The Importance of Evidence-led Strength Training in the Rebuild ATHlete Process: A Brief Literature Review

December 18, 2020

By: ATH Director of Human Performance Frank Bourgeois, PhD




As people become more active to improve general health and athletic performance there is an innate increase in the likelihood of sustaining an injury. A key element, regardless of injury stage, that aides in injury risk reduction and reduced recovery time after injury is the ability to generate force, or strength.


In this article, we discuss the favorable physiological and biomechanical adaptations that are associated with a planned, informed, methodical approach for reconditioning not only the affected body part, but for the entire body in three distinct categories: preventative and pre-operation, post-operation and acute treatment, and return to participation/competition.




Activities of daily life impose seemingly endless task, environmental and individual constraints on the human body [4,12,21,24,39]. An integral element in solving these motor problems is the ability to generate force. Force generation capacity, or strength, is widely accepted as foundational for injury risk reduction and performance enhancement [33,53,51,52]. Equally, the health and performance benefits of exposure to supervised evidence-led strength training are well documented [25,32,33,43,56]. The key principle underpinning the efficacy of this training mode is progressive mechanical overload [16,55]. That is – to gradually increase the application of an external load (i.e. force) on biological tissue. This mechanical overload has been shown to signal the advantageous remodeling of passive and active structures responsible for movement [1,10,55].


Increasingly, medical and performance practitioners are being challenged to address the immediate and long-term movement needs of an array of individuals that range from three days post-operation to high-performing athletic status. As such, there is research supporting the application of evidence-led strength training across this broad spectrum of psycho-physical conditions [11,17,20,23,25,41,43]. The aim of this report is to provide empirical data that highlight the importance of employing strength training to improve neuromotor capabilities in three identified categories: 1) preventative and pre-operative, 2) post-operative and acute treatment, and 3) return to participation and return to competition.


Preventative and pre-operation categories are defined as the periods of time when an individual is able to conduct normal activity (i.e. healthy status), and when an individual has a scheduled surgical intervention, respectively. Post-operation is defined as 1 to 3 days after surgical intervention, while acute treatment is defined as 4 to 14 days. Finally, return to participation and return to competition share the concept of criteria-based progression to globally reconditioning the body. However, they are distinguished by outcome specificity. The reconditioning of return to participation intervention is for resuming normal activity, while that of return to competition is for sport-specific high-performance.




Preventative and pre-operation


There is overwhelming extant data that demonstrate the positive influence strength training has on individuals categorized as preventative [32,34] and pre-operation [14,23,25,45]. Prophylactic effects associated with strength training include increased resiliency and function of cardiac [3,26] and skeletal muscle [1,14,18,25,26,36,40,55], connective tissue [38], nervous tissue [2,4,6,15,19,44], cardiopulmonary tissue [3,26] and metabolic processes [3,22,26,27]. The enhanced architecture and function within the neuromotor system is a result of consistent exposure to systemic mechanical overload [1,2,5,7,16,44,55]. That is, repetitively challenging the body to coordinatively operate beyond ‘resting state’.


These advantageous tissue modifications are largely realized via increased mechanical stress and strain tolerance due to increased muscle-tendon unit (MTU) length and increased force capabilities [33,55]. These protective qualities are associated with the enhancement of performance qualities. For instance, an increase in MTU length increases muscle fiber shortening velocity (i.e. speed of contraction), while an increase in force-generating capabilities will increase mechanical output in pushing and pulling tasks [33]. In the rehabilitation context, the benefit of enhancing biological features (e.g. a change in myosin isoform expression and increased collagen synthesis), and thus mechanical function (e.g. increased triaxial force production) prior to surgical intervention has been documented [14,22,23,25], with retention lasting 12 weeks post-operation [45]. Interestingly, in addition to heightened neuromuscular function following a 6-week pre-operative rehabilitation program compared to a control group, Hägglund and colleagues (2015) noted the increased efficacy of executing a rehabilitation program at a “specialized” facility, providing value to the centralization of supervised patient/athlete care [56].


