INJURY & PREVENTION

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Prehabilitation 101

By Eric Mink

Back in the 1980s, many coaches did not accept what is now considered obvious: that regular strength training can enhance athletic performance. The big lifters were primarily found in football, track and field, and to a lesser extent, skiing and wrestling. Over the past two decades, however, sports physiologists and exercise scientists have continued to show conclusively that correct strength and conditioning strategies can enhance the strength, power, and explosiveness of athletes in almost every sport.

Today, you will be hard pressed to find even a high school freshmen girl's basketball team that does not employ some form of resistance training. Athletes across all sports are bigger, stronger, faster, and more explosive than they were in the early 1980s. As a result of year-round, periodized training, we now regularly see athletes who can move with greater precision, make very rapid directional changes, and deliver more extreme impacts.

The downside of these bigger and faster bodies is that they produce more intense collisions, which lead to stress on joints and connective tissues and increased risk of injury.

To help prevent these injuries, trainers and physical therapists have begun to employ what they call "prehabilitation" strategies in order prevent injuries from arising in the first place. Prehabilitation is essentially preventive training to stop the problem before it happens. In a column for Soccer Science International, professional soccer coach and sports physiologist Rick Celebrini nicely summed up the three phases needed to come up with a good prehabilitation plan: 1) analyzing an uninjured player's movement patterns, 2) understanding the risks of the sport itself, and 3) considering other specifics such as the player's position. Following these three steps, concluded Celebrini, enables sports physiologists to better predict—and then develop training programs to prevent—injuries (1).

Once you understand what predictable injuries you may encounter in your sport, you can work with a trainer to design a prehabilitation program that combines a variety of cross-training exercise including strength training, conditioning, stretching, yoga, Pilates, and traditional rehabilitation techniques. You can then integrate this specialized program into your established sports training routine, paying close attention to the connective tissues, joints, and muscles that would normally have a high incidence of injury. In the long run, you will want to develop a year-round program that accomplishes the interrelated goals of enhanced performance and injury prevention. These techniques are sports-specific, and indeed athlete-specific, as they highlight the predominant muscle movement patterns present in the sport. Prehabilitation helps you:

  • achieve correct muscle balance among antagonistic muscle groups (muscle groups that work in opposition to each other);
  • use muscle groups in a sports-specific sequence;
  • boost the efficiency of the movement patterns inherent in your sport;
  • enhance joint mobility;
  • improve flexibility; and
  • enhance proprioception, which is the ability for your mind to sense the position of different joints in relation to the rest of the body.
Obviously, the prehab approach for an NFL lineman will be different that that of a recreational skier or soccer player, so we cannot adequately cover each sport in this article. What we can give you, however, is an overview of some prehabilitation strategies and their application for three injury-prone areas of the body: knees, rotator cuff, and lumbar spine.

