CSCCa and NSCA Joint Consensus Guidelines For Transition Periods

CSCCa and NSCA Joint
Consensus Guidelines for

Transition Periods: Safe
Return to Training
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Following Inactivity
Anthony Caterisano, Co-Chair,1 Donald Decker, Co-Chair,2 Ben Snyder, Co-Chair,1 Matt Feigenbaum,1 Rob Glass,3
Paul House,4 Carwyn Sharp,5 Michael Waller,6 and Zach Witherspoon2
1
Furman University, Greenville, South Carolina; 2New Mexico State University, Las Cruces, New Mexico; 3Oklahoma
State University, Stillwater, Oklahoma; 4Oklahoma Christian University, Oklahoma City, Oklahoma; 5United States
Olympic Committee, Colorado Springs, Colorado; and 6Arkansas Tech University, Russellville, Arkansas
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided
in the HTML and PDF versions of this article on the journal’s Web site (http://journals.lww.com/nsca-scj).
ABSTRACT GUIDELINES PROVIDE STRENGTH org/sport-science-institute/ncaa-injury-

AND CONDITIONING COACHES surveillance-program) indicate that,
THE INCIDENCE OF INJURIES AND
WITH A CLEAR FRAMEWORK FOR among all 25 NCAA sports programs,
DEATHS RELATED TO EXERTIONAL
SAFE AND EFFECTIVE PROGRAM football consistently has the highest
HEAT ILLNESS (EHI), EXERTIONAL
DESIGN IN THE FIRST 2–4 WEEKS injury rates for both games (35.9 injuries
RHABDOMYOLYSIS (ER), AND
FOLLOWING PERIODS OF INAC- per 1,000 athlete-exposures) and practi-
CARDIORESPIRATORY FAILURE
TIVITY OR RETURN FROM EHI OR ces (9.6 injuries per 1,000 athlete-
HAS INCREASED SIGNIFICANTLY exposures) (69,75,76). More striking is
ER. ADHERING TO THE CONSEN-
IN COLLEGE ATHLETES IN RECENT the fact that college football has the
SUS GUIDELINES, CONDUCTING
YEARS. DATA INDICATE THAT highest rate of sudden death, “cata-
PREPARTICIPATION MEDICAL
THESE INJURIES AND DEATHS ARE strophic” and “severe” injuries resulting
EVALUATIONS, AND ESTABLISH-
MORE LIKELY TO OCCUR DURING from player contact, and debilitating in-
ING EMERGENCY ACTION PLANS
PERIODS WHEN ATHLETES ARE juries requiring hospitalization that
WILL REDUCE THE INCIDENCE OF
TRANSITIONING FROM RELATIVE occurred during noncontact practices
INJURIES AND DEATHS IN COL-
INACTIVITY TO REGULAR TRAIN- or supervised strength training or condi-
LEGE ATHLETES.
ING. TO ADDRESS THIS PROBLEM, tioning sessions (23,25,74). In 2012, rep-
THE CSCCA AND NSCA HAVE resentatives from the NCAA, NATA,
CREATED CONSENSUS GUIDE- INTRODUCTION and medical organizations and the
LINES WHICH RECOMMEND strength and conditioning community
OVERVIEW
UPPER LIMITS ON THE VOLUME,
ince 1982, the National Collegiate
INTENSITY, AND WORK:REST
RATIO DURING TRANSITION PERI-
ODS WHERE ATHLETES ARE MOST
VULNERABLE. THE CONSENSUS
S Athletic Association (NCAA) and
the National Athletic Trainers’
Association (NATA) have collaborated
KEY WORDS:
Preparticipation medical evaluation;
emergency action plan; sudden cardiac
arrest; exertional heat illness; exertional
to maintain the largest ongoing colle- rhabdomyolysis; transition period;
giate sports injury database in the world training volume; training intensity;
Address correspondence to Tony Caterisano, (36). Data from the NCAA Injury Sur- work to rest ratio; 50/30/20/10 rule
tony.caterisano@furman.edu veillance Program (https://www.ncaa.
1 Copyright Ó National Strength and Conditioning Association Strength and Conditioning Journal | www.nsca-scj.com
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
CSCCa and NSCA Joint Consensus Guidelines
(including the National Strength and 2017. During the same time frame, 35 conditioning. It is important to note that
Conditioning Association [NSCA] and football players died during practice or conditioning activities often occur dur-
Collegiate Strength and Conditioning as a result of participating in preseason ing sport-specific practice, and such ses-
Coaches Association [CSCCa]) met to conditioning workouts. Autopsy stud- sions may not be programmed,
discuss and address the incidence of sud- ies showed that most of the deaths implemented, and/or supervised by
den death and debilitating injuries in col- were caused by exertional heat stroke a strength and conditioning coach. This
legiate conditioning sessions. This (EHS) or underlying heart conditions occurs despite previously published and
meeting resulted in the development, (https://en.wikipedia.org/wiki/List_ supported recommendations that all
publication, promotion, and endorse- of_American_football_players_who_ strength and conditioning sessions
ment of best practice recommendations died_during_their_careers). should be developed, implemented,
for strength and conditioning in colle- In addition to the cases of sudden and under the control of appropriately
giate sports (21). Although indirectly death, there has been an alarming trained and certified strength and condi-
related, the increasing incidence of increase in the number of athletes tioning staff (21,70). It has also been ex-
contact-related injuries, specifically spi- who have suffered debilitating injuries pressed that, in some circumstances,
nal cord injuries, concussions, and (e.g., cardiorespiratory failure, EHIs even if the strength and conditioning
chronic traumatic encephalopathy and exertional rhabdomyolysis [ER]) coach is directing the conditioning as-
(15,38,54,56,57), prompted the National during supervised strength and condi- pects of a sports-specific practice, he or
Football League (NFL) and the NCAA tioning sessions. The EHI-related death she may be subservient to the sports
to implement stricter rules governing of a college football player in June of coach and as such not have the authority
gameday competition and increase the 2018 is a reminder of the importance to determine how the conditioning ses-
penalties for infractions in an effort to of keeping appropriate medical care of sion or activity was planned and/or im-
provide greater oversight and better student-athletes at the forefront of plemented (70). Although a discussion
safeguard athletes. In 2017, the NCAA sports and athletic competition. In the on the roles and responsibilities of the
released their “Year-Round Football past, the thought that a highly condi- strength and conditioning and sports
Practice Contact Recommendations” tioned athlete might have a potentially coaches is warranted, it is beyond the
(www.ncaa.org/sport-science-institute/ fatal heart condition or be susceptible scope of this article, but should be part
year-round-football-practice-contact- to sudden death or hospitalization from of the discussion on improving the safety
recommendations), which placed addi- a non–contact-related incident might of student-athletes.
tional restrictions on practice sessions, have been unimaginable. But even one Strength and conditioning sessions
especially in the preseason, with the preventable death is unacceptable, and must be appropriately designed and
intent of reducing contact-related inju- 35 such events have occurred in the past implemented to reflect the individual
ries. The NCAA and several other ath- 2 decades. Although the likelihood of athletes’ current levels of fitness and
letic and medical organizations have also a college athlete suffering a potentially fatigue, so as to not induce excessive
worked diligently to provide university fatal event has always been, and exertion. An athlete’s current levels of
athletic programs and their coaching remains, minimal, strength and condi- fitness and fatigue are dynamic in
staffs with guidelines and best practice tioning professionals must be cognizant nature due to the acute and chronic
recommendations to reduce the inci- of the fact that the number of deaths effects of sport training, strength and
dence of non–contact-related injuries and hospitalizations has increased sig- conditioning, nutrition, hydration,
and sudden death (20,23,25,33). For nificantly. Attempts to understand the sleep, and various other factors (e.g.,
example, in an effort to reduce the underlying causes of these tragic events medications and supplements).
number of athletes suffering exertional have rightfully placed the profession The incidence of non–contact-related
heat illnesses (EHIs), the NCAA joined under scrutiny, triggered considerable injuries has increased significantly in
forces with the NATA, the NSCA, the public outrage, and resulted in efforts to the past decade, particularly in student-
CSCCa, and several other athletic and publish and implement preparticipation athletes who have recently returned to
medical organizations to develop guide- screening strategies, preparticipation training after a period of inactivity (i.e.,
lines for heat acclimatization that limit the medical evaluations (PMEs), injury after a vacation between or during aca-
number and intensity of summer practice prevention guidelines for practice ses- demic terms; January-February and
sessions and the equipment that can be sions and formal competition, and July-August) when their level of condi-
worn during those sessions (20,25). guidelines for establishing emergency tioning has likely decreased. According
The causes for concern and needs for action plans (EAPs). to the National Center for Catastrophic
intervention are clearly justified. In the Fatalities and catastrophic events in col- Sport Injury Research (NCCSIR)
past 20 years (1998–2018), 2 college legiate sports continue to occur despite (https://nccsir.unc.edu/files/2013/10/
football players died from direct con- rule changes to enhance student-athlete NCCSIR-34th-Annual-All-Sport-Report-
tact catastrophic neck injuries suffered safety and the availability of best practice 1982_2016_FINAL.pdf), the risk of non-
during games—one in 2001 and one in recommendations for strength and contact injury is significantly greater
2 VOLUME 41 | NUMBER 3 | JUNE 2019
after periods of inactivity if training and potential risks associated with related and exertional/systemic or
workloads and/or recovery strategies strength and conditioning training, indirect/non–contact-related. Trau-
are not adjusted to reflect athletes’ particularly during transition periods. matic injuries are those which result
reduced level of fitness. The NCCSIR The NCAA and the NATA have pub- directly from participation in the fun-
data indicate that almost 60% of non- lished and posted a series of journal damental skills of the sport. Exer-
contact injuries occur during these pe- and lay articles providing best practice tional/systemic injuries are caused by
riods in which the athlete is recommendations for the prevention system failure (usually cardiac or
transitioning back into training follow- and screening, recognition, and treat- thermoregulatory) as a result of exer-
ing a period of inactivity. This increase ment of the most common conditions tion while participating in an activity,
in noncontact injuries suggests that resulting in sudden death in athletes or by a complication which was sec-
athletes are being exposed to excessive (23), guidelines for preseason heat ondary to a nonfatal injury. These
workloads in the period immediately acclimatization (20), guidelines for pre- definitions are supported by previously
after their return to campus, and/or venting EHIs (25), and best practices published literature (74).
their training workload is being for sports medicine management at the
increased at a faster rate than is appro- college level (33). Recognizing the DISCLAIMER
priate. The risk for serious injury and increasing incidence of debilitating This document is intended to provide
death after a period of inactivity is well noncontact injuries, it is surprising that relevant practice parameters for
documented and was addressed in the there are presently no published guide- strength and conditioning professio-
2012 Inter-Association Task Force’s lines for college coaches and their nals to use when performing their
best practice recommendations (21): strength and conditioning staffs for responsibilities in providing services
“conditioning periods should be training loads to be used for progres- to athletes or other participants. The
phased in gradually and progressively sive conditioning following inactive pe- guidelines presented here are based
to encourage proper exercise acclima- riods (e.g., reporting for conditioning on published scientific studies, perti-
tization and to minimize the risk of after a winter or summer break, return- nent statements from other associa-
adverse effects on health.” The CSCCa ing to play after injury). The purpose of tions, analysis of claims and litigation,
and NSCA continue to support these this joint CSCCa/NSCA article is to and a consensus of expert views. How-
best practice recommendations for focus attention on non–contact- ever, this information is not a substitute
strength and conditioning sessions dur- related injuries and provide guidance for individualized judgment or inde-
ing transition periods for collegiate stu- pertaining to the retraining of college pendent professional advice.
dent-athletes. athletes during transition periods. The
recommendations and best practice Neither the NSCA, CSCCa, nor the
Freshmen student-athletes are a special contributors to this project assume
guidelines presented are in alignment
population of athletes that are at an any duty owed to third parties by
with those published previously by
even higher risk for injury because those reading, interpreting, or imple-
NATA, the NCAA Committee on
they transition from the training work- menting this information. When ren-
Competitive Safeguards and Medical
load demands of high school to colle- dering services to third parties, these
Aspects of Sports, the NCAA Division
giate sports. Although strength and guidelines cannot be adopted for use
I Football Oversight Committee, and
conditioning professionals account for with all participants without exercising
several other scientific, medical, and
this in their training workload pre- independent judgment and decision-
football organizations and are based on
scription for freshmen athletes, it is making based on the strength and con-
the emerging scientific consensus.
worth reiterating as a reminder, so all ditioning coaches’ individual training,
staff associated with the training, KEY TERMS education, and experience. Further-
health, and well-being of student- more, strength and conditioning prac-
For the purposes of these guidelines,
athletes have an integrated approach a “severe” injury is defined as resulting titioners must stay abreast of new
to this population. Transfer and walk- in loss of more than 21 days of partic- developments in the profession, so that
on student-athletes may also be at ipation. A “catastrophic” injury is these guidelines may evolve to meet
increased risk because they often defined as a permanent disability particular service needs.
approach training with a mentality of injury, serious injury (fractured neck Neither the NSCA, CSCCa, nor the
“more is better” in an effort to make the or serious head injury) although the contributors to this project, by reason
starting roster over established and/or athlete has a full recovery, transient of authorship or publication of this doc-
scholarship athletes. paralysis (athlete has no movement ument, shall be deemed to be engaged
The fact that tragic events continue to for a short time but has a complete in practice of any branch of professional
occur reflects a need for all sports recovery), heat stroke due to exercise, discipline (e.g., medicine, physical ther-
coaches, strength and conditioning sudden cardiac arrest (SCA)/severe apy, and law) reserved for those
staff, medical personnel, and adminis- disruption, or fatality. Injuries are clas- licensed under state law. Strength and
trators to be educated about the risks sified as traumatic or direct/contact- conditioning practitioners using this
3
Strength and Conditioning Journal | www.nsca-scj.com
information are encouraged to seek and personnel (e.g., athletic director). The the leading medical cause of death in
obtain such advice, if needed or desired, EAP should identify by name the per- NCAA athletes, and a majority (60–
from those licensed professionals. son or people responsible for the doc- 80%) of those deaths occur during or
umentation of all personnel training, as a result of participating in noncontact
IMPORTANCE OF equipment maintenance, policies and conditioning sessions (64). The 2 most
PREPARTICIPATION MEDICAL procedures, actions to be taken during common causes are hypertrophic car-
EVALUATIONS AND an emergency, and evaluation of any diomyopathy and congenital coronary
ESTABLISHING EMERGENCY response. The EAP should be coordi- anomalies, although there have been
ACTION PLANS
nated with the university’s campus a wide range of postmortem diagnoses
Most student-athlete deaths are pre- police and emergency services, the to include Marfan syndrome, myocardi-
ventable, and student-athlete health local EMS agency, and the local hos- tis, valvular heart disease, aortic dissec-
and safety remains the profession’s top pital. Of greatest importance, EAPs tion, idiopathic left ventricular
priority. The National Athletic Trainers’ need to be reviewed, discussed, and hypertrophy, long QT syndrome, Kawa-
Association Position Statement: Preventing practiced on a regular basis (103). saki disease, atherosclerotic coronary
Sudden Death in Sports (23) provides artery disease, and others (6,62–64,91).
detailed guidelines and recommenda- To provide appropriate care and deter-
mine when emergency treatment is Fewer than 20% of SCD cases occur as
tions for the prevention, screening, rec- a result of direct contact between athletes
ognition, and treatment of the most required, strength and conditioning
professionals need to recognize the during practice sessions (92). The most
common conditions resulting in sudden common postmortem diagnosis in these
death in organized sports. All college- signs and symptoms associated with
a variety of potentially fatal conditions. latter cases has been commotio cordis
level coaches, strength and conditioning (“agitation of the heart”), which results
staff members, athletic trainers (ATs), The 3 most relevant and potentially
fatal conditions are sudden cardiac when a traumatic blow to the heart
and athletic directors are expected to region induces a fatal ventricular arrhyth-
know the guidelines and assist in imple- death (SCD), exertional heat stroke
(EHS), and ER, and these will be mia and cardiac arrest. Unfortunately,
menting the policies and procedures autopsy reports do not always accurately
outlined in this document. Thoroughly described in detail in the following sec-
tions of these guidelines. Immediate depict the underlying pathological con-
screening athletes during the PMEs, dition, and standardized protocols for
creating and implementing EAPs, and emergency care for the athlete is critical
for each of these 3 conditions since cardiovascular autopsies are needed.
following the guidelines and recom-
mendations outlined by the NCAA waiting on an ambulance to arrive