Post-operation and acute treatment


The post-operative benefits of a reconditioning program with a concomitant focus on enhancing the strength capabilities and range-of-motion of coordinative structures have received enormous attention in sports medicine literature [46]. However, with the obvious advantage of strength training on the reconditioning process, attention has diverted to testing the efficacy of an accelerated reconditioning program – that is, a strength program aimed to encourage restoration of strength early (e.g. <10 months post-op) [46,47,49]. Though an area of controversy due to potentially heightened injury risk and other limitations [46,50,48], there is evidence of accelerated reconditioning being superior to that of a traditional program [47,48]. Shelbourne and Gray (1997) demonstrated favorable radiographs, acceptable range-of-motion and joint laxity, and muscle strength in a longitudinal study [48]. Importantly, individuals returned to normal activities on average in 3.1 weeks (range = 0.7 to 20, SD = 2.1), sport-specific activities reinstated at 6.2 weeks (range = 1 to 13, SD = 2.3) with full participation in competition occurring at 6.2 months (range = 2 to 18, SD = 2.3).


Return to participation and competition


It has been suggested that the emphasis of reconditioning interventions in this category, particularly in the latter days, should focus on load application that facilitates full restoration of coordinative structures associated with the involved area (e.g. reestablishing performance of the kinetic chain within the hip-knee-ankle complexes in locomotive tasks following unilateral knee injury) [13,21,24,29,55]. Additionally, and potentially more important, more attention is given to enhancing the global (i.e. whole-body) performance of an individual that desires to either return to normal activities or return to competitive environments [30].


Though end-goals may differ, each of these individuals necessitates a service that warrants a collaborative approach primarily between sports medicine and sports performance practitioners [9,30]. Such an interdisciplinary approach would substantially increase the likelihood of short- and long-term success via accurate identification for entry into respective programs [8,29,37], valid and reliable metrics to track function/performance [42,54] and appropriate systematic strength training [28,51].


Athlete Training + Health would like to thank Shelbie Miller of Texas Health Sports Medicine at Arlington for her assistance in the development of this manuscript. Thank You.


Click here for more information about ATH’s Rebuild ATHlete program. Call or email us to schedule your free evaluation today.



