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COMPETITIVE SPORTS AND PAIN MANAGEMENT

Review and Role of Plyometrics and Core

Rehabilitation in Competitive Sport
John Hill, DO, FACSM and Matthew Leiszler, MD
of Kibler et al. (24) summarizes core
stability as the ability to control the
position and motion of the trunk over
the pelvis to allow optimum production, transfer and control of force and
motion to the terminal segment in integrated kinetic chain activities. The
core of the body includes the spine,
hips, pelvis, proximal lower limbs, and
the abdominal region. This often is defined as a muscular box with the abdominals in the front, the paraspinals
and gluteals in the back, the diaphragm
as the roof, and the pelvic floor and hip
girdle musculature as the bottom (2).
The strength of these muscles allows the
system to stabilize the spine mechanically and then distribute and deliver
compressive, translational, and shear forces to and from
the rest of the body (15).

Abstract
Core stability and plyometric training have become common elements
of training programs in competitive athletes. Core stability allows stabilization of the spine and trunk of the body in order to allow maximal
translation of force to the extremities. Plyometric training is more dynamic
and involves explosive-strength training. Integration of these exercises
theoretically begins with core stabilization using more static exercises,
allowing safe and effective transition to plyometric exercises. Both core
strengthening and plyometric training have demonstrated mixed but
generally positive results on injury prevention rehabilitation of certain
types of injuries. Improvement in performance compared to other types
of exercise is unclear at this time. This article discusses the theory and
strategy behind core stability and plyometric training; reviews the literature on injury prevention, rehabilitation of injury, and performance enhancement with these modalities; and discusses the evaluation and
rehabilitation of core stability.

Introduction
Core stability and core strength have been seen as an
important aspect of preventing back pain since the late
1980s and 1990s. In the athletic population, especially elite
athletes, core strength often was assumed to be excellent, or
if found to be weak, improvements in core stability would
allow these athletes to perform better or rehabilitate from
injuries more effectively. However, this may not necessarily
be true (28). The purpose of this article was to explain the
theory behind core stability and plyometrics and explore the
role of these modalities in the competitive athlete.
What is Core Strength and Stability?
It should be understood that there is no single universally accepted definition of core stability, but the concept
Department of Family Medicine and Primary Care Sports Medicine,
University of Colorado School of Medicine, Aurora, CO
Address for correspondence: John Hill, DO, FACSM, Primary Care
Sports Medicine Fellowship, Department of Family Medicine and Primary
Care Sports Medicine, University of Colorado School of Medicine, AO1,
Campus Box F-496, 12631 East 17th Avenue, Aurora, CO 80045
(E-mail: john.hill@ucdenver.edu).
1537-890X/1006/00Y00
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Theory and Value of Plyometrics

Plyometric training is a specific type of training involving
exercises in which the active muscles are stretched prior to
shortening and usually requires explosive-strength training.
This type of training has been reported to invoke specific
neural adaptations such as increased activation of the motor
units, with less muscle hypertrophy than typically observed
after heavy static resistance strength training (41). Plyometric exercises can be done with or without external load.
Many studies combine both heavy strength training and plyometric exercises, and some studies have shown that power
and power-related skills are improved to a greater extent
when combining heavy strength training and plyometrics
than either modality alone (1).
Theory of Integration
In rehabilitation from injuries, athletes have received
benefit from both strength exercises and plyometric training; the integration of both of these components may yield
even better results (32). The overall goal in athletic rehabilitation is to return the athlete back to full participation as
soon as possible. Most sporting events require supranormal
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levels of conditioning and explosive application of strength,

which frequently can lead to reinjury. In theory, before returning to sport, the athlete must first demonstrate competence with plyometric exercises, and before these exercises
can be safely performed, they first must increase their core
stability safely with static load strength training. Effective
recovery from injury must begin with increased strength,
progressing to safe ballistic training before returning to the
sport that caused the injury.

