Exercises designed to challenge the core can be valuable interventions when preventing and treating sports-related injuries.
The best exercises for targeting and improving performance for athletes may be quite simple, but they may not be what you think…
Brian arrived for his evaluation with a history many physical therapists (PTs) have heard before: a strong orthopedic diagnosis for his shoulder problem, past therapy which helped decrease pain and improve function, return to sport, gradual return of the old problem over time…pause, rest, rehab, repeat… So it’s not surprising that he was completely perplexed when his shoulder was not touched during his assessment where he performed a series of neuromuscular and biomechanical tests designed to identify any weak links in his body. What was even more surprising followed: a reported 40% decrease in resting symptoms the evening of the assessment, and after two follow-up sessions over a 2-week period, he returned to baseball pain free with a program to integrate into his team’s training regimen.
Professional athletes present a unique set of challenges when it comes to developing injury-prevention programming or rehabilitation following an injury. Balanced strength, mobility, and proper neuromuscular connection to the deep torso establish a strong foundation for the demands of a wide spectrum of athletes. Joe Donahue, owner of ProSport Physical Therapy, states, “The greatest challenge of the modern-day sports medicine team is to find ways to integrate how we train the various aspects of injury prevention, management, and recovery.”
A long held and established concept for the treatment of low back pain and pelvic instability has proven to be an essential component of just about every type of sports performance and training program targeting athletes. Core instability has been associated not only with lumbar spine injuries but also with deficits in sports performance.
A recent study published in the Journal of Strength and Conditioning Research identified that core activation was greatest when the glutes and shoulders were also engaged. The study concluded that an integrated routine is best for “maximizing strength, improving endurance, enhancing stability, reducing injury, and maintaining mobility.” The idea of an integrated system where both local and global muscles serve the dual purpose of stability during mobility for forces to be transferred appropriately through the kinetic chain now dominates the performance industry.
A simple biomechanical concept is true for rehabilitation programs, fitness regimens, and performance training alike. Without proximal stability, distal mobility is limited and performance can be compromised.
Planes, Chains, and Auto-mobility
Our bodies move three dimensionally and rely on synchronized movements for optimal function in addition to unconscious “preparatory” movements. If one link in the chain is weak or out of sync, a faulty movement will occur and, if left uncorrected, will create dysfunction. If compensatory patterns are repeated often enough, they become a habit and are much more difficult to break once pain, inflammation, and stiffness begin to alter the input to the brain. When a change takes place on a neural level, these patterns can be eliminated and permanent improvements to strength, flexibility, and posture are possible.
Athletic and sport-specific movements are a series of chain reactions originating from the ground up. A throwing athlete generates energy from the feet, up through the core, and transfers it through the arm to the ball. Any deficit in this chain of events can decrease ball speed and precision, and this in turn can lead to overthrowing and, ultimately, injury. Pain is often felt in a region taking on the most stress but not always the site of the deficit. For example, elbow pain can result from overthrowing when in fact the deficit lies within the core. The core is not appropriately transmitting the forces through the arm, and voilá—abnormal force attenuation at the elbow joint.
Kinetic Chain Challenge
When screening for deficits within the athlete’s core, assessment of functional mobility during full-body movements allows for identification of kinetic chain dysfunction. Once mobility faults, or “weak links,” are identified, the whole system can be addressed as it relates to the particular weak link and specific neuromuscular re-education can occur. Interventions with high specificity result in faster return to play and improvements beyond the athlete’s current level of function. Strength and endurance testing should follow to ensure that all aspects of performance are addressed.
Studies have demonstrated that more than 50% of the force generated to throw a fastball comes from the trunk and the legs. A serve in tennis generates 54% of the force from the trunk and below.
The Torso Connection
A stable and mobile spine relies on the proper coordination of global and local muscles in the right amount at the correct time during a functional movement pattern. Panjabi demonstrated that dynamic stabilization resulted from a coordinated effort of anatomical supports created by active, passive, and neural components within the body. By establishing a solid foundation, spinal and distal segments move efficiently during sporting maneuvers, decreasing the likelihood of improper loading and, ultimately, injury.
