begins. Spending minimal time on the ground, the athlete repeats the sequence.
One set of 10 repetitions is performed.

Figur e 26- 7 Lateral cone hops (medium intensity). Three to


five cones or other obstacles are placed in a straight line about Figure 2 6 - 8 Jump from box (medium intensity). Standing on
3 feet apart, depending on the ability and height of the athlete. top of a 6- to 18-inch-high box with the feet shoulder width apart,
Standing with the feet shoulder width apart at the end of the row the athlete squats slightly and jumps slightly from the box onto
of cones, the athlete jumps laterally down the row of cones and the floor while concentrating on absorbing the landing force and
lands on both feet. At the end of the row the athlete changes "sticking" the landing with no loss of balance or sway. A vertical
directions and returns, with minimal time spent on the ground. jump from the box should not be performed; the jump direction
Three sets of 5 to 10 repetitions are performed (1 repetition = 1 is more horizontal than vertical. One set of 10 repetitions is
lap, return to start position). performed.
C H A P TE R 2 6 Pl y o m e t r i c Tr a i n i n g a n d D ri l l s 589

Figure2 6 - 1 0 Hurdle jumps (medium to high intensity). Three


to five hurdles are placed in a row. With the feet shoulder width
apart, the athlete begins with a half-squat with double-arm
action and leaps over hurdles consecutively while bringing the
knees high and spending minimal time on the ground with each
jump. Five to 10 repetitions are performed (1 repetition equals
Figure 26-9 Double-leg zigzag cone hops (medium to high one trip down the row of hurdles).
intensity). Five to 10 cones or similar obstacles are placed in a
zigzag pattern about 20 to 30 inches apart. The athlete hops
diagonally over each cone with minimal time spent on the ground
between each cone while changing direction. The athlete should
get as much vertical leap as possible and attempt to "hang"
in the air to clear each cone with the shoulders maintained
perpendicular to an imaginary straight line between the cones.
One set of 5 to 10 repetitions is performed (1 repetition equals
one trip down the row of cones).

A B
Figur e 26- 11 A and B, Box jumps (high intensity). Standing on the ground with the feet shoulder width apart about 2 feet in front
of a box, the athlete performs a slight squat with double-arm action and jumps explosively forward and vertically onto the box. After
a brief landing on the top of the box, the athlete jumps vertically and horizontally onto the ground. If multiple boxes are available, the
athlete immediately jumps to the next box of equal height; if only one box is used, the athlete turns around and repeats. Two sets of 5
to 10 repetitions are performed.
590 Physical Rehabilitation of the Injured Athlete

A B
Figure 26-12 A and B, In-depth jumps (high intensity). The athlete starts by standing at the edge of the top of the box with the feet
shoulder width apart, then steps (not jumps) off the box and lands on the balls of the feet to absorb the landing, but minimizes time on the
ground and immediately jumps vertically or horizontally explosively using double-arm action. One set of 5 to 10 repetitions is performed.

A B
Figure26-13 A and B, Chest pass. Standing facing a PlyoBack, the athlete uses both hands to hold a 3-lb medicine ball against the chest
and pushes the ball away from the chest into the PlyoBack, with the ball allowed to return to the starting position as the athlete catches it.

A B
Figure26-14 A and B, Two-hand overhead soccer throw. Standing or kneeling facing a PlyoBack, the athlete holds a 3- to 5-lb medicine
ball in both hands, raises the ball overhead, and then throws it into the PlyoBack. The athlete catches the ball overhead as it rebounds.
C H A P TE R 2 6 Pl y o m e t r i c Tr a i n i n g a n d D ri l l s 591

A B
Figur e26- 15 A and B, Two-handed side-to-side throw. Standing facing a PlyoBack, the athlete holds a 3- to 5-lb medicine ball with
both hands positioned over one shoulder, throws the ball into the PlyoBack, then catches it with both hands over the opposite shoulder,
and continues by alternating sides. This exercise can also be used to train rotation of the hips and trunk by allowing the body to rotate
slightly as the ball is caught.

A B
Figur e 26- 16 A and B, Two-handed side throw. Standing sideways in front of a PlyoBack, the athlete holds a small medicine ball in
both hands, brings the ball over one shoulder, then throws it in a sidearm fashion into the PlyoBack, and catches the ball while allowing
the body to turn slightly.

A B
Figur e 26- 17 A and B, Two-handed underhand throw. Standing sideways in front of a PlyoBack, the athlete holds a medicine ball
with both hands in front below waist level, brings the ball over to one side, throws it in an underhand fashion against the PlyoBack,
catches the ball, and then throws it again.
592 Physical Rehabilitation of the Injured Athlete

A B
Figur e 26- 18 A and B, Baseball toss at 90/90. Standing facing a PlyoBack with the arm at a 90 angle away from the body and the
elbow bent to 90 (cocking position), the athlete holds a 2-lb medicine ball, forcefully throws the ball into the PlyoBack, and then catches
it as it rebounds while maintaining the same position of the arm and elbow. This exercise can also be used to train the legs and trunk to
accelerate the arm by stepping out as the ball is thrown.

