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I know what you are thinking: “Who is this kid writing about lessons he’s learned after only five years in the field? Doesn’t he know Michael Boyle recently wrote one from 40 years of coaching that has WAY more wisdom packed into it?”

Yes, in fact I have read several articles in that type of style and enjoyed them so much that I wanted to write my own—so, shoutout to those coaches for inspiration! Obviously, this won’t be as impressive as Coach Boyle’s, but on the bright side for you, it’ll be MUCH shorter. While Coach Boyle has more wisdom to share than I do, I hope that my unique situation coaching at a small Canadian university can resonate with many readers and provide some takeaways.

I recently celebrated my 5^th year of being the Head Strength & Conditioning Coach at Trinity Western University, and in that short time I have learned MANY lessons. I wanted to boil it down to just five—so, while this won’t be as wisdom filled as a “40 years in the field” article, hopefully it can help those of you just getting started and make those early years a bit smoother.

1. Relationships Trump ALL

This one might seem obvious, but it still needs to be stated. As S&C/Performance Coaches, we work with people. They might be high school kids, student athletes at the college level, or professionals. Doesn’t matter—people are people, and being able to work with them is the most important part of your job. I have heard so many of my colleagues say that it is better to be a good person first (or a “certified nice person,” as Coach Boyle puts it) and then learn the science of training second. Way easier than trying to nerd out on the science and pick up the people stuff later.

I recently reread the principles from “How to Win Friends and Influence People” by Dale Carnegie (which is the best book on this topic), and they all still ring true. Smile, don’t criticize, give praise—these are all staples in my coaching, because I have learned that being a “good guy” is the easiest road to being a “good coach.”

How so?

Well, early on in my career I had good mentors show me the ropes. Plus, when I was an intern, I struggled with showing how much I cared and often started by spitting science at people.  Through the direction of my supervisors, I studied human behavior and tendencies, learned to communicate better…and lo and behold, it worked! Results are important, of course, but you are better off spending the first part of your career developing good relationships so that people know you care and know you want the best for them, and then you can get blood from the stone.

Results are important, of course, but you are better off spending the first part of your career developing good relationships so that people know you care and know you want the best for them, says @chergott9. Share on X

After all, it’s true… “Nobody cares how much you know until they know how much you care.”

2. Study. Hard.

One of my favorite ways to sum this one up is this: We all talk about athletes that are difficult to deal with and just throw up our hands and say “You can lead a horse to water, but you can’t make them drink.” My response is then: “Is the water you are leading them toward going to give them the nourishment they need?”

Yes, it is crucial to be a nice guy/girl (as I just finished saying), but it should also go without saying that you need to know your stuff when it comes to athlete preparation. The best way to get buy-in and build trust is to deliver results.

I got caught with this early in my career. Athletes would question the why of our training and I would throw out stock answers that would suffice for the time being, but then when sport coaches demanded more results and I had no answer to give them as to why we were failing to get them, I knew I needed to step up my game.

So, I went back to my university study habits and started creating a study schedule by creating “Reminders” of things I wanted to touch on each day. That way, I don’t get to check them off until I’ve done them—and as a Type A personality, this works for me (very well I might add). Things I have on my daily reminders list include:

1. Study a sport
2. Study sport science
3. Read an article
4. Reach out to a colleague/friend

These have helped to ensure I take time each day to learn, to grow and get better as a practitioner, and to go on countless Zoom calls and make site visits asking all my questions. This has not only led to better results for my athletes, but providing better explanations as to why we are doing certain training methods and exercises instead of just relying on doing what my mentors did. Plus, it has helped me develop a critical thinking brain, so I don’t just fall for the latest trend—I can stick to my guns because I know what we do works and I also know why (and how to communicate that effectively to my athletes and coaches).

3. Be a Role Model

I don’t mean you need to have an eight-pack, go for 10km runs every morning, and never get less than 8 hours of sleep—but, it helps to at least be a healthy person (or at least push yourself to be better in this area) so you know what it is like.

Get under the bar and train yourself, hard. Do conditioning work. Try out things you plan to have your athletes do before just throwing it at them. Sleep as much as you can and eat healthy. I know these are super general suggestions, but that is because it will look very different for everyone and in every context.

Get under the bar and train yourself, hard. Do conditioning work. Try out things you plan to have your athletes do before just throwing it at them. Sleep as much as you can and eat healthy. Share on X

As a dad of two girls under the age of three, I know what it is like to lose sleep—so, I can relate to my athletes and chat with them about strategies I use to maximize what I get, ideally helping them to do the same during paper/midterm season. I used to compete in Olympic Weightlifting, so I know what it was like to do exercises you hated that your coach programmed.

Now that I’ve retired from lifting competitively, I’ve really taken a dive into different training and conditioning protocols and have found that it makes it way easier to communicate the why and the how when you have personally done and experienced it. For example, over Christmas break I was experimenting with some bodyweight/low-equipment circuits for our athletes to do over similar breaks where they might not have access to a training facility or equipment. It sucked, but was doable so I knew I could give it to them with success. Yeah, they hated it too—but it got results!

Video 1. Bench Press.

Video 2. Loaded Chin-Ups.

I train myself and post some of those clips (especially PRs) on social media and YouTube (see above). When your athletes know you go through the ringer too, that helps them trust you as you hopefully know what they are feeling when they do a brutal set of 10 squats. It is much easier to trust someone who is willing to do what they prescribe instead of just reading what the research says from your ivory tower.

4. Write Plans in Pencil

This one can be summarized in one word: COVID. I started my tenure here at TWU during the spring of 2019, with the tail end of my first year being cut short due to the pandemic. Now, if I didn’t already do so before that, I learned to hold plans loosely and plan in pencil, not pen. Basically, just meaning that you need to be ready to adapt at any time, each and every day.

This could come in the form on an injured athlete needing a modification, a team being bagged in training right before lift due to poor performance, or obviously a global pandemic.

What I found the best to be able to help with this one is the first two lessons I mentioned: If you study hard and know your stuff and your why for programming, it is much easier to find alternative solutions based on injury or load management. And by having those great relationships, you can easily communicate why we are making the adjustment or maybe why we aren’t going to. But it all has to come from that level of love and trust you have built.

If you study hard and know your stuff and your why for programming, it is much easier to find alternative solutions based on injury or load management, says @chergott9. Share on X

Another strategy that helps with this is realizing that you are not the center of the world—most athletes don’t like lifting weights, and they came to this school to play the sport, NOT work with you. When I put all that into perspective, it helps take off some of the pressure I put on myself to be the best and for ME to be the one to make my athletes better. At the end of the day, running one recovery session on Squat Day ain’t gonna hurt.

5. K.I.S.S.

In my second year I thought I was really starting to get the handle on programming here. I was learning so much (see point two) and was incorporating as much as I could into my programs. We were hitting ALL the prehab, ALL the sport specific work, and ALL the niche things I learned.

Guess what was missing? A large enough dose of the basics that actually work.

It took one of our older athletes to have a meeting with me to explain how he felt about the program for me to realize that I had gotten away from the main thing for athletes at this level, which is usually just getting bigger, faster, and stronger so they can stay healthy and play their sport at a higher level.

Since then, I changed my laptop background to “KISS” (Keep It Simple, Stupid), trimmed my programs down and stuck to the basics that work. Sure, there are times I add new stuff and venture out, but those times become the exception, not the rule. “Master the box before you leave it” is a concept I now hold dear when I think about adding in something. Since then, my programs have gotten great reviews! No, they are not perfect and there is still tons to learn, but I have found that most athletes…

1. Don’t want to do a bunch of fluff but just train hard.
2. Don’t have time to do all the fluff.
3. Benefit WAY more from just keeping it simple.

So, I have developed a simple program template that I follow 90% of the time, with some deviation of course to try new things as mentioned. But, by keeping it simple (stupid), our results have improved and as mentioned, been enjoyed way more—which has vastly improved buy-in and effort.

By keeping it simple, our results have improved and as mentioned, been enjoyed way more—which has vastly improved buy-in and effort, says @chergott9. Share on X

Onward

So, there you have it, short and sweet (until I get to 40 years, like Coach Boyle).

Build relationships. Study. Be a role model. Be ready to adapt. Keep it simple. All helpful tools that I have learned, and I now you have too! At the end of the day, being a Strength & Conditioning Coach is the best job in the entire world (I mean where else can you work in shorts and sneakers every day while listening to rap music?). So, enjoy the journey and remember that you will make mistakes along the way. Those mistakes are what will help you correct your course and become the best coach you can be.

Good luck.

Peace. Gains.

Since you’re here…
…we have a small favor to ask. More people are reading SimpliFaster than ever, and each week we bring you compelling content from coaches, sport scientists, and physiotherapists who are devoted to building better athletes. Please take a moment to share the articles on social media, engage the authors with questions and comments below, and link to articles when appropriate if you have a blog or participate on forums of related topics. — SF

Many exercise science students do strength coaching internships, hoping the experience will help them land a full-time job. Unfortunately, paying jobs in strength coaching rarely present themselves quickly, particularly at the college and professional levels. Until that big break comes along, they often resort to Plan B: Personal Training. Things don’t always work out as expected.

One issue with Plan B is that health club managers expect their trainers to get clients by walking the gym floor and pitching their services to their members. This task is especially difficult because they must compete against other trainers who are going after the same members. Rather than “Welcome to the team!” the message may be more like, “It would be so nice if you were not here.”

Mike Carroll was a sales manager for several commercial health clubs, eventually owning a gym and coaching a weightlifting team that hosted the National Championships. He told me that the typical personal trainer at his health clubs “would last six months, so for a year, you would turn over your entire department.” When asked what characterized his job as a sales manager, Carroll replied, “More pressure! Now, I was responsible for not only my financial goals but also the financial goals of an entire department.”

If you survive the “initiation” period and recruit a significant number of clients to appease your boss, it may be quite some time before you earn the big bucks promised by many of the popular personal training certifications. Health clubs often start their trainers with a 60/40 split, with the gym taking 40 percent of the client’s fee. So, that $25 training session at 5:30 a.m. turns into $15, which in California is $5 less than the starting wage at McDonald’s. Further, many personal trainers work as independent contractors, so they lose out on health insurance and other benefits. Then there are the hours.

There is no such thing as working 9-to-5 in personal training. Just ask Nikki Gnozzio.

The Education of a Personal Trainer

Gnozzio was a scholarship field hockey player at Ohio University, earning First Team All Mid-American Conference honors. Sonny Sano was OU’s strength coach then, and Gnozzio’s work with Coach Sano inspired her to follow that path. Gnozzio got her chance in 2010 when she became an assistant strength coach at Providence College in Rhode Island under the direction of Head Strength and Conditioning Coach Ken White.

Providence College was unique in that it had two women strength coaches at a time when an estimated 85 percent of D1 strength coaches were men. The outlook is better now, but typically, their jobs are limited to “Olympic sports.”

Providence College was unique in that it had two women strength coaches at a time when an estimated 85 percent of D1 strength coaches were men, says Kim Goss. Share on X

While in Rhode Island, Gnozzio joined my weightlifting team and achieved respectable success for being new to the sport. A few years later, she moved to New Jersey and became a personal trainer. Those early years were rough.

Gnozzio trained clients six days a week in three locations, commuting up to three hours daily. “The hardest thing was learning to deal with people who had never actually pushed themselves and had very little body awareness,” says Gnozzio. “I never had to teach an athlete how to breathe or engage a muscle to use it. The general population requires so much more coaching for things athletes don’t have to think to do—their bodies naturally do it.”

After paying her dues on the road for five years, she opened The Junction Bodyworks, a massage and personal training facility in Livingston, New Jersey. Gnozzio made it, but the challenges associated with making a living wage in the personal training industry often cause many former strength coaches to quit the industry and seek employment elsewhere.

The challenges associated with making a living wage in the personal training industry often cause many former strength coaches to quit the industry and seek employment elsewhere, says Kim Goss. Share on X

If you’re a strength coach and want to improve your chances of not just surviving as a personal trainer but thriving, I have some practical advice. Why should you listen to me? I was a D1 college strength coach, ran several private gyms in the public sector, and was a writer for several companies that offered certification courses for personal trainers. Along the way, I’ve had the opportunity to talk to many of the world’s most successful gym owners and personal trainers, along with many who failed miserably. That’s my sales pitch—let’s get started.

How to Grow a Personal Training Business

Many personal training certification organizations promise big bucks to personal trainers who take their courses. Unfortunately, these courses often focus on training and offer little insight into how to succeed in the business. Below are ten suggestions to put your PT business in the black.

1. Look Like a Personal Trainer

You are a walking billboard for your business and your credibility will be questioned if you are not fit and dressed professionally. When I first met legendary Canadian strength coach Charles R. Poliquin in the early 90s, I asked him why he paid so much attention to arm training. He said he believed in “walking the talk” and shared a story to prove his point.