The preventative and rehabilitative focus of our exercise choices are shifting away from “fixing” the manifestations of poor patterns, such as inflammation and pain, and moving toward integrative corrective exercise. Now, the emphasis can be directed toward establishing the proper generation, dissipation, and transfer of forces during sports-related movements between the upper and lower extremities. Restoring balance within the mechanical patterns will support productive, pain-free movements in sports.
Tools for Exercise and Progression
As therapists, the goal is for our clients to achieve optimal independence with strategies for improving their understanding of their body, sports, and athletic demands, providing enough education to make smart choices on the field and in the training room, and give options for when we are not there to provide direct intervention. Many high knowledge-low tech products exist in the marketplace for use both in the clinic and at home. These types of products provide an easy way to ensure continuity of training, compliance, and prevention.
1) Compression bands
a) Compression bands work tissues on many levels. From reperfusing fluids to stiff or cold tissues after injury to compressing swelling out of soft tissues and joints, the compression will quickly alter the fascia’s relation to all other aspects of the neuro-musculo-fascial-skeletal system in response to movement. Based on the concept of tensegrity, this mechanism can alter neural input by making a quick change in the mechanical transmission of forces through the fascial system. Pro-Tec Athletics, based in Redmond, Wash, offers the IT Band Compression Wrap for targeted compression.
b) Compression +Tension + Movement = Fibrosis release.
c) The local endocrine response to temporary occlusion could potentially lead to improved healing times by increasing two chemical messengers: H.G.H. and N.O.
2) Neuromuscular taping techniques
a) Therapeutic tapes, such as Rock Tape from RockTape, Campbell, Calif, and Kinesio tape made by the Albuquerque-based Kinesio, are designed to support a recovering tissue, facilitate proper muscular firing, and enhance neuromuscular responsiveness. Physical therapists can help protect athletes from injury by using various techniques as strategies to support and augment the function of a muscle based on clinical findings.
3) Self-release techniques
a) Pre- and post-workout or game, using a foam roller or rolling stick such as the Tiger Tail made by Tiger Tail USA, Kent, Wash, Thera-band roller from Thera-Band, Akron, Ohio, foam rollers from OPTP, Minneapolis, or the Muscle Glide, manufactured by MuscleGlide, or even a foam roller with the ridged attachments, would be useful for self-massage. Self-release activities can assist in thinning out tissue thickenings in the connective tissue of a muscle, making it less rigid and more pliable. This allows the muscles to expand normally when they are contracting vigorously under high demand and load, resulting in fewer injuries.
4) Static-Dynamic flexibility and strength
a) Resistance bands
i) Dynamic stretches facilitated by resistance bands, available from companies such as Thera-band, the Warminster, Pa-based Stretchwell, SPRI Products, Libertyville, Ill, and NZ Manufacturing, headquartered in Tallmadge, Ohio, can be used for pregame or workout warm-up and set up the nervous system for optimal function and communication during competition. A good dynamic warm-up routine as preparation for play is best practice, with static stretches as needed specific to challenges identified in functional assessments.
b) Balance Mats
i) Balance mats, such as Airex Pads, made by the Magister Corporation, Chattanooga, Tenn, and the Fitter First balance pad from Fitter International, Alberta, Canada, are light, transportable, durable, and provide a variety of different options for use. Standing body awareness and grounding exercises in addition to balance training can be highly beneficial for athletes. Other exercises include squats, lunges, function lunges with pulley diagonals, and bilateral to unilateral work with progressions.
ii) Half Balls, such as those from OPTP, can be used to challenge balance, stretch the plantar fascia, and massage the feet. A user can also lay on the balls to target trigger points and other tension.
iii) The BOSU ball, produced by BOSU, Ashland, Ohio, acts to challenge the correct muscle firing sequence and timing to enhance proprioceptive training and get the user back to running, back to work, or back to the fields.
iv) In addition to restoring proprioception and balance while rehabilitating from injury, incorporating these exercises into a routine will help to maintain balance, safety, and function as they age.
c) Smart Roller
i) Foam rollers provide stretching, feedback, and self-mobilization to targeted areas. The smart roller has two different arcs which increases its versatility—directly as it relates to contact with the spine and indirectly as it relates to the level of instability it can create.
ii) Foam rollers can assist with supporting the manual work done in the clinic with great carryover to home. They provide self-soft-tissue mobilization, which can improve muscle flexibility, decrease tightness, lactic acid, muscle fibrosis (adhesions/scar tissue), and ultimately injury risk.