A B
Figur e 26- 19 A and B, Backhand external rotation at 0. Standing sideways with the involved side toward the PlyoBack, holding
a 1- to 3-lb medicine ball in the involved hand, and keeping the upper part of the arm against the body with the elbow bent to 90,
the athlete rotates the arm toward the chest, forcefully rotates out, throws the ball into the PlyoBack, and tries to catch the ball as it
rebounds with the palm toward the body and the upper part of the arm close to the side.

A B
Figur e 26- 20 A and B, Backhand internal rotation at 0. Standing sideways with the uninvolved side nearest the PlyoBack, holding
a 1- to 3-lb medicine ball in the involved hand, and keeping the upper part of the arm onthe involved side close to the body with the
elbow bent at 90, the athlete allows the arm to rotate out, forcefully throws the ball into the PlyoBack, and catches the ball while
maintaining the upper part of the arm against the body.
C H A P TE R 2 6 Pl y o m e t r i c Tr a i n i n g a n d D r i l l s 593

Conclusion l The frequency, intensity, volume, and duration components


of exercise prescription are extremely important. By defini-
tion, plyometrics requires maximal effort, so manipulating
Applied Anatomy/Physiology these components for effective and safe training sessions is
and Biomechanics of Plyometrics important to reduce the risk for overuse injury and overtrain-
l Plyometrics is based on the theory of the SSC, whereby ing. Volume is generally reflected as the total number of foot
active lengthening (eccentric contraction) of the agonist mus- contacts during a given session. Intensity is mostly related
cle produces energy that is stored in the musculotendinous to two-feet versus one-foot contacts, vertical and horizontal
unit to subsequently be used in a more powerful and efficient distances jumped, speed, height of jumps, body weight, and
concentric contraction. This eccentric-concentric coupling any added resistance applied. Frequency is simply the num-
forms the basis of the SSC. ber of training sessions per week, and duration is the length
l Three neuromuscular anatomic/physiologic areas are impor- of the workout session.
tant in understanding the biomechanics of plyometrics: l For lower extremity plyometric exercises, two-feet contacts
(1) the serial elastic and histologic components of muscles are generally less intense than one-foot contacts. Plyometric
and tendons (i.e., sarcomeres, fiber types, sliding filaments, exercises are typically classified into low-, medium- and high-
and metabolic properties), (2) proprioception mediated intensity categories. The individual exercises include jumps,
through muscle spindles and GTOs and their contribution hops, and bounds for the lower extremity. Upper extremity
to the stretch reflex, and (3) gross muscle-tendon complex plyometric exercises often use a medicine ball and include
architecture. weight-bearing push-uptype exercises.
l The three phases of the SSC and plyometric exercise are the l Recovery is a critical element of plyometric programming. As
eccentric phase, amortization phase, and concentric phase. a general rule of thumb, plyometric workouts should be con-
The eccentric phase consists of loading of the muscle spindle ducted only a maximum of two or three times per week. Track
during the eccentric contraction and storage of elastic energy. and field sports are traditionally more likely to use plyomet-
The amortization phase is the transition from eccentric to ric sessions more than twice per week. Major muscle groups
concentric muscle activity; this phase should be as short should never be targeted in plyometric workouts on succes-
as possible to minimize the loss of elastic energy as heat in sive days. Although strength and endurance training can be
the muscle. The explosive concentric contraction is the final performed concurrently with plyometrics in a comprehensive
phase. rehabilitation program, it is important to mix and match train-
ing sessions to prevent overuse and other injuries. For example,
performing upper body strength training on the same day as
Clinical Considerations for Plyometrics lower extremity plyometrics would be a possible option.
l Patients must be thoroughly evaluated before they l Overall, high-intensity plyometrics will rarely be used in ath-
participate in a rehabilitation program with plyometrics, letic training rooms and clinics during rehabilitation. Rather,
and goals established at the beginning of treatment should low- and medium-intensity drills will most likely be used.
be considered. Generally, the patient must have no joint Patients in outpatient clinics will mostly be limited to low-
effusion or inflammation, normal range of motion, normal intensity drills and roughly 20 to 60 contacts per workout to
joint alignment and mobility, soft tissue integrity and flex- begin the program while working up to a volume of 80 to 100
ibility, adequate strength both eccentrically and concentri- contacts per workout.
cally, normal reflexes, normal coordination, and no pain l The clinician is encouraged to use creativity in customiz-
during exercise. ing plyometric programming to achieve the best functional
l Strength and conditioning are of the utmost importance for outcomes for patients.
safe and effective plyometric training. Muscle performance
tests via exercise, as well as functional tests of strength, should
be administered before the clinician initiates plyometrics.
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