How to reduce the risk of football injuries with specific strength and conditioning

As many people already know, and may have experienced, there’s always going to be a risk of getting injured when you play sport. The most common injuries in the most popular sport in the world are all in the lower limb - anterior cruciate ligament (ACL) injury, ankle sprain, hamstring strain and groin strain. 

Have you got knee pain or ankle pain and need help with treatment and a specific rehabilitation plan? Click here to book your session now (online appointments also available). 

We are all aware that a structured progressive warm up that includes specific strengthening, DYNAMIC stretching (because static stretching before exercise has been shown to decrease muscular performance), changing directions and plyometrics reduces the risk of injuries. See here for examples of some specific warm up routines. Acquiring enough recovery and sleep, eating the right foods and concentrating on nutrition can improve performance. Also wearing the right protective gear and doing a proper cool down will all help towards reducing the risk of injuries. 

But why these specific injuries? Good question. It all comes down to this:

Can the body manage the load and forces of the specific movement patterns associated with football?

Has the body acquired the ability to move effectively as an integrated system by acquiring good neuromuscular control?

It is well known that strength training reduces the risk of injuries. A randomized study from The Journal of Strength and Conditioning Research by Zouita et al (2016) examined the effect of strength training on physical fitness and injury occurrence in 52 young elite soccer players. They were divided into two groups: experimental and control group (no strength training). The experimental group took part in 2-3 90-minute strength training sessions over 12 weeks (separated by 1-week recovery). The physical fitness parameters were sprint tests and jumping tests. The injury rates were recorded throughout the season. The experimental group performed significantly better in sprint running and there were also improvements in jumping tests compared to the control group. 17 injuries were recorded over the season, 13 from the control group and 4 from the experimental group. This shows that strength training not only reduced the risk of injuries, but induced performance improvement.

Strength and conditioning (S & C) that is sport specific is great for reducing the risk of injuries and improving football performance no matter what the age of the individual. S & C focuses on movement quality to improve performance. It’s about developing better movement patterns to reduce the risk of injury and therefore improving performance e.g. strikers being able to shoot with more power or accuracy, a midfielder with better passing accuracy, a goalkeeper with better reflexes in order to save a shot.

In this article there are plenty of studies (here if you want to see them) to show that a specific type of strength training provides a greater effect for reducing the risk of injuries, it’s called eccentric training. An eccentric muscle action is an overall lengthening of a muscle as it develops tension and contracts to control motion performed by an outside force. An example is the lowering phase of a deadlift or a calf/ heel raise (shown below). 

There are some studies from the aforementioned article on how football players with functional asymmetries between the quads and hamstrings can also possess a higher risk of injuries too. It isn’t just the hamstrings getting injured due to lack of eccentric strength and nordics can be useful in a S & C programme, the quads also are susceptible to injury if there is insufficient flexibility in the muscle group. Here are some exercises to help rectify this:

S & C is not only about weight training. To get the best out of S & C, a good coach will use most methods. For example speed and agility, plyometrics, core stability, mobility, balance and proprioception, and endurance. Here are some other benefits of getting a S & C coach. Check out an example of some plyometric hops: 

One method of training that often gets forgotten is proprioception. Proprioception is the awareness and position in the body. This can be worked on with specific exercises and balance work which greatly helps people become in tune with their bodies and reduce the risk of injuries. Here is an example of this type of training:

Álvaro Cristian Huerta Ojeda, et al (2019) concluded that it was not just a proprioceptive training programme that reduced the risk of injuries in football players but other programmes such as strength training, neuromuscular training, balance training and postural control training. Therefore the coach needs to ensure they are including very specific movements for the player to get them prepared for events such as hopping over a player to prevent from being tackled, changing direction quickly to confuse the opposition and having the ability to land efficiently from heading the ball but being shrugged by an opponent. The more specific the training, the more it will improve the player’s movement patterns to reduce the risk of injury because the player will have remembered that specific movement pattern and understand how to function and move better. 

Neuromuscular training is used to improve the nervous system's ability to generate a fast and optimal muscle firing pattern, to increase dynamic joint stability, to decrease joint forces and to relearn movement patterns and skills. The goal is to achieve a state of "readiness" of muscles to respond to joint forces resulting in enhanced motor control. It focuses on performing exercises that train the muscles and nerves to react and communicate better with each other so that the body can perform movement patterns and skills with biomechanical efficiency. It must include specific exercises to target the muscular and neural components of movement. Knowing how to land well from jumping with help reduce the risk of an ACL injury. It should include balance, agility, plyometrics, perturbation training and football specific movement patterns and should be implemented into football training sessions. Here The Total Player have demonstrated some multi-planar movements:

A paper from the Journal of Orthopaedic & Sports Physical Therapy gives a few exercise examples: the Star Exercise and Balance Reach Arm and Leg. We have teamed up with The Total Player who has kindly demonstrated these exercises below. 

