By Dr. Tim Laurent
Tim Laurent, EdD, ATC, CSCS, is the Athletic Training Program Director at Lynchburg College.
Training & Conditioning, 12.2, March 2002, http://www.momentummedia.com/articles/tc/tc1202/adjustments.htm
Today's competitive athlete can rarely afford to take time off from strength training --even when in-jured. Yet many injured athletes are told to avoid certain lifts to prevent damaging their weakened tissue during recovery. So how can an athlete continue working out without risk of further injury? The solution is to provide specific adjustments to strength-training routines that can enable injured athletes to maintain pre-injury conditioning levels while aiding recovery.
It is beyond the scope of this article to present every lift, every adjustment, and every pathology that an athlete could encounter. Therefore, I will illustrate this concept by presenting a common lift, the back squat, and address the possible adjustments that can be made to accommodate specific injury conditions.
HOW TO ADJUST
Figuring out how to adjust a lift for your injured athlete depends on the injury, the sport, and the athlete. Some adjustments to lifts will be temporary. Others may need to be continued indefinitely, depending on whether the injury is chronic or not.
In addition, these adjustments mean more than simply changing the amount of resistance in a lift. An adjustment can refer to altering the speed or range of motion used in a particular lift. It could also mean changing the hand or foot position. Or, an adjustment could be the substitution of one lift for another during recovery.
With each adjustment, the goal remains the same: to condition the athlete with strengthening exercises while simultaneously protecting the injury. Since the goal includes protecting the injury, it is important to coordinate your efforts with the athlete's physician to ensure that no additional injury occurs as a result of strength training.
THE BACK SQUAT
Before describing the adjustments to the back squat, it is important to understand the standard back squat form used by uninjured athletes.
To begin the back squat, the lifter positions himself or herself so that the bar is across the posterior deltoids at the base of the neck. The hands are slightly wider than shoulder-width apart as that athlete grasps the bar. The back is in a comfortable lordosis with the neck slightly extended, shoulders back, trunk slightly flexed, and the buttocks sticking out. The feet are positioned about shoulder-width apart with the toes slightly externally rotated to a comfortable position.
As the lifter descends, he or she maintains the lordotic posture. The hips, knees, and ankles move together so that the weight descends in a straight line toward the floor. Weight is maintained over the middle of the feet, not the toes, while the heels remain on the floor. Movement is smooth and controlled without ever putting stress on the lower back.
During the ascent, the movement is reversed, with the ankles, knees, and hips moving together to bring the body to the upright position. Erect posture is maintained as the weight travels in the reverse pattern. During both the descent and ascent, the knees follow the alignment of the toes.
Here is how the standard back squat described above can be altered to account for some common injuries:
Anterior shoulder instability: Anterior shoulder instability can be the result of a subluxation, a dislocation, or a rotator cuff strain. For a person with this type of instability, the standard back squat may put too much stress on the shoulder. Since the rotator cuff works extra hard to prevent anterior displacement of the shoulder when the shoulder is abducted and externally rotated (the position used in the standard back squat), the lifter may be unable to hold the bar without pain.
To allow the person with anterior shoulder instability to perform squats, the front squat can be substituted for the back squat. While a front squat is a different exercise than a back squat, it provides an acceptable substitute in cases of shoulder instability. However, as a result of the different posture assumed during the front squat, the distal quadriceps are worked more than the proximal quads.
Have the athlete begin by performing the front squat with his or her arms across the shoulder so that the right hand is at the left shoulder. By placing the bar on the anterior shoulders, the athlete's posture becomes more upright, which helps him or her maintain balance during this adjusted squat.
The foot position for this adjusted front squat is usually narrower than that of a standard back squat. However, the descent and ascent follow the same principles as the back squat with the hips, knees, and ankles moving together. When this squat is performed, it is also imperative that the knees follow the alignment of the toes so as to avoid rotational stress on the knees.
A second way to adjust the back squat for someone who is experiencing anterior shoulder instability is to have the lifter use a squat machine. Since the machine controls the path of the bar, the exerciser does not have to stabilize the bar as he or she descends and ascends. Instead, the athlete's entire effort can be concentrated on lifting rather than balance. The advantage of this lift is that since the arms are not needed to stabilize the weight on the shoulders, there is very little stress placed on the anterior shoulder.