  1. Aagaard P, Andersen JL, Dyhre-Poulsen P et al. A mechanism for increased contractile strength of human pennate muscle in response to strength training: changes in muscle architecture. Journal of Physiology. 2001;534(2):613-23.
  2. Aagaard P, Simonsen EB, Andersen JL et al. Increased rate of force development and neural drive of human skeletal muscle following resistance training. Journal of Applied Physiology. 2002;93:1318-26.
  3. Åstrand PO, Rodahl K, Dahl HA et al. Textbook of Work Physiology: Physiological Bases of Exercise. Champaign, IL: Human Kinetic; 2003.
  4. Bain S, McGown C. Motor learning principles and the superiority of whole training in volleyball. 2010.
  5. Bassel-Duby R, Olson EN. Signaling pathways in skeletal muscle remodeling. Annual Review of Biochemistry. 2006;75:19-37.
  6. Behm DG. Neuromuscular implications and applications of resistance training. Journal of Strength and Conditioning Research. 1995;9(4):264-74.
  7. Bourgeois FA, Gamble PG, Gill ND et al. Effects of a six-week strength training programme on change of direction performance in youth rugby athletes. Sports. 2017;5(4):83-100.
  8. Bundy M, Hodgson L. Medical Assessment and Pre-participation screening. In: Joyce D, Lewindon D, editors. Sports Injury Prevention and Rehabilitation: Integrating Medicine and Science for Performance Solutions: New York, New York: Routledge; 2016. p. 45-61.
  9. Chiu LZF. Dual role athletic trainer/strength coach. Strength and Conditioning Journal. 2008;30(1):26-8.
  10. Čoh M, Mackala K. Differences between the elite and subelite sprinters in kninematic and dynamic determinants of countermovement jump and drop jump. Journal of Strength and Conditioning Research. 2013;27(11):3021-27.
  11. Czuppon S, Racette BA, Klein SE et al. Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review. British Journal of Sports Medicine. 2014;48(5):356-64.
  12. Davids K, Button C, Araujo D, Renshaw I, Hristovski R. Movement models from sports provide representative task constraints for studying adaptive behavior in human movement systems. Adaptive Behavior. 2006;14(1):73-95.
  13. Davids K, Button C, Bennett S. Dynamics of Skill Acquisition: a constraints-led approach. Champaign, IL: Human Kinetics; 2008.
  14. de Jong SN, van Caspel DR, van Haeff MJ et al. Functional assessment and muscle strength before and after reconstruction of chronic anterior cruciate ligament lesions. Arthroscopy: Journal of Arthroscopic and Related Surgery. 2007;23(1):21-e1.
  15. Duchateau J, Semmler JG, Enoka RM. Training adaptations in the behavior of human motor units. Journal of Applied Physiology. 2006;101(6):1766-75.
  16. Enoka RM. Neuromechanics of Human Movement – Fifth edition. Champaign, IL: Human Kinetic; 2015.
  17. Faigenbaum AD, Myer GD. Resistance training among youth athletes: safety, efficacy and injury prevention effects. British Journal of Sports Medicine. 2010;44(1):56-63.
  18. Gabbett TJ, Whiteley R. Two training-load paradoxes: can we work harder and smarter, can physical preparation and medical be teammates? International Journal of Sports Physiology and Performance. 2017;12(s2):S2-50.
  19. Gabriel DA, Kamen G, Frost G. Neural adaptations to resistive exercise: mechanisms and recommendations for training practices. Sports Medicine. 2006;36(2):133-149.
  20. Geithner CA, McKenney DR. Strategies for aging well. Strength and Conditioning Journal. 2010;32(5):36-52.
  21. Ghez C, Krakauer J. The organization of movement. Principles of Neural Science. 2000;4:653-73.
  22. Gjøvaag TF, Dahl HA. Effect of training with different mechanical loadings on MyHC and GLUT4 changes. Medicine and Science in Sports and Exercise. 2009;41(1):129-36.
  23. Grindem H, Granan LP, Risberg MA et al. How does a combined preoperative and postoperative rehabilitation programme influence the outcome of ACL reconstruction 2 years after surgery? A comparison between patients in the Delaware-Oslo ACL cohort and the Norwegian National Knee Ligament Registry. British Journal of Sports Medicine. 2015;49(6):385-89.
  24. Guccione AA, Neville BT, George SZ. Optimization of movement: a dynamical systems approach to movement systems as emergent phenomena. Physical Therapy. 2019;99(1):3-9.
  25. Hägglund M, Waldén M, Thomeé R. Should patients reach certain knee function benchmarks before ACL reconstruction? Does intense ‘prehabilitation’ before ACL reconstruction influence outcome and return to play? British Journal of Sports Medicine. 2015; 49(22):1423-24.
  26. Hall JE. Guyton and Hall Textbook of Medical Physiology - Thirteenth edition. Philadelphia, PA: Elsevier; 2016.
  27. Hartman MJ, Fields DA, Byrne NM et al. Resistance training improves metabolic economy during functional tasks in older adults. Journal of Strength and Conditioning Research. 2007;21(1):91.
  28. Jeffreys I. The Developing Athlete. In: Joyce D, Lewindon D, editors. Sports Injury Prevention and Rehabilitation: Integrating Medicine and Science for Performance Solutions: New York, New York: Routledge; 2016. p. 415-428.