may result in death or permanent dis- Incidence. Although the incidence of
and NATA will lower the likelihood that sudden death due to an underlying car-
a debilitating or fatal incident will occur ability. Consistent with NATA and
NCAA recommendations, we urgently diovascular condition is relatively low at
and improve the probability of survival approximately 1:43,000 student-athletes
should an event occur. The importance advocate training all college coaches
and strength and conditioning staff per year, the rate of SCD is relatively high
of adhering to and implementing these (4–6 deaths per year) (60,64,91). When
safety practices cannot be overstated. members in first aid, CPR, and AED
use, so that they can assist the certified researchers have analyzed the database
The NATA position statement empha- ATs onsite in providing treatment until of all NCAA deaths, their findings consis-
sizes the importance of establishing licensed medical professionals arrive. tently indicate that males, black athletes,
and practicing EAPs to appropriately Although such care may be inadequate and basketball players are at a substantially
respond to potentially fatal incidents for some of the conditions described in higher risk, and that SCD is 3–5 times
(23). EAPs need to be specific to each these guidelines (e.g., SCD), and saving more likely to occur in black athletes
athletic facility and venue (e.g., weight an athlete’s life is not the responsibility (59,64,87,91). More research is needed
room, locker room, gym, and individ- of (nor is liability ascribed to) coaches or to determine whether there is a higher
ual practice fields). At a minimum, each strength and conditioning staff mem- incidence of potentially lethal cardiovas-
EAP should include the following: the bers, these professionals must make cular disease in basketball players or
scheduling and training of likely first every reasonable effort to ensure the whether the demands of the sport place
responders in first aid, cardiopulmo- health and safety of student-athletes. a substantially higher risk on those with
nary resuscitation (CPR), and auto- underlying disease. In any event, coaches,
mated external defibrillator (AED) SUDDEN CARDIAC DEATH ATs, and other medical personnel need to
use; the nearest location of necessary make every effort to identify those athletes
emergency equipment and supplies Pathophysiology. College athletes at increased risk and improve strategies to
(e.g., AEDs, ice chests), and the nearest are considered to be one of the healthi- prevent these tragedies.
location of telephones and the commu- est segments of our society, which is
nication plan to be used to contact why the diagnosis of SCA or SCD is Symptoms and treatment. In any
local emergency medical services always shocking and has a profound athlete who has collapsed in the
(EMS) and pertinent university impact on all of us. Tragically, SCD is absence of contact or trauma,
suspicion for SCA should be high until exertional syncope (temporary loss of EHIs. For example, athletes who have
normal airway, breathing, and circula- consciousness caused by a fall in blood the sickle cell trait or who have a previous
tion are confirmed. Agonal respiration pressure) or exercise intolerance, chest history of EHIs may be more vulnerable
or gasping for breath should be recog- pain or discomfort, cardiac arrest, or to EHIs, and especially EHS. Imple-
nized as a sign of SCA as should sudden death of a family member. Con- menting strategies to address the com-
seizure-like activity or jerking shortly tinuing education and gaining a broader mon causes and mitigate their harmful
after collapse. If normal breathing and knowledge base about the anatomy effects is the best approach to help ath-
pulse are absent, EMS should be and physiology of the cardiovascular letes avoid EHIs or reduce the risk of
alerted immediately and CPR should and pulmonary systems and complica- subsequent EHIs. The pathophysiology
be performed in the order of chest tions associated with cardiovascular of EHS is multifactorial and includes the
compressions, airway, breathing while disease and cardiac dysfunction body’s ability to thermoregulate effi-
waiting for arrival of the AED, and are essential for coaches and condition- ciently and acclimatize to conditioning
stopped only for rhythm analysis and ing staff members as well as ATs and in a hot and humid environment. An
defibrillation. This should continue health care professionals. At minimum, athlete’s physical condition, body mass,
until EMS or other medically certified relevant staff should be aware of state of hydration and electrolyte bal-
providers take over or the (previously the 12-point preparticipation cardio- ance, and health status are contributing
unconscious) athlete starts to move. vascular screening guidelines devel- factors as are certain types of medica-
Early detection, prompt CPR, rapid oped by the American Heart tions and whether or not the athlete car-
activation of EMS, and early defibrilla- Association in 2007 for competitive ries the sickle cell trait or has been
tion are vital to the athlete’s survival. athletes based on their medical history a previous “heat casualty” (30,84,104).
For any athlete who has collapsed and and physical examination (See Appen-
EHS is the most severe form of EHI
is unresponsive, an AED should be dix, Supplemental Digital Content,
and is characterized by central nervous
applied as soon as possible for rhythm http://links.lww.com/SCJ/A259) (89).
system (CNS) impairment and a core
analysis and defibrillation, if indicated.
body temperature greater than 1058F
The greatest factor affecting survival EXERTIONAL HEAT ILLNESSES
(or 40.58C) (5,18,47). EHS occur when
after SCA is the time from arrest to
defibrillation, with survival rates rang- Pathophysiology. EHIs encompass the body’s thermoregulatory system be-
ing from 41 to 74% if bystander CPR is a broad spectrum of disorders to inclu- comes overwhelmed due to excessive
initiated and defibrillation occurs de minor conditions such as muscle heat production (i.e., metabolic heat
within 3–5 minutes of collapse cramps (heat cramps), heat syncope, produced from exercising muscles)
(39,40,116). heat exhaustion, and exertional heat and/or a decrease in the body’s ability
injury, as well as the more severe clinical to dissipate heat effectively. Thermoreg-
Guidelines for prevention. The condition of EHS. Coaches and ATs ulation is a complex interaction of the
PME and traditional physical exami- need to be able to distinguish between CNS, the cardiovascular system, and
nations are essential but have signifi- the various EHIs to prevent and treat the skin to maintain a core temperature
cant limitations (88). Improved them appropriately. The risks of EHIs of approximately 98.68F (378C) (120).
screening strategies to include electro- are ever-present during exercise in the The body’s temperature-regulation cen-
cardiogram (ECG) and echocardio- heat but can also result from exercising ter is located in the hypothalamus and
gram (ECHO) need to be considered in normal environmental conditions. determines the setpoint for core tem-
for athletes in the highest risk group They usually occur during the first 5–6 perature. The body’s thermoregulatory
(e.g., black athletes with a pre-existing days of unaccustomed heat exposure system works through a negative feed-
cardiac condition or family history of (e.g., during preseason conditioning), back loop similar to a home heating
cardiovascular disease). But even these before athletes become acclimatized, system with the hypothalamus serving
types of tests are not definitive, and blood volume expands, and cardiovascu- as the thermostat. The hypothalamus
reports indicate that a substantial num- lar adaptations are complete. In 2015, the receives information regarding core
ber (up to 80%) of the athletes who NATA and NCAA released consensus and surface/skin temperatures from
suffered from SCD would likely not guidelines regarding heat acclimatization thermoreceptors and circulating blood.
have been reliably diagnosed with protocols for football athletes at the high The hypothalamus then directs thermo-
a 12-lead ECG administered during school and college levels (25) (Table 1). regulatory mechanisms to adjust
their preparticipation screening The NATA guidelines emphasize the accordingly to initiate the appropriate
(87,91). Detection of asymptomatic importance of the initial conditioning heat-transfer responses. If core temper-
cardiac conditions can be improved period without use of protective equip- ature falls below the normal setpoint
when standardized medical history ment, followed by a gradual addition of (i.e., 98.68F), peripheral vasoconstriction
forms are used to identify and attract further equipment. It is extremely impor- and shivering responses increase core
attention to an athlete’s personal or tant for all of us to understand the com- temperature. If core temperature rises
family history of previous episodes of mon causes and predisposing factors of above the normal setpoint, cutaneous
5
Table 1
Recommendations for the prevention of exertional heat illnesses (EHI)
1. Athletes should be screened by physicians to identify those with risk factors for EHI or a history of EHI.
2. Athletes with a history of EHI or susceptible to EHI must be closely monitored.
3. Athletes should monitor their hydration status and replace fluids before, during, and after exercise.
4. Athletes should sleep at least 7 hours per night in a cool environment and eat a balanced diet.
5. Athletes should be discouraged from using dietary supplements or other substances that have a dehydrating effect.
6. Athletes should be acclimatized to the heat gradually over a 7- to 14-day period. Recognizing that the first 2–3 weeks of
preseason practice present the greatest risk, all possible preventive measures should be used during this period.
7. Rest breaks should be planned, and the work-to-rest ratio modified to match environmental conditions and the intensity of the
practice session.
8. A heat acclimatization policy should be developed with guidelines formulated for hot, humid weather conditions based on the
type of activity and wet bulb globe temperature. In stressful environmental conditions, practice sessions should be delayed,
shortened, or rescheduled.
9. The sports medicine staff are required to educate coaches and athletes on preventing and recognizing the signs and symptoms
of EHI. The coaching and support staff must also review and rehearse their emergency action plan (EAP) specific to each training
and practice site and game venue.
10. A cold-water or ice tub and ice towels should always be available to immerse or soak an athlete with suspected EHI. Immediate
whole-body cooling is essential for treating EHI, especially heat stroke.
11. The assessment of rectal temperature is the clinical gold standard for obtaining core body temperature of athletes with EHI. No
other methods of obtaining core body temperature (e.g., oral, tympanic, and temporal) are valid.
12. Certified athletic trainers are the primary providers of medical care for athletes who display signs or symptoms of EHI and have
the authority to restrict an athlete from participating if EHI is suspected.
Reference: National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses (https://www.nata.org/sites/default/files/
ExternalHeatIllnesses.pdf ) (25).
vasodilation and increased sweating Heat acclimatization is an essential acclimatize and are at increased risk
occur to dissipate heat (120). Core tem- part of the conditioning process and for EHS because they have a lower
perature is determined by metabolic involves a series of adaptive physiolog- ratio of surface area to mass, and hence,
heat production and the transfer of ical responses to repeated heat expo- their bodies are less efficient at dissipat-
body heat to and from the surrounding sure over the course of 1–2 weeks. ing heat (25,27). Finally, the athlete’s
environment. Metabolic heat produced These adaptations include increases ability to acclimatize depends largely
by intense exercise may approach 1,000 in plasma/blood volume, stroke vol- on the intensity and frequency of prac-
kcal/h, with more than 90% of the heat ume, and sweat rate, and decreases in tice or conditioning sessions. High-
being generated from the exercise- heart rate, core temperature, skin tem- intensity exercise, regardless of
induced increase in muscle metabolic perature, and sweat loss (4,108). Ath- whether it is performed on the practice
activity. If the excess heat load is not letes should be allowed to acclimatize field or in the weight room, can elevate
efficiently dissipated away from the to the heat before practicing in pads or the core temperature of an at-risk ath-
body, core temperature climbs rapidly. participating in multiple practice ses- lete (i.e., one who is unfit, overweight,
The most efficient mechanism to dissi- sions per day (20,24). An athlete’s abil- or unacclimatized) to dangerous levels
pate heat is the vaporization of sweat ity to acclimatize largely depends on in less than 30 minutes. In fact, the
(i.e., evaporation), but this ability rapidly his or her initial level of fitness, as more relative intensity of exercise, which is
diminishes when the environmental highly conditioned athletes acclimatize based in part on the athlete’s fitness
humidity level is high or if the athlete more quickly. Trained athletes are level, has the greatest influence on
is wearing heavy clothing or equipment. much less susceptible to EHS due to the rate of increase in core temperature
Although EHS is most likely to occur in the training-induced physiological and risk for the athlete becoming a heat
hot and humid weather, it can manifest adaptations described above. Athletes casualty (25).
with intense exercise in any environ- with a high body mass index (BMI The athlete’s hydration status and cor-
mental condition. $30) also generally take longer to responding electrolyte balance also
play significant roles in EHI risk. Inad- considered a disease (i.e., sickle cell dis- related to exertional heat cramps,
equate fluid intake, excess sweat loss, ease) unless it is inherited from both and approximately 26% were a combi-
vomiting, diarrhea, medications, or parents. However, the sickle cell trait nation of exertional heat syncope and
supplements that have a dehydrating can result in an abnormality in the heat exhaustion. Fortunately, there
effect (e.g., diuretics, antihistamines, oxygen-carrying protein hemoglobin were no cases of EHS reported (31).
CNS stimulants, and antidepressants), found inside red blood cells. This The incidence of EHIs was more
and alcohol can all lead to a measurable genetic abnormality leads to the nor- common in the Southeast region,
fluid deficit. Dehydration of as little as mal biconcave disk-shaped red blood where they accounted for 446 of the
2% of body weight can negatively cells taking on a rigid, quarter moon or 553 cases. It was confirmed that the
affect an athlete’s performance and “sickle” shape under certain circum- incidence of EHIs increases signifi-
ability to thermoregulate effectively stances. Heat, dehydration, asthma, cantly in regions with relatively higher
(26). Caution should be taken to ensure exercising at altitude, and inadequate heat indexes, and especially when wet
that athletes arrive at practice euhy- acclimatization all increase the risk bulb globe temperature exceeds
drated (i.e., having re-established their for medical complications in athletes 82.08F (27.88C). In terms of timing,
weight since the last practice) and have with sickle cell trait. Although having heat illness was most common in the
the opportunity to regularly replace the trait is not a barrier to participating first 3 days of practice, and when
body water lost during practice. Mea- in competitive sports, athletes with the two-a-day practices began on day 6
suring body weight change before and trait experience higher rates of physical (of the preseason), there was an
after practice sessions and across suc- distress, including collapse and death increase in heat illness on days 7 and
cessive days is the preferred method for during intense exercise. 8. Collectively, the studies reporting
monitoring hydration status (120). on the incidence rates of EHIs indi-
Water loss that is not replaced by the Incidence. EHS is the third leading cate that the most dangerous time for
next practice session increases the risk cause of sport-related death among football players is during the first 14
for EHIs (19,120). During intense exer- college athletes, and football has the days of preseason practice.
cise in the heat, sweat rates can be as highest incidence rate among all inter-
high as 2 liters per hour (9). Hence, the collegiate sports programs (11). The Symptoms and treatment. The 2
rehydration rate may need to be number of sports-related EHS deaths main diagnostic criteria for EHS are
increased during conditioning sessions has doubled since 1975 with more CNS dysfunction and a core tempera-
conducted in the heat to minimize fluid deaths having been reported between ture greater than 1058F (or 40.58C)
deficits. Electrolyte imbalances, espe- 2005 and 2009 than during any 5-year (5,19). In addition to the fatally high
cially sodium and chloride, also result period of the preceding 30 years core body temperature, the key signs
from high sweat rates, and athletes (90,99). The National Center for Cata- and symptoms of EHS include physi-
who are not heat acclimatized can lose strophic Sports Injury Research data- cal collapse, seizure, inability to walk,
significant amounts of these electro- base also identified EHIs as the third hypotension, tachycardia, dizziness,
most common cause of sports-related and vomiting. EHS-related death is
lytes during conditioning sessions. It
fatalities in high school and college preventable through immediate recog-
is important to make sure that athletes
football players between 1990 and nition of symptoms, core (rectal) tem-
are aware that the loss of electrolytes is
2010, accounting for 15.6% (n 5 38) perature assessment, and rapid
equally important as the loss of water,
of reported deaths. Although the inci- treatment through cold-water immer-
and that replacing both reduces their
dence of EHS-related death is rela- sion (CWI) (5,23,25). Athletes who
risk of having EHIs or exertional hypo-
tively low among college athletes, the have EHS should be aggressively
natremia (from consuming too much
rate of occurrence of other forms of cooled, onsite if possible, within the
water) during conditioning sessions.
EHI remains disturbingly high. In “golden half hour” after collapse/onset
Finally, athletes who have the sickle a more recent study, researchers ana- of symptoms. The goal is to lower the
cell trait are at increased risk for lyzed data from 4 NCAA football sea- athlete’s body temperature to 1028F
EHS, collapse, and sudden death. sons (2004–2007) and divided the 60 (38.98C) or less within 30 minutes of
