ion Training

Interested in providing a massage therapist for each of your athletes? Try handing them a foam roller.

By Michael Boyle

A decade ago, strength coaches and athletic trainers would have looked quizzically at a 36-inch long cylindrical piece of foam and wondered, “What is that for?� Today, nearly every athletic training room and most strength and conditioning facilities contain an array of foam rollers of different lengths and consistencies.

What happened to bring foam rollers into prominence? The change has been in our attitude toward massage therapy. We have been slowly moving away from an injury care mode of isokinetics and electronics to more European-inspired processes that focus on hands-on soft tissue care. We now realize that techniques like massage, Muscle Activation (MAT), and Active Release Therapy (ART) can work wonders for sore or injured athletes.

In addition, the understanding at the elite athlete level is: If you want to stay healthy, get a good manual therapist in your corner. Thus, athletes at all levels are starting to ask for some form of soft tissue care.

What does all this have to do with foam rollers? As coaches and athletic trainers watched elite-level athletes experience success from various soft tissue techniques, the obvious question arose: How can I make massage available to large groups of athletes at a reasonable cost? Enter the foam roller.

National Academy of Sports Medicine President Micheal Clark, DPT, MS, PT, CES, PES, CPT, is credited by many—this author included—with exposing the sports medicine community to the foam roller. In one of Clarke’s early manuals, he included a few photos of self-myofascial release using a foam roller. The technique illustrated was simple and self-explanatory: Get a foam roller and use your bodyweight to apply pressure to sore spots.

Since then, many of us have discovered more uses for foam rollers, including injury prevention and performance enhancement. We’ve also moved away from the accupressure concept and now use them more for self-massage. And we’ve come up with specific protocols for different situations.

Essentially, foam rollers are the poor man’s massage therapist. They provide soft tissue work to the masses in any setting. But you need to know their nuances to get the most out of them.

What, How & When
A foam roller is simply a cylindrical piece of extruded hard-celled foam. Think swimming pool noodles, but a little more dense and larger in diameter. They usually come in one-foot or three-foot lengths. I find the three-foot model works better, but it obviously takes up more space.

They are also now available in a number of densities from relatively soft foam (slightly harder than a pool noodle), to newer high-density rollers that feel much more solid. The denser the athlete, the more dense the roller should be. Large, heavily-muscled athletes will do better with a very high density roller whereas a smaller, younger athlete should begin with a less dense product.

The application techniques are simple. Clarke’s initial recommendation was based on an accupressure concept, in which pressure is placed on specific surfaces of the body. Athletes were instructed to use the roller to apply pressure to sensitive areas in their muscles—sometimes called trigger points, knots, or areas of increased muscle density. The idea was to allow athletes to apply pressure to injury-prone areas themselves.

The use of foam rollers has progressed in many circles from an accupressure approach to self-massage, which I’ve found to be more effective. The roller is now usually used to apply longer more sweeping strokes to the long muscle groups like the calves, adductors, and quadriceps, and small directed force to areas like the TFL, hip rotators, and glute medius.

Athletes are instructed to use the roller to search for tender areas or trigger points and to roll these areas to decrease density and over-activity of the muscle. With a little direction on where to look, most athletes easily find the tender spots on their own. However, they may need some instruction on the positioning of the roller, such as parallel, perpendicular, or 45 degrees, depending on the muscle.

The feel of the roller and intensity of the self-massage should be properly geared to the age, comfort, and fitness level of the athlete. This is one of the plusses of having the athlete roll themselves—they can control the intensity with their own body weight.

There is no universal agreement on when to roll, how often to roll, or how long to roll, but generally, techniques are used both before and after a workout. Foam rolling prior to a workout can help decrease muscle density and promote a better warmup. Rolling after a workout may help muscles recover from strenuous exercise.

My preference is to have athletes use the rollers before every workout. We also use them after a workout if athletes are sore.

