Stride Strong Physical Therapy client, Lisa, performs a half deadlift — or a Warrior III pose in yoga — on top of a BOSU ball. Sydney, her physical therapist, is working on helping Lisa attain lumbo-pelvic control, gluteal activation, and balance training all in one exercise.
By Alice Holland, PT, DPT
Athletic injuries commonly occur in patients because of lack of proper conditioning for a sport. People from all spans of demographics and all ages are trending toward more sedentary lifestyles. With the ever-growing amount of automation in the workplace, for example, the average American now spends more time in front of a screen and keyboard than actually moving their limbs and trunk to do their jobs. Vocational activities are also trending in that direction as well—with the growing popularity of computer games and social networking over a device.
Regardless of these growing trends, sports-playing and athleticism is still highly revered in the American culture. Pressure to perform is still very high. One reason for the pressure is that university scholarships are awarded to the best athletes, and the possibility of receiving one of those coveted scholarships may create a strong incentive for parents to enroll their children into sports camps; sometimes from ages as early as 3 years. When children mature and grow into their early adulthood, that pressure does not subside but rather takes another form—the drive to perform physically at one’s best gives way to the desire to look and “feel” one’s best.
In order to effectively treat and prevent athletic injuries, clinicians must not only take a closer look at what is happening physiologically to the body at different age spans, but also consider the psychosocial aspects of what is happening during those ages.
Youth (ages 5-13 years)
The bony structure of children varies significantly from that of an adult. Because this age period is a time of immense growth of a child’s long bones to form into the adult stature, the physiologic nature inside the musculoskeletal system is geared to bias growth. Health of the epiphysis and physis of bones dictate how a child grows and regenerate from injury—in fact, 15% of all fractures among children involve the growth plate. The hypertrophic zone of the growth plate is a vulnerable but vital area where chondrocytes absorb nutrition for calcification. Disruption to these areas from slipping epiphyseal plates and athletic injuries—and the care and protection the child receives during rehabilitation—will determine whether the bone deforms permanently as it grows.
Bone is also more porous than an adult’s and exhibits more plasticity and elasticity. Because of this, fractures among this age group commonly occur as greenstick fractures. If the child is given excessive loading from an exercise, tendons may also be put on excessive strain such that tendon growth cannot keep up with load demand and the child develops Oschgood Schlatter’s disease or tendonitis.
Congenital malformations also have to be taken into account with this age group as these conditions are more likely to show up during this phase: Hip Dysplasia, Legg Calves Perthes Disease, and Scoliosis. Though they are considered congenital or formative, they pose a challenge to the caregiver and developing child because sports and activity may pose a higher risk to this subgroup.
It is for this reason that intense weight lifting should not be pushed onto this population. Rather, less regimented play should be encouraged that include body-weight resistive activities like running, jumping, skipping, throwing, and climbing. Such activities promote a symmetrical, multi-joint pattern of muscle activation and neurological development needed for the growing child. Light resistance with proper technique coaching will allow the child to develop kinesthetic awareness without putting undue stress on tendons and joints.
Nutrition and rest also play an important role as growth plates need both nutrients and time to grow and acclimate to physical demand. Maintenance of a fun atmosphere, rather an environment of overachieving, encourages a balanced and healthier approach to sports as it facilitates equalization of recovery and exertion.
High School and Collegiate (ages 14-22)
High school students and college athletes begin to experience a higher level of academic pressure and workload during this age. The negative effects of sedentary habits stemming from more deskwork compound on their bodies, despite the pressure to perform in sports. Conditioning and drills for sports falls by the wayside often because of the lack of time in the week to attend to all things important. Yet athletic pressure continues to increase as scholarships and monetary rewards play a larger and more competitive role in the student athlete.
Brian Blevins, DPT, works on strength and conditioning with a client at Stride Strong Physical Therapy. Among the practice’s services directed at athletes are return to sport screenings. The specialized screenings use functional movement to measure deficits, and provide targeted activities that will help the client improve.