The sickle cell gene is common among participating universities and colleges collapse. Morbidity and mortality are
people whose ancestry traces back to into 5 geographic regions (31). Players more strongly linked to duration of
areas of the world where malaria has were identified by position, equipment hyperthermia, as opposed to the
been common (e.g., Africa and India) worn, and the specific type of EHI they degree of hyperthermia, hence, the
and is believed to be a genetic adapta- suffered, and the researchers calculated “cool first, transport second” principle
tion acquired over generations to pro- the number of EHIs reported by ATs or (22). Immersing the athlete in cold
tect against malaria (43). One in 12 that caused players to miss practices water is the fastest method for
African Americans carries this gene between August 1 and September 30 whole-body cooling and is associated
compared with 1 in 10,000 Caucasian each year. Of the 553 cases of EHI with the lowest rates of morbidity and
Americans. The inherited trait is not reported, approximately 74% were mortality. If CWI is not available, other
7
modalities such as wet ice towels A recent death during football condi- EXERTIONAL RHABDOMYOLYSIS
placed over the entire body or tioning drills in 2018 was both tragic
cold-water dousing with or without and preventable. Based on the find- Pathophysiology. Rhabdomyolysis
fanning may be used but are not as ings reported (https://www.usmd. is a relatively uncommon but poten-
effective. Policies and procedures for edu/newsroom/Walters-Report-to- tially fatal condition characterized by
cooling athletes before transport to USM-Board-of-Regents.pdf ), it was the large-scale breakdown of skeletal
the hospital must be outlined and determined that there was a system- muscle resulting in the release of intra-
explicitly clear in the athletic depart- atic failure at every level of oversight cellular contents into the circulatory
ment’s EAP and shared with EMS res- (coaches, ATs, and university admin- system. These cellular contents include
ponders, so that treatment by all istrators). The conditioning test that myoglobin and potassium as well as
coaches, trainers, and medical profes- was conducted (and that resulted in the enzymes creatine kinase (CK), lac-
sionals involved is well-coordinated. If the student-athlete’s death) was on tate dehydrogenase, serum glutamic
the athlete’s body temperature is the initial day back from a 4-week oxalacetic transaminase, and aldolase
reduced to 1028F (38.98C) or less break, and there had been no acclima- (77,111). Release of these intracellular
within 30 minutes of symptom onset, tization period before the intense con- components causes electrolyte distur-
mortality approaches or is actually ditioning session; there was no bances such as hyperkalemia, which
zero, and most recover without serious reported record of individual fitness can lead to nausea, vomiting, mental
consequences. assessment by the strength and con- confusion, coma, and cardiac arrhyth-
ditioning staff before the conditioning mias. Rhabdomyolysis precipitates
session. When the incident occurred, acute kidney injury in 13–67% of
Guidelines for prevention. The the coaching and athletic training affected individuals and accounts for
most tragic fact surrounding EHS staff failed to recognize the severity 5–10% of all cases of acute renal failure
deaths in athletes is that the condi- of the incident and were reportedly in the United States. Urine may be
tion is entirely preventable. At the not familiar with the university’s dark, often described as tea-colored,
same time, the preventable nature of EAP; although visibly in distress, the due to the presence of the myoglobin.
EHS means there is ample opportu- student-athlete was “walked around Damage to the kidneys may result in
nity to prepare for these events and the field for 34 minutes after becom- oliguria or absent urine production,
decrease the likelihood of their ing symptomatic” for EHI; the stu- usually 12–24 hours after the initial
occurrence. The NATA, working in dent-athlete’s rectal temperature was muscle damage. These signs and symp-
conjunction with the NCAA and sev- not established nor monitored; the toms are nonspecific and may not
eral other athletic and medical or- student-athlete’s vital signs were not always be present. An elevated plasma
ganizations, published a position established nor monitored; immedi- CK level is the most sensitive labora-
statement in 2015 with specific ate and aggressive cooling of the tory marker, indicating muscle injury,
guidelines addressing the prevention, student-athlete did not occur, hyperkalemia, compartment syn-
recognition, and treatment for EHIs although ice packs and ice towels drome, and acute renal failure. These
(25). Their recommendations are de- were eventually used; cold-water are the major life-threatening compli-
signed to help strength and condi- immersion tubs were available but cations (85,94).
tioning professionals and ATs were not set-up before the practice When conditioning exercises or
maximize the health and safety of session activity nor were they used extreme physical exertion leads to
athletes as well as their performance. during the incident; the trauma bag rhabdomyolysis, it is clinically referred
However, individual responses to used for football conditioning had to to as ER. Although ER is the most
physiologic stimuli and environmen- be retrieved from the training room common diagnosis, rhabdomyolysis is
tal conditions vary widely for the rea- for treatment; there was a breakdown also associated with a number of other
sons described above (e.g., training in communication and confusion as to conditions to include crush injuries,
status, BMI, and hydration status). where staff personnel should meet hypothermia and hyperthermia, sickle
Therefore, the recommendations in EMS upon their arrival; staff person- cell trait (and other ischemic condi-
the NATA position statement do nel were not sent or directed to meet tions), snake bites, infections, medica-
not guarantee full protection from EMS at the predetermined location as tions, and inherited conditions (e.g.,
EHIs but are designed to mitigate was indicated on the university EAP. metabolic myopathies) (80). Regard-
the associated risks. Nonetheless, In summary, although the university’s less of the cause, the pathophysiology
their recommendations and preven- EAP may have met the intent of es- of muscle cell destruction follows
tion strategies should be carefully tablished guidelines, the university’s a common pathway. Damaged muscle
considered and implemented by coaching and athletic training staff cells are affected by direct cell mem-
coaches and ATs as part of an overall and administrators failed to plan, brane destruction or by energy deple-
strategy for the prevention and treat- practice, and implement best practice tion (i.e., adenosine triphosphate
ment of EHIs. guidelines. [ATP]). When Na+/K+-ATPase and
Ca2+-ATPase pumps in the cell’s mem- weight trainers who engage in high- had his athletes perform as many push-
brane become dysfunctional, excess volume training programs or hybrid ups as possible in a minute followed by
calcium begins to accumulate inside workouts that incorporate resistance as many free-standing squats in
the cell. Excessive intracellular calcium, training circuits with sprints a minute, repeating the cycle for 10 mi-
in turn, activates proteases and apopto- (12,16,28,48,49,110,113). Workouts that nutes. The conditioning session was
sis pathways. Simultaneously, the cell’s emphasize eccentric muscle contrac- followed by a strenuous swim workout,
inability to remove reactive oxidative tions also seem to place athletes at and the entire regimen was repeated
species leads to mitochondrial dysfunc- a higher level of risk for ER (29,79,121). the next 2 days. Not surprisingly, 7 of
tion (53). Collectively, these conditions One of the most publicized cases to the swimmers (males and females)
lead to muscle cell death and the date of ER occurred in January 2011 were hospitalized for ER. In 2011, it
release of the dead cell’s contents into (45,128). Two days after a 3-week win- was 3 members of a university wom-
the circulatory system as described ter break, the football team started an en’s soccer team; in 2012, it was 6
above. These guidelines will focus on intense strength training program that women’s lacrosse players; and in
the prevention, recognition, and treat- 2016, it was 8 volleyball players. Col-
included barbell snatches, pull-ups,
ment of ER. lege ROTC cadets have also been
dumbbell rows, and weighted sled
affected. In the most prominent case
drills. The most challenging task in
involving ROTC cadets, 11 of 44
Incidence. The syndrome of rhabdo- the workout was the assignment for
(25%) were hospitalized for ER after
myolysis was first described in detail athletes to perform 100 back squats
participating in a timed “extreme con-
during World War II after the Blitz of with 50% of their 1 repetition maxi-
ditioning program” that consisted of
London at which time it was associated mum (1RM) as measured at their last
a mile run, 100 pull-ups, 200 push-
with crush injuries (14). A similar con- assessment. Although the times for
ups, 300 free-standing squats, and the
dition was also reported in concentra- completing the squat workout were
completion of another mile run (113).
tion camp survivors (34). The first case not posted, the athletes were timed
of ER was reported in 1960 when 31 and may have viewed it as a competi- Collectively, the military studies and
US marines were hospitalized after per- tion. Within 1 week, 13 football players those involving college athletes indi-
forming an excessive number of squat were hospitalized with ER (their CK cate that specific factors increase the
jumps (50). More recent military studies levels ranged from 96,987 to 331,044 risk of ER to include hyperthermia,
indicate that ER occurs in up to 40% of IU/L, whereas normal levels are hydration status, whether the athlete
individuals undergoing basic training, between 22-198 IU/L). Although carries the sickle cell trait, and the
usually within the first 6 days. The mil- some of the athletes developed tran- types of supplements the athlete may
itary considers the primary risk factors sient renal dysfunction, none devel- be ingesting (www.health.mil/News/
for ER to be the trainees’ low levels of oped compartment syndrome, and all Gallery/Infographics/2017/04/04/
fitness and the introduction of repetitive were discharged within a few days as Update-Exertional-Rhabdomyolysis-
exercises (e.g., low-crawling push-ups, their symptoms subsided. This one Active-Component-US-Armed-Forces-
sit-ups, and squats). The military studies event led to the inclusion of an oblig- 2012-2016) (3,44,102). It should not be
conducted to date report that there is atory acclimatization period during surprising that ER is highly correlated
resolution of myoglobinuria (excess the initial days of preseason train- with EHI as both conditions can result
myoglobin in the blood) within 2 to 3 ing (www.iowaregents.edu/media/ when blood flow is shunted away from
days, with clinical improvement of most cms/finalreportonrhabdoincident- exercising skeletal muscle and toward
symptoms within 1 week. Also worth pdf1A6655AB.pdf ). the surface of the skin to dissipate heat
noting is that 25% of all cases of heat as the body attempts to thermoregu-
In the following year (2012), 5 football
stroke in the military between 1980 and late (16). Athletes who have the sickle
players were hospitalized after a similar
2000 were associated with ER, and that cell trait may also be at increased risk for
squat workout, with one athlete suffer-
acute renal failure developed in 33% of ER as the odd-shaped sickle red blood
ing compartment syndrome in both
those individuals (https://health.mil/ cells have a tendency to block small
quadriceps (109). In 2017, a strength vessels, leading to ischemic rhabdo-
News/Gallery/Infographics/2017/04/ and conditioning coach was sus-
04/Update-Exertional-Rhabdomyolysis- myolysis (43). Consequently, athletes
pended, and the university issued an who carry the sickle cell trait and expe-
Active-Component-US-Armed-Forces- apology on behalf of its athletic depart-
2012-2016) (1,7). rience exertional sickling may be at
ment after 3 football players were hos- a higher risk of death from ER than
Other than military recruits, college pitalized after enduring a series of those without the trait (3,44,61,65,125).
athletes returning from a period of inac- grueling strength and conditioning
tivity are the group most susceptible to workouts. Numerous athletes in
developing ER (1,3,7,44,46,82,98,102). NCAA programs other than football Symptoms and treatment.
It has also been reported in bodybuild- have been hospitalized for ER. In Although mild cases may not cause
ers, marathon runners, and recreational 2007, for example, the new swim coach symptoms, most athletes with ER
9
experience a common set of com- heart and other vital organs. In the Certainly, one of the challenges during
plaints (115,136). Most symptoms event that compartment syndrome the training of athletes is the design
appear within hours to days after the threatens muscle death or nerve dam- and application of the appropriate
condition develops. Common symp- age, a surgical procedure (fasciotomy) exercise, volume, intensity, and rest
toms include muscle pain that is often can be used to relieve tension or pres- that will maximize performance
aching and throbbing, muscle weak- sure and loss of circulation. enhancement while minimizing the
ness, muscle swelling or inflammation, likelihood of exercise-induced injuries.
dark- or cola- or tea-colored urine, gen- Guidelines for prevention. All the This includes the identification of
eral exhaustion or fatigue, irregular studies on ER referenced above share symptoms specific to ER, EHIs, and
heartbeat, dizziness, light-headed, or a common set of core characteristics. cardiac issues due to pre-existing
feeling faint, confusion or disorienta- All involve athletes or military train- health conditions and genetic factors,
tion, nausea or vomiting. A secondary ees/cadets performing a high volume as mentioned earlier in this article. It
condition called compartment syn- of submaximal resistance exercises or also requires clear, standardized train-
drome may occur after intravenous body weight exercises (push-ups, ing guidelines for new, returning, and
(IV) fluid is administered. This second- pull-ups, etc.) to fatigue and/or in post-ER/EHI athletes (122,133).
ary condition causes the compression a limited time frame. Most cases of Although no preventive intervention
of nerves, blood vessels, and muscle, ER cited above occur when an individ- will eliminate all risk, following a stan-
and can result in additional tissue dam- ual is exposed to a novel workout reg- dardized plan can minimize the risk
age and problems with blood flow. imen or following a period of inherent during transition periods.
Medical attention should be sought detraining (i.e., returning from winter The mission of this CSCCa/NSCA
any time an athlete presents with or summer break). Many occur in hot Joint Committee is to provide
symptoms associated with ER. environmental conditions or in train- evidence-based guidelines for training
Untreated cases can become serious ing facilities that have poor climate to decrease the risk of ER, EHIs, and
and may cause life-threatening compli- control. Athletes who are dehydrated cardiovascular-related incidents fol-
cations such as kidney failure or liver and/or carry the sickle cell trait are at lowing inactive periods. These guide-
problems. Blood tests for CK, a product increased risk. Finally, most cases lines should also apply to ‘optional’
of muscle breakdown, and urine tests involving college athletes were caused practices and workouts.
for myoglobin can help diagnose rhab- by a new or an overzealous coach
There are 3 scenarios that need to be
domyolysis (although in half of the ath- using exercise as punishment or trying
considered following a period of inac-
letes with ER, the myoglobin is to build “mental toughness” (46,109).
tivity. The first scenario is for returning
negative). Additional tests may be More often than not, it is a combination
athletes who have experienced a 2-
administered to rule out other prob- of these factors that results in athletes
week break or longer or for student-
lems or be used to check for being hospitalized for rhabdomyolysis.
athletes who are beginning under
complications. To maximize prevention strategies,
a new head sport coach. It should be
every strength and conditioning coach
Treatment depends on the severity of noted that these programming guide-
and his or her staff members, and all
the case, symptoms, and presence of lines should be applied to student-
ATs should be educated about ER, the
additional health complications that athletes in all sports. The second sce-
causes and symptoms, and engage in
may increase the risk of kidney damage. nario is for new athletes such as fresh-
best practices for preventing it.
In severe cases, kidney damage can be man or transfer student-athletes that
irreversible without early treatment. are coming off a period of inactivity,
RETURN TO TRAINING DURING
Hence, early diagnosis and treatment TRANSITION PERIODS or all student-athletes who are begin-
are critical for a successful recovery. In February 2018, the NCAA Chief ning under a new head strength and
Athletes who develop the symptoms Medical Officer, Brian Hainline, issued conditioning coach. The third scenario
associated with ER need to be quickly a set of guidelines recognizing that pe- is for student-athletes returning to
admitted to the hospital. Treatment riods where athletes have undergone training after an incident of ER or
with IV fluids helps maintain urine pro- significant detraining increase the like- EHI. This final scenario will involve
duction and prevent kidney failure. lihood of injury resulting from training. a 6- to 8-week rehabilitation program
Large volumes of water are often The guidelines recommend that dur- (117) to provide the reintroduction and
administered to rehydrate the body ing this time as athletes transition back progression of physical stress to the
and flush out any myoglobin. Dialysis into training, workouts should have student-athlete.
may be necessary to help the kidneys lower work-to-rest ratios and progress The Joint Committee recommends
filter waste products while they are gradually up to full intensity. In addi- that prescription of conditioning drills
recovering. Management of electrolyte tion, workouts should be documented after the period of inactivity follows
abnormalities (e.g., potassium, calcium, and made available for administra- a schedule of reduced volume or work-
and phosphorus) helps protect the tive staff. load adhering to the 50/30/20/10 rules