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Prevention of Injury
Deficiencies in certain aspects of core stability may predispose athletes to injuries of the back and lower extremities. Delays in trunk motor control reflex have been
linked to back pain and seem to be a predisposing factor (8).
In addition, athletes with deficiencies in hip abduction
and external rotation have been shown to be at a higher risk
of injuries of the back and lower extremities (29). More
specifically, weakness in the gluteus medius, vital for hip
abduction, seems to play a role in the development of
patellofemoral pain in women (48). Early fatigue in core
musculature also may play a role in predisposing athletes
to injury, as fatigue of the abdominal muscles has been
found to be a contributor to hamstring injuries (12). There
also may be gender differences in whether core stability
plays a role in risk of injury, as suggested by Zazulak et al.
(49), who found that increased trunk displacement and decreased proprioception on testing predicted knee ligament
injury for women, although these findings were not predictive in men.
Some clinicians have suggested that, in athletes, dynamic testing of core strength and plyometric ability may
be more appropriate to determine who is at risk for injury,
as opposed to more static core strength testing (9,36). One
such screening test is the Functional Movement Screen
(FMS), a series of seven movements performed by athletes,
in which range of motion, stabilization, balance, and symmetry are tested and scored by an observer based on set criteria. At this point, data to support or refute the FMS as
an injury predictor are limited, although one study in professional football players did find a significant correlation
between lower scores and increased risk of injury (26). Other
studies also have found that scores below a certain level did
correspond moderately with any type of injury and strongly
with serious injury in military officer candidates (35,38).
Whether rehabilitating an athletes core stability in those
with deficiencies actually decreases subsequent risk of injury, however, remains to be seen. Kiesel et al. (25) were
able to note an improvement in football players FMS score
following an off-season intervention program that focused
on each players deficiencies on a previous FMS screening
test. At this point, whether this improvement in scores will
result in fewer injuries has not been evaluated yet.
Logical deduction would suggest that if, as these studies
suggest, patients with core deficiencies are at increased risk
of injury, then correction of these core deficiencies would
help to prevent injury. At this time, current data are lacking
to show a relationship between core exercise and primary
prevention of injury. One intervention program combining
strengthening, coordination, and core stability exercises for
2

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the pelvis in Danish soccer players failed to show a statistically significant reduction in groin injuries, although the risk
of groin injury was reduced by 31% in players receiving
the additional program (22). A large female youth soccer
study in Norway also did not find any significant reduction
in injury for the intervention group who underwent core
strengthening in addition to balance, dynamic stabilization,
and eccentric hamstring stretch (45).
Literature supporting the role of programs designed to
improve neuromuscular control in improving biomechanics
and theoretically preventing injury is more robust in female
athletes, although still lacking in male athletes. There seems
to be a link between improved neuromuscular control and
decreased injury risk, although the specific role of plyometric
training in these programs is unclear at this time. Myer et al.
(32) found that a training program including plyometrics,
core strengthening and balance, resistance training, and
speed training did decrease knee valgus and varus torques
in female athletes, although it is unclear which component
of the program played the greatest role in improvement of
biomechanics.
Perhaps the most impressive data regarding actual prevention of injury with plyometric and neuromuscular training come from Hewett et al. (17,18), who have shown that
this type of training is beneficial in preventing anterior cruciate ligament injury in females. In addition, a meta-analysis
found that several neuromuscular training programs are
effective in decreasing knee injury rates (16). In males, data
are very limited, although the use of plyometric training in
triathletes has been shown to correct altered neuromotor
control when triathletes transitioned to running from cycling, theoretically reducing risk of injury (5).
Treatment of Injuries
Much of the literature regarding the use of core stabilization and plyometric exercise in treatment of injury exists in
reference to back pain. The presence of poor core stability
in patients with back pain, as well as sacroiliac pain, is
common (19Y21,23). As Akuthota et al. (2) noted, the evidence for core stabilization exercise as treatment for back
pain, however, is mixed and may not be more effective than
other exercise regimens.
Patellofemoral pain also has been linked to weakness in
trunk and core muscle strength, particularly in women with
delays in activation of the gluteus medius (10). Two studies
have shown improvement in pain symptoms of patellofemoral pain syndrome with strengthening of hip and core
musculature (14,33). It also has been our clinical experience
that strengthening, focusing initially on gluteus medius rehabilitation using side leg raises and side plank exercises with
eventual progression to more dynamic combination of these
two exercises, is effective in improving both biomechanics
and pain scores in patellofemoral pain syndrome. Randomized trials are needed to determine the existence or extent
of any true improvement with this intervention.
Effect on Performance
The relationship between core stability, plyometrics,
and performance has not been defined clearly yet. Part of
the difficulty in determining this relationship is difficulty
Plyometrics and Core Rehabilitation in Sport