Fitzgerald et al (2000) studied 26 patients with ACL rupture. The patients were randomly assigned to a standard rehabilitation programme with or without perturbation training exercises. Adding the perturbation exercises in reduced the risk of continued episodes of the knee giving way during sporting activities and maintained knee function at the 6 month follow up compared to the group who didn't perform the perturbation exercises. Here are some examples of Perturbation training:

Another question often asked after an injury, especially ACL injury is whether or not surgery is needed to be able to play sport again. Well a study done by Ihara and Kawano in 2017 found that around 80% of 102 individuals with an ACL rupture healed without surgery and just did rehabilitation only. 

To summarise:

• Dynamic stretching in a warm up is better for reducing the risk of injuries. Static stretching before exercise has been shown to decrease muscular performance.
• Acquiring enough sleep, recovery and adequate nutrition can all contribute to improved performance and thus decrease risk of injuries.
• Strength training, specifically eccentric strength training has been shown to reduce the risk of injuries. 
• Football players with functional asymmetries in the quads and hamstrings possess a greater risk of injuries - a lack of eccentric strength in the hamstrings and insufficient flexibility in the quads.
• An S & C coach will use all methods in their training programme - strength, agility, speed, plyometrics, balance & proprioception, neuromuscular training, core stability, endurance and flexibility. 
• Neuromuscular training is used to improve the nervous system's ability to generate a fast and optimal muscle firing pattern, to increase dynamic joint stability, to decrease joint forces and to relearn movement patterns and skills.
• Training the athlete in restoring or improve reaction times is referred to as perturbation training. Balance is a conscious effort to hold a position without falling.
• Surgery is not always needed to return to sport following a complete rupture of the ACL. 80% of 102 individuals healed with rehabilitation alone.

 References

https://www.footballscience.net/special-topics/injury-prevention/

https://www.footballscience.net/training/

Fitzgerald GK, Axe MJ, Snyder-Mackler L. (2000). The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physical active individuals. Journal of Physical Therapy in Sport. 80 (2):128-140

Ihara, H & Kawano T. (2017). Influence of Age on Healing Capacity of Acute Tears of the Anterior Cruciate Ligament Based on Magnetic Resonance Imaging Assessment. Journal of Computer Assisted Tomography. 41 (2), 206.

Kirkendale DT, Junge A, Dvorak J. (2010). Prevention of Football Injuries. Asian Journal of Sports Medicine. 1 (2): 81-92.

Zouita S, Amira Zouita B-M, Kebsi W, Dupont G, Ben Abderrarhman A, Ben Salah FZ, Zouhal H. (2016). Strength training reduces injury rate in elite young soccer players during one season. The Journal of Strength and Conditioning Research. 00 (0):13.

How to deal with an acute injury

It's all about the M.E.T.H!

RICE (Rest, Ice, Compression and Elevation) is a term that is used to supposedly help with treating sports injuries. Ice has been used for many years and helps to relieve pain from the injured area. But the evidence from Bleakley et al, 2004, found it to have an insignificant effect on soft tissue injuries. Athletes that used ice for longer than 20 minutes then returned to sport afterwards actually would be at a disadvantage due to a decrease in performance (Bleakley et al, 2012). Ice stops the inflammatory process and we need this process to happen to improve the healing of soft tissues. Ice and rest may delay healing time so therefore, we need to do the opposite, movement and heat!

Ice is no good for acute injuries like this ankle sprain!

What is the METH-od then?

MOVEMENT – controlled movement of the injured limb can increase blood flow, improve recovery and decrease the number of misaligned bits of collagen fibres (scar tissue) that is formed during the healing process.

ELEVATION – Bring the injured part higher than the heart to assist the movement and allow gravity to help remove the swelling. This will reduce the pressure of the swollen tissue and reduce pain.

TRACTION – This helps to move the fluid and help take the pressure off the injured part. Depending on where the injured part is, a therapist may have to do this part for you. It can help reduce pain when dealing with muscle spasms and compressed joints.