  29. Joyce D, Lewindon D. The Injury Risk Profiling Process. In: Joyce D, Lewindon D, editors. Sports Injury Prevention and Rehabilitation: Integrating Medicine and Science for Performance Solutions: New York, New York: Routledge; 2016. p. 62-76.
  30. Knowles B. Reconditioning: A Performance-based Response to an Injury. In: Joyce D, Lewindon D, editors. Sports Injury Prevention and Rehabilitation: Integrating Medicine and Science for Performance Solutions: New York, New York: Routledge; 2016. p. 3-10.
  31. Kubo K, Ikebukuro T, Yata H et al. Time course of changes in muscle and tendon properties during strength training and detraining. Journal of Strength and Conditioning Research. 2010;24(2):322-31.
  32. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine. 2014;48:871-77.
  33. Lieber RL. Skeletal Muscle Structure, Function, and Plasticity – A Physiological Bases for Rehabilitation. Philadelphia, PA: Lippincott Williams and Wilkins; 2010.
  34. Maffulli N, Longo UG, Spiezia F, Denaro V. Sports injuries in young athletes: long-term outcome and prevention strategies. The Physician and Sports Medicine. 2010;38(2):29-34.
  35. Maestroni L, Read P, Bishop C et al. Strength and power training in rehabilitation: underpinning principles and practical strategies to return athletes to high performance. Sports Medicine. 2019:1-14.
  36. McGuigan MR, Sharman MJ, Newton RU. Effect of explosive resistance training on titin and myosin heavy chain isoforms in trained subjects. Journal of Strength and Conditioning Research. 2003;17(4):645-51.
  37. Morriss C, Pask P. Determining Return to Play. In: Joyce D, Lewindon D, editors. Sports Injury Prevention and Rehabilitation: Integrating Medicine and Science for Performance Solutions: New York, New York: Routledge; 2016. p. 232-242.
  38. Narici MV, Maganaris CN, Reeves ND. Myotendinous alterations and effects of resistive loading in old age. Scandinavian Journal of Medicine and Science in Sports. 2005;15:392-401.
  39. Newell KM. Motor skill acquisition. Annual Review of Psychology. 1991;42:213-37.
  40. Pette D. Training effects on the contractile apparatus. Acta Physiologica. 1998;162:367-76.
  41. Pizzigalli L, Filippini A, Ahmaidi S et al. Prevention of falling risk in elderly people: the relevance of muscular strength and symmetry of lower limbs in postural stability. Journal of Strength and Conditioning Research. 2011;25(2):567-74.
  42. Prangley I. Assessing and Developing the Kinetic Chain. In: Joyce D, Lewindon D, editors. Sports Injury Prevention and Rehabilitation: Integrating Medicine and Science for Performance Solutions: New York, New York: Routledge; 2016. p. 77-94.
  43. Rössler R, Donath L, Verhagen E et al. Exercise-based injury prevention in child and adolescent sport: a systematic review and meta-analysis. Sports Medicine. 2014;44:1733-48.
  44. Sale DG. Neural adaptation to resistance training. Medicine and Science in Sports and Exercise. 1988 Oct;20(5 Suppl):S135-45.
  45. Shaarani SR, O’Hare C, Quinn A et al. Effect of prehabilitation on the outcome of anterior cruciate ligament reconstruction. American Journal of Sports Medicine. 2013;41(9):2117-27.
  46. Shaw T. Accelerated rehabilitation following anterior cruciate ligament reconstruction. Physical Therapy in Sport. 2002;3:19-26.
  47. Shaw T, Williams MT, Chipchase LS. Do early quadriceps exercises affect the outcome of ACL reconstruction? A randomized controlled trial. Australian Journal of Physiology. 2005;51:9-17.
  48. Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation: a two-to nine-year followup. American Journal of Sports Medicine. 1997;25(6):786-95.
  49. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. American Journal of Sports Medicine. 1990;18(3):292-99.
  50. Shelbourne KD, Wilckens JH, Mollabashy A et al. Anthrofibrosis in acute anterior cruciate ligament reconstruction and rehabilitation. American Journal of Sports Medicine. 1991;19(4):332-36.
  51. Smith DJ. A framework for understanding the training process leading to elite performance. Sports Medicine. 2003;33(15):1103-26.
  52. Stone MH, Moir G, Glaister M et al. How much strength is necessary? Physical Therapy in Sport. 2002;3(2):88-96.
  53. Suchomel TJ, Nimphius S, Stone MH. The importance of muscular strength in athletic performance. Sports Medicine. 2016;46(10):1419-49.
  54. Winkleman N. Assessing Athletic Qualities. In: Joyce D, Lewindon D, editors. Sports Injury Prevention and Rehabilitation: Integrating Medicine and Science for Performance Solutions: New York, New York: Routledge; 2016. p. 95-105.
  55. Wisdom KM, Delp SL, Kuhl E. Use it or lose it: multiscale skeletal muscle adaptation to mechanical stimuli. Biomechanics and Modeling in Mechanobiology. 2014;14(2):195-215.
  56. Zätterström R, Fridén T, Lindstrand A et al. Rehabilitation following acute cruciate ligament injuries – a 12-month follow-up of a randomized clinical trial. Scandinavian Journal of Medicine and Science in Sports. 2000;10:156-63.

Stay Up to Date

Sign up with your email address to receive news and updates.