From Back to Front

At Ohio State University, athletic trainers are attempting to prevent injuries before they start through a carefully designed prehab program.

By Doug Calland

Doug Calland, MS, ATC, is the Head Athletic Trainer for Football at The Ohio State University.

Training & Conditioning, 14.4, May/June 2004,

An athletic trainer’s job is focused on two things: preventing injuries and treating injuries. But too often, we think about these things in isolation.

Recently, at The Ohio State University, we tried to adapt some of our injury treatment work to injury prevention. After seeing a rash of shoulder injuries and back problems among football players over the past few seasons, we chose to implement a prehab approach. This entails having healthy players perform rehab exercises targeting key areas with the hopes of reducing injuries.

Every athletic trainer has lists of exercises used to help players recover from surgery and injury. At Ohio State, we figured that by employing these exercises on uninjured players, we could help avoid some of the injuries that were just waiting to happen.

With much cooperation and support from our strength and conditioning coaches and head football coach, we implemented our prehab plan during the 2003 preseason football camp. Although it is still too soon to evaluate the overall effectiveness of the program, we are planning to continue it for the 2004 season in the belief that it will reduce the incidence and severity of injuries.

The Theory
Most players and coaches understand the idea that strength and conditioning not only helps performance, but also reduces the risk of injury. A stronger player is less likely to get hurt than a weaker one, so it’s common practice for players to perform strengthening exercises that target specific areas, such as the neck and trunk musculature.

This is especially important in areas where there may be an underlying weakness. In some cases, this may result from a pre-existing condition or previous injury. In other cases, a weakness may develop from imbalances created when strengthening one area more than another.

For example, some of our players were developing large extrinsic musculature in their shoulders (pecs, lats, and delts) and not maintaining the intrinsic muscle strength in the rotator cuff that helps to stabilize the joint. Thus, they developed an imbalance between the extrinsic and intrinsic muscles, leaving themselves more vulnerable to injury.

The problem with strengthening the intrinsic rotator cuff muscles is that many players view the exercises as dull and boring. The rotator cuff is best strengthened by performing high repetitions of internal and external rotation movements with very light weights. Many football players think that working out with two-pound dumbbells is a waste of time, but the reality is that more weight is not always better. As soon as someone grabs a weight that is too heavy, which may be as light as five pounds, they’re no longer exercising the intrinsic muscles in the rotator cuff. Players who undergo reconstructive shoulder surgery quickly learn this concept as part of their rehabilitation.

Instead of limiting these intrinsic-muscle exercises to rehab programs, we work them into the players’ standard strength and conditioning program. Ideally, these additional exercises will prevent the imbalance, and thus reduce the chance of injury.

As athletic trainers, it’s fairly obvious to us when players are sustaining an increasing number of injuries to a specific region. When this occurs, we evaluate potential mechanisms and causes to explain the increase. Sometimes this is through collegial discussions with other athletic trainers to determine if they are experiencing the same increases that we are. It can also be helpful to look to other sports medical professionals, some of whom may be involved in other sports.

As we assessed our players’ injury histories to identify other at-risk areas, we quickly zeroed in on the lower back, which is prone to the same muscle-imbalance issues as the shoulder. Anyone who has ever dealt with a back spasm can tell you it’s the deep postural muscles that are affected. These small, deep muscles, once locked in spasm, can immobilize even the toughest athlete. So we developed a second program that emphasizes the development of the small intrinsic muscles in the back and addresses some common flexibility issues as well.

Coaches On Board
As with most injury prevention efforts, developing a prehab program goes well beyond the athletic training room. A prehab program only works when it has the full support of both the head coach and the strength and conditioning coaches. Without their full support, it is highly unlikely that the players will put their complete effort into the program.

Most coaches will respond well, however, if you can show them a need for this type of program by explaining how it will address problem areas that may be keeping players sidelined. Getting input from the coach regarding his or her areas of concern is an additional way to gain the acceptance of the program.

Fortunately, our head football coach, Jim Tressel, was instantly sold on the idea of prehab. He even suggested two additional areas that he wanted to see us address in the prehab program: hamstring musculature and the ankle-joint complex.

The strength and conditioning coach’s support is just as crucial as the head coach’s support. After all, the strength and conditioning coach will be the one devising workout plans and working with the players in the weightroom. The prehab program is designed to supplement the performance improvement program, not replace it, so the strength and conditioning coach will need to decide how to best fit the prehab exercises into his or her standard workout schedule.

