INJURY PREVENTION AND ROBUST ATHLETES

One of the most talked about items within sports these days is injuries and injury rehabilitation. The occurrence of career ending injuries is increasing and the age at which athletes are becoming injured is getting lower and lower. However, almost all non-contact related sports injuries ARE preventable. They are a direct result of poor mechanics (movement skills), poor posture and poor positioning. Coupled with elevated training load, reduced sleep and increased stress, we can start to map out why injuries occur.

Of course there are the un-preventable injuries that occur during contact in sports, such as knees, ankles and shoulders. These are tough on an athlete and can take up to 12 months to return from, if the rehab is successful. Many athletes have had their careers cut short due to contact injuries.

We classify injuries through three broad categories:

  1. Soft-tissue (muscles / tendons / ligaments)
  2. Contact (joints / ligaments / bones)
  3. Developmental or ‘overuse’ (growth plate / bone stress / movement dysfunction)

In this module, we are going to concentrate on both soft-tissue and developmental injuries/concerns and how we can help build ourselves to become more robust athletes. I will highlight some of the main issues and injuries and provide a structure that you can use to improve your injury resilience and reduce the need for injury rehabilitation.

SOFT TISSUE INJURIES

Soft tissue injuries are the most common injury in sport, and refers to any tissues that connect, support or surround structures and organs of the body.The injuries can range from a low level sprain/strain to a much more severe rupture/tear, with recovery times anywhere from hours/days to weeks/months.We need to be educated as athletes of the difference between muscle ‘soreness’ and muscle strain. Athletes that commence a new form of training, have an increase in training load or change their usual movement pattern will be subject to DOMS (delayed onset muscle soreness). This is a natural response from the body as it seeks to adapt to the new training stimulus and build the body back stronger for the following training sessions. This is the general rule of adaptation in an athlete:

Stress (training) + Rest (sleep & recovery) = Growth

We must acknowledge that our body will be sore and tired after training and that it requires time to recover and grow. Recovery times are dependant on our age, training history and type of training. As young athletes any type of aerobic training will not overly stress our system and recovery times will be relatively short.

However, as we age and begin to develop in to our body, recovery times will begin to increase and more specific recovery methods will need to be implemented.As an athlete you need to be aware of how well you recover and when it is best to take an ‘off day’ or ‘recovery session’.Once we have an idea of what muscle soreness feels like and what type of exercise induces muscle soreness, we can begin to formulate our training and recovery plan around it. Youth athletes should aim to take at least 24 hours recovery after a game before commencing training and 12 hours after a team training session.

When a soft tissue injury is more severe than muscle soreness it may require a complete change in your training and competing plan. Interventions need to be created to help rehabilitate the injury and progress you back to training and ultimately competition in a safe and systemised process.Again, this needs to be a calculated return with support from different medical teams. Doctors, physiotherapists and performance coaches need to work together to map out the best course of action and relevant requirements along the way.

When I come across an athlete with a soft tissue injury such as a hamstring strain I always ask the athlete the following questions:

  1. How did it happen?
  2. Has this injury occurred before?
  3. Was there any symptoms leading up to the injury?
    1. Training load increase
    2. Stress increase
    3. Sleep decrease
    4. Introduction of new training program
    5. Joint dysfunction (e.g. ankles or hips)
  4. Have you been referred to a physiotherapist
  5. How motivated are you to return from this injury in an efficient but comprehensive manner?

The injury rehabilitation process of a soft tissue injury is very much an individualised process, there is no recipe, no secret formula, but rather a tailored approach based on the athletes needs.

Here’s my framework I work with when an athlete presents with a soft tissue complaint. I’ve included examples for a moderate level hamstring strain in the first few days of rehab:

 

Can Do Cannot Do
Deep Stabilising System All Exercises

–          Dead bug

–          Pelvic alignment

Mobility Thoracic spine

Ankles

Limit hip mobility drills
Movement Patterns High Knee variations

Light load resistance work

Max intent drills

Sprinting

Force production / absorption Low load jumping

Bi-lateral

High level plyometrics

Uni-lateral

Stability A/K/H, Activation

Un-loaded lunge patterns, contra-lateral, balance, proprioception, low-load isometric

Hamstring dominant ex

Uni-lateral loaded

Eccentric focus e.g. Nordics

Strength Bodyweight No loaded exercises
Conditioning Upper body Lower body

CONTACT INJURIES

It’s an unfortunate part of modern day contact sports when athletes are subject to positions and loads which are too much for their system to handle and something has to give way. It’s also becoming an all too familiar sight and can discourage many athletes from playing the game they love.