One of the nice things about using the foam roller is that it can be done on a daily basis. In fact, in their book, The Trigger Point Therapy Workbook, Clair Davies and Amber Davies recommend trigger point work up to 12 times a day in situations of acute pain.

How long an athlete rolls is also determined on a case-by-case basis. I usually allow five to 10 minutes for soft tissue activation work at the beginning of the session prior to warmup. If my athletes roll after their workout, it is done for the same length of time.

Some Specifics
While the foam roller can be used on almost any area of the body, I have found it works best on the lower extremities. There is not as much dense tissue in the upper body and our athletes are not prone to the same frequency of upper body strains as lower. The hamstrings and hip flexors seem to experience the most muscle strains, so we concentrate on those areas.

Here are some protocols I use:

Gluteus max and hip rotators: The athlete sits on the roller with a slight tilt and moves from the iliac crest to the hip joint to address the glute max. To address the hip rotators, the affected leg is crossed to place the hip rotator group in an elongated position. As a general rule of thumb, 10 slow rolls are done in each position (although there are no hard and fast rules for reps). Often athletes are simply encouraged to roll until the pain disappears.

TFL and Gluteus Medius: The tensor fasciae latae and gluteus medius, though small in size, are significant factors in anterior knee pain. To address the TFL, the athlete begins with the body prone and the edge of the roller placed over the TFL, just below the iliac crest. After working the TFL, the athlete turns 90 degrees to a side position and rolls from the hip joint to the iliac crest to address the gluteus medius.

Adductors: The adductors are probably the most neglected area of the lower body. A great deal of time and energy is focused on the quadriceps and hamstring groups and very little attention is paid to the adductors. There are two methods to roll the adductors. The first is a floor-based technique that works well for beginners. The user abducts the leg over the roller and places the roller at about a 60-degree angle to the leg. The rolling action begins just above the knee in the area of the vastus medialis and pes anserine, and should be done in three portions. To start, 10 short rolls are done covering about one third the length of the femur. Next, the roller is moved to the mid-point of the adductor group and again rolled 10 times in the middle third of the muscle. Last, the roller is positioned high into the groin almost to the pubic symphysis for a final set of 10 rolls.

The second technique for the adductors should be used after the athlete is comfortable with the first one. This exercise requires the athlete to sit on a training room table or the top of a plyometric box, which allows him or her to shift significantly more weight onto the roller and work deeper into the large adductor triangle. The athlete then performs the same rolling movements mentioned above.

Although I primarily use the rollers for athletes’ legs, they can also be used with upper extremities. The same techniques can be used for pecs, lats, and rotator cuffs, although with a much smaller amplitude—making the movements closer to accupressure.

Assessing Effectiveness
Foam rolling is hard work that can even border on being painful. Good massage work, and correspondingly good self-massage work, may be uncomfortable, much like stretching. Therefore, it is important that athletes learn to distinguish between a moderate level of discomfort related to working a trigger point and a discomfort that can lead to injury.

When an athlete has completed foam rolling, he or she should feel better, not worse. And the rollers should never cause bruising. Ask the athlete how his or her muscles feel after each session to assess if the techniques are working.

I also judge whether foam rolling is working by monitoring compliance. If I don’t have to tell athletes to get out the foam roller before a workout, I know the techniques are working. Most do it without prompting as they see the benefits.

Rolling vs. Massage
The question often arises: “Which is better, massage therapy or a foam roller?� To me the answer is obvious: Hands-on work is better than foam. Hands are directly connected to the brain and can feel. A foam roller cannot feel. If cost was not an issue I would have a team of massage therapists on call for my athletes at all times.

However, having an abundance of massage therapists on staff is not in most of our budgets. Therein lies the beauty of the foam rollers: They provide unlimited self-massage for under $20. Sounds like a solution to me.

Michael Boyle, MEd, ATC, is a strength and conditioning coach and consultant based in Boston. He has trained numerous athletes, from amateurs to Olympians and professionals, and can be contacted through his Web site at: www.michaelboyle.biz.