Poliquin told me about a time early in his coaching career when he was hired to consult with a pro hockey team. When he arrived at their training facility, Poliquin said the athletes appeared apathetic about anything he had to say…until he took off his coat. That’s when they saw a pair of monstrous, bone-crushing pythons bursting out of his shirt sleeves. Their attitude changed immediately because, after all, someone with arms that huge and freaky must know what they were doing in the weightroom. I’m not saying you must look like the Incredible Hulk (or Wonder Woman) to get clients, but be lean and look athletic.

You must be well-groomed and dress appropriately even when training, as you will always be selling yourself. Also, don’t dress like a pirate or a scrub nurse—and don’t even think about those psychedelic clown pants!

You must be well-groomed and dress appropriately even when training, as you will always be selling yourself, says Kim Goss. Share on X

2. Know Your Target Market

Several years ago, I audited a seminar attended by dozens of successful personal trainers, many earning six-figure salaries. The instructor began by asking each participant to describe their typical client, and most responded with “Affluent women, ages 29 to 49.” No one said, “20-year-old Olympic hopefuls” or “5-star high school basketball players.”

When asked their primary reasons for seeking a personal trainer, many women answer surveys with “getting toned” and “building confidence.” However, the preponderance of surveys I’ve seen conclude that the primary reasons most women seek the services of a personal trainer are to lose fat or maintain their bodyweight. The takeaway is that much of your continuing education as a personal trainer should be on nutrition and exercise protocols to lose fat. Also, study corrective exercise and stretching methods, particularly when training older clients who often have postural issues and past injuries.

3. Network with Healthcare Professionals

Cross-referrals are incredibly effective for getting new clients and expanding your value. In Utah, Colorado, Texas, and Rhode Island, I developed relationships with sports medicine facilities and would refer my clients for their services. In turn, they would refer their clients to me. Winner, winner, chicken dinner!

Cross-referrals are incredibly effective for getting new clients and expanding your value, says Kim Goss. Share on X

Networking also includes attending personal training conventions—not just listening to lectures and seeing all the new cool training gizmos, but mingling with other trainers about how to improve and expand your business. Unlike your coworkers, you’re more likely to get good advice from someone who does not directly compete with you for clients.

What about franchises? Having the marketing power of a large organization behind you might help you attract new clients, but there are franchise fees and you often have to follow their business model and purchase equipment from their suppliers. After working under a franchise for several years and building a strong clientele, I’ve talked to many trainers who dropped the franchise tag, changed the name of their business, and ran their business their way.

4. Stay Abreast of Fitness Trends

Billionaire Warren Buffett is credited with the saying “The more you learn, the more you earn,” and it was one of Poliquin’s favorites. Again, walking the talk, Poliquin read at least 100 books annually and had a remarkable (perhaps even photographic) memory.

Poliquin learned German to study the research of the top German sports scientists and built an extensive library of all things muscle and strength. When I first met him in the early 90s, I saw his nearly foot-high stack of research papers. Poliquin would pay grad students to collect these papers and then would study them on flights. Beyond reading, Poliquin also spent at least 24 days a year attending seminars to learn from others. In December 1994, he told me he had achieved his goal of making a million dollars in a year—learn more, earn more.

Along with studying scientific publications about health and fitness, reading trade journals and books on the personal training business is invaluable. One journal I found especially helpful for personal trainers (now online and free!) is Certified by the American Council on Exercise. You won’t find hardcore research papers discussing oscillatory isometrics for improving knee stability in alpine skiers, but you will find practical, readable articles on business management and how to attract and retain clients. I also believe you should pay particular attention to articles on how to write business and marketing plans, as I found these can be valuable tools for running your business.

Along with studying scientific publications about health and fitness, reading trade journals and books on the personal training business is invaluable, says Kim Goss. Share on X

Many years ago, I passed the NSCA exam along with several certification programs from personal training organizations. Two valuable benefits of these organizations are that, after you pass their exams, you can access their trade journals and they put you on a trainer/strength coach contact list. If someone in your area is looking for an ACE-certified trainer and you have that credential, they will have your contact information.

What about all those YouTube ads that promise six-figure salaries by following the “proven money-making strategies” in their personal training business courses? Having looked at a few, I found they can offer valuable advice, but probably nothing you wouldn’t find in the trade journals. 

5. Develop Fair, Consistent Policies

Time is money in personal training, so you must develop policies that don’t cut into your bottom line. Insist that your clients tell you 24 or 48 hours ahead if they plan to cancel, as often you can fill that time slot if given notice.

Clients may take advantage of you if you don’t set strict policies. They might call just before their training session to delay it by 15 minutes so they can pick up some items from a local store or perform some other errand. If a client is late and you have an appointment immediately afterward, their session needs to be cut short—the tardiness of one person shouldn’t inconvenience your other clients. And this policy works both ways. If you must cancel at the last minute, compensate the client with a free workout.

6. Use Surge Pricing

Just as movie theaters offer discount matinees, establish separate rates for the most popular training periods. This approach is called surge pricing, a method Poliquin told me about in the 90s. For example, distinguish your training sessions as “red” and “blue” hours. The red hours are when most clients want to train, particularly between 5 p.m. and 8 p.m., so you charge more. When you fill all the time slots for the red hours, if a client quits, you charge more for the new clients taking that time slot.

A colleague in Canada told me he had clients prepay up to three weekly sessions for six months or more to reserve their favorite time slots. He also had the gym set up a service with a bank that would automatically withdraw money from their account every month for their convenience (plus, this system doesn’t remind them how much they are paying).

7. Sell Training Packages

Giving away a free training session to attract new business is fine, but your business should be based on packaged programs. Why? With pay-as-you-go single training sessions, you give your clients more opportunities to say “No,” and you have to keep reselling your services.

Giving away a free training session to attract new business is fine, but your business should be based on packaged programs, says Kim Goss. Share on X

Let’s say you just started your personal training business and established a rock-bottom price of $25 for a session, which can be anywhere from 30 to 60 minutes. After a free training session, offer multiple training session deals, such as the following packages that decrease from $50 per session to $25.

• Bronze: 5 sessions for $250
• Silver: 10 sessions for $400 (save 20%)
• Gold: 20 sessions for $500 (save 50%)

When potential clients see this price list, they might get excited to see they get half off when jumping from the Bronze to the Gold package. If a new client is a hard sell and settles for a Bronze package, you could offer them an upgrade to the Silver or Gold package after their first training session.

8. Expand with Online Training

The hottest trend in personal training is online training, which has seen a big boost after COVID-19 forced many gym goers to invest in home gyms. I have a few online training clients and I know two colleagues earning a six-figure salary from this business.

The hottest trend in personal training is online training, which has seen a big boost after COVID-19 forced many gym goers to invest in home gyms, says Kim Goss. Share on X

Poliquin offered online training in the early 90s, charging $350 for six-week workout packages—you had to commit for a year. The arrangement included two in-person assessments, and clients would pay in full for an entire year or give him post-dated checks of $350 each. He increased his fees significantly in the intervening time, increasing his rate by $5 every time one of his athletes won a medal in the Olympics or World Championships. In 1994, he told me he had 120 of these distance clients. Poliquin also did phone consultations, and one of his clients was Ben Patrick, the Kneesovertoesguy.

Canadian strength coach and Posturologist Gagné was featured in Freelap Friday Five and is shown in the lead photo coaching Justine Dufour-Lapointe, 2014 Olympic Champion in moguls skiing. Gagné was forced into online training with COVID-19, and now his daily schedule is packed with online clients. Gagné has given seminars in 22 countries, and this exposure enabled him to attract online clients from other countries.

Finally, before COVID-19, one personal trainer who worked in a gym where I trained athletes combined in-person and online training. She would train several athletes in a group session while training one client online with her webcam. When COVID-19 hit, this approach gave her a head start for online training as she already had clients online and her former in-person clients knew she offered this service.

9. Supplements and Merch

Selling merchandise such as T-shirts, jackets, and water bottles with your company logo can provide a nice revenue stream. Unquestionably, the most significant way a trainer can increase their non-training revenue is by selling supplements.

Unquestionably, the most significant way a trainer can increase their non-training revenue is by selling supplements, says Kim Goss. Share on X

While working for companies that offered personal training certifications, I’ve met many trainers who earned $10,000+ each year selling supplements. I know one personal trainer with a private gym in a small town with maybe three dozen clients, but his yearly profit from supplement sales exceeded $20,000! “Hey, everyone could use a good multivitamin, right? And have you heard about the many benefits of fish oil and Vitamin D3?” Yes, the money is tempting, but you must also be careful about supplements.

I know one personal trainer who faced a significant lawsuit because of adverse reactions to the supplements he sold the client. There is also the risk that a supplement, unless it is an NSF Certified for Sport® supplement, can be tainted and cause an athlete to fail a drug test. My understanding is that NSF-certified supplements are the only ones many professional sports teams will endorse. There is a risk in selling supplements if you are not a nutritionist—especially if you claim those supplements have specific benefits.

10. Buy Insurance

We live in a litigious society, and a personal trainer is in a risky business if they don’t have personal trainer’s insurance. Dr. Marc Rabinoff is a sports liability consultant who has worked on over 600 litigations in the fitness industry. I’ve written dozens of articles with Dr. Rabinoff, and he will tell you that a waiver or assumption of risk form is no guarantee that you will not get sued if you injure a client, especially if that injury is due to negligence. Basic insurance plans are only a few hundred bucks a year, but it’s a must-have investment.

How about one bonus suggestion: Don’t Get Cocky! A colleague of mine had a successful personal training business and a private gym, often giving 30+ training sessions a week. He charged $35 an hour but figured he could dramatically increase his income and work less by charging everyone, even current clients, $65. He figured wrong.

He promptly lost two-thirds of his clients. Not only did his income take a horrific hit, but so did his ability to attract new clients, as his gym was in a remote area. He relied on word-of-mouth marketing to attract new clients, and doubling his rates so abruptly didn’t get him any new referrals.

In another case, I know a D1 strength coach who was part of a college football team that went undefeated the previous year. He left the school to spend more time with his family and thought his reputation as a college strength coach would put him in big demand as a personal trainer. It did not, and after a few months, he went back to teaching high school, a profession he had worked in before becoming a strength coach.

The ultimate goal of many strength coaches is to work with athletes, but the market is saturated, especially at the college and professional levels. The solution may be to earn enough money from personal training to open a gym where you can train athletes and the general population. Who knows, maybe after spending time in the private sector, you might find that personal training is your true calling.

Since you’re here…
…we have a small favor to ask. More people are reading SimpliFaster than ever, and each week we bring you compelling content from coaches, sport scientists, and physiotherapists who are devoted to building better athletes. Please take a moment to share the articles on social media, engage the authors with questions and comments below, and link to articles when appropriate if you have a blog or participate on forums of related topics. — SF

References

Goss, Kim. “Confessions of a Hardcore Gym Owner,” BFS magazine, July/August 2005, pp 18-22.

Hennessy, Kristin. “AB-5 Law Requires the California Fitness Industry to Convert 1090 to W2.” Band of Hands, ND.

Carrasco, Laanna. “Breaking Barriers: Women in Strength Coaching.” BFS magazine, July/August 2012, pp. 44-47.

Goss, Kim. “Lawsuits: Give Yourself a Sporting Chance.” BFS magazine, September/October 2004, pp. 62-65.

In a unique field that can be just as giving as it is—at times—draining, coaches need equally unique solutions. In the same way there’s no “one-size-fits-all” solution for training athletes, there’s also a lot of nuance that comes with each next level of progress as a professional. Although traditional advice you’ve probably heard before does apply in this professional pursuit, real-life application and learning from personal experience is how you take general advice to a an always-changing field.

I’m not here to act like I came up with this advice myself or that this is the first time these pieces of advice have been spoken into existence. I’m just here to say from being in the field since 2016, from the countless conversations I’ve had with knowledgeable and selfless coaches, learning from my own mistakes and failures, and from feedback I’ve gotten from sharing this advice with coaches younger than me, I believe it’s valuable to pass along.

Although the core concepts of these three pieces of advice might be a little cliche, hopefully the phrasing and application are not. And let’s be honest, cliches are only cliches because they’re overused, and they’re only overused because they’re true; no one would be perpetuating inaccurate advice. Let’s dive into three simple ways that you can start setting yourself up for more professional success.

1. Be a (Respectfully) Savage Texter

The challenge we run into is two-fold: odds are, if you’re doing great things and trying to get ahead in this field, you’re very busy. And on the flip side, odds are, if someone is interesting enough to stay in touch with and provides a lot of value to you, they’re just as busy—if not even more so. I’ve been fortunate enough to have been given time by many smart and kind people, sometimes 45 minutes and sometimes up to 3 hours. But in the unusual and almost-always-extended hours we work in this field, carving out an hour to hop on the phone might not always be the most feasible or respectful use of someone’s time.

