The opportunity to take part in the medical care and performance enhancement training of athletes is greater than ever before. Professional teams, educational and health care institutions, and private facilities are evolving, and employing strength and conditioning professionals, health care specialists, sports scientists, nutritionists, etc. to assist athletes in achieving their optimal level of performance on the field of play. When an unfortunate incident occurs and an athlete is injured, requires surgery, or presents with physical irregularities, they likely will require medical care, as well as physical rehabilitation. In recent years, the medical professions of orthopedic sports medicine and sports rehabilitation have placed a strong professional emphasis on injury prevention and return to play at preinjury levels of performance.
Planning for the athlete’s performance enhancement training and sports rehabilitation program design should include a proven philosophical foundation that will result in a successful outcome. It is acknowledged that certain athletes are genetically more physically gifted than others—i.e., strength levels, elastic abilities, etc. That stated, this blog post will present a brief narrative of a performance enhancement training philosophy and foundation founded years ago by my good friend and one of my mentors, Hall of Fame (HOF) strength and conditioning coach Al Vermeil.Planning for an athlete’s performance enhancement training and sports rehab program design should include a proven philosophical foundation that will result in a successful outcome. Click To Tweet
During his illustrious career, Coach Vermeil has attained seven World Championship rings and is the only S&C coach to win world championships in two different American professional sport leagues, the National Football League and National Basketball Association. His “Hierarchy of Athletic Development” has been recognized and utilized by S&C professionals around the world, including additional HOF S&C coaches who have secured national and world championships as well.
Our practice has also modified and adapted Coach Vermeil’s hierarchy as a foundation in our sports rehabilitation and return to play philosophy1,2for the successful treatment of the athletes placed in our care. Al Vermeil’s Hierarchy of Athletic Development, as well as the modified rehabilitation model, is presented in figure 1.
The Stages of the Vermeil Hierarchy
There are six “levels” of the hierarchy. The first two are:
- Evaluation/Testing – Every athlete, whether engaged in the performance enhancement training or sports rehabilitation environment, will require evaluation and testing to determine such criteria as their medical and training history, sport(s) and position of participation, exercise contraindications, etc., as well as a demonstrated presentation of all physical assets and deficits. The S&C and/or rehabilitation professional should incorporate a proven system of evaluation/testing, where a comfort level with the preferred testing model is also present for ease and confidence during the implementation of this process. This evaluative/testing process will help determine the valuable information necessary for the establishment of the overall training and/or rehabilitation program design.
- Work Capacity – This is the ability of the athlete to physically perform exercises with proper technical proficiency repetitively over time, without the inducement of excessive physical fatigue. During the course of training or rehabilitation, physical fatigue will occur as a result of the effect of participation in prolonged exercise execution. This includes, but is not limited to, participation in daily, weekly, and monthly programmed sessions over the duration of the entire training and/or rehabilitation period.
The establishment of an ample work capacity will enable the athlete to appropriately recover after the conclusion of one training/rehabilitation session and before the next scheduled session. An appropriate work capacity will also provide a “work capacity reserve.” This reserve is essential over a prolonged season schedule, as well as for the unique circumstances that arise during game day competition, where teams are required to continue play for extended periods of time (i.e., overtime, double overtime, sport tournaments, etc.).
The establishment of a sufficient work capacity will ease excessive fatigue. The onset of excessive physical fatigue may result in a number of undesirable physical adaptations. These include, but are not limited to, decreased muscle force output, reduction in the rate of force development, poor technical exercise performance, changes in joint biomechanics, poor kinesthetic awareness, disproportionate distribution of applied exercise stresses, and possible overuse-type soft tissue injuries (e.g., sprains, strains, tendinitis, etc.).
One method to consider for improvement of the athlete’s work capacity is the programming of Javorek exercise complexes. S&C coach Istvan Javorek established these exercise complexes, and athletes may perform them, when appropriate, with either a barbell or dumbbells. These complexes require the athlete or patient to perform 5–6 distinct exercises, one immediately after another, for a prescribed number of specific exercise repetitions, to ultimately complete a single complex “cycle.” In addition to the enhancement of the athlete’s work capacity, Javorek complexes also provide the following advantages:
- Enhanced overall joint mobility.