The result of this increased time in the sedentary state compounded with an increased athletic demand is an overtrained athlete in sports play with an underconditioned body. Strength training is absolutely necessary for performance and injury prevention because biomechanical demands are higher in the upper echelon of athletic performers. Coaches push for faster speeds, shorter times, longer lengths, and more spins to reach regional, state, and national championships. Much to most athletic coaches’ disappointment, all of these skills are not always innate in the student athlete. Repetition, practice, and attention to form is necessary; drills have to be deconstructed down to focus on proper muscle activation.
To prevent injury and re-injury in this age group, coaches, physical therapists, and sports psychologists need to work closely to develop a balance so that the student does not skew over to unhealthy training habits. In particular, coaches need to work in unison with physical therapists to collaborate on specific training drills for the athletes to practice, and physical therapists need to understand the benchmarks that coaches are trying to attain.
The typical injuries this age group faces is a higher-level and higher-demand form of what adults experience: joint damage, joint laxity and pain, tendonitis, and muscle strain. Luckily for them, however, healing times are lower and physical rehabilitation is more effective because of the regenerative effects of youth.
Working Ages (ages 23-55)
This age group has an exponential increase in sedentary time compared to the high school and collegiate ages. Subjected to 8+ hour workdays in front of computers and devices, a gradual decline in this age group’s health and posture is observed. Even more traditional labor-intensive workers have seen a rise in automation at the workplace and they, too, fall victim to trending sedentary lifestyles. This is accompanied by a trend toward expanding waistlines, stress eating, and substance abuse.
For those who want to break away from the unhealthy causes of these trends, folks relegate themselves to exercising and sports-playing on the weekends when they have more time. Termed “weekend warriors,” our drastically unconditioned brethren fight hard to attain the athletic physiques and performance they had when they were younger, injuring themselves in the process. Without conditioning, drills, and proper progression of activity, physical therapists see a large variation of injuries in this population. Mostly cartilaginous tears, muscle strain, tendonitis, and tendon tears fill clinicians’ daily schedules.
The answer for this age group is for folks to find and make time for strength and conditioning training. Perhaps enlist the help of a personal trainer or physical therapist in helping them in designing a progression to address their strength and stability deficits. A physical therapist can also help the working generation avoid poor postural habits at the workplace that may make their injuries worse. Proper dynamic warm-up before a sport has also shown evidence in reducing sport-related injuries.1
55 Years and Older
The main concerns for the older generation generally have to do with poor healing potential after activities. Decades of wear and tear, compounded with decades of deteriorating posture, makes them vulnerable to large injuries that require surgical and pharmaceutical intervention. As tendons, muscles, and cartilage becomes more desiccated through aging, structure and tensile strength weakens. Senior athletes experience a higher chance of structural breakage with slower healing progression. As physical therapists, we see injuries stemming from arthritis, wear-and-tear of joints, osteoarthritis, and osteoporosis.
Most seniors who reach the age of 65 years have already experienced some form of surgery—this entails challenges when they perform sports and athletics. Joints never recover fully from invasive surgeries and though the surgeries reduce pain and suffering, structural integrity of tissues almost never fully recovers to its original stability.
Despite the challenges facing the senior population, though, it is shown that regular, gradated dosage of exercise—both resistive and cardiovascular—has multiple benefits for fitness, mental health, and joint health.2 Regular exercise causes aging muscle to maintain its integrity and its atrophy is slowed, if not reversed; cardiovascular health improves; and incidences of depression is reduced. Time for recuperation and nutrition must also be respected and be part of the exercise/rehabilitation regime.
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Treatment of Athletic Injuries
Below is an outline of the different phases of rehabilitation for a sports athlete of any level of age. Dosing may vary to their abilities and sport. However, the progression should follow the outlined skeleton. Inflammation control should be given due diligence concurrent with exercise prescription because inevitably joints, muscles, and tendons will be strained during the process. This can be done via icing and vaso-pneumatic compression if severe edema is present.
Resistance Training
It is important to perform a thorough Manual Muscle Test for the athlete. Involved limb strengths are necessary as is sports-specific muscle groups, along with core muscle testing. Since athletes operate at a higher force demand and capacity, even if a patient is measured at 5/5 it is still important to keep in mind that 5/5 strength still may not qualify the athlete as functional in their sport. A movement analysis is still necessary.