Contact injuries occur when players compete for space, a ball or position on the field and extreme load is placed on their joints and the bodies structural system. Bones, joints and connective tissue are ultimately the final tipping point when the load becomes too much to handle resulting in dislocations, fractures and ruptures.

Our ankles, knees, fingers and shoulders are some of the more vulnerable areas in our body and any trauma to these areas can create season if not career ending injuries.

All contact injuries are different and must be treated by the correct medical professionals. Seek advice from more than one surgeon if surgery is required. Shop around for the best physiotherapist and ensure that your injury rehabilitation plan post trauma is the best on the market.

I am going to provide a basic overview of how we would help an athlete with an acute ankle sprain, a very common injury for many athletes. Again, whilst we can provide a ‘template’ for injury rehabilitation, all injuries must be treated unique to the athlete.

Minor ankle trauma template:

Phase One (The next day after the injury):

  • Continue with the classic ‘RICE’ approach
    • Rest
    • Ice
    • Compression
    • Elevation
  • However! We need to encourage fresh new blood in to the affected area and this happens through movement.
  • Mobilise the joint through ranges that are free from pain
    • Pull your toes back to your knee
    • Push your toes away from your ankle
    • Spell the alphabet with your big toes
  • Load the joint through ranges that are free from pain
    • Walking
    • Balancing
    • Climbing stairs

 

Phase Two:

  • Continue with phase one exercises first
  • Mobilise the joint through progressive loading
    • Standing on your feet attempt to touch your knee to your toes – work through a range that is pain free
    • Calf raises – stationary and then walking
  • Load the joint through progressive dynamic ranges
    • Skipping
    • Jogging
  • Balance and wobble
    • Create an un-steady surface and work on your balance
    • Allow the foot to organise itself an find the most efficient position

 

Phase Three:

  • Continue with phase two exercises first
  • Incorporate jogging and running in to the program
  • Begin to stress the ankle laterally
    • Jumping and landing – small
    • Lateral lunge
  • Build in to more dynamic and higher velocity movement patterns
    • Skip for distance
    • Skip for height

 

Phase Four:

  • Continue with phase two and three exercises first
  • Incorporate change of direction drills through ranges that are pain free
    • Lateral bounding
    • Ladder drills
    • Hopping
    • Jumping and landing
    • Drop step / cut / pivot

 

Once an athlete has reached phase four, every effort should be made to return the athlete back to full training as efficiently as possible. It must be noted that the athlete will not have run at full speed for a period of time so this must be progressively implemented back in to the training plan by the support staff.

Many athletes will find they are more confident with their ankle strapped for training and games, this provides support and ultimately a stronger ankle complex. Strapping for up to 3 months is often seen, however athletes will still need to train during the week without strapping present. Loading of the connective tissue without the strapping provides a stimulus for growth and development which is important after the rehab of a joint.

DEVELOPMENTAL INJURIES / OVERUSE AND OVERLOAD CONCERNS

It is not uncommon for youth athletes to experience either developmental or overuse trauma in their lower limbs. When an athlete experiences rapid growth during their developmental years they can be subject to these conditions, namely severs, Osgood schlatter’s and osteitis pubis.

There are many different factors affecting and causing these conditions, however a well structured training program can negate some, if not all effects. Much of the research around points to neuromuscular control (control of limbs through the brain), co-ordination and appropriate movement patterns as the main contributors to helping improve the symptoms of these conditions.Below, I have targeted four main conditions with information on how I would treat an athlete presenting with symptoms and/or diagnosis.

OSGOOD SCHLATTERS DISEASE

 Description of the injury:

Osgood Schlatter’s disease is a rupture of the growth plate at the tibial tuberosity of the knee and it occurs due to rapid growth at the knee. Osgood Schlatter’s involves lower limb abnormalities such as trauma, local alteration of the chondral tissue and mechanical overpull by the extensor muscles (quadriceps) at the knee joint which can result in patella and traction apophysitis. Excesive pain and swelling at site of tendinitis in the knee joint may indicate injury.