By Staff

In December of 2004, Courtney Evans should have felt like she was on top of the world. The top blocker and server on the Tufts University volleyball team, the junior middle hitter led the Jumbos to a 28-6 record and second place in the New England Small College Athletic Conference. Despite that success, she felt nothing like a fine-tuned athlete.

Instead, Evans was exhausted and experiencing extreme abdominal pain. She had also noticed a loss of appetite and energy—although she didn’t tell her teammates or coaches.

Somewhat concerned, but not overly-worried, Evans described the symptoms to her father, Douglas Evans, MD, Surgical Oncology Chief at The University of Texas M.D. Anderson Cancer Center. Initially, Dr. Evans thought his daughter was simply lactose intolerant and recommended a dairy-free diet.

When the pain and exhaustion remained, Dr. Evans quizzed a number of the hospital’s gastrointestinal experts, who believed the symptoms were consistent with a bacterial infection and prescribed an antibiotic. The antibiotic alleviated some of Evans’s symptoms, but it wasn’t enough. So at the conclusion of the season, she went to Massachusetts General Hospital for testing.

A colonoscopy revealed Evans’s symptoms had a cause: She was in the early stages of Crohn’s Disease, a rare, chronic, episodic illness affecting the gastrointestinal tract that afflicts more than 500,000 people in the United States. Doctors put Evans on Imuran, an immunosuppressant, and she returned to campus. But her energy continued to wane and her appetite plummeted. Evans struggled to get through her final exams, and returned home to Houston for winter break simply exhausted.

The cause of Crohn’s Disease is unknown and there is currently no medical or surgical cure. An inflammatory bowel disease, Crohn’s causes blockages in the intestines, resulting in chronic diarrhea, abdominal pain, fever, and weight loss. The pain can be intense, with symptoms dominating a patient’s everyday activities. For Evans, who would lose 30 pounds in the two months following her diagnosis, the disease caused episodes of extreme abdominal pain and diarrhea that had her sprinting to the bathroom every 45 minutes.

When Evans told Head Volleyball Coach Cora Thompson, CSCS, about the diagnosis, Thompson was naturally concerned. And when she received a phone call from her star hitter over winter break warning her that the symptoms had worsened and Evans had lost a significant amount of weight, Thompson grew more worried. At five-feet-11-inches tall and 165 pounds, Evans was a lean, lanky athlete for whom bodyweight was already at a premium.

However, that phone call could not prepare Thompson for what appeared before her eyes when Evans walked into her office at the start of the spring semester. “My heart dropped as soon as I saw her, and I became extremely concerned,� says Thompson. “Her muscles were completely gone—her arms were so thin. She was so weak and gaunt. It was very, very scary. She didn’t have 20 pounds to lose to begin with!�

Upon her return, Evans had some tough decisions to make. First, a planned trip to study abroad was cancelled, and Evans signed up for only three courses—the minimum to be considered a full-time student at Tufts. Thompson helped make arrangements for Evans to move to a dorm on campus where she could be more closely monitored.

“My parents didn’t want me to go back to school at all, but there was no way I was giving up my senior season,� says Evans, who had been voted co-captain for the upcoming year. “At first, I basically went to class, then straight home to sleep. I was anemic and had zero energy.�

Evans’s health continued to decline and by January she had lost another 10 pounds, bringing her down to about 135. “I couldn’t keep anything in my body and I didn’t have an appetite,� says Evans. “I didn’t want to eat because it only made me more sick.�

But Evans did not want to hand in her uniform or kneepads either. So, Thompson and Athletic Trainer Patricia Cordeiro, ATC, met with Evans and figured out a strategy to get her back on the court. “We put some very basic plans in place, and vowed to keep everybody on the same page,� says Cordeiro. “We wrote out a timetable for her that said, ‘By this point you need to see this specialist, and by this point you need to do this,’ and so forth.�

Evans says creating a formal plan was a big help in her recovery. “That’s something I really needed because I’m a go-with-the-flow type of person and wouldn’t have done it on my own,� she says. “Everyone was motivating me throughout the process. Pat was very diligent about keeping me in the moment. She was accommodating and completely supportive. She never said, ‘This is going to be a really hard road, you better get ready.’ It was always, ‘Here’s what we’re going to do, let’s get started.’�

Thompson also spent a lot of time on the phone with Evans’s parents, working with them to find the best specialists. Early in the semester, she drove Evans to see a nutritionist in Boston. “Because there is no known cure, a patient’s best method of managing Crohn’s Disease is through medication and improved nutrition,� says Thompson. “Some of the nutritionist’s ideas were a little funky and hard for Courtney to get used to at first, but they helped a lot. For instance, the nutritionist told her she needed more flax seed in her diet. Courtney had to go out to a health food store and buy flax seed and be conscious about adding it to her morning yogurt. Those kind of details were a big change for her.�

Thompson, who also serves as a strength coach at Tufts, tried to find out all she could about what her player was battling. “In addition to researching on the Internet, I talked to our athletic trainers and anybody else who might know anything about Crohn’s,� she says. “But to me, getting her in the hands of the right doctors and helping to expedite the recovery process was more important than becoming an expert on the disease myself. I saw my job as finding the resources she needed and working with her parents and the specialists.

“I wanted to make sure Courtney knew I was there for her,� Thompson adds. “I also wanted her to feel structured and to feel like part of the team—not like she was out there floating around amongst the masses. And most importantly, I wanted to make sure she knew we weren’t giving up on her.�

Though she realized her coach was squarely in her corner, Evans still experienced bouts of depression that spring and decided to get help from a sports psychologist employed by the university. “A lot of times I felt depressed about not being able to do what I used to do, and I didn’t want to burden my friends by talking about it all the time,� says Evans. “So I started seeing the sports psychologist once a week. We not only talked about my illness, but also about dealing with the responsibilities of being a captain the next season. It was really helpful to think ahead about that kind of stuff—it helped me keep my mind focused on getting back to where I was before.�

In March, Evans, who was anemic, started getting IV infusions of iron, which were easier for her to take than oral iron supplements. And slowly, she noticed her energy levels rising. At that point, even though she still experienced symptoms of Crohn’s, Evans began working with a Tufts personal trainer for 45 minutes a day, three times a week.

“We wanted to prescribe exercises that kept her comfortable, and we found that stretching was the thing,� says Cordeiro. “She did lots of static stretching with long, prolonged movements that lasted for 30 to 120 seconds. She started each session by working on her priority areas—whatever was tightest. And it really seemed to improve some of her symptoms.�

By the end of April she began some basic strength training using very light weights. Because the goal was to increase Evans’s body weight, the program was designed to limit her cardio conditioning. “We started doing really basic circuit training on machines,� says Cordeiro. “Eventually, she progressed to lower-body exercises like squats and leg presses using light weight. By then the team was doing their team lifting and she worked out at the same time. It was a good way to keep her connected with her teammates and focused on her goal.�

By the end of the spring semester, Evans had put on more than 10 pounds and was starting to feel a little better about her chances of returning to the court for the 2005 season. But she wasn’t even close to feeling like her old self. So that summer, Evans’s doctors put her on a new IV medication called Remicade. The results were startling. “After two infusions, I felt 100-percent better. After the third infusion, I felt completely normal again,� says Evans. “It took away my symptoms completely. It has been a miracle drug for me.�

Spending the summer in Cape Cod, Mass., Evans hired a personal trainer and attacked her workouts with newfound energy and vigor. Intense lifting three times a week packed pounds on Evans’s frame while hardening and tightening her muscles. “That summer I set a personal best in the squat and restored my vertical jump to what it was before I got sick,� she says. “It was a lot of hard work, but I regained everything I had lost during the spring semester.�

When Evans returned to Tufts for volleyball preseason practice in August, Thompson was again blown away by what walked through her office door. “When I first saw Courtney, she flexed and said, ‘Look! Muscles!’� says Thompson. “She was lean and strong and her body mass index had improved over what it was before the Crohn’s. Then I sat back and watched her play a couple pickup games—that’s when I realized she was back to her old form.�

And that form carried her team to another level. The Jumbos won a school-record 29 games and advanced to the regional finals in the NCAA Division III championships. During that magical season, Evans played in every match, earning first team all conference honors.