In the unusual and almost-always-extended hours we work in this field, carving out an hour to hop on the phone might not always be the most feasible or respectful use of someone’s time, says @CoachBigToe Share on X

There’s plenty of advice—like commenting on everyone’s Instagram posts to show you see it—but nothing makes me roll my eyes harder more than receiving 3 fire emojis on an Instagram post. Or how I used to tag all the relevant people in my tweets to try to spark discussion, which, even as the creator of these discussions, I found the notifications very annoying.

So, what’s just as simple and actionable, but still genuine and not annoying? How do you maintain somewhat frequent contact without blowing up a colleague’s phone, respecting their time, and keeping it personal? Insert texting.

Here’s a story of when this first hit me:

The first few years of my full-time coaching career, I went very hard in the proverbial networking paint. Intentionally reaching out to people, hopping on the phone, connecting with the people they then connected me with, keeping track of it all in Excel (obviously), and so on. It got to a point where I had a solid base of people whom I had 3rd and 4th interactions with. I was sharing these experiences with Steve Breitenstein, a colleague and mentor who inspired much of this article (and my other articles as well), and I said, “I feel like I only text these people when I want to hop on the phone, I don’t want it to feel like I’m just using them for that.”

“When’s the last time you texted them about anything else besides that?” he replied. Cue the awkward silence and instantaneous self-reflection.

Steve then gave examples of how to stay in touch beyond just hopping on the phone:

• Stay up to date with their sports team and send a congratulations text after big wins.
• Genuinely comment on a social media post of theirs that you enjoy (not every single one).
• If they come up in a conversation that you’re having with someone else, send a text saying ‘hey, I thought about you and referenced a prior conversation of ours with someone else, thanks for that.’

That’s how you turn professional relationships into more personal ones, slowly and consistently over time.

And, admittedly, there have been many times in the past that I’ve thought about someone like an athlete or colleague or parent but didn’t send a text, and I wish that I had. Would it have had a gigantic impact on our relationship? Probably not. But would it have improved it compared to not sending the text at all? Absolutely.

Main Lesson: Don’t be obnoxious or abuse having someone’s phone number, but be genuine in sending a simple text when you think about someone or something relevant to your relationship/previous conversations. It’s a simple way to help your professional relationships turn into more personal ones over time. If you’re thinking about sending someone a text, send it.

2. Keep a ‘Problem Solving’ File

Training principles are the same for all athletes, everyone is given the same textbook for the CSCS exam, and everyone’s journey probably starts out in a pretty similar fashion (as an intern, fingers crossed that it’s paid). But one thing I believe is that although the correct answer is usually “it depends” when talking about the art and science of coaching, true expertise lies in nuance and being able to explain that. Your ability to say, “It depends and here’s why,” followed by a personal experience or two to show how you’ve developed your spin on that topic is huge in showing your value and knowledge.

Your ability to say, ‘It depends and here’s why,’ followed by a personal experience or two to show how you’ve developed your spin on that topic is huge in showing your value and knowledge, says @CoachBigToe Share on X

A classic job interview question I’ve faced multiple times is “tell us about a time you handled adversity in the workplace.” And that’s definitely a common format of an interview question: “share a story about” then insert anything like “dealing with conflict” or “having a tough conversation with a head coach” and so on.

For this anecdote, I’ll talk about adversity. As I was preparing for it a few days prior to an interview, a few stories immediately popped into my mind. The two examples I had ready were a little outdated and didn’t feel strong enough to demonstrate my problem-solving abilities. Then, fortunately, a fantastic example I forgot about hit me the night before the interview. I was saved at the last moment by recalling that more impactful story, but imagine how much less nerve-wracking my preparation would’ve been if I thought of that one right away? Had I already had a catalog of examples written down, how much more efficient that process would’ve been?

Additionally, being able to recall previous experiences is valuable in other situations, such as mentoring others. Being able to say to a colleague or younger coach, “I totally understand where you’re coming from, I’ve actually been through something similar (insert your own story).” Imagine how much more receptive that person would be compared to just saying, “That sucks, here’s some unsolicited advice.”

Spend a little bit of time on the front end to save yourself time on the back end (and save a headache) by writing down your stories as they come. It should be more detailed than it is not, but 5 to 10 bullet points of each big experience in your journey will set you up for a lot of success. Either as a note on your phone or a Word doc on your computer:

1. Introduction/background
2. When it happened
3. How things progressed
4. Thought process when evaluating your options
5. Setbacks (if any)
6. How the situation was resolved

Combine this with a general category of “adversity,” “training philosophy,” “difficult conversations,” or any traditional interview question and you’ll have a great ‘problem-solving file.’

Lastly, this catalog can be valuable to yourself personally. Being able to reflect on your journey puts things in perspective and helps you appreciate all the moments, big or small and positive or negative, that have brought you to this moment right now.

Main Lesson: Every few weeks, spend some time recalling, categorizing, and writing down your important stories and experiences to help out both yourself and others.

Every few weeks, spend some time recalling, categorizing, and writing down your important stories and experiences to help out both yourself and others, says @CoachBigToe Share on X

3. It’s About What People Know You For

Going back to my hardcore networking days, it’s crazy to reflect back on the literal networking tree I had and all the branches of how people got there. The tree was so impressive it would come up in conversation, and after showing it to someone to demonstrate how I got connected with them, that would be followed up with something along the lines of, “You must be a good person if all those people kept passing your name along…”

And at first, it was very flattering. But that comment was always followed up by “…so I’d be happy to connect you with my people, but I can’t speak for you as a professional because I just haven’t seen you work.”

We’ve all heard it before when first getting into the working world and receiving networking advice: “it’s all about who you know.” Although that’s true, that’s only part of it. The product of even more conversations with Steve led to the rephrasing instead to: “it’s all about who knows you.” It’s about who knows you well enough to vouch for you, to toss your name out there and recommend you—not just personally, but also professionally.

But there’s a third iteration of this advice that recently hit me…let’s say you do get to a point where people in your network are willing to vouch for you and say, “I know Matt, he’s a great guy” to their colleagues or whoever it may be. Odds are that sentence will be followed up with the context, such as “we had a few great phone calls” or “he was super helpful on this one Excel problem” or “he connected me with a few of his colleagues with similar interests.”

Once someone knows you, that’s followed up with what they know you for.

I know what you’re thinking next, “But how do I ‘work’ for those people to show myself as a professional if they’re far away and I already have a job?” or, “How do I get someone to ‘know me’ just through the phone and computer?”

The answer? Creatively. It starts with a genuine phone call, then a few thoughtful texts (like I talked about above…woah…), having a thoughtful social media profile (as a “living, breathing resume,” another Steve quote) so they can see you as a “professional” from a distance, then offering your time/help whenever you can. It can be offering to solve an Excel problem they said they’ve been having, or opening up your network to them if they’re looking to connect with a specific type of person you know, or simply acting on their advice and following up with how it went (I talked about this relative to being a good mentee).

Main Lesson: Pivot from “it’s all about who you know” to “it’s all about who knows you.” Be creative in finding ways to show your value and getting others to know you for both being a good person and a great professional.

Pivot from “it’s all about who you know” to “it’s all about who knows you.” Be creative in finding ways to show your value and getting others to know you for both being a good person and a great professional, says @CoachBigToe Share on X

Now It’s Just Action

I love a good quote, a good metaphor, or a complex topic boiled into a simple phrase. But at the end of the day, if you want to improve yourself, you need to take action and make it happen. Hopefully it was obvious how each of the three pieces of advice have simple action items that you can do starting tomorrow (or even today…) to start creating better connections and setting yourself up for more professional success in the future. Good luck, be genuine, and do these things over a long period of time.

Since you’re here…
…we have a small favor to ask. More people are reading SimpliFaster than ever, and each week we bring you compelling content from coaches, sport scientists, and physiotherapists who are devoted to building better athletes. Please take a moment to share the articles on social media, engage the authors with questions and comments below, and link to articles when appropriate if you have a blog or participate on forums of related topics. — SF

Endurance cycling can be addictive, driving athletes to push their limits constantly. In my case, the moment I started beating my own records and times, it left me hungry for more. This pursuit isn’t just for adults—even teenagers are drawn to the challenge, often adopting strict diets and workout routines to excel. However, the pressure to perform better can lead some to obsess over their body image, which can result in a cycle of underfueling.

Various factors contribute to underfueling, including intense workouts without adjusting food intake and anxieties about weight and performance. Regardless, this behavior can hamper athletic performance and pose health risks. Coaches should prioritize ensuring young endurance cyclists get adequate nutrition to prevent underfueling and safeguard their future well-being. Learn more about the long-term consequences of underfueling and some strategies to help young cyclists reach their full potential.

Underfueling Translates to Higher Risk of RED–S

Proper nutrition is vital for athletes but most crucial among still-growing teens. Those with suboptimal energy intake may be at greater risk of underfueling, which happens when total caloric and macronutrient intake is low.

Inadequate energy intake poses a higher risk of Relative Energy Deficiency in Sport (RED-S), which is defined by the International Olympic Committee (IOC) as “a syndrome of impaired physiological and/or psychological functioning experienced by female and male athletes caused by problematic low energy availability (LEA).”

LEA can be intentional or unintentional. Intentional LEA happens when athletes restrict their dietary intake to control body weight or composition. Pervasive issues around body image and traditional beliefs—such as “eating is cheating”—can result in intentional LEA. One study suggests cycling is a sport with a high prevalence of eating disorders, such as binge eating, anorexia nervosa, and bulimia nervosa. Furthermore, cyclists perceive leanness as vital to their success and can thus manipulate their nutritional intake.

Regardless of the sport and sex, a team’s culture can also contribute to intentional LEA. A culture where people insult other athletes’ body weight and shape can push victims to overexercise and eat less.

Unintentional low energy availability (LEA) happens when cyclists fail to meet the energy requirements of the sport due to a lack of knowledge. Share on X

Consequently, unintentional LEA happens when cyclists fail to meet the energy requirements of the sport due to a lack of knowledge. It can be quite common for young athletes to underfuel since they’re unaware of training demands. Financial problems and low appetite can also contribute to this condition.

Long-Term Implications of Underfueling

According to Rebecca McConville RD, LD, CSSD, CEDS, RED-S-related problems can happen when the body has 250 calories less than its daily requirement over five days. Young endurance cyclists who don’t have enough energy intake could face long-term implications.

Significant fatigue during training sessions conducted after proper rest can indicate inadequate energy levels. According to Jessica Crandall, RDN, CDE, feeling lethargic, weak, and sore are signs of improper fueling, which may lead to a weakened immune system. Coaches can also detect signs of fatigue through body language and other non-verbal communication cues, including mood changes and a lack of willingness to train for long periods. 

Underfueling can delay muscle glycogen replacement and repair of muscle tissue, hindering training. Not getting enough energy requirements may also lead to decreased immunity, increasing susceptibility to injury and illnesses. 

Severe calorie deficiency among women can cause estrogen levels to drop, delaying the menstrual cycle and the onset of puberty. This symptom is a sign of a subcategory of RED-S called “the female athlete triad,” which describes the three interrelated issues of irregular menstruation, bone loss, and disordered eating. Someone can have one, two, or all three parts of the triad. Signs to look out for include missed periods, weaker bones, and low BMI.

Figure 1. Recommended daily carbohydrate intake by weight. Data Source: Gatorade Sports Science Institute.

Most bone density is formed during the teenage years. Reduced bone formation in early adulthood can lead to long-term issues with osteoporosis and bone weakness. The loss of estrogen can lead to a lack of bone density and may put female endurance riders at a higher risk of stress fractures and osteoporosis.

Though the majority of research on underfueling and LEA has been on females, the IOC now recognizes its negative implications among males, including reduced testosterone production. A study shows male endurance athletes who have LEA are at risk of insufficient testosterone production, which may lead to decreased bone mineral density. However, more research is necessary to understand the effects on men better.

Nearly one in three adolescents ages 13 to 18 will experience anxiety disorder in the United States. The pressures of staying fit can affect the mental health of athletes. Stress levels and mood are also affected if the body isn’t fueled enough. For instance, 90% of serotonin is synthesized by enterochromaffin cells in the intestinal epithelium. This chemical is crucial for mood regulation, appetite, and sleep cycle.

Poor energy intake can backfire on the athlete’s performance through decreased endurance, training response, and motivation. Unfortunately, they may respond to decline through more extensive training, which can deplete more of the energy they need to function.

Poor energy intake can backfire on the athlete’s performance through decreased endurance, training response, and motivation. Share on X

Identifying and Managing RED-S

According to a study conducted by Cycling Weekly, 30% of female respondents and 15% of males have RED-S symptoms. Among female cyclists who were not on hormonal contraception, 39% cited menstrual problems.

