What is the third layer from the bottom in the bottom-up rehab pyramid?

• A. Strength and endurance
• B. Neuromotor control / proprioception
• C. Function / performance
• D. Range of motion / flexibility

Answer: (A)

In a bottom-up rehab framework, progress is built from foundational aspects up to higher-level function. The layers from bottom to top typically unfold as: range of motion/flexibility, neuromotor control/proprioception, strength and endurance, and finally function/performance. The third layer from the bottom is strengthening and endurance because once the joint can move through an adequate range and the nervous system can coordinate basic movements, the next essential step is rebuilding the muscles’ capacity to generate and sustain forces. This strength provides the actual capacity to tolerate loading during activities and sport, supports joint stability, and helps prevent re-injury. Range of motion sits lower as the foundational movement capacity, and function/performance sits at the top as the culmination of all the prior elements, while neuromotor control is important for coordination but does not by itself provide the loading capacity that strength does.