Despite exhausting her collegiate eligibility, Evans was not ready to stop competing. Two weeks after the team’s final game, Evans told Thompson that she wanted to start training for the Boston Marathon. “We were coming off a grueling season and to have her say that was mind boggling,� says Thompson. “She trained all winter long, was eating a ton, and feeling great. It was amazing considering a year earlier she couldn’t even get off the couch.

“The whole experience of rehabbing from Crohn’s Disease taught her a lot about nutrition and what her body could handle,� Thompson adds. “And throughout her marathon training she kept asking Pat and I, who have both run marathons, for advice.�

That spring, Evans completed the 26-mile race in less than six hours. She was escorted to the finish by Thompson, who met Evans at the 17-mile mark, and seven of her teammates, who joined in with four miles to go. “The girls were wearing T-shirts that read, ‘Court Support’ on the back and chanting her name and getting the crowd into it—I’m getting a little choked up just talking about it,� says Thompson. “Granted, they were silent after about a mile as they tried to keep up with Courtney.

“It’s so inspirational to think that she started that 15-month ordeal flat on her back and ended it by crossing the finish line of the Boston Marathon,� Thompson continues. “And in the middle, to have the best season in school history—I really couldn’t have scripted a better story.�

Evans is currently a teacher and Head J.V. Volleyball Coach at Episcopal High School in Houston. She says the lessons she learned last season have helped shape her coaching philosophy. “The whole never-give-up mentality is the basis of my coaching style,� says Evans. “I never hang my head on the bench and I’m always encouraging our players—no matter how dire the circumstances seem. Cora taught me that if I don’t give up on the girls, they won’t give up on themselves.�

Though she still receives Remicade transfusions every two months, Evans says she has the disease well under control and feels healthy and strong. Ultimately, she says having Crohn’s Disease has taught her a lot about herself. “I always thought I was mentally tough, but I learned exactly how tough I am,� says Evans. “It would have been really easy to let my situation get the best of me, especially at the beginning of that spring semester. I got sad, but I never let it get out of hand and a lot of credit for that goes to my support system: Cora, Pat, my personal trainer Dan, and my friends and parents.

“Also, I learned to never say no to somebody who was trying to help me,� she adds. “As a very independent person, it would have been natural for me to say, ‘Thanks, but I can do this on my own.’ If I had done that I don’t think I would have been able to get well as quickly as I did. It helped so much to have other people beside me saying, ‘You’re going to be fine, we have a plan.’ Having people do all those little things really added up.�

Boston University’s strength and conditioning program for women’s softball has the team off and running toward newfound success.

By Victor Brown III

The game of softball is characterized by quick reactions and repeated high-power-output movements. With only 60 feet separating each base and 40 feet between the pitcher’s plate and home plate, softball players need powerful acceleration in the batting box, on the base paths, and on defense.

At Boston University, our softball strength and conditioning program stresses the development of linear and lateral speed and acceleration, rotational strength and power, power endurance, and improved batted ball velocity. For reducing injuries, we emphasize training the posterior chain and a full-body warmup.

This philosophy resulted in team single-season records for stolen bases and home runs in 2006, and helped the Terriers lead the America East Conference in stolen base percentage, with four players contributing 10 or more steals. Additionally, our strength and conditioning program has helped produce the school’s top two career, and top three single-season home run leaders.

STRENGTH TO PLAY
In order to be successful at the NCAA Division I level, softball players need to train for power. They need power to hit the ball, make strong throws, and to run and jump on defense and on the basepaths. Here at BU, beginning in late October, our players spend four days a week in our off-season strength and conditioning program.