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in establishing how to best test both core strength and performance. There are too many variables at play in most
sports to link any change in performance directly to core
strengthening and plyometrics, and therefore, substitute measures are used to try to determine any improvement.
Several studies have attempted to determine the relationship between core strength and sports-related athletic testing. Sharrock et al. (42) did note a correlation between
core strength, as measured by a double-leg lowering test,
and testing a medicine ball throw. However, no relationship was noted between core strength and the 40-yd dash,
agility run, or vertical jump. Nesser et al. (34) measured core
strength using the trunk flexor test, trunk extensor test, and
lateral musculature test and compared performance in the
bench press, squat, power clean, 20- and 40-yd sprint, shuttle
run, and countermovement vertical jump in college football players. Results were inconsistent, although there were
mild-to-moderate correlations between core testing and performance measurements, suggesting perhaps a potential weak
relationship between core strength and performance.
Other studies have evaluated a group of athletes undergoing a core strengthening program and compared pre- and
postprogram sports-specific testing measures versus those of
controls. Tse et al. (46) found no correlation between a core
strengthening program and the vertical jump, broad jump,
shuttle run, 40-m sprint, overhead medicine ball throw, or
2,000-m maximal rowing ergometer test in college-aged
rowers. Stanton et al. (44) looked specifically at Swiss ball
training to improve core strength and found no improvement in treadmill VO2max, running economy, or running
posture compared to controls. Sato and Mokha (40), however, did note some improvement in 5,000-m run time in
the core strengthening group compared to controls.
Similar to studies in prevention, there is some question
whether there is disparity in validity of static core strength
testing versus dynamic testing. Okada et al. (36) found no
correlation between isometric strength of the core and
dynamic movements in the FMS, suggesting that strength
on isometric strength of the core is not necessary to score
well on more dynamic movement screening. Although there
were several correlations between each of these screening
tests, the authors concluded that moderate to weak correlations identified suggest core stability and FMS are not
strong predictors of performance.
Plyometric training techniques are diverse but, as a general rule, employ fast, powerful movements with jumping
and other sports-related movement. Most data have shown
a positive effect of plyometric training on performance with
several specific athletic movements or tests. Vertical jump
height has been shown to be improved using a traditional
program consisting of static flexibility, balance, strengthening, agility, and plyometric exercises in young athletes
(13). Running economy also has been shown to improve
with short-term plyometric training in highly trained runners (41,43). Plyometric training also has been shown to
improve peak power output, squat jump, countermovement
jump, and sprint velocity in soccer players during the season compared to controls (6). Improvements also have been
seen in studies with swimmers and preadolescent boys
(27,37). A meta-analysis of plyometric training studies
also found an association between training programs and
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vertical jump height, although both randomized and nonrandomized trials were included in the meta-analysis (30).
Not all studies have found performance-enhancing effects
of plyometric training. Ronnestad et al. (39) found that
plyometric training added no additional gain in professional
soccer players when added to a strength training regimen. It
is also not clear whether plyometric training by itself is
superior to other training methods. The study of Ronnestad
et al. did not include a plyometrics-only group, but the
strength training-only group was noted to have gains compared to controls. Olympic weight training also has been
noted to have an effect similar to that of plyometric training on vertical jump height (3). Sprint training has been reported to have training effects in athletic performance similar
to or even greater than those of plyometric training (31).