Table 2
Overview of recommended guidelines for training after transition periods
Status Conditioning activities Testing Weight training Plyometrics

Midseason Conditioning program on file with appropriate sport administrator
athletes
Returning 50/30% weekly reduction 20/10% weekly reduction in FIT rule to guide ,70 foot contacts per session
athletes from max conditioning workload (volume, volume, intensity, and first week, 1:4 W:R. ,100
or new volume on file over 2 intensity, or rest time) for W:R ratio over 2 foot contacts/session, 1:3
sport weeks. Even any tests over 2 weeks. weeks. IRV between W:R second week. Intensity
coach distribution per week. 11 and 30 (Tables 7 as appropriate.
and 8).
New 50/30/20/10% weekly 50% reduction in testing FIT rule to guide ,70 foot contacts per session
athletes reduction from max volume, completed on first volume, intensity, and first week, 1:4 W:R. ,100
or new conditioning volume day. 30/20/10% weekly W:R ratio over 2 foot contacts/session, 1:3
head on file over 4 weeks. reduction in test volume if weeks. IRV between W:R second week. Intensity
strength Even distribution per repeated in following 3 11 and 30 (Tables 7 as appropriate.
coach week. weeks. and 8).
Return 50/30/20/10% weekly 50% reduction in testing Gradual increase over 5 ,80 foot contacts per session
from ER, reduction from max volume, completed on first weeks (Table 9), at low intensity, 1–2
EHI, or conditioning volume day. 30/20/10% weekly followed by FIT rule sessions per week, gradual
long on file over 4 weeks. reduction in test volume if limitations for 1 week. increase in foot contacts
inactivity Even distribution per repeated in following and intensity over 5 weeks
week. weeks. (Table 10)
EHI 5 exertional heat illness; ER 5 exertional rhabdomyolysis; IRV 5 intensity relative volume.
for a 2-week period (for returning of training and should be performed The 50/30/20/10 rules and the FIT
athletes/new head sport coach), or at 50% of the test volume on file with rule will ensure that strength and con-
a 4-week period (for new athletes/ the administrator with a 1:4 or ditioning coaches are evaluating their
new head strength and conditioning greater W:R. In the case of an athlete programs to be certain that student-
coach). These are summarized in returning from a period of inactivity athletes return to training in a safe,
Table 2. These rules provide a recom- of 2 weeks or more, the reduction in effective manner. These guidelines are
mended percentage weekly reduc- conditioning volume would be at meant to protect student-athletes in all
tion of volumes and/or workloads least 50% in the first week, and then sports, but also strength and condition-
for conditioning and testing in the 30% in the second week, returning to ing coaches and universities without
first 2–4 weeks of return to training, standard loads thereafter. Any testing stifling the expertise, autonomy, and
based on the uppermost volume of would be performed at a 20% reduc- creativity of the strength and condi-
the conditioning program. This con- tion in the workload (through reduc- tioning coach. These rules, used during
ditioning program should be submit- tions in volume, intensity, or rest the first 2–4 weeks of mandatory train-
ted to an appropriate sport time) if completed in the first week ing after a period of inactivity, give
administrator before the return to and a 10% reduction if completed in every strength and conditioning coach
training. For example, with a new the second week. Furthermore, the a standardized roadmap, much like
athlete entering the program, the FIT rule (frequency, intensity vol- ATs have with the concussion proto-
conditioning volume for the first ume, and time of rest interval) out- col. The recommendations are based
week would be initially reduced by lines the recommendations for on research on detraining showing that
at least 50% of the uppermost condi- resistance training during these tran- reduced activity can lead to decreases
tioning volume on file, and by 30, 20, sition periods. The following para- in muscle strength (2,32,59,131), aero-
and 10% in the following 3 weeks, graphs and associated tables bic capacity (73,127,130,131), anaero-
respectively, with a 1:4 or greater describe the application of these con- bic capacity (73,93,137), and induce
work:rest ratio (W:R) in the first cepts. Note that each coach may skeletal muscle atrophy
week, and a 1:3 W:R or greater in decide to reduce the volume and/or (32,59,78,100,101,132). These decre-
the second week (21). For these intensity by a greater amount based ments are seen in a wide range of ages
new athletes, a conditioning test on environmental conditions and/or (2,67,78,105,135), potentially inducing
must be completed on the first day individual athletes’ needs. injury or illness. Although some studies
11
Table 3 tests may vary from program to pro-