Research has shown three factors contribute to batted ball velocity: lean body mass, lower body power, and grip strength. To develop lean body mass and lower body power, players are put through an initial four-week hypertrophy phase using loads between 60 and 75 percent of their individual 1-RM. That is followed by six weeks of basic strength and power training using approximately 70 to 90 percent of their 1-RM. We then start our preseason training, which lasts three to four weeks, with a goal of attaining peak strength and power.

Our staple lifts during these periods include squats, lunges, straight-leg deadlifts, cleans, snatches, glute-ham and partner-ham raises, and sequential/diagonal chops. We also emphasize pulling movements for the scapular-thoracic joint, such as dumbbell rows, cable-rope rows, bent-over rows, and inverted rows, as well as chin-ups and pull-ups. Other exercises include the bench press, incline bench press, close-grip bench press, and alternating dumbbell incline bench press.

The use of overhead lifts by overhead throwing athletes has long been a controversial topic among strength coaches. Athletes who play baseball and softball perform countless sport-specific repetitions during play and practice, using shoulder and arm movements above 90 degrees horizontal abduction. Therefore, I believe it is essential for the athletes to strengthen this plane of movement. However, it is important to determine when is the most appropriate time during the training year to perform overhead movements because of the susceptibility of the shoulder complex to sustain injury.

The key is frequent communication with the sport coach to accurately gauge the amount of overhead stress your athletes are putting on their shoulders and arms outside the weightroom. We train using a high volume of overhead movements during the off-season, when the athlete is performing the least amount of throwing. As the team begins preseason practices, the volume of overhead strength training decreases and combination lifts and complexes are incorporated into their workouts. Once the season starts, overhead lifts are eliminated.

Various forms of grip strengthening and prehab for the hand, wrist, and forearms are done twice a week during both off-season and preseason training. When a bat makes contact with a ball, a significant amount of compression occurs to the ball, and much of the initial kinetic energy of the ball is lost. Our goal is to limit the significance of dampening forces. Some of our favorite exercises to do this include dumbbell wrist throws, dumbbell farmer’s holds, and plate gripping, as well as towel-grip holds performing chin-ups and inverted rows. We also do a rice bucket forearm/hand circuit (open-close, hammer, open-the-jar, close-the-jar), which is performed 20 times. And we wrap a towel around the handle for many of the dumbbell exercises, such as dumbbell rows, dumbbell split squats, and walking lunges, allowing players to grasp as a method of incorporating functional grip-strength work.

Ballistic-resistance training has been shown to increase throwing and base running performance, and thus it is an integral part of our program. Players begin plyometric training as a group and pitchers and position players are later separated to build strength and power for their position-specific movements. Split jumps are used to improve lower-body power in pitchers while rotational and lateral plyometrics are used to teach hitters and position players how to generate power in a rotational and lateral manner. Three of our favorites are 90-degree box jumps, 180-degree hurdle hops, and lateral drop jumps. Weighted jump squats are also used occasionally.

Medicine ball exercises are implemented to tax the entire kinetic chain in a sequential manner. To work the shoulder complex, players perform overhead wall dribbles and single-arm wall dribbles incorporating a variety of stances based on position- specific needs.

Twist throws are also used to develop power for position-specific movements. Pitchers perform twist throws in a split stance and progress to using a lunge step—this teaches them to produce force in a sagittal and transverse plane simultaneously. Position players either utilize a stride step or simply lift the front foot up and down depending on their individual hitting style. Slap hitters perform twist throws in a split stance parallel to the wall. We will progress to performing twist throws on a slide board to teach all players to produce force in a frontal plane while simultaneously generating force along a transverse plane, which occurs when players swing a bat.

Strengthening the hips and groin is also critical. We use the slide board, the mini-band, and lateral resistor work for these areas. Additionally, players perform lunge movements in various planes to prepare for on-the-field demands. Infielders move predominately from side-to-side, thus we use the cross-over step lunge, 45-degree lunge and reach, reverse lunge, and lateral lunge. Outfielders must turn and run to a spot for a driven ball, so for them we use open-step lunges to develop their first-step. Pitchers perform forward lunges and split squats to assist in developing the leg drive that is crucial for their push off. And everyone does walking lunges to develop the propulsive strength needed for running.