The disadvantage of this technique is that since the lifter does not have to stabilize the weight, there is little effort used to balance the weight. One primary advantage of free weights over machine weights is that balance and coordination are worked continuously as the weight is stabilized.
Hamstring strain: Hamstring strains are very common injuries among sprinting athletes. Since the hamstrings work both the knee and hip during sprinting, they need to be rehabilitated and conditioned both as knee flexors and hip extensors. Even with this approach of working the hamstrings at the knee and the hip, hamstring rehabilitation and reconditioning can be difficult. The best approach is not only to make the hamstrings work on both joints, but also to make the hamstrings work at a variety of hip and knee angles.
A person with a hamstring strain may initially need to use a narrow stance when doing a squat to limit stress on the medial hamstrings. As the athlete's hamstrings recover and become better conditioned, he or she should progress to using a variety of squat stances, including a wide stance. This variation allows the athlete to work the hamstrings in a number of positions. Depending on the severity and location of the injury, any position may feel more or less comfortable than another. A wide stance will target the inner hamstrings. So, while it may be desirable to avoid stress on the inner thigh during the early stages of rehabilitation, it may be necessary to stress the inner thigh as the athlete progresses.
To determine what squat stance the athlete should use, start with no weight and have the athlete move through the full squat range. Do this in a variety of stance positions. If no pain is felt, add weight gradually until you determine which foot position feels comfortable and which foot position needs to be avoided. The lifter will likely notice that the different foot position alters his or her ability to lift heavy weight. This is okay. The goal is to work the hamstring. After the hamstring is completely rehabilitated the athlete can assume the most comfortable squat stance position.
Patellar tendinitis: Excessive jumping is often the cause of patellar tendinitis. A patient with patellar tendinitis often feels pain when the knee is loaded in a flexed position (such as squatting). This pain will typically result in a reduced range of motion. For example, a lifter who has reduced range of motion in the knees typically descends appropriately until he or she reaches the maximum comfortable knee flexion. At that point the athlete may exaggerate flexion in his or her back to allow the bar to move closer to the floor. Or, the athlete may rotate his or her body to put more weight on the uninjured knee. By doing so, the athlete runs the risk of creating new injuries in the back and knees.
A more appropriate adjustment is to widen the stance and/or change the external rotation of the foot. By externally rotating the foot, the patella now tracks slightly differently in the patella-femoral groove. A word of caution when making this adjustment: Good mechanical principles of the squat must always be followed, which means that the knees must always follow the alignment of the toes. If the knees do not follow the toe alignment, the lifter is putting undue rotational stress on the knee. The body is well equipped to handle stress that is parallel to ligaments and muscles, but it is much less able to handle rotational stress. Remember, using poor form during a lift can cause injury even if the athlete uses an amount of weight that was comfortably used prior to injury.
A second lifting adjustment for patellar tendinitis is to perform the squat slowly, especially in the descent. This will likely require the athlete to use a lighter weight than is typically lifted. By moving slowly, the lifter holds stress on the tendon for a longer period than in a normal squat. Being less dynamic than muscle, tendon needs to have stress applied over a longer period to adapt and strengthen. The tendon also needs more rest, so do not forget to allow extra rest time between workouts.
Ankle sprain: A person who has sprained his or her ankle often loses dorsiflexion. This loss is greater when the sprain is to the deltoid ligament on the medial side of the ankle or to the anterior inferior tibiofibular ligament at the syndesmosis.
While medial and high-ankle sprains are not as common as lateral-ankle sprains, their effect on the ability to squat is great. They limit dorsiflexion to a much greater extent and for a longer period than the typical lateral-ankle sprain. Therefore, the appropriate adjustment is one that lessens dorsiflexion at the ankle during a squat. By widening the squat stance, a person naturally limits the amount of dorsiflexion needed to perform the squat. This adjustment allows good squat form without compromising the injury.
The opposite technique (narrower stance) is then employed when a person wants to work on increasing dorsiflexion. By narrowing the squat stance, the ankle goes through greater dorsiflexion. During early rehabilitation, the wide stance should be used to ensure that the ankle is protected. During late rehabilitation, the narrow stance should be used to ensure that the ankle is worked throughout the full range of dorsiflexion.