Chapter 2 Injury prevention

CHAPTER CONTENTS

Core stability

Low-load stability muscles

Floor exercises

High-level mobility muscles

Gym ball exercises

Higher-level exercise

Gluteal muscle (glutes) exercises

Proprioception or balance exercises

The lower limb

Knee drives

Walk-through lunges

Jump lunges

Shoulder and upper limb

Taping

Warm-up

Physical elements

Sport-specific and mental elements

Stretching

Static stretching

Duration of static stretching

Muscles

Tendons

Hold–relax stretch technique

Dynamic stretching

Repetitions

Protective equipment

Cool-down

When not to do a cool-down

Recovery

Ice baths

Timings

Massage

The ability to prevent an injury is the ‘holy grail’ of all sports therapists. To reduce the occurrence of an injury and thereby keep the athlete training and competing is the ultimate in excellent care. There are many factors that contribute to achieving this goal and there are many factors that we have no control over that may jeopardise our best efforts; however, one way of identifying which athlete is at risk of what injury, is to perform a screening or profiling medical. This is a top-to-toe musculoskeletal survey of the athlete, taking into consideration their sport, playing position, demands of the sport, their morphology, strength, stature, muscle balance, proprioception, posture, biomechanics, joint range of movement and stability, body control, flexibility and coordination. This is a long list but the process involves progressing through the body, examining each joint and muscle group with the insight of the athlete’s past injury history, identifying as you go along any deficiencies, imbalances, structural abnormalities or injuries that would put the athlete at risk of injury. A suggested medical examination protocol is shown in Figure 2.1.

Figure 2.1 Medical examination form.

For this process, a list of identified weaknesses can then be addressed by prehabilitation exercises. ‘Prehab’ exercises to address deficiencies have been shown to reduce injury incidence and are now an integral part of athlete training regimes. There is no fool-proof plan that will keep athletes injury-free but below are some of the essential factors that need to be addressed to succeed.

CORE STABILITY

‘Core stability’ has been an ‘in-vogue’ area for sports medics, conditioners and coaches alike. It relates to the musculature around the trunk and pelvis and the move towards ensuring that an athlete has a stable trunk and pelvis which will provide the base for all other movements of the limbs to work from.

It is an area where there is a spectrum as to what it actually means and what should actually occur. Some physiotherapists are at one end and talk about segmental stability of each spinal level, while it tends to be the conditioners who are at the other end of the spectrum and who see it as using all the trunk muscles strongly together to provide the base. In practice, a middle ground needs to be found and both groups of people need to interact and work together to provide the athlete with the best possible programme.

Everyone is in agreement that this stable base around the trunk and pelvis is required to allow the athlete to perform to the best of their ability, but that it is also important to help prevent injuries. It has been shown that instability or excess movements at and around the pelvis can cause compensatory movements to occur at the more distal joints. For example, athletes who have poor gluteal control around their hip and pelvis are unable to control the hip in load-bearing positions, which can cause the hip to internally (medially) rotate. This puts extra load through the knee with a valgus stress being exerted and hence causing compression to the lateral compartment and stress to the medial ligament. These alignment changes can cause tightness to the iliotibial band and subsequently can cause a lateral tracking of the patella. Further down the chain, it will cause a medial rotation force to the tibia and exert extra load through the medial longitudinal arch of the foot.

An example of this, in the upper limb, can be where poor stability in the lumbar spine leads to protective stiffness developing in the thoracic spine to try and provide the athlete with some stability or rigidity. This stiffness (most commonly limiting extension) leads to excess movement occurring in the shoulder to compensate for the lack of thoracic extension, and is common in athletes who participate in sports that require their shoulder to move repetitively over their head, such as tennis players. This excess movement often leads to instability at the joint or rotator cuff tendinopathies or tears.

Physiotherapists have recently talked about two general groups of muscles: low-load stability muscles and high-level mobility muscles, both of which are discussed below.

Low-load stability muscles

These muscles, which include the transversus abdominis, multifidus and even the deep parts of psoas, have been discussed as muscles that work at low load and are postural control muscles. They work to provide segmental spinal stability and control and have been shown to have an anticipatory role in controlling the trunk, as they contract before limb movements occur and hence provide the stable base required. However, they have also been shown to lose this anticipatory timing when pain is present and this has been proposed as one reason that low back pain continues and recurs.

Studies have shown that re-training these muscles after an episode of low back pain can reduce the recurrence from about 70% to about 30%. It is therefore an important area for athletes to train to prevent injuries and stop their recurrence.

The exercises in the studies initially tried to isolate a contraction of each muscle and then gradually add load while maintaining the contraction. In practice, more than one of the muscles work at the same time and it is this co-contraction that is effective in maintaining spinal stability. The muscles still need to work and be taught to activate at approximately 30% of maximal contraction but co-contraction is acceptable.

The traditional transversus abdominis exercise is in crook lying and gentle flattening of the low abdomen towards the spine, while breathing. A facilitation technique for those athletes who are struggling with the concept is to use the muscles that stop them from urinating and this can help activate the transversus muscle (Fig. 2.2).

Figure 2.2 Transversus abdominis exercise.