HEAT – Inflammation is the body’s natural response to injury so by applying heat, this will allow to speed up this process. A study was done on the effects of cold vs heat on people with acute low back pain, they found significant evidence that heat wrap therapy and heated blankets decreased pain immediately after application (French et al, 2006). A smaller study demonstrated the same results where pain from DOMS had decreased and function had improved after wearing heat wraps compared to cold wraps (Mayer et al, 2006). 

A long hot bath can alleviate acute symptoms and can aid in healing soft tissue injuries.

Watch this video of Dr Kelly Starrett talking about RICE vs METH

When you damage your tissues either by an injury or through DOMS (delayed-onset-muscle-soreness), you are healed by inflammation and other processes. Your body sends inflammatory cells to the recently damaged tissue to help heal them. These cells are called macrophages and release a hormone called Insulin- like growth factor into the damaged tissues. Applying ice to reduce swelling delays the macrophages from releasing the hormone to help with healing.

Inflammation needs to happen as this is how the body protects itself following an acute soft tissue injury. It does this by removing the damaged tissue and then the healing process can begin. The inflammatory process improves blood and lymphatic flow to and from the injured tissues. This is what helps bring healing nutrients and the chemical mediators to help clear out the damage tissue. Some of these mediators will help limit the amount of swelling, which causes an increase in pain sensitivity. Once this fluid is filled up with waste products, it can then be drained via the lymphatic system. The lymphatic system relies on muscles to contract and relax properly to help flush the waste away.

5 signs of inflammation

1.      Swelling

2.      Redness

3.      Heat

4.      Tenderness

5.      Loss of function

So, RICE isn’t good?

Rest doesn’t inspire tissue repair. Inactivity causes muscle weakness and therefore less lymphatic drainage which will not help in the inflammatory phase of healing. It also causes abnormal scar tissue formation which can cause further issues in the other phases of healing. Cross-friction massage can help with this and can be done by a sports therapist.

There isn’t much scientific evidence that ice helps. Ice slows down the removal of waste products and inhibits the development of new cells. Compression isn’t bad but needs to be done at the right time. Compression can be done by using a voodoo floss band (as used by Dr Kelly Starrett). It has been shown to help remove the blood with the debris and bring fresh new blood with those healing properties to the injured tissue. You can floss any part of the body but will need a Sports Therapist to help with this treatment technique. Here is a video on flossing the knee: 

Watch this video on how to floss the knee and reduce knee pain! 

Take home points

• Inflammation is a GOOD thing. Without it, there’s no tissue repair.
• Too much rest causes muscles to waste away. The body needs to undergo a mechanical change by doing exercise.
• Icing before sports and activity has been shown to have negative effects on sports performance e.g. strength, speed, power and agility.
• Massage, elevation and compression are effective ways to reduce swelling.

References

Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sport Med. 2004; 32:251–261.

Bleakley CM1, Costello JT, Glasgow PD. Should athletes return to sport after applying ice? A systematic review of the effect of local cooling on functional performance. Sports Med. 2012 Jan 1;42(1):69-87.

French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. A Cochrane review of superficial heat or cold for low back pain. Spine (Phila Pa 1976). 2006 Apr 20;31(9):998-1006.

Mayer JM, Mooney V, Matheson LN, Erasala GN, Verna JL, Udermann BE, Leggett S. Continuous low level heat wrap therapy for the prevention and early phase treatment of delayed-onset muscle soreness of the low back: a randomized controlled trial. Arch Phys Med Rehabil. 2006 Oct;87(10):1310–7.

The pelvis and its role in functional movement

What is functional movement?

Functional movements are movements based on real life situational biomechanics. For example, squatting and lunging. Your body is an integrated system. This means your muscles do not work in isolation. They work together with other muscles to produce movement. For example, the biceps muscle flexes the elbow, but there will be other muscles acting as synergists (pecs and deltoid muscles) to help control the movement. Other structures in the joint such as ligaments also play a role in helping to create movement by providing stability through certain movement patterns. A dysfunction in these movement patterns can cause a decline in athletic performance and therefore injury and pain.

4 important sling systems of the pelvic region

1.      Anterior oblique system – external and internal obliques and opposing groins, along with the intervening abdominal fascia. This is involved in stabilisation of the lumbar spine, thoracic spine, rib cage, pubic symphysis, and hips. It also helps with whole body pushing movements and helps transfer forces between the upper and lower body (Lee, 1999).

2.      Posterior oblique system – the lats, thoracolumbar fascia and opposing glute maximus and medius. This involves stabilisation of the lumbar spine and sacro-iliac joints. It helps to turn out the kinetic chain, helps with whole body pulling movements and helps transfer forces between the upper and lower body. This system is most commonly seen in gait because of its fight to control rotation of the pelvis which occurs in the gait cycle (Lee, 1999).

