Injury prevention

Chapter 2 Injury prevention

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.

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’ 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.

image 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).

image 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.

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.

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Jul 18, 2016 | Posted by in SPORT MEDICINE | Comments Off on Injury prevention

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