QUICK & EFFICIENT
Most actions in sports take fewer than five to 10 seconds to complete, often even quicker in softball, and rarely does an athlete reach maximum speed during play. Thus, acceleration and quick reactions are required for movements like exploding out of the batters box, getting a good jump on the ball defensively, and running the base paths either during a hit-and-run or a straight steal. In response, acceleration and movement efficiency drills are performed on a daily basis in the off-season.

During the first phase of training, various pillar and arm-swing drills are executed along with a variety of acceleration drills like lateral starts and split-stance accelerations. In the next phase of training, we progress the difficulty of our movement efficiency drills and begin to incorporate objects for reaction training. We have found ball drops are an excellent drill for improving acceleration. Both infielders and outfielders can execute the drill from either a defensive ready position or a stealing start position. Towel drops provide another advanced option. The towel is thrown from behind the shoulder of the player, who must sprint to the spot beneath the towel as it comes into sight, the same way they sprint to a spot for a fly ball.

During the latter phases of training, movement efficiency drills become even more advanced by adding visual tracking and cognitive training. For example, we use number ball drops, in which various numbers are written on the six sides of a tennis ball. Players accelerate upon release of the ball. Immediately prior to catching it, the player is required to call out the last number on the ball they see. Colored ball drops are another option. Execute the drill by using two different colored balls. Upon release, call out the color of the ball the athlete is to grab as they accelerate toward it. These drills foster quick thinking and precise reactions.

We also incorporate resisted sprinting and complex training to improve acceleration during this final stage of training. Hill sprints and towing sleds are used for resisted sprinting. We perform a heavy squat movement followed by a plyometric exercise or maximum effort sprint during our complex training.

ADDING IN CONDITIONING
Conditioning the softball athlete is important for many reasons. The first reason is for improving speed. I believe to become faster, we must train the body to fire and move at a greater speed than it is accustomed to. So, even though the athletes may never get to their top speed during competition, I want to see them achieve it during workouts.

We use short intervals when doing speed work. The majority of our maximum speed sprint training takes less than 10 seconds. In addition, a 1:12 work-to-rest ratio is used for ATP-PC recovery.

Power endurance must also be considered for softball performance. The game is characterized by repeated high-power output movements, and the ability to maintain power throughout a long at-bat or a double-header is critical. We begin training using work-to-rest ratios of 1:3, then progress to 1:2. We use various modes of conditioning including slide boards and bike sprints. Maximum speed and metabolic conditioning days are alternated to allow for energy system recovery.

In competition, our base runners are called upon to steal and hit-and-run at various times. There are times when the base runner is on the move and the batter hits a ball into foul territory. The base runner must return to the base and get ready to sprint maximally again on the next play with a short amount of rest. During the preseason, we begin to incorporate active recovery into our metabolic conditioning to simulate the demands of this type of base running. To make it more sport-specific, we use a variety of starts and signals for our sprints, like signs for a delayed steal, straight steal, and a simulated windmill pitch.

During the season, the players get into a daily routine of performing conditioning drills after our on-field warm-ups, but volume and intensity change weekly based on such variables as number of games in a week or day, how many innings a position player was active, and number of innings pitched. Our speed and acceleration training is primarily performed on game days, and is short in duration, long in recovery. Interval training is carried out on practice days and includes a day of active recovery work. Tempo conditioning is performed at 90-percent effort and administered the day prior to doubleheaders and on Sundays for pitchers and position players who played more than three innings during the previous day’s game(s).

PITCHING INJURIES
Research has shown that the majority of injuries a softball pitcher encounters are due to overuse, and they primarily involve the shoulder. Understanding the biomechanical movements and what muscles are active during the various phases of the windmill pitching motion is imperative to properly condition a pitcher.