5) Basic-Complex patterns integrating the inner and outer units together for kinetic chain function
a) Integrative Core work using static and dynamic balance sequences can be performed in all three planes of motion using Pilates and CoreAlign equipment with progressively more challenging activities. If the objective is to start in a standing position, the CoreAlign, available from Balanced Body, based in Sacramento, Calif, is the optimal piece as the movement sequences can be carried over into the field environment even if a CoreAlign is not readily available. Going further, proprioception stability and strength can be challenged in a more complex dynamic environment that includes the Balanced Body Reformer, Reformer-Trap Combo, Trapeze Table, and Wunda Chair.
b) Suspension training. Every athlete can benefit from work focused on integrating their core with upper- and lower-quadrant strength and stability with neuromuscular patterning. The Redcord mini, which is produced by the Norway-based Redcord AS, utilizes dual suspension points as a point of instability that forces co-contraction and challenges stability in a variety of myofascial chain challenges positions to identify and uptrain any weak links identified during clinical assessments. Fitness Anywhere LLC, San Francisco, offers the TRX Suspension Trainer, a system for suspension training, and Endorphin Corporation, Pinellas Park, Fla, produces pulley systems also for upper- and lower-body workouts.
a) Dynamic flexibility and strength programs including elements of Pilates, balance, and suspension training can provide an effective neuromuscular warm-up. It can be done in a setting which can be administered to teams and specifically designed to address patterns of imbalance identified by trainers and therapists, and delivered in a manner that increases the knowledge base for injury avoidance and management as a whole and include the team in the prevention process.
Sports Injury Prevention and Treatment
Exercises designed to challenge the core and produce efficient normal movement patterns by using an array of tools can provide excellent intervention options within the clinic with excellent carryover for home use and field use. The most effective technique for treating a sports-related injury is to prevent one from happening in the first place. If patterns are identified early on and re-educated or corrected before becoming deeply set into the nervous system, preventing injury becomes a part of daily life, like brushing your teeth—the outcome that always leads to a wider and brighter smile! PTP
Dawn-Marie Ickes, MPT, PMA-CPT, is the owner of Evolve Integrative Wellness Physical Therapy and Pilates, Orange County, Calif, specializing in Integrative Corrective Exercise, Sports Performance/Dance Medicine, and Women’s Health. Ickes developed education programs for fitness and health care professionals that aim to bridge the gap between medical and movement science, creating opportunities for an effective continuum of care in any setting. Ickes is also creator of Evolve@ and the Pilates Post-rehab Specialist Mentoring Series. For more information, contact [email protected].
1.Brown TN, Palmieri-smith RM, Mclean SG. Comparative adaptations of lower limb biomechanics during unilateral and bilateral landings after different neuromuscular-based ACL injury prevention protocols. J Strength Cond Res. 2014;28(10):2859-2871.
2. Gottschall JS, Mills J, Hastings B. J. Integration core exercises elicit greater muscle activation than isolation exercises. J Strength Cond Res. 2013;27(3):590-596.
3. Kibler WB. Clinical biomechanics of the elbow in tennis: implications for evaluation and diagnosis. Med Sci Sports Exerc. 1994;26(10):1203-1206.
4. Tsao H, Galea MP, Hodges PW. Driving plasticity in the motor cortex in recurrent low back pain. Eur J Pain. 2010;14(8):832-839.
5. Woollacott MH, Shumway-cook A, Nashner LM. Aging and posture control: changes in sensory organization and muscular coordination. Int J Aging Hum Dev. 1986;23(2):97-114.