Athletes and coaches can monitor RED-S if the levels of metabolic hormones and substrates—including 3,3,5-triiodothyronine (T3), growth hormone, leptin, cortisol, and glucose—have been altered. Validated tools such as the RED-S Clinical Assessment Tool can also be used by a trained sports medical physician to assess a young cyclist’s risk of this condition.

This instrument features biochemical markers and functional issues because of LEA, such as recurring bone stress injuries. While physical qualities such as body weight and fat are also assessed, some individuals with RED-S may have standard body mass.

Strategies for Optimizing Energy Balance

Optimal energy intake should be the cornerstone of every athlete’s diet. Nutritional and calorie requirements depend on age, sex, and activity. Since adolescent cyclists are still developing, their consumption should match their activity level and support their growth.

Active teenage males need 2,600–3,200 calories daily, while females in the same age bracket require about 2,200–2,400 calories a day. However, the more active adolescents are, the more calories they need. The body’s required energy is known as basal metabolic rate (BMR), ranging from around 1,200 to more than 3,000 calories per day.

A BMR calculator can help coaches personalize an athlete’s daily caloric requirements for various activity levels. However, this tool only guides coaches when creating a diet plan, not as a prescription for health and nutrition. The BMR formulas for men and women are as follows:

• Men: BMR = 88.362 + (13.397 x weight in kg) + (4.799 x height in cm) – (5.677 x age in years)
• Women: BMR = 447.593 + (9.247 x weight in kg) + (3.098 x height in cm) – (4.330 x age in years)

After identifying the BMR, coaches can help combat LEA by ensuring an athlete’s diet is enough to cover their needs. They can achieve energy balance by computing energy availability (EA) using the equation:

• EA(kcal/kgFFM/day) = [EI(kcal/day)−EEE(kcal/day)] / FFM (kg)

EI = energy intake, EEE = exercise energy expenditure

Nutritional Strategies

Adolescent athletes need appropriate food to fuel their bodies. When creating a nutritional plan, consider including sources that help boost performance and recovery. For instance, one cup of blueberries offers 24% of an individual’s daily value of vitamin K and 22% of manganese, which help boost bone density and reduce proneness to muscular strains. Choosing nutrient-dense foods can help athletes manage a healthy weight and enhance muscle strength.

Carbohydrates are the most essential fuel for an adolescent cyclist. Because carbs are stored as fuel, cyclists need them before training. On the other hand, fats usually get a bad reputation because they are about twice as calorie-dense as carbs and proteins. However, fats are essential for nutrient absorption and hormonal production.

According to exercise physiologist Dr. Tim Podlogar, athletes must utilize fats and carbohydrates efficiently since glycogen stores are limited. Fat stores are larger but only work in aerobic activities, so the body requires oxygen to translate fat into energy. Stores of carbohydrates are smaller, but the body can utilize them in anaerobic processes, meaning it can get energy even without oxygen.

The body needs time to adjust breathing when cycling. During this anaerobic process, the body requires glycogen, so it must get energy from sources that don’t need oxygen.

Figure 2. Recommended carbohydrates in relation to exercise. Data source: Gatorade Sports Science Institute.

Carbohydrate intake should range from 7 to 12 g·kg-¹ body mass (BM) to ensure optimal muscle glycogen availability during competition and intense training. For exercise lasting more than 60 minutes, it is recommended to consume carbohydrates of 1 to 4 g·kg^-1 BM one to four hours before activity.

Endurance athletes should ensure half of their plate consists of carbohydrate sources—rice, bread, oats, and tortillas—on heavy training days. The standard carbohydrate recommendation for high school athletes is 360–500 grams daily.

Junior athletes can struggle to identify thirst during a ride, so starting hydrated is always recommended. Share on X

Good hydration is also crucial for optimal performance and recovery. Junior athletes can struggle to identify thirst during a ride, so starting hydrated is always recommended. Less than 2% dehydration of total body weight can significantly reduce skill, exercise, and mental performance.

Fuel Well for Optimal Health and Performance

RED-S can impact anyone, but its effects are more pronounced in young athletes who are still developing. As a coach, it’s essential to understand cycling is not just a sport—it’s a lifelong pursuit for teens that requires sustainable habits on and off the track.

Help the future generation of cyclists achieve their best health and performance by prioritizing proper nutrition, adequate rest, and long-term health over immediate results. Along with a personalized nutritional plan, regularly monitoring food intake and performance can help ensure proper caloric balance and instill self-care habits that will benefit teens throughout their lives.

Since you’re here…
…we have a small favor to ask. More people are reading SimpliFaster than ever, and each week we bring you compelling content from coaches, sport scientists, and physiotherapists who are devoted to building better athletes. Please take a moment to share the articles on social media, engage the authors with questions and comments below, and link to articles when appropriate if you have a blog or participate on forums of related topics. — SF

Injury prevention programs (IPPs) have been shown to be effective at reducing the risk of injury. The 11+, for example, has been shown to reduce hamstring injuries by 60%, hip and groin injuries by 41%, knee injuries by 48%, and ankle injuries by 32%. It reduces the risk of all injuries by 39% (Thorborg et al., 2017).

According to Arundale et al., 2023, the components of effective injury risk reduction programs include:

• Implementation at the youth level.
• Beginning in the pre-season and continuing through the regular season.
• Being performed multiple times for an overall time of at least 30 minutes per week.
• Being multifaceted and including a combination of strength and plyometric exercises.
• Having a high level of compliance.

Even the best program in the world won’t work if it doesn’t get done.

Unfortunately, implementing IPPs has proven to be challenging. Barriers to implementation are varied and context-dependent.

In elite women’s footballers from the 2019 FIFA World Cup, players identified player motivation and the attitude of coaches as the primary barriers to implementation (Geertsema et al., 2021). A review of IPPs found that motivation, time requirements, skill requirements for program facilitators, compliance, and cost were all barriers to implementation (Bogardus et al., 2019). In my own experience as a youth soccer coach, a lack of confidence in delivering the program, a lack of field space, and limited time seem to prevent coaches from implementing IPPs.

In my experience as a youth soccer coach, a lack of confidence in delivering the program, little field space, and limited time seem to prevent coaches from implementing IPPs, says @NSurdykaPhysio. Share on X

As physical therapists, athletic trainers, performance coaches, and sport scientists, we have access to scientific knowledge on IPPs. However, we are not always the people best positioned to deliver these programs, especially at the youth level, where it is crucial to begin their implementation. While 59% of physical therapists worldwide are aware of IPPs, only 37% actually implement any in their current practice (Al Attar et al., 2021).

Outside of professional academies, how many of us are ever consistently present at training sessions at the youth level? How many of us have access to youth athletes for the recommended 2–3 times per week? To make the most impact and deliver IPPs to the largest number of athletes possible, it has to come from the people who are actually there with them on a regular basis: their coaches (Bizzini and Dvorak, 2015).

Coaching the Coaches

As we all know, it can take years for scientific knowledge to be translated into practice. However, I believe there are ways that we can begin educating coaches on IPPs. Ideally, youth soccer leagues and national federations would mandate that training on IPPs be part of coaching education courses and a requirement to obtain a coaching license.

Outside of governance and policy at the macro level, healthcare and performance professionals can run off-season or pre-season clinics and symposiums to teach local coaches how to run an IPP with their teams. Instead of focusing community outreach on individual teams or clubs, promote a one-day training course for as many youth coaches as possible. Social media can also be a powerful tool for disseminating information to the general public.

If coaches are to be the primary stakeholders responsible for the delivery of IPPs, then the challenges they face in implementing them need to be addressed. One barrier to IPP implementation by youth coaches is a lack of resources and education on what IPPs are, why they’re important, and how exactly to deliver them. Our role, then, as healthcare and performance professionals, needs to shift away from strictly the delivery of these programs to the education of coaches. If we can effectively educate them to deliver IPPs, then more youth athletes might get access to them. When we educate coaches on IPPs, it’s important to highlight their effectiveness in reducing injury risk to increase motivation and buy-in.

In order to enhance buy-in from coaches, the IPP needs to be easy to integrate into the team’s normal training structure. At the youth level, teams might have access to half a pitch for 60–90 minutes twice per week. Coaches perceive that IPPs take too much time (Minnig et al., 2022) and can feel pressure to jump right into the training session to maximize their time on the pitch. There are a couple of ways that we can address this barrier—perceived or real—and help coaches implement IPPs in their training sessions.

Strategies for Implementing IPPs

In 2019, Whalen et al. found that moving part 2 of the 11+ (strength, plyometrics, and balance exercises) was still effective at reducing injury risk while also improving compliance at the semi-professional level. This might be an effective strategy at the youth level because it reduces the time spent performing the 11+ before starting the training session. Coaches can have the athletes perform part 2 of the 11+ while they are wrapping up the session and summarizing key coaching points. They can also perform this part of the 11+ off to the side of the field so they don’t have to worry about going beyond their allotted time slot or being in the way of another team starting their training session.

Another possible method of addressing this time barrier is to integrate components of an IPP more seamlessly into the session. Most youth soccer training sessions begin with some type of technical warm-up, consisting of anything from passing patterns to dribbling in a grid. Why not try to integrate aspects of an IPP into this technical warm-up that coaches are already doing?

Why not try to integrate aspects of an injury prevention program into the technical warm-up that coaches are already doing? asks @NSurdykaPhysio. Share on X

If the team’s technical warm-up is dribbling inside a 20x20m grid and working on individual skills, you can add in the exercises that are part of the 11+. So instead of having the athletes do the running exercises down a straight line of cones, they simply perform them within the 20×20 grid, mixed in with the technical skills. Below is an example of a dribbling and individual ball control technical warm-up performed with components of an IPP for youth soccer players:

Each player has a soccer ball inside a 20×20 grid.

Instructions: Dribble your soccer balls. The only rules right now are don’t stop moving unless I say “freeze,” don’t bump into anyone, and don’t leave the grid unless I tell you to.

Have them do this for about a minute. Then tell them to freeze to listen to the following instructions: Now, every time I say the number 1, I want you to leave your soccer ball, go find another soccer ball, do 10 toe taps, then go back to your ball and start dribbling again. When I say the number 2, I want you to stop your soccer ball, side shuffle to another soccer ball, box the ball 10 times, then side shuffle back to your soccer ball and dribble again. When I say the number 3, I want you to leave your soccer ball, run as fast as you can outside of the grid, and then run back to your soccer ball as fast as you can and start dribbling again.

In this part of the warm-up, the players are getting additional technical work on the ball and have also been introduced to high knees (via the toe taps), side shuffling, changing direction, and scanning the environment for a free soccer ball. I usually do 3–5 rounds of each number randomly before mixing it up again.

Here’s an example set of instructions for the next round of the warm-up:

Now, every time I say the color purple, I want you to stop your soccer ball, jump over it with both feet together, turn around and jump over it again, and then start dribbling again. When I say yellow, I want you to stand on one leg, hop sideways to land on the other leg, hold it for two seconds, then hop back to the other leg and hold for two seconds, then start dribbling again. When I say green, I want you to do fast feet forward for 10 steps and fast feet backward for 10 steps, then start dribbling your soccer ball again.

Again, I’ll randomly call out colors and try to hit 3–5 rounds of each color. In this section of the warm-up, they end up doing double-leg hopping, skater hops, quick changes of direction, and some single-leg balance. In this entire technical warm-up example, the athletes not only perform movements often seen in effective IPPs, but they also get touches on a soccer ball, which helps with their technical skill development and coach and player buy-in.

If the team’s technical warm-up consists of passing patterns, you can also add in the exercises that are part of an IPP. For example, a common passing warm-up in youth soccer is to have four players in a triangular shape with two players at one point (point A) and one player each at the other two points (points B and C) of the triangle.

One of the players at point A has a soccer ball and passes to the player at point B. Player 1 then follows their pass and runs from point A to point B. Player 2 receives the ball, passes to player 3 on point C, and then runs from point B to point C to follow their pass. This continues with players passing the ball to the next player and following their pass on the jog.

Instead of jogging, though, the players can be instructed to perform movements that are part of an IPP. The path from point A to point B can be a jog, point B to point C can be a side shuffle, and point C to point A can be a backpedal. After a couple of rounds, have the players change directions with their passes and change the movements. So now, point A to point C is bounding, point C to point B is a single-leg hop, and point B to point A is a high skip.

The passing pattern can then be varied to mix up the technical component and introduce further IPP movements. Now, have discs set up in a diamond shape with players lined up across from each other at points A and C.

Player 1 has the ball at point A and passes the ball to player 2 at point C. Player 1 then runs to point B and cuts inside to the middle of the diamond, while player 2 passes the ball to player 3 at point A. Player 3 does a short pass to player 1 inside the diamond, who passes it back to player 3 in one touch and then spins out and runs to the end of the line at point C. Player 3 then plays a long pass to player 4 at point C and repeats the same process that player 1 had previously done.