For resistance training, it is important to train the athlete in specific muscle group contractions—concentric, eccentric, and isometric loading with clean, specific exercises need to be the most basic building method to strengthen a muscle. A multiple number of training tools are available to assist open- and closed-chain resistance. TheraBands, available from TheraBand, Akron, Ohio, help with compliance of home exercises because they are portable, easy to use, and vary in intensity. Exercise tubing offers a more durable alternative to TheraBands and is available from several manufacturers in the physical therapy market. Stretchwell, Warminster, Pa, offers its Fit-Lastic Therapy Products with the ROY G. BIV system of progressive resistance are made from natural rubber latex and include tubing, straps, and therapy bands. Another source, OPTP, Minneapolis, has a variety of latex therapy products available, including Franklin Bands, that offer various resistance levels, in addition to Sanctband resistive bands and tubing.
Power Training
Resistance training is a basic building phase for muscle growth and strength, but power training allows the athlete to train into acceleration and deceleration of limbs, similar to their movement when they are playing their sport. Simple concentric exercises can be advanced to include a speed and distance component in repetitions. Exercises can also be advanced to mimic the sport activity (jumping up to spike a volleyball, for instance), and the athlete can be challenged to do this against tubing or weight resistance, or bungee cord resistance for higher levels of power training. Examples of equipment include: the Vertimax trainer from Tampa, Fla-based Vertimax, the Shuttle jumping machine from Shuttle Systems, Bellingham, Wash, and bungee-cord waist attachables.
Cardiovascular Training
Cardiovascular endurance is lost when the athlete is paused from their sport for physical rehabilitation. Cardiovascular equipment can be used to build strength and endurance in the interim, including treadmills, ellipticals, bikes, and lateral trainers such as the Helix lateral trainer from Boston-headquartered Helix. The company offers the HLT3500 Touch upright lateral trainer and the HR3500 Touch recumbent trainer; both of which can be used to build strength and endurance. Another manufacturer, the Jonesboro, Ark-based company Spirit Medical, offers the MS300 and MS350 semi-recumbent total-body steppers. Both are made to be useful in building cardiovascular endurance, and are engineered to provide a quadrilateral exercise pattern to distribute effort among all limbs. Both the MS300 and MS350 are designed for use even by very deconditioned individuals.
Cross-training is also important to maintain endurance and strength, even while the affected injured limb is put to rest. For instance, if a soccer player is out for menisectomy rehabilitation, the athlete could be encouraged to bike or swim to maintain cardiovascular endurance.
Movement Analysis
In the later stages of rehabilitation, as the athlete becomes stronger and is able to perform their sport activity, the physical therapist must watch the patient perform their sport movement. Deficits in timing, body mechanics, and angles must be watched closely to ascertain whether the athlete is at risk for reinjuring themselves. This may lead to more progression of their strength training drills. Movement analysis would also help in facilitating a relationship with the athlete’s coach for better integration into performance benchmarks. Some physical therapists use video recording and playback software to help with quick movement analysis. At Stride Strong Physical Therapy, Kinovea software along with video cameras equipped with Firewire are used to record and view runners’ strides. Other popular software include Dartfish and Contemplas.
Functional Movement Screens
Before returning an athlete to his or her sport, a physical therapist must also determine whether the athlete is rehabilitated fully enough to not risk reinjury. Functional scoring tools are most useful in mathematically analyzing this risk, and common tests include the Y-balance test to measure differences of range and strength from limb to limb. Functional Movement Screen systems also allow for specific measurements of functional activities and allow for comparison with standard measurements to determine if deficits still need to be ironed out in rehab. PTP
Alice Holland, PT, DPT, is a physical therapist and director of Stride Strong Physical Therapy of Portland, Oregon. The practice treats a large number of athletes and runners for sports rehabilitation. For more information, contact [email protected].
References
1. LaBella CR, Huxford MR, Grissom J, Kim KY, Peng J, Christoffel KK. Effect of neuromuscular sarm-up on injuries in female soccer and basketball athletes in urban public schools. Arch Pediatr Adolesc Med. 2011;165(11):1033-40.
2. Bouaziz W, Vogel T, Schmitt E, Kaltenbach G, Geny B, Lang PO. Health benefits of aerobic training programs in adults aged 70 and over: a systematic review. Arch Gerontol Geriatr. 2017;69:110-127.