- Enhanced exercise technical proficiency.
- Stimulation of the neuromuscular system.
- An increase in overall strength levels.
The remaining levels of the hierarchy include the enhancement of the physical qualities that are necessary for the athlete to achieve their desired level of athletic performance. It is important to note that the ideal enhancement of a specific physical quality is dependent upon the optimal development of its physical quality predecessor, with the physical quality of strength serving as the foundation. For example, if strength is defined as the ability to produce force, and the physical quality of explosive strength (power) consists of a velocity component during exercise execution, then if an athlete is unable to produce adequate levels of force (strength), how can they possibly produce adequate levels of force rapidly (explosive strength)?Place emphasis on the improvement of the specific physical quality desired during the specific phases of the enhancement training or rehabilitation cycle. Click To Tweet
It is also important to mention that all physical qualities, as determined by the S&C and/or rehabilitation professional, may be trained simultaneously. However, they should place the emphasis on the improvement of the specific physical quality desired during the specific phases of the enhancement training or rehabilitation cycle.
- The Physical Quality of Strength – As previously noted, this is the foundation from which all other physical qualities evolve. Therefore, the optimal development of this foundational physical quality is essential during the athlete’s participation in both the athletic performance enhancement training and rehabilitation settings. The human body was created for movement, yet how is movement possible without the application of force?Enhanced strength qualities will provide improvement in the application of force, rate of force production, joint stability, soft tissue and joint “stiffness” (a requirement for an optimal stretch shortening cycle to occur), body propulsion, deceleration, and change of direction capabilities, as well as injury prevention. With skill and athleticism deemed equal, it is the stronger athlete who will usually prevail during athletic competition.
- The Physical Quality of Explosive Strength – This physical quality is the first to introduce a velocity component during exercise execution. Power is defined as force x distance divided by time. Time is now a factor, requiring athletes to perform exercises at higher velocities compared to strength type exercises. Explosive strength may be developed from a number of modalities, which include, but are not limited to, the application of weighted implements such as a barbells and dumbbells, medicine balls, jumps, throws, and sprinting. It is important to note that the execution of explosive strength type exercises requires the athlete and/or an external resistance to be displaced from one position to another at high velocity while maintaining proper technical exercise proficiency.
- The Physical Quality of Elastic/Reactive Strength – This quality relies upon the stretch shortening cycle (SSC) and the ability to exert force during a high-speed movement. The SSC is the basis of plyometric type exercises and is a natural muscle/tendon function where a soft tissue complex is stretched immediately before a concentric muscle contraction. This exercise eccentric/quasi-isometric/concentric contraction results in a more forceful output than a concentric contraction alone. To optimize elastic energy contribution, there must be a brief transition period (amortization) between eccentric and concentric contractions. Dr. Dietmar Schmidtbleicher classified the SSC as either slow, e.g., >.25 second ground contact time, or fast, e.g., <.25 second ground contact time.3
- The Physical Quality of Speed– The achievement of ideal movement velocity (e.g., sprinting, jumping, throwing, etc.) relies on the athlete’s genetics and optimal enhancement of all of the aforementioned physical qualities in combination with their demonstrated exceptional and economical technical proficiency with high-velocity movement skill attained via coaching and repetitive movement skill practice.
Figure 2 presents a 100-meter sprint task, which demonstrates the interrelationship of all these physical qualities.
In a review of figure 2, you will observe the relationship of all the physical qualities of the hierarchy of athletic development during an athletic endeavor. At the initiation of the 100-meter sprint, the physical quality of strength plays a significant role in the athlete’s forward propulsion/movement from a dead stop position. Explosive strength then evolves as velocity is incorporated into this athletic task. The athlete continues to achieve higher sprint velocities where elastic/reactive abilities play a significant role and then concludes with them reaching optimal maximal speed velocities.