Allan Johnson, our strength and conditioning coach for football, has been very supportive of the prehab program from the moment we first mentioned it to him. He had even added rotator cuff band work to the players’ programs well before the 2003 season.

Making It All Work
When we introduced our prehab program to the players during the 2003 preseason summer camp, we divided everyone into two groups, freshmen and returning players. We then split each of those groups into smaller units of six to eight players, usually by position.

The sessions with the new players were generally more straightforward, since these athletes faced a wide range of new learning experiences of which the prehab program was one component. The returning players took a little more convincing, since this program varied from what they were used to. In addition, the benefits were harder for them to see and quantify than those of their other strength work. However, once the returning players felt the effects of the prehab exercises, they realized the importance of continuing the program and its potential to decrease their injury risk.

The program consisted of four 15-minute sessions, one on each of the four identified areas: the shoulders, back, hamstrings, and ankles. The sessions were run concurrently by either an athletic trainer or strength and conditioning coach so that all four "schools" were completed within a total of one hour. The school instructor worked with the players on how to do the prescribed exercises and explained why we were having them do these exercises. It was important to keep the groups relatively small because we wanted to be able to provide each player with individual attention in order to make sure he could perform the exercises correctly and understand exactly what we wanted to accomplish.

We repeated these sessions two more times during camp to make sure that players were performing the exercises correctly. We were helped by new NCAA preseason practice rules that prohibit teams from holding two-a-day sessions on consecutive days, thus providing some ready-made time for the additional prehab sessions. While the defense worked with their coaches, we would have the offensive players come in for prehab sessions. Then we would bring the defense in for prehab sessions while the offense went into meetings. With a year’s experience under our belts, we’re hoping we can go a little more in depth on certain exercises for the returning players this season while retaining the same basic structure as last year for incoming players.

Once the players were instructed in the details of the prehab program, it became the strength and conditioning coach’s responsibility to work it into the day-to-day workouts. This was facilitated by selecting exercises that could easily fit into what the players were already doing or by emphasizing certain aspects of those exercises. This also reduced the possibility of overloading the athletes with increased volume and potentially exacerbating chronic injuries.

For example, much of our prehab shoulder work requires multiple reps with low weights. These can be completed during the players’ leg days in between their other exercises. Working the intrinsic muscles of the back required few additional exercises, but rather players made sure these muscles were worked during the lifts they were already performing.

Players who had a history of injury in any of the four areas skipped the respective school and continued with the rehabilitation program that was previously designed. These athletes did participate in the other schools.

School Work
Shoulder school: The main concern in developing the shoulder school was keeping a good balance between the intrinsic and extrinsic muscles. We address this with several rotator cuff exercises with light resistance and multiple repetitions. (Table One below describes the shoulder school.)

The scapular muscles also require attention to keep the shoulder in balance. These muscles provide symmetry to the shoulder and take stress off the anterior shoulder. Many athletes work the anterior shoulder and chest, but neglect these important stabilizing muscles.

Shoulder flexibility is a very important part of our prehab program, and demonstrating proper stretching of the shoulder areas is a key component of the shoulder school. We also stress to the players the importance of squeezing the back of their shoulders together when doing other exercises, such as lat pull-downs. The combination of rotator cuff strength, and scapular stabilization and flexibility should help reduce injuries to the shoulder area.

Back school: Core work is nothing new for most athletes, but the back school is designed to help players develop the smaller muscles that may lock into spasm. For the back, we talked to the players extensively about working the intrinsic muscles during their existing strength work by clinching their glutes and focusing on keeping the belly button close to the spine. To help them understand this concept, we explained that it’s similar to using the muscles used to start and stop urine flow.

Another emphasis here is on the proper alignment of hips and shoulders. Once the athletes understand and focus on the neutral spine position, almost any exercise can help build the small muscles in the back. We also use abdominal work and pelvic floor exercises along with exercise ball work to improve stability as well as adding flexibility components. (Table Two below describes the back school.)

Hamstring school: Hamstring injuries are very frustrating because they are very unforgiving. Once an athlete seems to have recovered from this type of strain, it is not uncommon to either reinjure the same leg or stress the opposite side. The main way to prevent this is by increasing both the strength and flexibility of the hamstrings in relation to the quadriceps.