Reductions in workload for team-based field sport repeat sprint ability (RSA) gram but should fall in line with estab-
test lished standards by sport and skill level
(e.g., Division I athlete). Standardized
Week (reduction %) Volume Intensity (s) Rest time (s) tests and norms for different athletes
Week 1 volume (20%) 230 yds 6–8 45 can be found in the NSCA’s Guide to
Tests and Assessments (97). Coaches
Week 2 volume (10%) 260 yds 6–8 45 should apply these changes in inten-
Week 3 volume (normal) 285 yds 6–8 45 sity, volume, or both to the standards
they have set for their given program as
maximal capacity expected of the ath-
indicate that previously trained athletes from the uppermost volume on file in lete for each conditioning drill.
undergoing short periods of detraining week 1 with a 1:4 or greater W:R and
(1–4 weeks) do not exhibit a large de- 30% in week 2 with a 1:3 or greater RETURN TO TRAINING 50/30/20/10
training effect (51,59,72,78,106,124), W:R. For example, if the total condi- CONDITIONING RULE FOR NEW
the preponderance of evidence sup- tioning volume for football athletes is ATHLETES, OR PROGRAMS WITH
A NEW HEAD STRENGTH AND
ports at least a brief period of lower 4,000 yards per week, this should be CONDITIONING COACH
workload to offset detraining effects reduced to no more than 2,000 yards On entry into a program, new athletes
that might appear, especially with lon- in the first week and a maximum of (freshmen or transfers) may not be
ger periods of inactivity. 2,800 yards in the second week during physiologically prepared for the de-
the transition period. The daily volume mands of testing or training after
RETURN TO TRAINING 50/30/20/10 must be reasonably distributed over 2 a period of detraining. Two to 4 weeks
CONDITIONING AND TESTING or more days per week to avoid injury. of detraining can result in decreases in
RULE FOR RETURNING ATHLETES
If conditioning testing is completed, aerobic and anaerobic performance
OR PROGRAMS WITH A NEW
HEAD SPORT COACH then the workload (whether through (73) with associated decreases in cap-
Retraining following short detraining intensity, volume, rest time, or a com- illary density and blood volume (100).
periods can induce restorative im- bination) should be reduced by 20% in Likewise, brief detraining periods result
provements in aerobic and anaerobic the first week and 10% in the second in only small decreases to strength (71).
performances (73,100,127), as well as week. Because of the reduction in However, longer periods of inactivity
muscular strength and hypertrophy workload, there is no mandate to (including a lack of in-season training)
(67,105,106,132,134). Retraining is change the W:R for these testing ses- result in much larger strength losses
especially effective for developing mus- sions. Tables 3–6 outline examples of (58,83,123), and thus, the retraining
cle strength and hypertrophy as there application of the rules for testing of process must be undertaken with more
is evidence that the myonuclei ob- returning athletes. For example, the caution. Understanding timelines asso-
tained during hypertrophy are main- application of a standard repeat sprint ciated with the degree of detraining
tained even during extreme atrophy ability (RSA) test with duration of 6–8 and retraining provide a justification
(13,55). Myonuclei serve as required seconds should consist of 45-second for reduced volume and/or intensity
machinery for muscle growth, thus rests between bouts, and in the case of training when embarking on a new
a greater number of myonuclei facili- of team-based field sports, should not program or resuming training during
tate the restoration of skeletal muscle exceed a weekly sprint volume of 285 transition periods.
mass lost during inactive periods. Fur- yards in the first 2 weeks of condition- Because the detraining period and
thermore, studies involving humans ing (66). The 20% and 10% reductions physiological conditioning will vary
(8,41,52) and rats (10) have shown ini- would result in a sprint volume of from athlete to athlete and will be
tial training and/or retraining enhances approximately 230 and 260 yards, especially unknown for athletes with
myocardial morphology and function. respectively, before reaching the 285 no previous history or test results in
Therefore, a 2-week transition period yards (Table 3). Exercise-induced mus- the program, the Joint Committee
of decreased workload should be suffi- cle damage in the form of delayed- mandates a safety precaution consist-
cient to allow athletes to fully recover onset muscle soreness has been shown ing of a minimum 50% reduction in
any loss in strength or metabolic capa- to result in decreased performance in volume from the uppermost condi-
bilities following inactivity. However, RSA (37), and this is taken into account tioning volume on file in week 1, and
extra caution should be exercised when with the reduced workload in the first 2 30, 20, and 10% reduction in the fol-
assigning volume loads for returning weeks under these guidelines. Addi- lowing 3 weeks, respectively. A 1:4 or
athletes. Therefore, the Joint Commit- tional examples of options for reduc- greater W:R should be used for week
tee recommends that weekly conditions in testing workload can be seen 1, and a 1:3 or greater W:R for week 2.
tioning volume be reduced by 50% in Tables 4–6. The standards for these For these new athletes, conditioning