How to Evaluate Core Strength and Deficiencies

Considering the wide variety of movements associated
with sports, intuitively, athletes must possess sufficient
strength in hip and trunk muscles to provide stability in all
three planes of motion. Research demonstrates that the contribution of different muscle groups to lumbar stability depends on the direction and magnitude of trunk loading (7).
The abdominals control external forces that might cause the
spine to extend, laterally flex, or rotate and control excessive anterior pelvic tilt. Hip abductors and external rotators
also play an important role in lower extremity alignment.
They help maintain a level pelvis and prevent excessive hip
adduction and internal rotation during single-limb support
(29). In addition to this, biomechanical studies have shown
that hip muscle activation significantly affects the ability of
the quadriceps and hamstrings to generate and resist forces
experienced by the entire leg during jumping (4).
Many tests have been proposed for assessment of core
stability in the general population, but there is a lack of
consensus on how to measure core strength (2). Athletes
often have reassuring results when tested by low-exertion
examinations, but the demands of their sport require significantly increased core strength and control in order to
resist fatigue. The following is the protocol we use to evaluate for core strength and deficiencies. The first test, performed while the patient is standing, is observational.
Without giving the patient any verbal clues, one looks at
the alignment of the pelvis from the side. Ideally, the waist
should be horizontal, with engagement of the trunk musculature (Fig. 1A). If the pelvis tilts forward, oftentimes,
one will find weakness in the quadratus lumborum, rectus
abdominis, and obliques (Fig. 1B). The single-leg squat is a
functional, closed-chain test that has been shown to be a
reliable test for global core stability (11). The starting
position is to stand on the test leg with the hip and knee in
neutral anatomical position. The athlete then moves at a
self-selected pace into a squat position and then returns to
the starting position (Fig. 2A). It is our belief that if core
stability is present, then throughout the entire plane of
motion, alignment should be maintained between the hip,
knee, and ankle, without the contralateral hip dropping
and the knee moving into valgus (Fig. 2B). If this is performed competently, then one moves into a progressively
more difficult test: the lateral step-down (Fig. 2C). Again,
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Figure 1: Pelvic alignment examination. A. Good pelvic alignment. B. Poor pelvic alignment.

the alignment should be maintained between the hip, knee,

and ankle. The last global assessment of core instability is
plyometric: the hop test. This is performed on one foot at a
time in a similar fashion as the single-leg squat. The athlete
begins the test in a squatted position, jumps off the floor,
and lands. The examiner should assess for knee alignment,
height of jump, and stable, aligned soft landing.
The next assessments are done with the athlete lying on
his or her side, testing both injured and uninjured sides for
comparison. These tests can be used as instruction for a
static strengthening program directed to the athlete before
plyometric rehabilitation is begun. The side plank or bridge

measures lateral core strength, particularly the quadratus

lumborum (Fig. 3A). The athlete is positioned on his or her
side supporting the upper body on the elbow in 0 degrees
of trunk flexion with legs fully extended and feet placed one
on top of the other. He or she is asked to lift his or her hips
off the table, using only his or her feet and elbow for support. The examiner records how long he or she can hold this
position. In our experience, this position should be held
without alterations in form for 45 to 60 s to demonstrate
competency. The next test, the side leg raise, measures hip
abductor strength, primarily the gluteus medius (Fig. 3B).
The athlete is positioned on his or her side in 0 degrees of
trunk flexion with legs fully extended and feet placed one
on top of the other. The upper leg is abducted completely
with maximal hip external rotation to fully recruit the gluteus medius, at which point the examiner resists this motion. Subjectively, strength can be assessed as strength of
3, 4, or 5 of 5. If the athlete performs both of these tests
with competence, they are combined. This combination,
side plank and side raise, is more demanding, and we suggest it should be performed with competence before progressing to plyometric rehabilitation (Fig. 3C). As discussed
previously, the athlete is positioned on his or her side supporting his or her upper body on his or her elbow in
0 degrees of trunk flexion with legs fully extended and feet
placed one on top of the other. In this position, he or she
begins to perform side raises of his or her leg, maintaining
this full trunk extension. In addition to testing the muscles
previously noted, the clinician now is able to assess neuromuscular coordination, hip adductor strength, and abnormal recruitment of the iliopsoas. The patient should be
observed for overall stability and trunk flexion. If the
abductors are weak, we believe that increased recruitment
of the iliopsoas muscle is noted by forward flexion at the
waist. This test is difficult for the general population to
perform, but many athletes can perform at least five of

Figure 2: Single-leg squat testing. A. Single-leg squat. Good limb alignment. B. Single-leg squat. Valgus collapse of knee. C. Single-leg
side step. Good limb alignment.