Meanwhile, player 2, who had initially received the ball from player 1 at point C and then played a pass to player 3 at point A, will run to point D, backpedal to point C, and then sprint to the end of the line at point A. From a technical perspective, this warm-up includes one-touch, short, and long passes. From an IPP perspective, it includes changing direction, multidirectional running, and sprinting.

While the athletes do the exercises, I explain which parts of the body the exercises address and why they’re so important to help decrease the risk of injuries in those areas, says @NSurdykaPhysio. Share on X

I mentioned earlier that part 2 of the 11+ can be moved to the end of practice to help with buy-in and still be an effective way to reduce the risk of injury. I also try to do these exercises with the athletes while the parents are there so that the parents can see them, too. While the athletes do the exercises, I explain which parts of the body the exercises address and why they’re so important to help decrease the risk of injuries in those areas. This helps to increase player motivation and gets the parents bought in and educated on what they can potentially do at home as well.

These are the exercises I typically do with the athletes at the end of the session and how I coach them:

• Squats – Keeping your feet flat on the floor, lower down like an elevator, and stand back up. If I notice that athletes have their feet really close together or really far apart, I’ll tell them to stand with their feet on either side of the soccer ball (most kids don’t understand the concept of putting their feet hip-width apart).
• Lunges – Take a step forward, bending both knees, then step back again. Usually, a demonstration works best for a lunge. I also tell them to pretend there’s a laser beam coming out of their kneecap, and I want them to keep that laser beam pointed right in front of them the whole time.
• Heel Raises – Go up onto your toes and then slowly lower down again. I often have them do this while holding a partner’s hands for balance.
• Planks – Make your body as straight as a board and try to freeze in that position. I’ll go around while they do this and kick a soccer ball underneath them to make sure they aren’t sagging their hips down, or I’ll tap on their lower back if they have their hips up in the air too high.
• Copenhagens – Lift the inside of your shoe up to the sky. I always start with Level 1 Copenhagens, in which they are lying on their side.
• Nordics – Make your body as stiff as a board, kick your heels up into your partner’s hands, and lower yourself down to the ground as slowly as you can. It takes kids a couple of sessions to understand how to do this exercise correctly, and they usually need some hands-on guidance. Don’t get discouraged—they can and do learn how to do this pretty well with enough practice.

Where Does Dynamic Stretching Fit In?

So, I covered running exercises, changes of direction, and plyometric exercises within the technical warm-up. I also discussed that strengthening exercises can be done at the end of the session to help improve implementation and explained how I typically do that. One thing I have not yet addressed is stretching.

Some IPPs include dynamic stretches, but they have not been shown to be a vital aspect for effectively reducing injuries. However, there are times that I’ll include a few dynamic stretches if time allows. When I do include some dynamic stretches, I always make sure I add some player education simultaneously. Usually, I’ll include a walking quad stretch, walking calf and hamstring stretch, and lateral lunges.

As the athletes do the stretches, I tell them what part of the body we are focused on (quads, calves, hamstrings, and adductors/groin) and explain that those are the areas used most in soccer. My intention in doing this is simply to educate the athletes on their bodies. Most kids won’t actually feel any stretch, and that’s okay. These are still good movements for youth athletes to do whether they feel a stretch or not (single leg balance, lunging, reaching, etc.).

Most kids won’t actually feel any stretch, and that’s okay. These are still good movements for youth athletes to do whether they feel a stretch or not, says @NSurdykaPhysio. Share on X

The warm-ups I just used as examples are simply that—examples. The exercises that are done are representative of some of the components in IPPs, like the 11+. They can (and should) be varied and progressed as the athletes become more adept at performing them.

Coaches should be educated on how to progress and coach these exercises. It’s helpful to teach principles instead of scripted progressions because coaches can feel comfortable varying and progressing the exercises to suit their team. Here are some general principles that might help coaches progress the exercises in an IPP warm-up:

• Start double leg and progress to single leg.
  • Double-leg jumps over the ball to single-leg jumps over the ball.
• Start with lower hops and progress to higher jumps.
  • Hops over an invisible line on the ground → hops over a disc → hops over a ball.
• Use the first section of the warm-up for running-based movements such as jogging, side shuffling, and some change-of-direction tasks. Use the second part of the warm-up for jumping, hopping, and more challenging change-of-direction activities.
• Simple → Complex
  • For younger kids or novice players, start with simple, one-step instructions. “When I say the color green, jump over the ball.” With older or more experienced athletes, you can add some complexity to the instructions. “When I say the color green, stop your ball, run to a different ball, do five juggles, and then backpedal back to your ball.”
  • Note: You can also add a bit more of a cognitive challenge in your instructions. “When I say something that is the color green (like celery or grass), do five squat jumps.”

It’s also essential that the athletes are not simply given instructions on what to do but are shown and told how to do the movements as well. It’s important for kids to be able to explore various movement patterns and come up with their own solutions to motor challenges, so we don’t want to overcoach them, but we should still give them some cues.

Here are some of the cues I typically use with youth soccer players:

• Jumping and landing exercises: When you land, I don’t want to hear a sound.
• Changing direction: Get low to the ground and look up to make sure you can still see the ball and players around you.
• Side shuffling: Don’t click your heels.
  • Note: I used to say, “Don’t click your heels; you aren’t Dorothy trying to go back to Kansas,” but I’m finding that many kids these days haven’t seen “The Wizard of Oz,” so this cue has been less effective.
• Single-leg balance: Freeze like a statue.

Making a Difference at the Youth Level

In summary, IPPs like the 11+ effectively reduce the risk of injuries, but only when adhered to. It’s important to start IPPs at the youth level; there are, however, several barriers to implementation. Coaches should be the ones delivering IPPs at the youth level, which means our roles as healthcare and performance professionals need to shift away from the delivery of IPPs and toward the education of coaches. The barriers facing youth coaches need to be addressed, including the lack of confidence in knowledge and ability to deliver IPPs, session time, and field space.

Coaches should be the ones delivering IPPs at the youth level, which means our roles as healthcare and performance professionals need to shift toward the education of coaches, says @NSurdykaPhysio. Share on X

Integrating aspects of a successful IPP into a technical warm-up and moving the strengthening exercises to the end of the session are two tactics to help reduce the real and perceived barriers faced by youth coaches. Teaching coaches principles rather than scripted warm-ups might give them more confidence in their ability to program and progress IPPs into their sessions based on their team’s needs and abilities.

Lead Photo by Andy Mead/YCJ/Icon Sportswire

Since you’re here…
…we have a small favor to ask. More people are reading SimpliFaster than ever, and each week we bring you compelling content from coaches, sport scientists, and physiotherapists who are devoted to building better athletes. Please take a moment to share the articles on social media, engage the authors with questions and comments below, and link to articles when appropriate if you have a blog or participate on forums of related topics. — SF

References

Thorborg K, Krommes KK, Esteve E, Clausen MB, Bartels EM, and Rathleff MS. “Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: a systematic review and meta-analysis of the FIFA 11 and 11+ programmes.” British Journal of Sports Medicine. 2017;51(7):562–571. doi:10.1136/bjsports-2016-097066

Al Attar WSA, Yamani SA, Alharbi ES, et al. “283 Sports injury prevention programs: awareness, implementation and opinion of physical therapists worldwide.” British Journal of Sports Medicine. 2021;55:A110.

Minnig MC, Hawkinson L, Root HJ, et al. “Barriers and facilitators to the adoption and implementation of evidence based injury prevention training programmes: a narrative review.” BMJ Open Sport & Exercise Medicine. 2022;8:e001374. doi:10.1136/ bmjsem-2022-001374

Whalan M, Lovell R, Steele JR, and Sampson JA. “Rescheduling Part 2 of the 11+ reduces injury burden and increases compliance in semi-professional football.” Scandinavian Journal of Medicine and Science in Sports. 2019;29(12):1941–1951. doi:10.1111/sms.13532

Bizzini M and Dvorak J. “FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide-a narrative review.” British Journal of Sports Medicine. 2015;49(9):577–579. doi:10.1136/bjsports-2015-094765

Arundale, A.J.H., et al. (2023) “Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention.” The Journal of Orthopaedic and Sports Physical Therapy, 53(1), pp. CPG1–CPG34.

Bogardus, R.L. et al. “Applying the Socio-Ecological Model to barriers to implementation of ACL injury prevention programs: A systematic review,” Journal of Sport and Health Science. 2019:8(1);8–16.

Geertsema, C. et al. “Injury prevention knowledge, beliefs and strategies in elite female footballers at the FIFA Women’s World Cup France 2019,” British Journal of Sports Medicine. 2021;55(14):801–806.

With various sports finding ways to play and practice year-round, volleyball continues to drive up practice and tournament demands every year. For a high school volleyball athlete, school season leads right into club after a short break, with club leading into a break of 1–2 months before summer training for school season starts back up again. Add in sand volleyball, which takes place throughout various times of the year, and you get an athlete who is susceptible to overuse injuries and overall burnout. If you’re looking to plan a traditional “off-season,” you’ll find minimal time to reap the benefits and end up leaving potential gains on the table—so finding a more dynamic system ready for anything is the better option.

A good program for an athlete playing so much of the same sport will need to find the balance between performance and health. Share on X

A good program for an athlete playing so much of the same sport will need to find the balance between performance and health. Chasing gains in the weight room with poorly timed and inappropriate methods can build up too much fatigue for optimal volleyball performance, but too much “playing it safe” on the health side of the spectrum, and you can have detrained athletes who won’t see any progress in developing physical outputs.

I’m in the fortunate position to train volleyball players throughout the year and have had zero long-term injuries and achieved numerous PRs on our KPIs (key performance indicators, or things we want to set records in) throughout this past school and club season. Three things have stuck out to me that could help others if they find themselves training high school volleyball athletes.

1. Isometric/Eccentric Methods Are Healthy Add-ins

Unless you somehow don’t have Instagram or X or just haven’t read up on trends within strength and conditioning, you already know about the benefits eccentric and isometric tempo training can have for an athlete. In short, eccentric training is the resisted lengthening of the muscle, and isometric training is producing force where a muscle’s length isn’t changing. Performance benefits from these methods are well known, with eccentric strength always being higher than concentric strength for potential gains, as well as isometrics (primarily overcoming) being able to produce forces much higher than concentric lifting. These are great for a total body vision, but I will look at their use primarily for the lower body here.

Methods of each I prefer include:

Eccentric

• Overloaded eccentrics (80% +) (rarely used)
• Slow eccentrics (60%–75% of 1RM)

Isometric

• Overcoming (pushing against an unmoving object)
• Yielding (holding at various positions)

During competition, the lower body of a volleyball player is constantly asked to perform fast concentric actions in various ranges of motion: front row players jumping and landing constantly at the net, as well as back row players reaching low ranges at high speeds to meet the ball for defensive plays, have their hips, knees, and ankles constantly moving at high speeds to make plays. To get the balance the body likes, these methods will contrast the body’s explosive actions during a volleyball game with slower/yielding lifts that will drive performance on the court with a base of health from the weight room.

The soreness that eccentric training can cause is a well-known factor, and I know some coaches reading this have never considered eccentrics in season, for understandable reasons.

Muscle lengthening has been known to provoke strong delayed-onset muscle soreness and can be a fatiguing stimulus on the nervous system as well; however, I’ve been able to mitigate these effects with proper intensities and volumes (just like any exercise). The best scenario is having athletes who have experienced eccentric training, as their bodies will be ready for it.

Keeping slow eccentrics within the percentage ranges that are away from a maximal stimulus or choosing smaller isolation exercises instead of compound lifts has helped mitigate those effects in my athletes’ training. If it is a worry, then saving it for training periods without as much competition can be great as well, and using isometrics can carry a decent amount of the workload.

2. Know the Right Kind of Jumps to Attack

It can be very easy to refrain from the intensity of jumping with all the jumps that occur in practice and games, but again, if we hold back too much, we cannot grow. Tyler Friedrich’s article, “An Alternative Way to Think about Plyometric Training for Women’s Volleyball,” sheds light on the fact that most of the jumps within practice and games don’t end up being near any personal bests as far as jump heights go.

If we hold back too much, we cannot grow. Share on X

That article was for college players who are among the top female jumpers in the world—so, in the case of high school players who, on average, do not reach that level of height, the jumps can have even less of a nervous system stimulus than what Friedrich highlighted. This is not to downplay the fatigue that comes with jumps happening in practice and games, but when looking to keep plyometric and jump training in the program, this data can help us pick our training methods.

I put this fatigue into an “extensive” category with lots of quick, medium-/low-intensity ground contacts that can wear on the feet, ankles, knees, and entire lower body complex. Filling the extensive bucket means the intensive bucket can have more attention put on it. Lower rep sets for maximum intensity can get the strong nervous system drive we want to tap into high-threshold motor units. This doesn’t mean I don’t plan extensive jump work, as I try to keep in all important qualities all the time, but we know where to put our higher workloads from the data.