Floor exercises

All the floor exercises are started in the supine position, with the athlete’s knees bent up (crook lying) with lumbar neutral maintained with the activation of the low level core muscles, such as the transversus abdominis.

1. Bent knee fallout

• The athlete palpates the anterior pelvic bones and slowly rolls alternate knees towards the floor keeping the foot on the floor. The athlete stops when the pelvic control is lost and the opposite pelvic bone rises into their fingers (Fig. 2.3).

2. Unilateral hip flexion

• The athlete has their hands under the lumbar spine to monitor the movement and slowly lifts and lowers alternate knees towards the chest. He/she stops and lowers if lumbar neutral is lost by either excessive pressure or a pressure loss felt through their hands under their lumbar spine. The exercise is progressed to flexing both hips and bringing both knees up towards the chest and then lowering again (Fig. 2.4).

3. Unilateral hip and knee extension

• The athlete starts with both feet lifted off the floor at a 90° hip flex. The athlete then extends one hip so the foot is an inch off the floor and then extends the knee until the point where lumbar neutral is lost. The progression is to do this with both legs together (Fig. 2.5).

Figure 2.3 Bent knee fallout.

Figure 2.4 Bilateral hip flex.

Figure 2.5 Unilateral hip and knee extension.

The floor exercises can be progressed and a gym ball can be used to make the core stability exercises more difficult and interesting for the athlete. The athlete needs to activate the transversus abdominus and other stability muscles while performing these exercises.

High-level mobility muscles

The main function of stronger muscles of the trunk such as the rectus abdominis, erector spinae and oblique muscles is to move the trunk. However, in many athletes who have a poor low-level core, these muscles are also used to produce stability or rigidity through an isometric type contraction. It is difficult for the muscles to do two jobs at the same time which are at opposite ends of the spectrum. They cannot stabilise isometrically on one hand and then cause movement through a concentric contraction on the other, and therefore athletes must be able to activate the deeper stability muscle as well. However, these mobiliser muscles are needed when greater loads are exerted to the body and to contribute to the stability of the spine through their contraction as the stability muscles cannot cope on their own. This co-contraction is vital to prevent injuries and allow a stable platform for the limbs to work from in high demand and loading sports.

Examples of low-load floor-based exercises with progressions to gym ball exercises and finally to higher-load core exercises follow.

Gym ball exercises

1. Single leg extensions

• The athlete lies with the shoulder blades on the ball, feet on the floor and the buttocks raised, so the lumbar spine is in neutral. The athlete then extends one knee to lift the foot off the floor and holds the position (Fig. 2.6).

2. Prone hip extensions

• The athlete is in a prone position with hands on the floor and feet or shins on the ball. One foot is then lifted off the ball and lumbar neutral is again maintained (Fig. 2.7).

3. Supine hip extension

• The athlete lies supine with the feet resting on the ball. He then lifts his buttocks off the floor by pressing through his heels (Fig. 2.8A). This can be made more difficult by then lifting one leg off the ball (Fig. 2.8B).

Figure 2.6 Single leg extension.

Figure 2.7 Prone hip extension.

Figure 2.8 (A) Supine hip extension. (B) Supine hip extension with one leg lifted off the ball.

Higher-level exercise

1. Plank

• The athlete is prone with his elbows under his shoulders. He lifts his pelvis off the floor so he is resting on his elbows and toes only. Load can be added to his back to make the exercise more difficult through free weights (Fig. 2.9).

2. Traditional sit-ups and their many variations will train the high-level muscles in small movement but will also help strengthen them for their control role as well.

Figure 2.9 Plank.

Another vital part of trunk and pelvic stability are the gluteal muscles. While the gluteal muscles are important in producing movements of the hip joint, they are also responsible for providing stability to the sacroiliac joint and vital in controlling the rotation of the hip in weight-bearing positions. It is their role in maintaining a neutrally rotated hip which is vital in providing the stable base for the lower limb to function from. It is most often a lack of lateral rotation control which causes problems in the lower limb and there are, therefore, some useful gluteal strengthening exercises, which are highlighted below.

Gluteal muscle (glutes) exercises

1. The clam

• Sidelying, the hips and knees are flexed to 90°, the top knee is lifted up using the glutes and keeping the heels together

• This can be progressed to lifting the top leg up so that the heels are also apart (Fig. 2.10).

2. Glutes, standing at wall

• The athlete stands side-on to the wall with the hip nearest the wall flexed to 90°. The hip is pushed into the wall while the standing hip is externally rotated, with the standing leg being the glute that is working (Fig. 2.11).

3. Hip extension/abductions in sidelying

• Sidelying, the athlete starts with the upper hip flexed and adducted slightly across the body. The exercise is to quickly extend and abduct the hip up and behind, and then return back to the starting position (Fig. 2.12).

Figure 2.10 The clam.

Figure 2.11 Glutes in standing at wall.

Figure 2.12 (A,B) Hip extension.

With the stable platform provided by good co-contraction of all of the above muscles, the athlete is less likely to sustain overuse injuries which are commonly triggered by poor movement patterns and excess load being transferred to the tendon or muscle. These exercises are therefore vital to every athlete, to prevent missing valuable playing time.

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