3.      Lateral system – gluteus medius and minimus, groins and opposing QL (lower back muscle). This helps to provide lateral stability in the pelvis, for example, walking and climbing stairs etc. It deals with single leg movement patterns and whole body frontal plane (sideways) movement. It also helps transfer forces between the upper and lower body. A weakness in this system can lead to hip pain, knee pain, ACL injuries and ankle sprains (Lee, 1999).

4.      Deep longitudinal system – spinal erectors (lower back), thoracolumbar fascia via sacrotuberous ligament, biceps femoris (hamstring), head of fibula, peroneals and tibialis anterior (shin muscles). This system helps to create stability of the lumbosacral complex and the foot and arch complex. It helps to control supination and pronation of the foot from heel strike through to mid-stance of the gait cycle. During high intensity activity, it provides a communication for proprioceptive information about ground reaction forces (Lee, 1999).

As a population, the focus is more pointed towards “posterior chain” work because of tight hip flexors and quads. Sometimes, this isn’t the case with athletes and the development of exercise programs should be dealt with more profoundly. Understanding the mechanics of the body is an important part of creating better exercises for better pain free movement.

The components of fitness are extremely important for optimum health. Many people workout to become stronger for their sport, run quicker, lose weight, improve mobility, increase stamina and for the general feel-good factor. These are all great reasons to train, but there is so much more to training then this. We need to think about training our neuromuscular system! What about balance, co-ordination, agility, power and reaction time? These components are just as important as strength training or endurance training. If you do strength training in the gym or you do long runs and keep getting aches and pains, maybe you need to think about adding in some of these to help improve your overall health and fitness.

References:

Lee, Diane, “The Pelvic Girdle: An approach to the examination and treatment of the lumbo-pelvic-hip region”: Churchill Livingstone, 1999, Toronto, Canada

FASCIA and why it’s important to YOU!

DO YOU FEEL ACHY AND SORE BUT DON’T KNOW WHAT’S CAUSED IT? 

Fascia is a sheet of connective tissue made up of dense protein fibres. It weaves through the body like a spider’s web and interlinks with just about EVERYTHING! It helps support your bones, muscles, joints, tendons, nerves, ligaments AND organs! You have 6 times more sensory neurons in fascia than any other tissue of the body (except skin). This webbing helps all the body tissues to communicate with each other, for example, that feeling of needing to stretch in the morning or that feeling when you get out of your chair and need to move about. Ideally, your fascia should be supple, can glide, slide and twist easily like thin sheets of rubber. When something goes wrong, signals from the nerve endings are silent and confused and this is when your brain interprets it as pain or discomfort.

Think of fascia like a sponge, when it dries out it goes hard and inelastic. It can be easily broken with a bit of force, for example, twisting your back and bending at the same time to reach for something under the car seat. You haven’t done this movement in ages so all those stiff fascial tissues are more susceptible to pain and discomfort due to being like that hard sponge. We all need to strive for our fascia to be like the wet, hydrated sponge because it has more resilience and flexibility. You can squeeze it and twist it, but it will not break.

 There is a superficial layer that covers fat, nerves, blood vessels and other connective tissue, then there is deep fascia surrounding muscle, muscle sections and individual cells. When fascia becomes hard and thick, this is when trigger points can develop. Trigger points are extremely sore spots in muscles that send pain to other areas of the body. Trigger points are formed by sudden muscle overload, sustained low-level static contractions, eccentric contraction (when a muscle contracts and stretches at the same time), gross trauma, chronic muscle tension, overuse, or a sustained rapid movement. Examples of this can be holding your phone to your ear for too long, typing quickly on a computer keyboard, sitting at a desk with your head too far forwards, repetitive tasks or movements at work, slipping on ice, falling on your shoulder or hip, or simply increasing volume in a short amount of time working out in the gym.

If you are not quite there and not in need of trigger point therapy yet, here are some TOP TIPS on how to keep your fascia hydrated and well! But if you do want a trigger point therapy session then you can find us here.

 • Drink enough water. For every kg of body weight drink 30ml of water. So a 70kg individual will need 2.1 litres of water a day. If exercising, add 0.5-1.0 litres for every hour of exercise.

• Make sure you MOVE differently every day. Vary your gym routine every 6-8 weeks and try a mixture of physical activity e.g. walking, weight training and cardiovascular fitness. Change the intensity of training too.