Variations of jumps/plyos I like include:

• Resisted jumps (dumbbell, hex bar, barbell, band-resisted)
• Seated jumps for maximal height/distance,
• Broad jumps
• Depth/Drop jumps

Having tools like a jump mat or hurdles for the athletes to try and jump over is key to getting output with direct feedback of jump heights being known right away and helping create a fun, competitive environment. Intent is the key to any training program’s success, and when I can get it, I will go after it. Reps and sets can vary, but 2–4 sets of 3–5 reps for these types of jumps has been a good sweet spot and can be more with an athlete who has a younger training age.

A few other notes:

• Complex training is a great method for potentiating jumps while conserving training time. Heavier lifts/jumps paired with bodyweight/unweighted jumps can be an effective addition.
• Olympic lifting has had a great transfer to jumping for my athletes on their own and in complexes. (I will not waste my time arguing about whether Olympic lifts should be done.)
• Depth/drop jumps and landings are also a strong stimulus on the lower body and, along with all the practice and game jumps, can build fatigue fast. However, these allow the athletes to adapt to landings far higher than their current jumps give them and won’t be a problem when timed and dosed correctly.

3. Build a Strong Base with Variation

A base of physical literacy within core movement patterns is one of the first things I try to increase in an athlete when they begin training with me. The core themes of squatting, hinging, single-leg movement, and upper pushing and pulling will build the movement toolbox that will help them develop over time. When the athletes are first learning, I like to slow-cook their process with foundational movements that can get the point of each across. For example, goblet squats are almost always the first squatting movement I teach, and the athlete will stick with that for two blocks of a couple of weeks. After a good time developing the correct technique and learning the “why” behind the squat, we can move to a barbell.

New athletes to the weight room can get away with making progress from this for a long time, so there isn’t the need to vary the movement approach too much. But I have athletes who have been training for years, and for a lot of them, the weight room is an outlet from the sport of volleyball itself. It offers the physical fulfillment they’re used to in something different than the sport they play at least twice a week, almost year-round. So, for the experienced athlete, I need to look into how I can keep building upon the physical abilities they’ve gained in the weight room and give them something they want to push toward without things becoming less engaging.

In addition to keeping intrigue within the program, variation widens the base of the athletes’ preparedness. Share on X

In addition to keeping intrigue within the program, variation widens the base of the athletes’ preparedness. By keeping the core movement patterns within your program but also switching variations at a good pace, you’re building a base of physical GPP with new tissue developed and movement literacy learned, but also working the fundamentals of the pattern your system has. There are different ways coaches like to teach their squatting movements, but in my system, I’m hoping my athletes can transition front squats to back squats (and vice versa) from one training block to the next. Our squatting pattern is still being trained, but the slightly different physiological benefits these movements have from one another can be just enough to create a change for that athlete.

Louie Simmons was the first to bring the idea of true variation to training with his conjugate method system, looking to avoid the law of accommodation with his powerlifters. Stating that the body will adjust to the stimulus that is continuously put on it, his ideas of max effort variations constantly changing helped him dominate the geared powerlifting world for years.

With all that being said, my volleyball players are the furthest thing from geared powerlifters, so squat suits and bench shirts will not be needed. However, switching between movements within our core movement patterns contributes to the athletes’ overall growth without feeling repetitive and becoming accommodated for no growth. A time frame of 3–4 weeks per training block is the sweet spot to have enough time to squeeze all we can out of those variations without overstaying our welcome.

As for which movements to pick, having a good understanding of what athletes know can guide the process. When there is a stretch of a couple of weeks where the athlete has no tournaments, introducing a brand-new movement can help bring new growth. When we know we are coming to a volleyball-packed couple of weeks, switching to a variation that we know the athlete has literacy with is the better option, considering that brand-new movements can be more fatiguing on the body.

When there is a stretch of a couple of weeks where the athlete has no tournaments, introducing a brand-new movement can help bring new growth. Share on X

Remember, just like the difference between medicine and poison being dosage, the same goes for methods of training. Knowing how much of something to do and when to do it is incredibly important when trying to push athletic development within a competition period.

While this seems like a concept better suited for the more experienced athlete, early variations for accessory movements can be introduced for beginners very well. Even if your goblet squats and push-ups stay as staple movements for a while, making minor adjustments to your lower-tier accessories can go a long way. New core work every block or switching from DB to cable rows keeps things surprisingly fresh for someone new to the iron game.

Along with the exercises used, variation of the movement planes and where you move within space is also important. While every sport has its bias and specific needs, the chaos on the field of play can never be completely accounted for. In the case of volleyball, athletes practice their skill sets for various jumping, blocking, setting, and passing scenarios; awkward setups and reactions to a play can lead the body into positions it’s never seen before, which can ultimately lead to injury. If we are going to do our best to “bulletproof” these athletes, we need to leave no stone unturned.

To fill this need, I have my athletes cover a variety of resistance and movement exercises in the three planes of motion: the sagittal (forward and backward movement), the coronal (lateral), and the transverse (rotational movement). Within these planes, we not only want to build tissue within the primary movers but also work to increase movement speeds and the ability to be fluent within those spaces. Grouping movements for the planes, I look to label them as either “resistance” or “movement” exercises.

These are general terms, but you can get the idea. Examples of each can look like:

• Sagittal: forward or reverse lunges for resistance, linear sprints for movement.
• Coronal: lateral lunges for resistance, shuffling for movement.
• Transverse: Pallof press with rotation for resistance, medicine ball step-in throws for movement.

The more we can build through variability, the higher the chances that an ‘unseen’ position to the body isn’t as unseen as we think, and we will not only survive the position but thrive in it. Share on X

Challenging these plans with new variations, speeds, and tempos allows for a full toolbox of resilient tissue to be built. The more we can build through variability, the higher the chances that an “unseen” position to the body isn’t as unseen as we think, and we will not only survive the position but thrive in it.

Improve Performance While Maintaining Health

We are fighting the battle of fatigue when it comes to training athletes who always have competition going on. With volleyball, I’ve found that there’s always the attraction to playing it safe and getting these players through their season—but there’s too much potential in what they could do to have them skip their training for weeks on end during a competition period. Health is always first and foremost for these athletes and will be considered before anything else, but I believe we can achieve a solid increase in performance throughout their careers while keeping them on the court happy, healthy, and playing the game they love.

Since you’re here…
…we have a small favor to ask. More people are reading SimpliFaster than ever, and each week we bring you compelling content from coaches, sport scientists, and physiotherapists who are devoted to building better athletes. Please take a moment to share the articles on social media, engage the authors with questions and comments below, and link to articles when appropriate if you have a blog or participate on forums of related topics. — SF

According to the research, maximal running speed can only be maintained for approximately one second, even by the world’s most naturally gifted and best-trained athletes. Depending on the athlete’s level, they can cover anywhere between 10 and 12 meters (approximately) in one second. After that, any further efforts can only briefly maintain the top speed and then attempt to minimize the inevitable deceleration. After about one second of maximal speed, the only question is what the deceleration rate will be.

For that reason, evaluating maximal running speed for more than one second will also include the sprint endurance component. Therefore, the 10-meter (m) fly runs are the only simple and cost-effective way to evaluate maximal running speed. To clarify, flying 20s, 30s, and longer distances also include the sprint endurance evaluation, and absolute speed is no longer achievable.

10m fly runs are the only simple and cost-effective way to measure maximal running speed. Share on X

Based on the maximal speed an athlete can produce, a potential for maintaining and enduring it can be closely estimated. That leads to a conclusion about the direct relationship between maximal running speed and the potential of enduring it; in other words, the higher the maximal speed, the greater the starting point for the speed to be endured. That puts the importance of maximal speed into perspective.

A Speed Experiment

The study I undertook aimed to evaluate the maximal sprint speed in one male college-aged club athlete. The track was marked with cones and athletic tape across the lane at the start of the acceleration. We used the same marking procedure at the beginning and end of the 10m fly zone. In addition, the fly zone was marked at four additional positions, spaced 25 centimeters apart before and after the 10-meter markers, to ensure the step count and timing precision in case the athlete made his first step before or after the designated 10-meter zone.

This track marking method created a 1-meter zone before and after the beginning and end of the 10m fly zone. That made it a 2-meter total distance at the beginning and 2 meters at the end of the 10m fly zone, plenty to ensure the athlete wouldn’t be able to make the initial step outside of the zone. 

The athlete wore sprint spikes and was recorded with a smartphone from about 6m–10m, running perpendicularly to the video-recording camera. The phone was held horizontally, about 1.4–1.5 meters above and parallel to the ground. The camera was set to “slow-mo” mode or 240 frames per second (FPS) video quality. After the videos were recorded, they were transferred to a “Coach My Video” application (CMV), where the 10m flying times and relevant running-quality parameters were calculated within a 0.004/s (four one-thousandths of a second per frame) precision. Each video was analyzed in the CMV app, one at a time.

The maximal sprint speed was measured for 10 meters after a 30-meter approach under four different conditions in the order listed below:

1. Free run.
2. Acceleration assistance with an elastic “overspeed” cord + release approximately 10 meters before the 10-meter fly zone beginning.
3. With half-pound ankle cuffs around each ankle.
4. With 1-pound ankle cuffs around each ankle.

The athlete was instructed to produce maximal effort during the 30-meter acceleration phase and throughout the 10m fly zone. The first run was performed after the athlete was warmed up and fully rested. Each of the three subsequent runs was performed after six minutes of rest, which is considered a full recovery, meaning that each subsequent run began without the presence of fatigue.

Why Are These Results Relevant?

The purpose of this pilot experiment was to measure maximal speed times and their contributing factors precisely to familiarize the reader with the degree of change between each of the four different types of sprints performed.

The most important factors are:

• Ground contact time (GCT).
• Step frequency (rate).
• Distance per step.

Understanding maximal speed and its determinants allows coaches and athletes to reduce or even eliminate the guesswork from training. 

Understanding maximal speed and its determinants allows coaches and athletes to reduce or even eliminate the guesswork from training. Share on X

Compared to the free run, results from the overspeed cord-assisted and half-pound and 1-pound ankle cuff/leg runs provide information on when assistance and resistance types of runs can be applied during preparation. In contrast, free runs can be used almost throughout the year.

Video 1. Free Run.

Figure 1. Abbreviations key: a) (FT) fly time from 30m approach; b) (SN) step number; c) (SL) step length; d) (SR) step rate/10m; e) (GCT 1–4) ground contact time per step; and f) (AVG) average.

*All distances are in meters (m).

**All times are in seconds (s).

***Air times are considered irrelevant and were not calculated.

Figure 2. Differences in 10m sprint assistance and resistance times and distances are calculated from Free Run and expressed as a percentage (%).

*Values are calculated from figure 1 and rounded to the closest .25.

**For FT and GCT, a lower % indicates better values.

***For SL and SR, a higher % indicates better values.

****The abbreviation key is identical to figure 1.

Overspeed Cord-Assisted Run

As expected, the overspeed cord showed a faster 10m time than the free run. The running time/speed improved by 3.75%, and the average four-step length increased by 4.5%. This data shows that the overspeed cord-assisted acceleration is a powerful tool for training those functions.

Video 2. Assisted sprint using overspeed cord.

Simultaneously, the step rate decreased minimally by .5%, while the four-step average GCT did not change. This data indicates that different training methods should be used to train only the GCT and step rate/frequency, the essential contributing factors in maximal speed training.

The overspeed cord training method is typically recommended for advanced athletes during the late-season or competitive training cycle several weeks before the main competition. Also, if an athlete hits the speed plateau or “speed barrier” in training, this method is a well-known strategy to help athletes overcome it.

Caution should be used, as overspeed training arguably poses a greater injury risk than the free run since the running speed becomes artificially enhanced beyond the athlete’s natural ability. Additionally, supramaximal speed sprints dictate that athletes should be monitored even more closely, as they pose a greater risk for the sympathetic overtraining type. Elastic cords should be fully covered with fabric to prevent possible injuries caused by unexpected tearing and snapping back at the athlete or the partner while towing the athlete.

Resistance Runs with Ankle Cuffs

As expected, in comparison to the free run, both resistance runs, with half-pound and 1-pound ankle cuffs per leg, produced slower running times and lower speed-determining factor values.

Resistance runs with a half-pound ankle cuff/leg caused a speed loss of 1.75% from the free run, a 2% longer average step length, a 3.75% reduction in step rate (frequency), and a 7.5% longer four-step average GCT.

Video 3. Sprint with ankle cuffs providing weighted resistance.

Compared to the free run, the 10m fly run with a half-pound ankle cuff/leg showed a steep loss of running speed. When adding another half-pound per leg, an additional loss of speed by 3% followed, making it a total 4.75% difference between the free run and run with a 1-pound ankle cuff/leg. Compared to the free run, while wearing 1-pound ankle cuffs/leg, the average step length dropped by 2%, the AVG step rate dropped by 2.5%, and the AVG four-step GCT plummeted by a staggering 13%.

