When it comes to injury rehabilitation, one component that is often misunderstood – or, at least, poorly applied – is loading. For some practitioners, loading (resistance training) is seen as something to be excessively delayed or avoided for fear of compromising healing and risking further damage. For others, it ends up being reduced to a handful of generic strengthening exercises with vague loading parameters.

At Elevate, we adopt a different view when it comes to loading injured tissues during rehab. We see progressive strength training as the primary mechanism through which injured tissues heal optimally, regain strength & capacity, and develop long-term resilience.

In order to help us conceptualise and simplify our approach to loading during rehabilitation we created our “Loading Ladder.” This blog explores the philosophical foundations of the ladder and how we think about loading within the context of injury rehabilitation.

Stress Is Not The Enemy

Injuries occur when an imposed stress exceeds the capacity of the tissue to resist it, resulting in excessive strain and, subsequently, damage. This simple relationship often leads to an oversimplified solution: remove stress and the problem disappears.

Whilst we absolutely need to respect biological healing and avoid placing additional stress on the system in the acute phase immediately after an injury occurs, long-term stress avoidance can heighten the negative outcomes associated with injury, primarily muscle atrophy and impaired voluntary activation (Murphy et al., 2024). We can think of this as affecting both an athlete’s hardware (muscles) and software (neuromuscular system).

Conversely, early loading has been demonstrated to improve return to play time with no significant increase in subsequent re-injury risk for acute muscle injuries (Bayer et al., 2017).

It is commonly understood that appropriate levels of stress, when balanced with effective recovery, is an essential part of eliciting positive physiological adaptation (Selye, 1950). Whilst biological healing sets the ceiling for what is appropriate (i.e. stress capacity), how we load determines whether that ceiling is ever reached.

In summary, stress is not something to be feared throughout the rehab process, rather, it is something to be applied intelligently to, first, combat maladaptation and, second, restore & improve function.

The Real Enemy

As previously mentioned, injuries can affect both an athlete’s hardware and software, causing a rapid decline in function in the period immediately after. Our job as rehab coaches is to combat this during the early stages of rehab i.e. “stop the drop”. Doing this well sets the foundations for progressively returning athletes to the high intensity actions associated with their sport.

So how do we do this? Understanding what stimulates positive adaptation for an athlete’s hardware and software helps us to reduce the impact of injury on these for our athletes.

On the hardware side of things, mechanical tension is widely recognised as being critical to stimulating muscle hypertrophy (Roberts et al., 2023) and therefore forms the basis of how we progress the dynamic side of our loading ladder.

In order for muscle fibres to experience tension, they first need to be recruited. This presents a problem for early stage rehab as recruiting high threshold motor units is difficult when athletes don’t have the stress capacity to perform intense resistance training with high external loads.

Instead, we use blood flow restriction training, which helps to boost adaptation with low-load resistance training (Wernbom et al., 2013). Once athletes have the capacity to tolerate higher levels of mechanical tension, we progressively re-introduce isotonic strength work (at increasing intensities) before climbing the ladder further with AEL and manual eccentric training at the top.

Whilst levels 1-2 of the ladder are all about “stopping the drop”, the increasing mechanical tension achieved with levels 3-5 provide more potent tools for recruiting and adapting high threshold motor units (whilst staying within the limits of stress capacity). Given these motor units are essential for high-speed and high-force sporting actions, the development of these is essential to returning athletes “quicker and better”.

What About The Software?

Similar to the dynamic side of the ladder, the isometric side of the ladder is initially geared towards addressing the reduced voluntary activation associated with injury. Our early stage isometric work is critical in achieving this as it allows us to:

• Precisely control force output and intensity
• Load injured tissue early in shortened ranges, reducing the level of strain and therefore not compromising healing
• Minimise tissue jerk early, which again is beneficial from a tissue healing perspective

As we progress up the ladder, the use of longer duration holds offers the opportunity to safely develop tissue capacity and train the connective tissues. Later, the re-introduction of high intensity, explosive contractions, with our ramps & pushes, targets restoration and subsequent development of rate of force development qualities within the target muscles.

The combination of both sides of the ladder ensures we are progressively exposing tissue to increasingly high magnitudes and rates of force within our loading sessions throughout the rehab process, ensuring they are prepared for the stress of returning to high intensity sporting actions.

But Why Choose a Ladder?

GCSE P.E. students throughout the UK will all be able to cite progressive overload as being a key principle of effective training regimes. And yet, when it comes to the world of injury rehabilitation, this is often taken for granted.

Frequently rehab programmes suffer from a lack of intensity, with injured athletes just going through the motions/living in the ‘comfort zone’. Or, if progressive overload is  considered, it is reduced to a simple concept of adding more weight to a bar.

At Elevate, we look at progressive overload as being more nuanced, occurring not just by increasing external load but via:

• Increasing intensity (force output)
• Increasing time under tension duration
• Increasing the rate of force development within a contraction
• Improving force production through increasing ranges of motion

Each rung of the loading ladder represents a meaningful increase in stress, aligned with tissue healing and neuromuscular readiness with a view to progressively preparing athletes to tolerate the eventual demands of their sport.

Final Thoughts

When loading is applied too aggressively, too conservatively, or without context, re-injury risk increases. When applied progressively, purposefully and systematically, loading becomes a powerful tool to restore function, capacity and performance.

In the next blog, we’ll walk through exactly how the Loading Ladder comes to life, breaking down each level, its intent, and the rationale behind it.

References

Bayer, M. L., Magnusson, S. P., & Kjaer, M. (2017). Early versus delayed rehabilitation after acute muscle injury. New England Journal of Medicine, 377(13), 1300-1301.

Murphy, M. C., Rio, E. K., Whife, C., & Latella, C. (2024). Maximising neuromuscular performance in people with pain and injury: moving beyond reps and sets to understand the challenges and embrace the complexity. BMJ Open Sport & Exercise Medicine, 10(2).

Roberts, M. D., McCarthy, J. J., Hornberger, T. A., Phillips, S. M., Mackey, A. L., Nader, G. A., … & Esser, K. A. (2023). Mechanisms of mechanical overload-induced skeletal muscle hypertrophy: current understanding and future directions. Physiological Reviews. 103, 2679–2757.

Selye, H. (1950). Stress and the general adaptation syndrome. British Medical Journal, 4667, 1383-1392.
Wernbom, M., Apro, W., Paulsen, G., Nilsen, T. S., Blomstrand, E., & Raastad, T. (2013). Acute low-load resistance exercise with and without blood flow restriction increased protein signalling and number of satellite cells in human skeletal muscle. European Journal of Applied Physiology, 113(12), 2953-2965.

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At Elevate: Speed & Rehab, we specialise in Performance Rehab for athletes dealing with ACL, hamstring, calf, ankle, hip & groin injuries; helping you reduce recovery time and get back performing at your best, and beyond. Whether you’re an athlete looking for expert sports rehabilitation, or a coach or physio wanting to develop your practice, we’ve got you covered. Find out more by clicking here