Table 4 in volume over a 4-week period before
Options for reductions in workload for 110-yard sprint test for American a return to regular training. Overall, this
football (101) return to training for a student-athlete
after release from the medical staff may
Week Options for reduction (%) Repetitions Intensity (s) Rest time (s) be a 6- to 8-week period to provide ade-
Week Volume (20%) 13 15 45 quate time to build a strength and con-
1 ditioning base (117). The progression of
conditioning and weight training must
Intensity (20%) 16 18 45 take into account managing of training
Rest time (20%) 16 15 54 load, recovery, and fatigue to reduce the
chance of reinjury (129), more specifi-
Intensity (10%) and rest time 16 17 50
cally a reoccurrence of ER and EHI.
(10%)
Week Volume (10%) 14 15 45
FIT RULE FOR WEIGHT TRAINING
2
ACTIVITY
Intensity (10%) 16 17 45 Return to weight training during a tran-
sition period following a period of active
Rest time (10%) 16 15 50
rest or minimal training requires atten-
Intensity (5%) and rest time (5%) 16 16 47 tion to the physical stress applied to
incoming and returning athletes. In the
Week Normal 16 15 45
3 first 2 weeks, the strength and condition-
ing coach should be cognizant of the
Example provided is for skill positions. Baseline intensity for linemen is 18 seconds. type of training stimulus, volume, inten-
sity, frequency, and the potential risk for
each student-athlete. The FIT rule is de-
testing must be completed on the first while a 1-week phase II begins the use signed to ensure that frequency, intensity
day of return to training and should be of aquatic exercises and warm-up exer- relative volume (IRV), and time of rest
performed at 50% of the standard vol- cises. Phase III adds resistance exercises interval are appropriately administered
ume of the test on file with the admin- performed with body weight only, core to minimize the chance of severe muscle
istrator, using 1:4 or greater W:R. training, stretching, and addition of sta- damage.
Although not mandatory, testing may tionary cycling on the fourth day. Finally, Frequency is defined as the number of
be repeated but should follow the rule phase IV introduces resistance training training sessions completed per week
for conditioning activities, with a 30/ with 20–25% of estimated 1RM, agility for a specific muscle group or move-
20/10% weekly reduction in volume at exercises and running (122). These 4 ment type (95). For example, the
standard intensities and rest times. phases follow the progression of physical student-athlete might train a total of 5
function after injury as outlined by Cart- days in the week, but only train lower
THE 50/30/20/10 CONDITIONING wright and Pitney (17) that includes an 8- body for 3 days, so the frequency for
RULE FOR RETURN TO TRAINING step plan of (a) mobility, (b) flexibility, (c) lower-body movements would be 3.
AFTER LONG INACTIVITY, proprioception, (d) muscular strength,
EXERTIONAL HEAT ILLNESS, OR The strength and conditioning coach
EXERTIONAL RHABDOMYOLYSIS (e) muscular endurance, (f) muscular must use discretion on how to distribute
The return to training recommendations power, (g) cardiovascular endurance, training exercises to meet the frequency
that have been previously outlined apply and (h) sport-specific function. Once parameter for each muscle group or
to student-athletes who are free of the student-athlete completes the 4 movement type. It is recommended that
a recent ER or EHI incident that pre- phases and has been released to the frequency not exceed 3 days in the first
vented them from training, but for strength and conditioning coach, it is week following a period of inactivity and
student-athletes who have suffered seri- the coach’s responsibility to continue no more than 4 days in the second week.
ous injury, EHI, or ER, the recovery is the progression. The monitoring of the IRV is a derivation of volume load that
more difficult. The time frame a student- student-athlete’s recovery and program includes the %1RM (95,107,138) and is
athlete may be removed from training effectiveness during the return to training calculated with the following equation:
and practices may vary, but once he or is critical for effective physical adapta- Sets 3 Reps 3 %1RM as a decimal
she is released from hospitalized medical tions (118). The strength and condition-
care, the return to training process can ing coach will continue with the gradual
5 IRV units:
begin. Schleich et al. (122) outlined a 4- increase in volume of conditioning drills
phase approach with phase I being 2 and weight training following The strength and conditioning
weeks of activities of daily living only, a minimum 50/30/20/10% reduction coach has a wide range of set and
13
Table 5 periods. After reviewing the informa-