• You can’t stretch fascia. Ever tried stretching your IT band? Nope, can’t be done! It takes a lot of force to create a stretch. But you can stretch the muscle that fascia can cling on to. Slowly stretch first thing in the mornings before you get up out of bed (check out this video on loosening your back). Stretching is important to help elongate the muscles, so make sure you do a good muscle stretching routine every day.

 • Go to a foam rolling/ mobility class. Foam rolling is a self- help tool where you can help de-sensitise the fascia and get rid of those low-level aches and pains.

Foam rolling and mobility class

• Let the therapist handle it. If you think you don’t have the time to do all these self-help tips to keep your fascia healthy. Let me take care of it for you. You can now book myofascial release sessions for the whole body and get everything treated!

To see what else we can help with - click here.

Knee Pain in Cyclists

Knee pain in cyclists

Everyone is likely to develop knee pain even if your bike has been assessed and setup correctly. This can be due to over-training, e.g. in Spring time when cyclists often increase their training volume in a short period of time because they have left it too late to get fit for their races.

The most common causes of knee pain in cyclists are:


* Incorrect saddle height or position.
* Broken pedal axel following a crash.
* Crank too long - especially if you have chondromalacia.
* Pushing excessively high gears (slow cadence in cold weather)
* Too much leg work in the gym – not enough stretching and mobility work!
* Cleat alignment – can affect the menisci, ITB or patella maltracking if tibial rotation occurs.
* Individual cyclist anatomy – everyone has different sized pelvic frames and this affects knee alignment so be sure to get a bike with a Q factor to suit your pelvis. This only really applies to people with wide hips or very slim people.

Types of knee pain

Patella tendonitis and patellofemoral syndrome can be caused by pushing yourself too in big gears, or having the saddle positioned too low or too forwards, or having the foot too far forward on the pedal. Therefore, when the crank is vertical, the quads become too dominant. Other ways of developing these injuries can be when the crank arms are too long, or there is a leg length discrepancy in the cyclist. So be sure to check these out if you start to develop anterior knee pain.

Pain can also develop at the back of the knee in which case can put tension on the hamstring and calf muscle. This pain can be brought on by the saddle being too high or too far back, or if there is too much pedal float, or again a leg length discrepancy. These can be resolved by correcting the set up of the bike to decrease the stress at the back of the knee. Excessive dorsiflexion of the ankle when the crank is near enough horizontal can lead to stretching of the calves and hamstring tendons behind the knee. Having an arch support or calf strengthening exercises will help overcome this.

The medial collateral ligament and surrounding tendons (pes anserine) can also become painful on the inside of the knee. Causes can be when the cleat position is too wide (toes point out), excessive sideways movement of the knee, or a fixed foot. The cleat can be moved inwards to help with medial knee pain.

ITB pain can also occur on the outer side of the knee and can be due to excessive sideways movements of the knee, having the cleat positioned too narrow so that the toes point in or having too little pedal float. By correcting foot alignment, this should stop any irritation of the ITB on the outer side of the knee. If you have had pain over a long period of time and it hasn’t healed with just rest and fixing the foot alignment on the bike, it could be a degenerative meniscus. This is because structures like this have less blood supply so therefore have a longer healing time.

Knee assessments can help find out why you are getting pain when cycling.

The best thing to do if you get knee pain is not to ignore it. It will most likely not go away by itself because something has aggravated it in the first place, which means something needs to change. Take time to rest the knee for a few days and take anti-inflammatory drugs (I prefer to take natural anti-inflammatories such as arnica oil or pills) in this time period. Do some hot and cold contrast bathing in this time to stimulate blood supply and speed up the healing process. Start back on the bike with trainers to determine if the cause of your pain is due to cleat setup. However, if the pain still occurs in trainers, it is most likely due to overuse. If it is due to overuse, the best thing to do is start off with smaller rides and gradually increase the time on the bike. Riding in smaller gears is also beneficial at this stage as there is less strain on the knees, if pain still persists, see a Sports Therapist for treatment.

Ensure you are doing at least a 30 minute warm up and doing specific dynamic stretches to the quads, TFL muscle (attached onto the ITB), hamstrings, calves, glutes and lower back.


There is so much research to show that we get knee pain because of weak glutes and a weak core. Are you incorporating glute and core strengthening into your cycling training? Activating your core and glutes will improve posture and help keep your body aligned so it stays pain free. 

If you would like any further advice on stretching or need to book in for treatment please contact Sports Corrective Therapy. They will take you through a thorough assessment and alleviate your pain and set you up on a rehabilitation to prevent your pain from coming back!