If you review the diagram in figure 2 in reverse, you will observe the following. The athlete will likely not achieve optimal velocities of the physical quality of speed without the optimal development of the physical quality of elastic/reactive strength. Optimal levels of elastic/reactive strength will require the optimal enhancement of the physical quality of explosive strength. Finally, the athlete will not reach the desired levels of the physical quality of explosive strength without the optimal development of the physical quality of strength. Thus, this particular review demonstrates the interrelationship for physical quality enhancement, as well as the rationale for each specific physical quality’s dependence upon the optimal development of its predecessor in the athletic development hierarchy.
The Hierarchy of Athletic Development: Rehabilitation Modified
The injured and/or postsurgical athlete will likely present with very specific, as well as related, physical deficits and anatomical insults and/or changes as compared to a “deconditioned” athlete. Therefore, additional modifications are made to the hierarchy to accommodate for this special rehabilitation classification of athletes.Our modification of Vermeil’s Hierarchy of Athletic Development for rehabilitating athletes includes a mobility/movement and a muscle reeducation/work capacity component. Click To Tweet
As in Vermeil’s original Hierarchy of Athletic Development, evaluation and testing are performed. However, this process is now more specifically influenced by the medical condition and pathology of the athlete and will include any and all surgical interventions. Upon conclusion of the evaluation and testing level of the hierarchy, the additional rehabilitation modifications include the following:
- Mobility/Movement – This added level of the rehabilitation hierarchy requires the athlete to re-establish the joint mobility, soft tissue compliance, and movement skill patterns required for activities of daily living and serve as a segue to resume “athletic type training” active exercise performance. Injured and postsurgical patients will, over time, advance their mobility and movement patterns to progress to the eventual removal of assistive devices such as crutches when resuming a normal lower extremity gait pattern on all surfaces. Sit to stand, acyclical and cyclical activities, and other additional patterns of movement also need to be restored.
The same may be said for the post-injured or postsurgical upper extremity and spine patient. Suitable technical exercise performance cannot occur without the athlete able to demonstrate specific movement patterns while maintaining and, when necessary, appropriately altering precise exercise postural positions.
- Muscle Reeducation/Work Capacity – After the incidence of injury and/or surgical intervention, a muscle and/or muscle group(s) may “shut down,” so to speak. An example would be the arthrogenic muscle inhibition of the quadriceps muscle group after anterior cruciate ligament (ACL) reconstructive surgery5. This muscle inhibition is due to noxious accumulative factors, including, but not limited to, the episode of injury, the invasive feature of surgery, and the requirement of a tourniquet (length of time) during surgery. Once a strong active muscular contraction is restored, this achievement, in association with the restoration of mobility and movement, will allow for the performance of suitable exercises and the progression to the work capacity phase of the hierarchy.
The continued advancement of the hierarchy remains the same during the course of rehabilitation as it does during athletic performance enhancement training; however, exercise selection, training modalities and techniques, and program design may differ. Regardless of the methods and exercises utilized, the desired achievement of the optimal development of all physical qualities stays the same.
The Necessity for the Application of Stress (Exercise Intensity)
The application of stress is required during the athlete’s exercise performance for physical adaptation to take place. The body goes through various physiological changes when placed under stress. This stress response of the body is exhibited in general adaptation syndrome (GAS), which was first described by Hans Selye, a Viennese scientist4.
GAS occurs in three stages: the alarm stage, the resistance stage, and the exhaustion stage. In regard to exercise adaptation, each stage is as follows:
- The Alarm Stage – During the alarm stage, a stressor in the form of exercise “intensity” is applied to the athlete. The exercise intensity may consist of an applied external weight, specific exercise velocity, box height, jump height or distance, etc. It is important to note that the athlete must be unaccustomed to the applied stressor. Once a stressor is applied, the body moves from its baseline or homeostasis to the alarm stage. During the alarm stage, the body perceives this applied stressor and reacts with a “fight or flight” response, as the sympathetic nervous system is stimulated and the body’s resources are prepared to meet the threat or danger (i.e., the applied stressor).