Options for reductions in workload for 60-yard shuttle test for collegiate tion in Table 8, coaches should begin
basketball: 18 total reps divided among 3–4 sets, 12 seconds to complete, 45 to evaluate the periodized lifts in their
seconds rest between reps, and 90 seconds between sets current programs, which they may
find already fall within the designated
Week Options for reduction (%) Repetitions Intensity (s) Rest time (s) guidelines.
Week Volume (20%) 14 12 45
1 TRIPLE EXTENSION EXERCISES
Triple extension exercises (e.g.,
Intensity (20%) 18 14 45
cleans, snatches, etc.) are unique in
Rest time (20%) 18 12 54 their demands on the body.
Although there has been no known
Intensity (10%) and rest time 18 13 50
(10%) research on volume limits for triple
extension exercises, and although no
Week Volume (10%) 16 12 45 cases of ER have been reported due
2 to a high volume of loaded triple
Intensity (10%) 18 13 45 extension exercises, precautions
should still be taken to avoid unnec-
Rest time (10%) 18 12 50 essary risk. Strength and condition-
Intensity (5%) and rest time (5%) 18 13 47 ing coaches who do use triple
extension exercises in their student-
Week Normal 18 12 45 athletes’ programs should subscribe
3
to best practice protocols in terms of
volume, intensity, and W:R ratio.
Based on best practices, the Joint
rep combinations or manipulations programs or hybrid workouts that
Committee recommends that for all
that can be used in his or her stu- incorporate resistance training circuits triple extension exercises, IRV
dent-athlete’s training program. A sys- with sprints. In most of the cases of ER should not exceed 25 units in the first
tematic review by McMaster et al. (95) in student-athletes referenced earlier, 2 weeks during transition periods. In
indicates that IRVs between 11 and 20 student-athletes were subjected to addition, daily total volume as
provide the greatest strength increases, a W:R of 1:1 or less. Additional rest defined by sets 3 repetitions in these
whereas IRVs between 21 and 30 pro- time, however, is necessary as it allows exercises should not exceed 50 rep-
duce strength increases that are some- the cardiorespiratory and circulatory etitions while weekly total volume
what lower. An IRV below 11 may not system to deliver oxygen to muscles should not exceed 125 repetitions
be adequate to improve strength. and reduce the potential for muscle in week 1 and 150 repetitions in
Therefore, the Joint Committee recom- cell damage. Consequently, based on week 2.
mends an IRV between 11 and 30 for the W:R guidelines provided in the
a specific muscle group or movement Inter-Association Task Force for Preventing PLYOMETRIC EXERCISES
type. IRVs of greater than 30 are con- Sudden Death in Collegiate Conditioning Although loaded triple extension exer-
traindicated in the 2 weeks following Sessions, the Joint Committee recom- cises are traditionally used for develop-
period of inactivity. Table 7 provides mends that all weight training activity ing power, many programs use
practical examples of how to apply use a 1:4 or greater W:R during week 1 plyometric exercise as the primary
IRV to a weight training program. Each and a 1:3 or greater W:R during week 2 method of training to improve power
strength and conditioning coach will (21). The rest provided during more in student-athletes. These exercises
use his or her own judgment regarding traditional strength training will be should also be monitored and docu-
limitations on the return to training much greater, but this minimum stan- mented by the strength and condition-
program. The options presented are dard will provide protection for ing coach in the first 2 weeks following
meant to illustrate the freedom for var- student-athletes engaging in high- periods of inactivity. Applying the FIT
ious styles of programming within the volume/high-intensity training ses- rule to plyometric exercise may be
FIT rule. sions. The Joint Committee recom- more challenging because of differen-
Time of rest interval, also known as mends that strength and conditioning ces in body mass and relative strength
work-to-rest ratio (W:R), is a vital coaches follow the parameters outlined levels, but an estimate could be ob-
component that must be considered by the FIT rule in Table 8 to further tained using the 50/30/20/10 rule.
in reducing the risk of ER in student- protect student-athletes against the For example, based on previously
athletes. As described earlier, ER is increased risk of ER during their return accepted volume recommendations of
often related to high volume training to regular training during transition 120–140 foot contacts for in-season

Table 6
Options for reductions in workload for half gasser test for collegiate softball: 20 reps, 106 yards per rep (sprint distance is
53 yards one direction), 19 seconds to complete 1-repetition, 1-minute rest
Week Options for reduction (%) Repetitions (yards) Intensity (s) Rest time
Week 1 Volume (20%) 16 (1,696) 19 1 min

Intensity (20%) 20 (2,120) 23 1 min
Rest time (20%) 20 (2,120) 19 1 min 12 s
Intensity (10%) and rest time (10%) 20 (2,120) 21 1 min 6 s
Week 2 Volume (10%) 18 (1,908) 19 1 min
Intensity (10%) 20 (2,120) 21 1 min
Rest time (10%) 20 (2,120) 19 1 min 6 s
Intensity (5%) and rest time (5%) 20 (2,120) 20 1 min 3 s
Week 3 Normal 20 (2,120) 19 1 min
athletes (112), plyometric workouts in ADDITIONAL CONSIDERATIONS coach to individualize testing for these
the first 2 weeks should not exceed 70- FOR WEIGHT TRAINING RETURN student-athletes. Therefore, the initial
foot contacts in week 1 and 100 in FROM EXERTIONAL tests in the weight training program
RHABDOMYOLYSIS AND
week 2 for the average-sized athlete, should assess all muscle groups that
EXERTIONAL HEAT ILLNESSES
using exercises of an intensity deter- will be tested on unrestricted return
Testing the student-athlete’s muscular
mined by the strength and condition- to training. The tests for strength and
strength and power levels after ER and
ing coach. This should be modified for power would count as a training ses-
EHIs requires attention to the eccen-
athletes with higher body mass or ath- sion in the first week because the load-
tric muscle contractions as they are
letes with lower than average strength ing will be stressful on the recovering
precursors to ER in particular (42).
levels, at the strength and conditioning muscles. After a hiatus from strength
Before unrestricted weight and power
coach’s discretion. Returning athletes and conditioning as result of ER/
training, student-athletes need to first
can engage in normal volumes in EHI, the inclusion of weight training
return to baseline muscular strength or
weeks 3 and 4 while new athletes that emphasizes or incorporates an
power levels. This can be based on test
should follow a 20/10% reduction dur- eccentric muscular contraction must
results for the athlete before the injury.
ing that time. The time of rest interval be gradually reintroduced because
Strength and power levels vary per
for plyometric exercises should have eccentric training has been accepted
sport, athlete position, training age,
as a mechanism that increases the
a 1:4 or greater W:R in week 1 and and previous injury history, thus
chance of muscular damage that may
a 1:3 or greater W:R in week 2. requiring the strength and conditioning
result in temporary decreases in phys-
ical performance (37,81,96,119). The
appropriate and consistent application
Table 7 of eccentric training, however, can
Intensity relative volume (IRV) practical examples in the first 2 weeks after increase physical performance
a transitional period (96,139) and should be included as
Example Sets Repetitions % 1RM IRV units Range level soon as tolerated by the athlete. These
student-athletes returning to training
1 3 12 0.65 23.4 Acceptable after ER or EHIs should be treated
2 5 10 0.60 30.0 Acceptable as beginning athletes that have no
experience with any weight training
3 5 8 0.70 28 Acceptable activities and should follow previously
4 8 5 0.75 30.0 Acceptable described guidelines (126). After the
testing sessions, frequency should
5 10 10 0.50 50 Much too high begin with only 2 weight training ses-
Includes warm-up sets. sions in the first and possibly second
week, progressing to 3 times a week
RM 5 repetition maximum.
(126). If muscle soreness dissipates
15
Table 8
The FIT rule
Category Week 1 parameter Week 2 parameter Citation