Knees
NFL fans know the dangers of knee injury; knee ligament tears or multiple tears (such as the ACL, MCL, and PCL) regularly sideline high-profile NFL players. And it's not just contact sports that hit you in the knees; traumatic knee injuries are common to athletes in many sports. By conditioning your body to move more efficiently, and by training your knee to be balanced and reactive, you can help minimize your risk of knee injury. Follow the movements below to help you prehabilitate your knees and keep them strong all year long:
  • Proprioception (see Photo 1) Standing on the floor or on an exercise mat and holding a physioball in both hands, establish correct squatting technique by pressing your hips back, aligning your knees with the mid-foot, retracting your scapulas (shoulder blades), and tightening your abdominal wall. Shift your weight to balance on one foot and then move the physioball in a diagonal plane, from the height of your left quad to the height of your right shoulder. Once you've mastered that movement, throw a physioball through a range of motions (up, to the side, diagonal) to practice absorbing shock in your legs and joints more effectively when stress comes from different angles. When doing these exercises, try to use your glutes and hamstrings as the prime stabilizers. Perform three sets of 15 throws. You can increase difficulty by standing on a balance pad.
  • Reactive stability jumps (see Photo 2): Reactive stability training is great for skiers, since their legs are constantly eccentrically loaded (when absorbing a bump, for instance) and encounter rapidly changing surface conditions. To do reactive jumps, hold a physioball at waist height and assume the correct squatting position described above. Close your eyes and jump either laterally or at an angle as explosively as possible. Cushion your landing by focusing on absorbing the landing through your hips. and have a partner immediately push or pull the physioball at the exact moment of your landing. The knees, core muscles, and upper body muscles must instantly react to this changing movement to prevent from being knocked over. Perform two sets of 12 jumps.
  • Hamstring and glute complex strength: Overdeveloped and tight quads, common among athletes and body builders, can negatively affect the knees. To address this risk, do strict machine hamstring curls, Romanian deadlifts. and physioball leg curls. Romanian deadlifts are similar motion to standard deadlifts, except that when you lift the barbell from the ground you press your hips back further to ensure that your glutes and hamstrings are the prime mover. To do physioball leg curls, lie supine (on your back) on the floor or an exercise mat with your calves resting on a physioball. Lift your hips off the ground, dig your heels into the ball, and then curl the ball towards your glutes, using your hamstrings as the prime mover. To get started, pick one of these three exercises and perform three set of 10 reps. Rotate in a different exercise every few weeks to keep challenging your glutes and hamstrings
  • Flexibility training: Movements that target the quads, particularly the vastus medialis and hip flexors, can help reduce tension around the knees. Quad stretches can be performed by standing in an upright position, then bending the knee and raising the heel of your foot to your glute. Grasp the foot with the hand on the same side to stretch the quad muscle group further. End your knee prehab by doing one set of these 30-second flexibility stretches for each leg.
Rotator Cuff
Pitchers, volleyball players, swimmers, and water polo players are all particularly prone to rotator cuff problems, but they can affect just about anyone who is physically active. The prehabilitation exercises below can help you prevent painful and debilitating rotator cuff injuries:
  • Scapula stabilizer (see Photo 3): Lie prone (face down, torso on the bench) on a flat workout bench with your knees bent. Form a "T" with your arms outstretched and be sure your thumbs point to the sky. Contract your trapezius muscles (the large, flat triangular muscles on each side of the upper back) and rhomboid muscles (the muscles underneath the traps) as you squeeze your shoulder blades together. Pause and hold for two seconds, then repeat. Do three sets of 15 reps, and hold light dumbbells in hands if you need them.
  • Anterior deltoid stretch (see Photo 4): This classic yoga position loosens the anterior deltoids, pecs, and biceps—all muscles that weight trainers tend to overwork as they focus on the muscles they can see in the mirror. Standing straight on the floor or on an exercise mat, grasp your hands behind your lower back with your palms facing each other. Drop your shoulder blades downward as you open your chest and shoulders. Be sure to maintain a neutral lumbar spine—do not arch your lower back. Squeeze, exhale, and hold for 10 seconds. Repeat five times.
  • Cable external rotation This is a standard rehab move to strengthen the under-active muscles of the rotator cuff. Stand tall, bend your elbow at a 90-degree angle, with your lower arm parallel to the floor, and grasp a lightly weighted cable that is anchored at elbow height on a cable machine. Squeeze your upper back and externally rotate to open the lower arm, moving your arm away from the torso like a door hinge. Perform two sets of 12 reps on each side.
Lumbar Spine
Doctors estimate that 90 percent of Americans will have some form of lower back pain in their lifetime. A healthy back goes beyond just having "strong" erector muscles. To prevent lower back injury, you should do a variety of training techniques every day, such as interspersing light stretching throughout your work day, particularly if you sit at a desk all day; strengthening your upper back muscles to improve posture; and improving your core strength with core-muscle exercises such as strength training and Pilates. Other lumbar prehab moves include the following:
  • Strengthening exercises for the transverses abdominus (Tva) (see Photo 5): People who routinely do crunches generally have strong rectus abdominus muscles, but they often neglect the underling Tva muscles, which play an prominent role in pelvic stabilization. One exercise that can strengthen the Tva muscles is the quadruped. To do the quadruped, get on your hands and knees on an exercise mat and flatten your back. Extend your left arm so it is parallel to the floor. Simultaneously kick your right heel to the sky, keeping your knee bent at a 90-degree angle. Be sure to squeeze your glutes and tighten your abdominals when performing this exercise. Perform three sets of 15 reps for each leg.
  • Flexibility training for the erectors and glutes: Lying on your back on an exercise mat, bend one knee and clasp it to your chest. Extend the other leg out straight along the ground. Squeeze your knee to your chest, exhale, and pause, then alternate and bring your opposite knee to your chest. Perform three sets of 15 reps for each leg.
  • Flexibility and strengthening for the hamstrings:Dynamic stretches, such as straight-legged hamstring swings, are important moves for lengthening the hamstrings. To do a straight-legged hamstring stretch, begin by standing upright and holding a fixed pole or similar with your right hand for balance. Drive your left foot upwards to the sky, keeping your leg straight, and swing forward and back using your hip complex as the prime mover. Switch legs and repeat. Static stretches should be performed after a light warm up, and include seated stretches on the bench with one leg outstretched. To do this stretch, straighten the leg and reach toward your shin or foot, extending both arms outward. Hold each stretch for 30 seconds.
If you're not practicing prehabilitation, chances are you're risking injury and failing to maximize your performance potential. No matter what your age or skill level, the above prehabilitation moves will help balance and condition your most vulnerable joints and hopefully afford your body years of high performance.

Resources
1. Celebrini, Rick "Prehabilitation or Prehab" Soccer Science International. 2004.

Eric Mink is a former professional football player and the founder of a sports performance clinic specializing in physical training, joint rehab, and nutrition for athletes. Mink has written analytical reports on the pharmaceuticals and nutritional supplement industries, as well as a range of articles in the areas of sports training and rehab, nutrition, and training theory and practice.