As the data shows, runs with ankle cuffs do not immediately improve any of the maximal speed components. They should be used primarily during training cycles focused on strength building. Running-specific resistance training is compatible with most types of strength training and can be effectively implemented into the training program during the training cycles emphasizing strength gain.

As the data shows, runs with ankle cuffs do not immediately improve any of the maximal speed components. They should be used primarily during training cycles focused on strength building. Share on X

If weightlifting training is planned for the same day as anaerobic-alactic resistance runs, it should be done as the second part of the practice, not vice versa.

To minimize the risk of injuries, the training effect of preceding general conditioning (GPP) should become relatively stable before advancing to more sprint-specific efforts such as resisted runs. Coaches should carefully plan gradual additional increments of the ankle cuff weight, resisted sprint distance, and volume. They should never use resistance runs in the weeks leading up to competition, as this will slow down the nervous system (CNS) and reduce the athlete’s performance.

By understanding the data from figure 1 and the differences presented in figure 2, coaches can decide on the type of running stimulus most suitable for their athletes’ needs in training.

To accurately select, dose, and effectively fit each type of training stressor into the general training plan, coaches should frequently record their athletes using the video recording method described at the beginning of the article, document data, and analyze how far the athlete’s sprint parameters are from the desired values at any time during preparation.

It is important to mention that too many coaches and athletes rely on auto-timing systems, often with questionable precision. While such timing systems can be practical for large groups or beginner athletes, other than measuring the flying times, they were not designed to measure GCT, step length, rate, or relevant body angles—the essential components of the athlete’s step pattern to be analyzed and trained based on those values. Because of that, when using auto-timing systems in training, it is impossible to pinpoint the exact factor that needs improvement: GCT, step frequency, step length, or the athlete’s mechanics.

Training Ideas

Other sprint-specific resistance and assistance training methods that provide relatively similar types of stress to sprints performed with ankle cuffs and an overspeed cord, respectively, are listed below:

Resistance training:

• Up the hill/stair runs.
• Sled or partner pulls and pushes.
• Weighted vest or weighted shorts.
• In the water (with or without water resistance equipment).
• Against the wind.
• On sand.

Assistance training:

• Downhill to flat.
• Self-propelled, curved treadmill.
• Stick drills (wickets) with sticks spaced closer than the natural stride length (10%, 15%, 20% closer, etc.).
• With the wind.
• Running in the air (hanging off the pull-up bar or gymnastics rings or from the parallel bars).
• Antigravity treadmill.

Running speed-specific training methods that isolate its components from figure 1 and detail how to effectively implement maximal speed, resisted speed, and assisted speed training into a general training plan are beyond the scope of this article. Please consult the references listed or other adequate literature for that purpose.

Since you’re here…
…we have a small favor to ask. More people are reading SimpliFaster than ever, and each week we bring you compelling content from coaches, sport scientists, and physiotherapists who are devoted to building better athletes. Please take a moment to share the articles on social media, engage the authors with questions and comments below, and link to articles when appropriate if you have a blog or participate on forums of related topics. — SF

References

Korchemny R and Hoskisson JL (1994). Innovations in speed development, an advanced model. Dr. Remi Korchemny, 6435 Ridgewood Drive, Castro Valley, California 94552.

Mann R and Murphy A (2022). The Mechanics of Sprinting and Hurdling. Independently published.

Walker J, Tucker C, Paradisis G, Bezodis I, and Bissas A. (2019, February). Biomechanical Report for the IAAF World Indoor Championships 2018, 60m Men & 60m Women. Birmingham, UK: International Association of Athletics Federations. www.Worldathletics.com. Retrieved April 1, 2024, from World Athletics.

The pursuit of speed, strength, and all things athletic places intense, repeated physical demands on the human body. With this highly intense demand being a prerequisite for peak athletic performance, athletes are all too familiar with incurring the various musculoskeletal injuries and disorders that can arise—the effective treatment and resolution of the underlying condition impeding performance is then of paramount importance for any serious athlete.

With the world of rehabilitative technology evolving at an ever-quickening rate and athletes looking for the quickest path back to full health, one particular intervention—known as extracorporeal shockwave therapy (ESWT), or shockwave therapy—has created quite the buzz among athletes and practitioners alike.

While this therapeutic intervention has been gaining popularity in recent years, it’s imperative for coaches, athletes, and clinicians who are considering incorporating it into their rehabilitative endeavors to have a rudimentary understanding of this modality. This includes its mechanism of action, the conditions it can treat, and, most importantly, the research behind ESWT’s ability to treat various disorders. This basic understanding is all in the name of ensuring optimal outcomes for those looking to make a full return to their athletic pursuits.

This article will walk you through these various facets pertaining to shockwave therapy, hopefully allowing you to make more informed decisions when it comes to administering or receiving shockwave therapy for your or your athlete’s needs.

How ESWT Works

While the in-depth mechanisms behind shockwave therapy are outside the scope of this article, a basic rundown is warranted for:

• How this therapy is administered.
• What shockwaves are.
• How shockwaves are believed to produce their desired effects on injured tissue.

With that said, don’t get too hung up on the details; for the average reader, knowing the scientific consensus of shockwaves’ effects on human tissue is what truly matters here (and will be discussed after this section).

Shockwave therapy has been used for treating various bone and soft tissue disorders involving the musculoskeletal system for the past 20 years.¹ The process involves a handheld applicator being applied directly onto the skin over the area being treated as a series of shockwaves are administered to elicit their therapeutic effects.

The term ‘shockwave’ is a bit of a misnomer; no electrical activity or ‘shocking’ is involved with shockwave therapy. Shockwaves are acoustic energy waves. Share on X

The term “shockwave” is a bit of a misnomer; no electrical activity or “shocking” is involved with this treatment. Shockwaves are acoustic energy waves (pressure waves) that consist of high peak-pressure amplitudes rising to their peak pressure within nanoseconds and dying out within microseconds (i.e., transient pressure oscillations).² So, once the peak pressure of this sonic energy wave has been reached, its pressure drops to a negative value within microseconds.

As a shockwave passes through tissues within the body, its high-pressure phase can be reflected (bounce off) or absorbed by the tissue(s). As the negative phase of the shockwave interacts with these tissues, air bubbles are created in a process known as cavitation. These microbubbles then implode, leading to direct and indirect effects within the tissue(s) being targeted.³

If that sounds a bit confusing, don’t sweat it. Essentially, it’s a sonic pulse that works in the same way a fast-flying aircraft produces a sonic boom, and it leads to stimulation of human tissue at the cellular level.

More specifically, these “sonic booms” that penetrate the tissue stimulate physiological cellular activity of the targeted tissue through a process known as mechanotransduction.^4,5 This fancy-sounding word simply means that a physical impulse or mechanical force is being converted into cellular activity within the targeted tissue(s).

While the specific biological changes that occur to tissue through ESWT are far outside the scope of this article, tissue regeneration through the delivery of shockwaves has been shown to occur by inducing:^3,4,6,7

• Blood vessel formation (known as neovascularization).
• Growth factor release.
• Inhibition of inflammatory molecules.
• Increased tenocyte proliferation and collagen synthesis.

Additional effects have also been documented; however, the above effects are likely the primary mechanisms involved with optimizing cellular activity and health. Despite the scientific community’s general understanding of these biological changes occurring from ESWT, the exact mechanisms for how these biological and physiological responses occur are not fully understood.

Parameters of ESWT

As with any therapeutic intervention that can be implemented, shockwave therapy relies on a series of parameters that must occur to achieve the overall desired treatment effect. For the average reader, I would advise not to get hung up on these specifics; I have merely (and briefly) included them for clinicians and the curious of mind who like knowing the details of therapeutic interventions.

When treating various orthopedic disorders, shockwave parameters include:⁸

• Pressure distribution.
• Energy flux density.
• Total acoustic energy.

Pressure distribution refers to the area of tissue being stimulated from the shockwave being administered.

Energy flux density refers to the measure of the energy per square area that is being released by the sonic pulse at a specific point. Or, more simply put, it’s the intensity at the focal point of the shockwave. It is measured in joules of energy per area (mJ/mm²).

The extent of energy flux density can be classified as high or low; however, there is no scientific consensus on these particular definitions. It has been proposed as a guideline that low-energy ESWT involves a flux density below 0.12 mJ/mm², while high-energy flux density is above 0.12 mJ/mm².¹

Total acoustic energy refers to the energy flux density within a single shockwave pulse multiplied by the total number of pulses administered.

Focused vs. Radial ESWT

It’s worth noting that when administering ESWT for musculoskeletal conditions, two primary types of shockwave therapy can be administered to injured tissue:

1. Focused shockwave therapy.
2. Radial shockwave therapy. 

Focused shockwave therapy is the more “pure” or established form of shockwave therapy within the medical world. Much of the research involves studying the effects of EWST using this form of treatment.¹ It involves administering shockwaves to a much more focal region of tissue, typically 2–8 millimeters in diameter.

Radial shockwaves are not concentrated directly over the targeted tissue in the same manner as focused shockwaves. Instead, the pressure waves disperse outward from the applicator tip of the device. The primary benefit is that this allows for the treatment of larger areas of tissue with less precision. However, these pressure waves do not penetrate as deep, and their characteristics are different enough that some authors contest they should not be considered true shockwaves.^1,9

The existence of two different forms of shockwave therapy muddies the water when looking at the research and is a potential reason why results can vary differently across studies. Share on X

While both forms of shockwave therapy are employed in literature and clinical settings, the existence of two different forms of ESWT muddies the water when looking at the research (this will be discussed further in the article) and is a potential reason why results can vary differently across studies.

Analyzing the Scientific Research

Enough research on ESWT has been performed that meta-analyses and systematic reviews often exist for specific orthopedic conditions. Despite this, I certainly can’t cover the findings for every condition. Rather, my aim is to skim the surface for the overall scientific findings for conditions most likely to affect the SimpliFaster audience and point those interested in further details in the right direction. For those looking to dive into the specifics of ESWT for specific orthopedic conditions (issues affecting muscles, tendons, bones, and joints), the references listed at the end of this article will serve as a solid starting point.

When analyzing the research behind ESWT’s effectiveness on various orthopedic conditions, I have tried to include findings from results and discussions within meta-analyses and systematic reviews, which offer the highest level of evidence possible within research.

Findings for Tendinopathies

Tendinopathy is one of the most commonly diagnosed conditions within athletic populations, with reports of approximately 30% of all elite athlete injuries.¹⁰ As such, findings of ESWT’s effects on tendon health should be of paramount interest to coaches and clinicians alike who are involved with athletes.

In the lower extremity, the most commonly afflicted tendons are the Achilles tendon, the plantar fascia, gluteal tendons (notably the glute medius and minimus), the patellar tendon (knee tendon), and the tibialis posterior tendon (near the inside of the ankle).¹¹ For athletes involved in running-based sports, tendinopathy in the knee, foot, and ankle appears to be the most common.¹²

In the upper extremity, the rotator cuff and the flexor and extensor tendons of the elbow are most commonly affected, though I am not covering the upper extremities in this article.¹⁰

When looking at ESWT’s effects on tendinopathy, the quick takeaway is that shockwave therapy has been found to have a notable influence on reducing pain and producing health-promoting biological effects. Meta-analyses for the treatment of patellar tendinopathy, Achilles tendinopathy, and rotator cuff tendinopathy have shown statistically significant effects for various aspects of improving tendon health and function.

When looking at ESWT’s effects on tendinopathy, the quick takeaway is shockwave therapy has been found to have a notable influence on reducing pain and producing health-promoting biological effects. Share on X

Critical to this topic, however, is that multiple adjunctive treatments should still be considered and implemented (when appropriate) alongside ESWT to ensure optimal tendon stimulation and subsequent healing. Which specific combined interventions lead to superior outcomes is likely best left to the clinician. The research isn’t entirely clear as to which combined intervention(s), when stacked with ESWT, will offer the best results.⁴

Based on our understanding of the cellular processes that arise and occur with tendon stimulation, it seems that combining ESWT with optimal tendon loading parameters will yield the best possible outcomes, though again, this depends greatly on the athlete’s condition. I have written a detailed article on SimpliFaster for the latest findings for tendon loading when treating tendinopathy, which can help provide a foundation for this approach.

Anecdotally, I will say that my patients experience far better outcomes when ESWT is paired with a loading program suitable for their needs, abilities, and overall condition. I often need to reduce training load, volume, and intensity to an appropriate level as well.

For conciseness and to appeal to the general nature of running- and sprinting-based readers on this site, I’ll only cover lower-body tendinopathy and soft tissue findings here.

