Strengthening Is Not The Same As Rehabilitation

There is a huge misconception floating in fitness centers all over the place- that injury is the result of weakness. "My back hurts; it must be weak." "I keep rolling my ankle. What can I do to make my ankles stronger?" 

Not every injury results from weakness. In fact, noted physiotherapist and strength coach Gray Cook and his team at Functional Movement Systems looked at the data before and since developing the FMS. The three leading causes for injury, they have found, are:

• Previous Injury
• Asymmetries 
• Motor control issues

CASE STUDIES

I met a young soccer player who had not played in a while, but was hoping to return to the game. He had stopped playing because of an ACL injury. He was not alone. I met two more athletes, promising, but also with fairly recent operations. One was a lacrosse player, the other had switched from baseball to slow pitch before hearing that dreaded "pop" sound. I talked to these guys individually, and even trained one of them for a couple of weeks. All three could be found on the leg press and leg extension machines when they came into. They all skipped the balance work they were given as homework by their physios. I tested them and was not surprised to find that they all scored poorly, even on the uninjured leg.

Rotation Movement That Causes ACL Injury

A regular gym-goer told me that his back and shoulder were hurting. "What do you think I should do?" He didn't seem like he would hang around long enough for me to get more information. I got his info, and since he had mentioned they only hurt when he did certain movements, I advised staying away from those movements and promised to send him a research paper that had some good information for back pain. I met the guy a week later.

"How's the pain," I asked. "Receded, I hope."

"It's not as painful now. I still have to do more strengthening work though," came the reply.

I mention this guy because its not just athletes who are in a hurry to get back to playing. Weekend warriors with gym memberships do this too. Think of the dads who 'come out of retirement' for their kid's Father-Son day game, or take part in a little sports day event.

The prevalent ignorance is not because people choose to be stupid. They just don't get it. They think they were weak to begin with, hence the injury. They think since they've had to sit out while recovering, their strength capacity is the only thing deconditioned.

A LITTLE SCIENCE

A medial knee position during the stance phase when running may affect the line of pull of the quadriceps and contribute to the etiology or exacerbation of overuse injuries such as patellofemoral pain.

Stefanyshyn et al., (2006) hypothesized that increased internal hip and knee abduction moment during running results in greater forces on the lateral facet of the patella. These faulty/altered biomechanics likely result in increased contributions from the vastus lateralis, extensions of the iliotibial band, or both. Greater force on the patella from these tissues may result in greater retropatellar stress and activation of nociceptive fibers in patellar subchondral bone or synovium. They concluded that increased knee abduction impulses should be deemed risk factors that play a role in the development of patellofemoral pain in runners.

THE EVIDENCE

One of the main culprits when athletes have altered mechanics is the hip. Studies have been conducted assessing the effectiveness of strengthening the joint in these situations. In one, females with patellofemoral pain (PFP) demonstrated significantly less peak hip adduction while running at the end of a 2‐week training program when they were given visual 3-D feedback of what the hip was actually doing while they ran. (Noehren B, Scholz J, Davis I., 2011). In another, a study including a 14‐week rehabilitation ‐program for PFP that also included visual feedback and hip strengthening exercises was also found to decrease pain and hip adduction angle during a single leg step down. (Mascal C, Landel R, Powers C., 2003). Finally, in a study by (Herman D, Oñate J, Padua D, et al., (2009) peak hip adduction and knee abduction angles during a drop jump activity decreased among subjects who received visual feedback for altering movement performance and strength training. Most importantly, subjects who received the strength training intervention alone did not experience these changes.


Decreases of 15% in internal hip abduction and a 23% knee abductor moments were reported by Earl et al following an 8‐week “proximal stability program” that included five weeks of training including attention to lower extremity alignment during exercises for patellofemoral pain.

Wouters, et al., (2012) found internal hip and knee abduction moments decreased by 23% and 29%, respectively. They also found that subjects demonstrated less knee abduction excursion and increased knee adduction excursion during the stance phase of running after the movement training program.

The relevance of these studies is that hip strengthening alone may not be an effective remedy for altered lower extremity running mechanics that may increase the risk of running related injury. Based on the available evidence, it seems programs should emphasize neuromuscular control ‐elements such as guided practice of movement performance and visual, verbal, and tactile feedback rather than hip strengthening alone.

Motor control, stability, mobility. These three things are very important. We can't see them when they're there but we are immediately drawn to them when they are absent. How often have we seen players walk off the field only to hear that they picked up a knock and were substituted at half time? I'm writing this because I'm hoping the thing that draws us to the absence of those three factors is injury. If it is, hopefully we won't skip over them in favor of speed work, some weights and plyometrics.

There ought to be a progressive approach to returning to play. Address mobility. Soccer players are notorious for skipping the warm up. Or they have one, but it is ridiculous. Why is it that the numbers reflecting non-contact ACL injuries continues to increase when FIFA has had a prevention program out for years?...

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Reference

Wouters, I., Almonroeder, T., DeJarlais, B., Laack, A., Willson, D. and Kernozek, TW. (2012). Effects of A Movement Training Program On Hip and Knee Joint Frontal Plane Running. Int J Sports Phys Ther. 7(6): 637–646.