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Plyometrics and Core Rehabilitation in Sport

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athlete is advanced to the combination exercise. The combined exercise is intense and requires coordination of the
various core muscle groups on opposite sides of the body.
When the athlete can perform at least three sets of 15 of this
combined activity, we believe he or she will have achieved
adequate core strength and stability to safely begin plyometrics. As the intensity of plyometric activity is increased
without evidence of reinjury, the athlete slowly is returned
to his or her sport. Plyometric activity now is intensified
as his or her sport-specific demands are increased. As the
athlete is allowed to return to full sports participation, core
stability and strength must be maintained. A simple way of
achieving this is to continue three sets of 30 of the combined
side plank and side raise on each side, performed three times
a week.
In our experience, the guiding principles of rehabilitation
is to identify the area of weakness, obtain static muscle
strength, improve neuromuscular feedback, progress to safe
plyometric training, and then introduce the demands of the
athletes specific sport. Please see the Table for a logical progression of rehabilitation from injury.
Conclusions
In theory, core stability and plyometric exercise are vital
aspects of a training program for competitive athletes. Prior
to initiation of sport-specific plyometric training, evaluation and rehabilitation of core strength should be addressed.
Current data are conflicting, although there is a general
Table.
Example of core rehabilitation and plyometric training in competitive
athletes.

General
1. Identify the weakness.

Figure 3: Side plank and side leg raise testing/exercises. A.

2. Obtain static core strength in all regions.

Side plank/bridge. B. Side leg raise. C. Combined side plank and side
leg raise.

3. Advance to plyometric training before return to sport.

these combined side plank/leg raise repetitions. Ideally, we

theorize that the patient should be able to competently
perform 30 of these combined raises on each side.

Progression of rehabilitation (goals are listed)

1. Full leg side raises: three sets of 30 on each side
2. Side plank/bridge: hold stable position for 45 to 60 s on
each side
3. Combined side plank and leg side raises: three sets of
30 on each side

Restoring Function Bu Addressing

Core Deficiencies
When comparing the core stability of athletes with the
general population, we believe that clinicians often are reassured falsely and believe that athletes are stronger than
they really are. By including the dynamic or plyometric hop
test and the combined side plank/side raise, subtle strength
differences may be unmasked.
Frequently, the physical therapist or the athlete will push
dynamic, plyometric rehabilitation before adequate core
strength is achieved, so unless the examiner can identify the
weak muscular regions and intervene, the athlete often will
become reinjured (47). Our recommendation is that, individually, the side plank and side raises must be performed
with proper form, technique, and endurance, before the
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4. Front, side, and back single-leg hops: one set of 10 in each

direction on each leg
5. Begin introducing sport-specific activities: approximately
10% to 25% effort of sport
6. Continuous hurdle jumps: five sets of 5
7. Scissor jumps for height: five sets of 8
8. Progress to sport-specific activities: effort slowly
increased
Maintenance
1. Full sport participation
2. Continue combined side plank and side leg raises: three
sets of 30 for each side, three times per week

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trend toward supporting the use of core stability exercises

and especially dynamic plyometric training to prevent
and rehabilitate certain types of injuries. At this time, it
is unclear which, if any, aspects of performance are improved with core stability or plyometric programs and how
these modalities may compare to other training programs.
Athletes often have greater core strength than the general
population, but their sport-specific demands are also much
higher. To identify core instability and rehabilitate injuries successfully, the plyometric single-leg hop test and
combined side plank/side raise strengthening should be
considered. Further studies should focus on the role of
core and plyometric exercises in sport-specific training
to optimize injury prevention, injury rehabilitation, and
performance.
The authors declare no conflict of interest and do not
have any financial disclosures.
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Plyometrics and Core Rehabilitation in Sport

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AUTHOR QUERIES
AUTHOR PLEASE ANSWER ALL
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AQ1 = Please check if the terms Wabdominals,W Wparaspinals,W and WglutealsW can be
changed to Wabdominal muscles,W Wparaspinal muscles,W and Wgluteal
muscles,W respectively.
AQ2 = Please check if the statement WAt this time...prevention of injuryW may be
changed to WAt this time, data showing a relationship between core exercise
and primary prevention of injury are lacking.W
AQ3 = Please check if Wdouble-leg lowering testW is presented correctly.
AQ4 = Please check if Wstrength on isometric strength of the coreW is presented
correctly.
AQ5 = The term WyouthW was changed to Wyoung.W Please check.
AQ6 = Please check if changes made to WOlympic weight training...those of
plyometric trainingW reflect the intended meaning.
AQ7 = Please check if changing all instances of WyouW to WoneW is appropriate.
AQ8 = Please check if changes made to WThis combination...progressing to
plyometric rehabilitationW reflect the intended meaning.
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4, provide the first 4 authors and follow with an et al.
AQ10 = References were renumbered. Please check.
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