Frequency 3 sessions/wk maximum 4 sessions/wk maximum McMaster et al., (95)
IRV 11–30 units 11–30 units McMaster et al., (95)
Time rest interval 1:4 W:R minimum *1:3 W:R minimum Casa et al., (25)
*W:R ratio after 2 weeks should be a minimum of 1:2 for the remainder of the preseason (21).
IRV 5 intensity relative volume.
within 48 hours after the end of the intensity, as higher intensity exercises the same guidelines as those of
weight training session, then higher usually involve significant eccentric student-athletes returning from active
training frequency may be included. activity. Before the addition of any rest period. After 14 days or more of
Rest periods between sets in these first plyometric exercises, student-athletes detraining (with no activity as could be
2 weeks of training after ER should be should be free from muscle soreness the case for an athlete returning from
at minimum 5 minutes for strength and after linear sprint sessions. The ER), athletes may demonstrate decre-
power development (126). Table 9 pro- strength and conditioning coach’s ments in strength performance,
vides a possible progression for decision to include plyometric and whereas active rest periods of adequate
student-athletes returning from ER. agility exercises, and the rate progres- training volume or intensity may pre-
The decision to include plyometrics, sion of such, should be carefully con- vent a decrement (68,71). For those
speed, and agility exercises should sidered for each student-athlete and recovering from ER, physical perfor-
meet the criteria previously established may not coincide with their weight mance increases should follow the
for the beginner level inclusion for training regimen. Once linear sprints guidelines outlined by Schleich et al.
these activities (e.g., back squatting can be performed without increased (122) and described earlier in this doc-
1.5 times body weight (35,112)). For muscle soreness and the student- ument, or an equivalent protocol
student-athletes returning from ER/ athlete is able to perform them at their deemed safe by the sports medicine
EHIs, plyometric exercise volume previous training volumes, then agility staff. Once this protocol is completed
should be no more than 70-foot con- and change of direction drills can be and the athlete is released by the sports
tacts in the first week and gradually added. The FIT rule will be applied medicine staff, the 50/30/20/10 rule
increased to 100-foot contacts depen- to these student-athletes only after and FIT rule should be followed.
dent on muscle soreness (Table 10) they have achieved baseline levels for Student-athletes returning from ER
(112). The intensity classifications as all strength and power tests. or EHIs will need continued monitor-
described by Potach and Chu (112) will The progression of a strength and con- ing for injury reoccurrence and may
allow strength and conditioning ditioning program for a student-athlete require a greater amount of time to
coaches to appropriately adjust recovering from ER does not follow develop a level of physical fitness that
Table 9
Suggested weight training progression for return to training after exertional rhabdomyolysis
Week Sets Set volume (repetitions) Intensity (% of 1RM) Rest time (min) Frequency (d)
1 1–2 5–6 Light (,75%) 5 1–2

2 2–3 5–8 Light (,75%) 3–5 1–2
3 2–3 3–6 Moderate (75–85%) 3–5 2–3
4 2–5 2–6 Moderate (75–85%) 2–5 2–3
5 2–5 1–6 Mod. heavy (85–90%) 2–5 2–5
6 FIT rule applied
RM 5 repetition maximum.

Table 10 testing protocols and training pro-
Plyometric training progression for return to training after exertional grams and provide documentation to
rhabdomyolysis the designated athletic administrator
or university compliance officer. The
Week Session volume Intensity Rest time (min) Frequency (d) documentation and submission of
(foot contacts) these assessments and training pro-
1 70 Low 5 1–2 grams is the minimum requirement,
and more precise monitoring and doc-
2 80–100 Low 3–5 1–2
umentation of athletes’ fitness level,
3 80 Moderate 3–5 2–3 health status, hydration level, and use
of medications and dietary supple-
4 80–100 Moderate 2–5 2–3
ments is strongly recommended.
5 80 High 2–5 2–5 Strength and conditioning coaches
may elect to be more conservative in
6 FIT rule applied
their exercise prescription based on
Intensity is classified as low, moderate, or high based on vertical displacement, leg support, individual athletes’ needs or environ-
velocity of movement, etc., as described by Potach and Chu (112). mental conditions. If there is an inci-
dent of ER, EHI, or a cardiovascular-
can accommodate higher training vol- or lower volume (e.g., distances com-
related event, the NCAA can begin the
umes and intensities (86,100,114). pleted) for those athletes. Furthermore,
investigation by consulting the docu-
Satkunskiene et al. (119) suggest that
mentation provided to the compliance
running technique may be slightly
TESTING FOR RETURN TO officer and by interviewing the student-
TRAINING altered after acute muscle damage, and
athletes involved. As a profession,
that consequently, coaches should note
It is paramount that strength and con- strength and conditioning coaches
and monitor any changes in running
ditioning coaches establish new base- stand at a crossroads and need to be
technique. Anaerobic baseline tests
line testing values and compare them proactive in effecting change in the
should be specific to each sport and
with established norms or previous training of all student-athletes.
appropriate for the student-athlete re-
baseline values. Szczepanik et al. Strength and conditioning coaches
turning to training. It is of paramount
(133) address the need of identifying must continue to develop profession-
importance that the strength and con-
these student-athletes that are high risk ally with the intent of decreasing neg-
ditioning coaching staff closely moni-
for ER and would require screening by ative outcomes of student-athlete
tor the athletes during these tests for
medical staff during initial entry into training. The intent of these guidelines
signs of distress, curtailing the test if
a collegiate sports program. It is rec- is to provide clear parameters to
appropriate. The nature of ER requires
ommended that the strength and con- decrease the risk of issues such as
that the conditioning be individualized
ditioning coach register a standard ER, EHIs, and cardiovascular-related
as the recovery period will vary with
conditioning test for athletes of a given incidents through guidelines for
each student-athlete and his or her
sport with the appropriate administra- coaches in the first 2–4 weeks of man-
speed of adaptation (30,42).
tor. As dictated by the 50/30/20/10 datory strength and conditioning train-
rule for athletes returning from ER, ing following periods of inactivity. The
EHI, or long-term inactivity, testing CONCLUSION 50/30/20/10 rules for conditioning
should be performed at 50% of the reg- The implementation of the new activities and the FIT rule for weight
istered test volume. If these student- CSCCa and NSCA guidelines to training will help strength and condi-
athletes are returning after a bout of include the documentation of testing tioning coaches evaluate their pro-
ER, this new test will provide informa- and training programs is essential for grams and administer them in a safe
tion on the amount of change (if any) the prevention of EHIs, ER, and inju- and effective manner.
that needs to be addressed in training. ries related to preexisting cardiorespi-
For example, if a coach normally uses ratory conditions or genetic factors. SUMMARY
a repeated 300-yard shuttle test with Substantial evidence indicates that stu- Based on the information presented in
a 2-minute rest to assess the percentage dent-athletes are at a significantly these consensus guidelines, the Joint
of change between the first and second greater risk when they return to train- Committee representing the CSCCa
test, he or she would instead use a single ing following a period of inactivity, and the NSCA provides the following
300-yard test. A poor performance on during the active recovery phase fol- collective recommendations:
this test compared with data on file or lowing an injury, or when there is It is critical for the strength and con-
normative data would require the a change in coaching staff. The ditioning coach to have access to
strength and conditioning coach to strength and conditioning staff should preparticipation medical evaluations
assign longer recovery (3–5 minutes) carefully plan, implement, and evaluate (PME). Look for “red flags” on
17
pre-existing conditions (i.e., sickle accessible. In addition, athletes Finally, it is strongly recommended
cell trait), that would put specific should be allowed to acclimatize to that all workouts be preplanned, so
athletes at risk. It is also important extreme environmental conditions that a written copy is logged for each
for the strength and conditioning through progressive conditioning. day. Once planned, the strength and
coach to be aware of acute illnesses, The head strength and conditioning conditioning staff and/or sports
medications (both prescriptions and coach should record a written con- coaches should not exceed this level
over the counter drugs), and nutri- ditioning program that is considered of volume and intensity. Training
tional supplements athletes may be the upper limit for conditioning vol- should not be used as a punishment
taking, (including preworkout drinks), ume. This will be used, depending on or to test the commitment and/or
and side effects of those supplements the status of the athlete, to determine mental toughness of the athletes.
during exercise. the maximum allowable limits using These recommendations are not
It is critical for the head strength and the 50/30/20/10 rules in the first 2– exhaustive and do not address every
conditioning coach to have a written 4 weeks of training after periods of type of injury that can occur in all
emergency action plan (EAP). Every inactivity, as outlined in these guide- sports. It is the responsibility of each
member of his or her staff should be lines. In addition to the 50/30/20/10 coach to use good judgment in design-
aware of the plan and know his or rules for returning and new athletes, ing a safe and effective training pro-
her role in performing the plan in an programs should adhere to the FIT gram for his or her athletes. It is the
emergency situation. It is recom- rule for resistance training. hope of the Joint Committee that fol-
mended that an in-service practice Student-athletes who are new to the lowing these guidelines will signifi-
run of the procedure be performed training program (freshmen and cantly reduce the likelihood of
annually, at minimum. transfers) or returning from injuries preventable deaths and debilitating in-
All strength and conditioning should be tested to determine their juries from strength and conditioning
coaches should have proper educa- current level of fitness. The test will activities.
tion, experience, and an NSCA-/ be determined by the head strength
CSCCa-approved certification. It is Conflicts of Interest and Source of Funding:
and conditioning coach, but the stan- The authors report no conflicts of interest
also recommended to partner and
dard tests that are used in the pro- and no source of funding.
communicate with recognized pro-
gram should be registered with the
fessional organizations to review ACKNOWLEDGMENTS
appropriate athletics administrator.
and implement best practices to The authors, CSCCa, and NSCA
It is recommended that the strength
ensure the safety of all student- would like to acknowledge the contri-
and conditioning coach use 50% of
athletes. This includes working butions of the following individuals in
the volume of these standard tests
closely with sport coaches, sports the completion of this project: Riley
for athletes who are new to the train-
medicine personnel, and administra- Allen (University of Mississippi); Scott
ing program or returning from injury.
tive staffs.
Once an appropriate conditioning Bennett (Radford University); Jennifer
All strength and conditioning
program is determined for new ath- Jones (Purdue University); Ken Man-
coaches must know the early signs nie (Michigan State University); Scott
and symptoms of exertional injuries letes, the volume should not be
increased by more than the recom- Sinclair (University of Georgia); and
outlined in this article. This includes Brent Feland (Brigham Young
exertional heat illness (EHI), exer- mended amount per week. For ath-
letes returning from EHI or ER, the University).
tional rhabdomyolysis (ER), and
other cardiac-related issues that can progression should follow the rec-
occur during training. All strength ommendations outlined in this doc-
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CSCCa and NSCA Joint Consensus Guidelines For Transition Periods

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ABSTRACT GUIDELINES PROVIDE STRENGTH org/sport-science-institute/ncaa-injury-

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Status Conditioning activities Testing Weight training Plyometrics

Table 3 tests may vary from program to pro-

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Table 5 periods. After reviewing the informa-

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Week 1 Volume (20%) 16 (1,696) 19 1 min

Category Week 1 parameter Week 2 parameter Citation

IRV 5 intensity relative volume.

1 1–2 5–6 Light (,75%) 5 1–2

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