Prehabilitation Exercises: helping to reduce risk of injury

The concept of ‘prehabilitation’ exercise training is now becoming well-known among trainers and therapists involved in sports performance preparation. Prehabilitation involves strength and conditioning exercises for specific muscles that help to reduce injury risks, before an injury actually occurs. It’s the classic ‘an ounce of prevention is better than a pound of cure’ approach to physical training. Prehabilitation is sport-specific and targets common injuries and strength imbalances that occur in the particular sport.

For example, a common injury suffered by tennis players (and famously Tim Henman last year) is shoulder tendinitis. This is often caused by the high forces involved in the overhead serving action on the shoulder and the fact that tennis players develop an imbalanced shoulder musculature. Specifically, the front shoulder muscles and internal rotators are too strong in comparison to the rear shoulder and external rotator muscles.

Armed with this information about the sport and knowing that shoulder injuries are common, the personal trainer or therapist working with a tennis player should recommend that exercises to develop rear shoulder and rotator cuff strength are included in the strength programme. This will avoid any potential strength imbalance and raise the player’s ability to withstand the forces of the serve – hence ‘pre-habilitating’ the injury.

The following is a brief summary of common injuries, the sports in which they often occur, and recommended prehabilitation exercises. From the head down.

Preventing Shoulder tendinitis

Sports: swimming, tennis, javelin, discus, shot put

As mentioned earlier, shoulder tendinitis is related to weak rotator cuff musculature and an imbalance of strength about the shoulder. The following are exercises that would be very useful for shoulder injury prehabilitation.

1. Shoulder rear diagonal pull with band
This exercise works the whole of the rear deltoid, rhomboids, teres minor and major and supraspinatus and infraspinatus (see illustrations below).

2. Row – single arm
This exercise works the rear deltoid, rhomboids, mid trapezius and latissimus dorsi muscles.

3. Shoulder rotation external with band
This exercises works the infraspinatus and teres minor muscles along with the rear shoulder muscles.

Preventing Tennis/golfer’s elbow

Sports: tennis, golf

Often this injury occurs because of poor technique, which places too much strain on the wrist musculature. This stress can be offset by strengthening the wrist muscles, particularly the wrist extensors.

Wrist extensions

Grasp a dumbbell in each hand. Sit on a stool and place each elbow on your thighs. Position your hand so each wrist can move freely. Start with your palms face down and let your wrists flex. Pull the back of your hand upwards, lifting the weight. Lower slowly and repeat.

The same exercise can be performed with resistance bands. The advantage of the band is that rotation can be added to the movement, making it more sport-specific.

Preventing Anterior knee pain

Sports: running, squash, tennis

Anterior knee pain often involves the patello-femoral joint and problems with the tracking of the patella. Another common over-use knee injury is patella tendinitis. The pain in both of these injuries is often at the front of the knee – hence the name anterior knee pain.

Strong quadriceps muscles are important for avoiding this injury, particularly the vastus medialis oblique (VMO) muscle. The VMO is located on the inside of the knee just above the joint. The VMO muscle’s fibres are aligned inwards and pull the patella medially, keeping it aligned and running smoothly over the femur. Any misalignment and the cartilage under-surface of the patella can be damaged. The following is a useful exercise for strengthening the quadriceps.

Leg press

This exercise is best performed from a starting knee angle of 90° and can be progressed to single legged to make it more demanding. I recommend starting two workouts of three sets of 10 repetitions for four weeks and then completing two workouts of three sets of six reps for a further four weeks, trying to push as heavy a weight as possible.

Preventing Non-contact ACL or MCL sprain

Sports: Football, Netball, Skiing

This serious knee injury (anterior/medial cruciate ligament sprain) often occurs when the knee is extended and rotated at the same time, which can happen during landing from a jump and during falls.

The risk of this injury can be reduced by having strong quadriceps and hamstring muscles. In fact, a good ratio of hamstring-to-quadriceps strength has specifically been shown to reduce knee ligament injury risks since the hamstring supports the ACL’s pull on the tibia.

1. The squat
Closed-chain exercises such as the squat are excellent functional exercises for the quadriceps. Perform sets and reps as described above for the leg press for maximum strength improvements.

2. Leg curl
Leg curls can specifically strengthen the hamstrings in a general manner. Repeat the above sets and reps scheme.

3. Proprioception exercises
Learning to land with a soft contact and bending the knees is an important skill. Another important skill is changing direction and pivoting off one side to move to the other. Again, the movement should be taught with a slightly bent knee to increase stability. These movements can be practised to increase skill levels and joint position sense to help reduce injury risks.

Preventing Ankle sprain

Sports: rugby, netball, football

Ankle sprains tend to be accidental and sometimes related to the surface the sport is played upon. However, having strong lower leg muscles and good proprioception in the ankle joint can reduce the risk of this injury. The following are useful exercises.

1. Calf raise with band pull
This exercise strengthens the ankle stabiliser muscles while working the calf muscles, making it quite functional. The athlete must resist the pull of the band and keep the ankle aligned while moving up onto the toes (see illustration above).

2. Ankle eversions
This exercise strengthens the muscles on the outside of the ankle, increasing their resistance to lateral buckling. Specifically, the eccentric strength should be emphasised by resisting the pull of the band back (see illustration below).