 

 

 

Exercise Prescription:

Progression Strength Exercises Core Strength Flexibility
The following exercises should be carried out consistently until the athlete is pain free through strenuous activity and thus can return to sport. Also, as the athlete matures the injury will go away Strengthening of the knee flexors:

·         Floor- one leg bridge back

·         Db reverse lunge

·         Bodyweight deadlift

Strengthening of the knee extensors:

·         Wall Hold

·         One leg 1/4 Squat

DSI:

·         Floor Dead cockroach

·         Ball – back bolts

Trigger Point:

·         Quadriceps

·         Hamstrings

·         ITB

·         Deep Hip Rotators

·         Hip Flexors

 

Foam Roller:

·         Quadriceps

·         Hamstring

·         ITB

 

OSTEITIS PUBIS

  Description of the injury:

It is apparent OP is a serious injury that requires rehabilitation over a prolonged period of time and the athlete must take time away from their given sport. Anterior pelvic tilt and decreased length of iliopsoas and quadriceps muscles is very common in athletes with OP. Furthermore, adolescent athlete’s who experience OP lose hip rotation and previous obstetric history can play an important role in the etiology and management of the condition 2003). Thus, elite players are seen to be more at risk than recreational athletes and the injury takes at least several months to a year for full recovery.

 

Exercise Prescription:

Progression Strength Exercises Core Strength Exercises Flexibility
Exercises should be in a progression and athlete must see a physiotherapist in order to return to sport as soon as possible.

Return to sport tests include:

Thomas test, squeeze test and physical compression over pubic symphisis.

Hip stability/lower body strength:

·         Bodyweight squat/deadlift

·         Two leg bridge back (hold)

·         Mini-tramp 2-2 bounce.

Assist with strengthening the adductors include:

·         Side squat/lunge, Diagonal lunge, Mini Lunge – Cushion

·         Full Lunge (step through) Cushion

To stabilize the hips immediately post injury (DSI):

 

·         Seated Diaphram

·         Ball – back bolts

 

Progression:

·         Elbow knee leg lift

·         Bridge back hold

·         Ball – Stepping &

Ball – Lateral Roll & the “Hold” versions of these two exercises

·         Bridge back and curl

·         Ball – Frog kicks

Trigger point:

 

·         Hip flexor

·         Gluteus maximus

·         Hamstring

·         Calf

·         Adductor

 

SHIN SPLINTS

 Description of the injury:

Evidence of shin splints among many athlete populations that encompass any form of running can cause this common lower limb overuse injury – specifically seen in dancer’s (Sommer & Vallentyne, 1995). MTSS is one of the most common lower leg injuries in sports and it is apparent that 6-16% of all running injuries occur from MTSS. This common overuse injury occurs in up to 13.1% of all runners. Sixty-percent of those presented with this complaint have errors in training. Most commonly symptoms occur after a rapid increase in training of duration, intensity, increased hill training or frequency of training.

 

 

Exercise Prescription:

Progression Strength Exercises Core Strength Exercises Flexibility
Return to sport:

Talus mobilization and no running until physiotherapist agrees (usually within 2-12 weeks)

Return to running warm up (2-12 weeks)

– Dynamic warm up (12-18 weeks)

Lower body stability/strength:

·         Soleus hold

·         Floor calf raises

·         8 point balance

·         Heel walks

·         Step calf raise

·         Progress to Squat/Lunge and Calf raise exercises as seen fit.

DSI:

·         Talus mobilization

·         Floor dead-cockroach

·         Elbow knee leg lift

 

Trigger point:

·         Calf

·         Peroneus

·         Plantar Fascia

·         Hamstring

 

 

SEVER’S DISEASE

Description of the injury:

SD is another overuse growth plate injury at the bottom of the calcaneous with repetitive microtrauma and traction on the calcaneal apophysis as seen in the above figure. According to Micheli & Ireland the most common associated foot condition was pronation. This pronation is caused by instability of the sacroiliac joint which tightens the tensor fascia latae (TFL), which causes internal rotation of the femur, therefore causing a collapse of the foot on an inverted position.

 

Exercise Prescription:

Progression  Strength Exercises Core Strength Exercises Flexibility
Return to sport:

-Talus mobilization

-Successfully complete Return to running warm up

Until pain free:

·         Diagonal wall toe raise

·         Bridge back and curl

Once pain free:

·         Soleus Hold (BW) -Eccentric Focus Floor (progressing to Step)

·         SL & DL Calf Raise (Db/BW)

·         Split squat and side squat is last progression

DSI:

·         Floor Dead cockroach

·         Elbow knee leg lift

·         Ball – back bolts

·         Deep neck bolts

·         Seated Diaphragm

Trigger point/spikey ball:

 

·         Tensor Fascia Latae

·         Gastrocnemius

·         Quadriceps

·         Hip flexor

·         Hamstrings