Knee Tendinopathies

Overall, the findings for ESWT to produce statistically significant and favorable changes for patellar tendinopathy seem quite promising. A meta-analysis by Mani-Babu et al. reviewed seven papers examining the efficacy of ESWT on characteristics of patellar tendinopathy and found six out of seven of those papers to report significant improvement in symptoms after treatment, concluding it to be a largely successful form of conservative treatment.¹³

As with essentially all other systematic reviews that have analyzed the efficacy of ESWT, the review mentions that each paper utilized different shockwave parameters when providing treatment to the patellar tendon, making it difficult to determine optimal shockwave parameters when treating the condition. (This is a common theme within almost all ESWT meta-analyses dealing with soft-tissue pathologies.) The authors are quick to point out that more research is needed to determine optimal treatment parameters.

A similar meta-analysis by Liao et al. examined the effects of ESWT to reduce pain and improve functional outcomes for individuals with various soft tissue disorders of the knee (such as pes anserine tendinopathy, IT band friction syndrome, and post-traumatic tendon/ligament stiffness, among others) in addition to patellar tendinopathy.⁵ The results of this meta-analysis determined that ESWT showed significant moderate evidence for safety and efficacy for improving overall treatment success, reducing pain, improving functional recovery, and performance-based outcomes.⁵

Readers should note that in this meta-analysis, some studies utilized focused shockwave therapy while others utilized radial shockwave therapy. As such, the authors mention it is unclear whether therapeutic effects on these knee disorders differ from one shockwave form to another. (This is another common theme in many ESWT meta-analyses.)

Achilles Tendinopathy

With the Achilles tendon being one of the most adversely affected tendons in the lower body and the cornerstone of any athletic activity involving jumping and running, the effects of ESWT on this region of the body have been well studied. On the whole, meta-analyses tend to go back and forth on the efficacy of ESWT on different portions of the Achilles tendon. It would seem that some of this is due to examining various studies that largely use different shockwave parameters within each respective study.

Mani-Babu et al. concluded in their analysis that ESWT has moderate evidence for being more effective than eccentric loading for insertional Achilles tendinopathy and equal to eccentric loading for mid-portion tendinopathy. They are quick to point out that combining EWST with eccentric loading may likely produce superior outcomes.¹³

Similarly, a systematic review by Cathy Speed concluded that focused and radial shockwave therapy both have limited evidence to suggest they can be beneficial to insertional and mid-portion Achilles tendinopathy.¹

To cloud the water even more, a meta-analysis by Fan et al. concluded through a subgroup analysis that low- and mid-energy level ESWT led to better functional outcomes and improved pain outcomes than patients who received other treatment interventions.¹⁴ They are quick to note within this paper that further investigation should take place to determine the optimal energy level of shockwave delivery.

Determining the optimal energy level of shockwave therapy is critical as it likely largely influences efficacy and outcomes when treating Achilles tendinopathy. Share on X

This last point regarding the optimal energy level of shockwave therapy is critical to understand, as it likely largely influences efficacy and outcomes when treating Achilles tendinopathy (or other tendinopathies, for that matter). A brief discussion of optimal parameters is given later in this article.

Findings for Plantar Fasciitis

An extensive volume of research on ESWT’s ability to treat plantar fasciitis has been undertaken over the past decade, with results generally finding favor in its ability to reduce pain and improve functional outcomes.

A meta-analysis by Sun et al. examining nine randomized controlled trials of ESWT on 935 patients with plantar fasciitis concluded that focused shockwave therapy could relieve pain in chronic plantar fasciitis but could not draw conclusions about radial shockwave therapy.¹⁵

In a meta-analysis with the same title, Aqil et al. concluded that ESWT produced favorable results for reducing pain in patients with chronic plantar fasciitis and recommended its use for those failing to make improvements after three months of other conservative measures.¹⁶

When determining optimal parameters, a systematic review and network meta-analysis by Chang et al. concluded that optimal delivery parameters when treating plantar fasciitis with focused shockwave therapy should involve selecting the highest tolerable energy output within a medium intensity range.¹⁷ They also concluded that radial shockwave therapy could be an appropriate alternative due to its lower price point and therapeutic effectiveness.

Other Lower Body Conditions

The research and subsequent effects of ESWT extend beyond soft tissue conditions. While not covered in this article, when pertaining to the lower body, favorable findings within meta-analyses have been found for knee osteoarthritis, acute and chronic soft tissue wounds, and medial tibial stress syndrome (shin splints), among others.^18–20

Primary Advantages of ESWT

When considering treatment interventions, coaches and clinicians alike should have a preliminary understanding of the inherent risks and advantages they feel may be warranted for their athlete.

Regarding the use of ESWT for soft tissue disorders, this treatment is largely regarded as safe when used by trained professionals and can, therefore, be considered a first-line treatment option for soft tissue disorders that fail to resolve through traditional interventions. Its non-invasive nature can reduce risks that are inherent with injection-based therapies (such as infection) and surgeries.^1,3,8,21

While it’s disputed whether they produce different outcomes, both focused and radial shockwave therapy are largely considered safe forms of shockwave delivery. Share on X

Additionally, ESWT is becoming more commonplace within clinical practice, adding a convenience factor for those looking to receive this treatment. Radial shockwave is typically found in clinics more often than its focused counterpart due to its more economical price point. While it’s disputed whether they produce different outcomes, both are largely considered safe forms of shockwave delivery.

Shortcoming #1: Lack of Ideal Parameter Usage

For all that we know about the effectiveness of shockwave therapy on various tissues within the body, there is a bit of the Wild West when it comes to a scientific consensus as to the ideal combination of parameters to use.⁴

ESWT treatment parameters often vary across studies, and there is often a surprising lack of recorded parameters (pressure distribution, energy flux density, and total acoustic energy) within studies, causing great frustration to researchers (and clinicians such as myself); a study that shows statistically significant effects on a specific condition without fully listing parameters that were selected is like providing a treasure map without a compass.

As such, it’s often up to clinicians to use anecdotal evidence to select the combination of parameters they believe to be best for the individual whom they’re treating, making for a notable shortcoming at this time when assessing the scientific strength of ESWT.

Shortcoming #2: Focused vs. Radial ESWT

As alluded to earlier, the research regarding the superiority for different orthopedic conditions when comparing focused and radial shockwave therapy is quite unclear. To further complicate matters, it has been suggested that radial shockwave is an inaccurate term and that radial pulse therapy is more accurate for various reasons.¹ It has been noted by the same author that some studies involving “low energy” shockwaves are, in fact, referring to radial pulse therapy.

I make mention of this preceding paragraph to highlight a likely cause for discrepancies between randomized controlled trials examining the effectiveness of ESWT on a particular condition; not only are parameters often not reported, but the type of shockwave administered (i.e., focused versus radial) is not mentioned within certain studies.

In knowing that respective shockwaves have different characteristics (and likely therapeutic effects), treating a particular condition with radial shockwaves might not elicit favorable results, while treating the same condition with focused shockwaves might (and vice versa). This has the potential to lead to conflicting findings within the literature (and likely does).

ESWT Can Be Beneficial

While the research leaves more to be desired as to the precise mechanisms of how shockwave therapy works, which type of shockwave is most effective for a respective condition, and which set of treatment parameters will likely yield the best outcomes possible, it’s nonetheless quite clear that ESWT can offer benefits regarding tissue healing, pain reduction, and functional improvement for various orthopedic conditions.

Athletes, coaches, and clinicians looking for safe, non-invasive treatment for tendinopathies and soft tissue disorders, and potentially for bone healing, will likely experience the best results for what ESWT can offer and should consider combining this treatment with additional intervention such as physical therapy to maximize therapeutic outcomes. 

Since you’re here…
…we have a small favor to ask. More people are reading SimpliFaster than ever, and each week we bring you compelling content from coaches, sport scientists, and physiotherapists who are devoted to building better athletes. Please take a moment to share the articles on social media, engage the authors with questions and comments below, and link to articles when appropriate if you have a blog or participate on forums of related topics. — SF

References

1. Speed C. “A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence.” British Journal of Sports Medicine. 2014;48(21):1538–1542.

2. Ogden JA, Tóth-Kischkat A, and Schultheiss R. “Principles of shock wave therapy.” Clinical Orthopaedics and Related Research 1976-2007. 2001;387:8–17.

3. Wang CJ. “An overview of shock wave therapy in musculoskeletal disorders.” Chang Gung Medical Journal. 2003;26(4):220–232.

4. Ioppolo F, Rompe JD, Furia JP, and Cacchio A. “Clinical application of shock wave therapy (SWT) in musculoskeletal disorders.” European Journal of Physical and Rehabilitation Medicine. 2014;50(2):217–230.

5. Liao CD, Xie GM, Tsauo JY, Chen HC, and Liou TH. “Efficacy of extracorporeal shock wave therapy for knee tendinopathies and other soft tissue disorders: a meta-analysis of randomized controlled trials.” BMC Musculoskeletal Disorders. 208;19(1):278. doi:10.1186/s12891-018-2204-6.

6. Chao YH, Tsuang YH, Sun JS, et al. “Effects of shock waves on tenocyte proliferation and extracellular matrix metabolism.” Ultrasound in Medicine and Biology. 2008;34(5):841–852.

7. Martini L, Fini M, Giavaresi G, et al. “Primary Osteoblasts Response to Shock Wave Therapy Using Different Parameters.” Artificial Cells, Blood Substitutes, and Biotechnology. 2003;31(4):449–466. doi:10.1081/BIO-120025415.

8. Wang CJ. “Extracorporeal shockwave therapy in musculoskeletal disorders.” Journal of Orthopaedic Surgery and Research. 2012;7(1):11. doi:10.1186/1749-799X-7-11.

9. Cleveland RO, Chitnis PV, and McClure SR. “Acoustic field of a ballistic shock wave therapy device.” Ultrasound in Medicine and Biology. 2007;33(8):1327–1335.

10. Millar NL, Silbernagel KG, Thorborg K, et al. “Tendinopathy.” Nature Reviews Disease Primer. 2021;7(1):1–21.

11. Riel H, Lindstrøm CF, Rathleff MS, Jensen MB, and Olesen JL. “Prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice: a registry-based study.” BMC Musculoskeletal Disorders. 2019;20(1):239. doi:10.1186/s12891-019-2629-6.

12. Francis P, Whatman C, Sheerin K, Hume P, and Johnson MI. “The proportion of lower limb running injuries by gender, anatomical location and specific pathology: a systematic review.” Journal of Sports Science and Medicine. 2019;18(1):21.

13. Mani-Babu S, Morrissey D, Waugh C, Screen H, and Barton C. “The Effectiveness of Extracorporeal Shock Wave Therapy in Lower Limb Tendinopathy: A Systematic Review.” The American Journal of Sports Medicine. 2015;43(3):752–761. doi:10.1177/0363546514531911.

14. Fan Y, Feng Z, Cao J, and Fu W. “Efficacy of Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Meta-analysis.” Orthopaedic Journal of Sports Medicine. 2020;8(2):1–9. doi:10.1177/2325967120903430.

15. Sun J, Gao F, Wang Y, Sun W, Jiang B, and Li Z. “Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: A meta-analysis of RCTs.” Medicine (Baltimore). 2017;96(15). Accessed January 20, 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5403108/

16. Aqil A, Siddiqui MRS, Solan M, Redfern DJ, Gulati V, and Cobb JP. “Extracorporeal Shock Wave Therapy Is Effective in Treating Chronic Plantar Fasciitis: A Meta-Analysis of RCTs.” Clinical Orthopaedics and Related Research. 2013;471(11):3645–3652. doi:10.1007/s11999-013-3132-2.

17. Chang KV, Chen SY, Chen WS, Tu YK, and Chien KL. “Comparative effectiveness of focused shock wave therapy of different intensity levels and radial shock wave therapy for treating plantar fasciitis. A systematic review of network meta-analysis.” Archives of Physical Medicine and Rehabilitation. 2012;93(7):1259–1268.

18. Hsieh CK, Chang CJ, Liu ZW, and Tai TW. “Extracorporeal shockwave therapy for the treatment of knee osteoarthritis: a meta-analysis.” International Orthopaedics. 2020;44(5):877–884. Doi:10.1007/s00264-020-04489-x.

19. Zhang L, Fu X, Chen S, Zhao Z, Schmitz C, and Weng C. “Efficacy and safety of extracorporeal shock wave therapy for acute and chronic soft tissue wounds: A systematic review and meta-analysis.” International Wound Journal. 2018;15(4):590–599. doi:10.111/iwj.12902

20. Forogh B, Karimzad Y, Babaei-Ghazani A, Janbazi L, Cham MB, and Abdolghaderi S. “Effect of extracorporeal shockwave therapy on medial tibia stress syndrome: A systematic review.” Current Orthopaedic Practice. 2022;33(4):384–392.

21. Dedes V, Stergioulas A, Kipreos G, Dede AM, Mitseas A, and Panoutsopoulos GI. “Effectiveness and safety of shockwave therapy in tendinopathies.” Materia Socio-Medica. 2018;30(2):131.