To build strength, we vary hamstring workouts to include fast reps with lower weight in both seated and standing positions. To make the most efficient use of the players’ time, we stress flexibility on the days following heavy conditioning days or lower leg days. Proper warmup, cooldown, and rest are also stressed both in and out of the playing season.

Instituting a solid running program during off-season training specifically for short and long sprint work and change of direction also helps to reduce hamstring injuries. We emphasize a proper daily warmup, which includes flexibility, football-related movements, and motion patterns. Workouts are scheduled four times per week and broken into two segments. Mondays and Thursdays are used for agility and position-specific drills. These include multiple-change-of-direction drills with bags, cones, and similar devices. Tuesdays and Fridays are focused on forward and lateral speed, speed mechanics, and plyometrics. The most important consideration is the ability to transfer skills from the conditioning program to the football field. (Table Three below describes the hamstring school.)

Ankle school: Of the four schools, the ankle school requires the greatest amount of dedicated work because it relies heavily on balance and proprioception. We use sport-specific balance exercises, such as playing catch with a football while standing on one leg, as well as drills that require athletes to adjust to frequent changes in surface. We like to use cup drills, where athletes pick up and place down cups while standing on one leg, and eyes-closed drills on foam rubber boxes, where athletes perform simple movements while standing on a slightly unstable surface. Because athletes are most susceptible to ankle sprains when they’re fatigued, much of our ankle work is done at the end of the workout so the players can get a good sense of how their muscles and joints will work when they’re tired. (Table Four below describes the ankle school.)

Of course, none of these efforts will prevent all injuries. We know our players will continue to get hurt and that the main use for most rehabilitation exercises will be to help athletes return to play. But we believe an hour of prevention is better than months of cure.

Table One: Shoulder School
Focus: scapular control and upper-back development, good form, and intrinsic shoulder muscle groups.

Main points
• Stress symmetry between opposite muscle groups and planes.
• Use rotator cuff strength and function exercises, emphasizing light resistance.
• Include shoulder and upper-back flexibility component.
• Teach players awareness of joint position during exercises.
• Emphasize squeezing the scapular muscles during any big muscle group work and controlling the weight during dumbbell exercises.

• Corner stretch forward and backward.
• Internal/external rotation at 0 and 90 degrees (3 x 15 each side with light resistance).
• Partner-assisted rhythmic stabilization (5 x 20 seconds each side).
• Full can (3 x 15).
• Prone reverse flys with light weight (3 x 15).

Table Two: Back School
Focus: good form, targeting intrinsic muscle groups in the back.

Main points:
• Increase flexibility to maintain lumbar curve and proper SI joint and hip mobility.
• Stabilize spine using deep intrinsic muscles.
• Promote the relationship between hip flexors, hamstrings, and deep, lower abdominal strength for good back health.
• Strengthen muscles with ball stability exercises, core strength development, and neutral spine positions.
• Stress good posture and core control with all lifts by keeping the belly button toward the spine and squeezing the buttocks.
• Emphasize keeping the butt out during squats.

• Single, straight leg v-sit (with adduction).
• Ball stability exercises (bounce, opposite arm & leg, bridge, superman).
• Start/stop urine flow for recruitment of multifidii and transverse abdominus.
• Exercise ball squeeze and raise.

Table Three: Hamstring School
Focus: flexibility, functional strength, and maintenance of proper quad/ham ratio.

Main points
• Increase general flexibility, including hip flexors, hamstrings, quad, and groin.
• Stress proper in-season maintenance (warmup, cooldown, rest, and recovery).
• Stress flexibility after lower leg days, heavy conditioning days, and to combat fatigue.

• Dumbbell straight legs.
• Seated hamstring machine.
• Standing cuff weight bands with speed component (minimal during preseason camp).
• Partner stretches (including 90/90 stretch).

Table Four: Ankle School
Focus: strength, proprioception, and balance.

Main points
• Use sport-specific balance exercises.
• Employ isolated ankle strengthening.
• Stress proper stretching techniques.
• Make players adjust to new surfaces and frequent surface changes.
• Schedule ankle exercises for end of sessions when players are fatigued.

• Way-band exercises.
• One-legged ball catch.
• Cup drills.
• Eyes-closed exercises.
• Heel cord and peroneal stretches.
• Dot drills.
• Heel walking/toe walking .