- The Resistance Stage – In this phase, the body resists and compensates (adaptation) as the parasympathetic nervous system attempts to return many physiological functions to normal (homeostasis) levels. However, as observed in figure 3, adaptation to the applied stressor exceeds the baseline of homeostasis while the body focuses resources against the applied stressor, remains alert, and is now prepared for the same stressor (i.e., intensity) when reapplied in the future.
This is the reason why appropriately programmed and applied stressors must be unaccustomed in nature. For the athlete to remain unaccustomed to the applied stressor, and continual adaptation to occur, the intensity levels of applied stress must appropriately increase over time. These stressors should not only include enhancement of the described physical qualities, but progressions in exercise volume that will enhance work capacity as well.
- The Exhaustion Stage – This is the last phase of Selye’s GAS. In this stage, if the stressor(s) continues beyond the body’s capacity, the resources become exhausted and the body becomes susceptible to disease and/or death. Note how the line on the graph enters the “detraining” zone and continues to descend below the baseline of homeostasis. During exercise performance, the exhaustion phase (i.e., excessive fatigue) is synonymous with overtraining. Overtraining may lead to the previously mentioned negative physical adaptions, including soft tissue type overuse injuries. Therefore, an appropriate level of work capacity established prior to the athlete’s initiation into the “formal” training period will help athletes resist exhaustion during physical enhancement training.
Also note that the athlete may plateau or enter the detraining zone due to a lack of appropriate stressor (i.e., intensity) application. A repetitively applied “accustomed” (i.e., the same intensity-level stressor) or too low an intensity stressor (i.e., too light an applied weight, too slow an applied velocity, etc.) will likely not result in the positive physical adaptations desired. Thus, too low a level of applied stressor may result in the discarding of valuable athletic enhancement training and rehabilitation time.
There is an absent response phase in Selye’s GAS model and that is the phase of recovery. Whether in the performance enhancement training or rehabilitation environment, the athlete must be permitted to adequately physically recover in preparation to perform optimally in the next scheduled enhancement training or proper rehabilitation session. Many factors contribute to the athlete’s recovery. These include, but are not limited to, proper exercise programming, suitable nutrition intake, proper sleep patterns, specific and proven recovery techniques, and, yes, the aforementioned establishment of an appropriate work capacity.
Modify, Adapt, and Apply It
Coach Al Vermeil’s Hierarchy of Athletic Development has served as a valuable philosophical foundation model to assist in program design for both the athletic performance enhancement and sports rehabilitation environments. The physical quality of strength is the foundation of this model, which must also coincide with an appropriately programmed application of stress. It should also be acknowledged that the establishment of a work capacity is essential before the introduction of formal training, and the application of levels of “high intensity” are relative to the physical demonstrated abilities of the individual athlete. The utilization of the Hierarchy of Athletic Development, its modification as adapted to the sports rehabilitation setting, and the appropriate periodic application of unaccustomed stress will ultimately result in the desirable physical qualities and performance achievements of the athlete.
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1. Panariello, R.A., Stump, T.J.S., and Maddalone, D. “Post-Operative ACL Rehabilitation and Return to Play after ACL Reconstruction.” Operative Techniques in Sports Medicine. 2016; 24(1): 35–44.
2. Panariello, R.A., Stump, T.J.S., and Cordasco, F. “The Lower Extremity Athlete: Post-Rehabilitation Performance and Injury Prevention Training.” Operative Techniques in Sports Medicine. 2017; 25(3): 231–240.
3. Schmidtbleicher, D. “Training for power events.” Strength and Power in Sport. 1992; 1:381–395.
4. Selye, H. “The general adaptation syndrome and the diseases of adaptation.” The Journal of Clinical Endocrinology.1946;6(2): 117–230.
5. Sonnery-Cottet, B., Saithna, A., Quelard, B., Daggett, M., Broade, A., Ouanezar, H., Thaunat, M., and Blankney, W.G., “Arthrogenic muscle inhibition after ACL reconstruction: a scoping review of the efficacy of interventions.” British Journal of Sports Medicine. 2017; 53(5): 1–11.