The windmill motion consists of three phases: preparatory, force, and follow-through. The preparatory phase varies from pitcher to pitcher, with some bringing the arm back to 90 degrees of extension and others using no extension, but all pitchers bring the ball to the six o’clock position to initiate the pitch. The force phase is most important and is comprised of four subdivisions:

1. The arm is elevated from a six o’clock to a three o’clock position. The supraspinatus, infraspinatus, subscapularis, and deltoid are all active in this position.

2. When the arm moves from three o’clock to 12 o’clock, the supraspinatus, infraspinatus, teres minor, and posterior deltoid are functioning.

3. The arm shifts beyond the 12 o’clock position to nine o’clock and the subscapularis, teres minor, serratus anterior, and posterior deltoid are operating.

4. These same muscles remain activated during the final portion of the force phase and also during the follow-through phase.

Conditioning just the rotator cuff muscles, however, is insufficient when preparing a windmill pitcher for the demands of a softball season. Training the entire kinetic chain along with the shoulder complex is key. In addition, the posterior deltoid, pectoralis major, and serratus anterior all play critical roles during the windmill pitching motion. Work must be done both above 90 degrees horizontal abduction and in neutral.

Our pitchers perform a shoulder complex twice a week during the off-season using both tubing and light dumbbells. To relieve the volume placed on the shoulder region during the spring season, a shoulder complex is performed once a week for maintenance. Here is a sample routine (each exercise is performed 10 times):

• Horizontal Abduction to 90/90 External Rotation
• Triceps Extension
• Biceps Curl
• Full Cans
• Forward Diagonals
• Backward Diagonals
• Serratus Punch w/Internal Rotation
• Neutral Internal Rotation
• Neutral External Rotation
• 90/90 Internal Rotation
• 90/90 External Rotation
• Glenohumeral Extension w/External Rotation

The wrist and elbow are also areas of concern and thus we incorporate various modes of training to increase hand, wrist, and forearm strength. Pronation, supination, ulnar and radial deviation, flexion, and extension work are all done, as well as wrist throws and gripping exercises. Much of our grip work is “hidden� in the workout as part of a tri-set or functional-based lifts using towels, ropes, or dumbbells. Adequate lower back strength and endurance are also incorporated to properly prepare for the demands of pitching over the course of the season.

THE NORTHEAST GAME
A final important element of our strength-training program deals with our geographic location. Research shows that softball players in the colder regions of the Midwest and Northeast sustain more injuries than those in the warmer regions of the South and West. Therefore, we construct our warmup routine very carefully.

Our on-field prep work is active, dynamic, and encompasses movements specific to the throwing, running, and fielding requirement for the game of softball. Traditionally, softball players have started warming up by throwing the ball. But we take a completely different approach using dynamic exercises for the shoulder complex before a single ball is thrown. We warm up to throw, not throw to warm up. (See “On-Field Warmup� below.)

By thinking carefully about the dynamics of the game and considering the injuries its athletes sustain, we have been able to develop a functional, sport-specific program for our softball players. They are looking forward to using it with even more success this spring.

To access references for this article, please log on to:
www.AthleticSearch.com/BUsoftrefs.

Table One: On-Field Warmup
The following is the warmup routine our softball players use before a practice. The movement exercises are done for 20 yards.

Jog to Poles x2
Arm Circles w/Pronation x10
Arm Circles w/External Rotation x10
Field Goals x10
Full Cans x10
Diagonals x10
Bear Hugs x10
High-Knee Lunge Walk
Heel-to-Butt w/Lean
Cross-Over Toe Touch (R+L)
Inverted Hamstring w/External Rotation
Backward Lunge + Twist
Lateral Slide Thru (R+L)
High-Knee Skip
Cross-Over Skip
High Knees x2
Butt Kicks x2
Carioca (R+L)
Delayed Steal x75%, x90%, x100%
Inchworm

Table Two: Sample Week
The following is an example of one week of conditioning during fall off-season training. All off-season weightroom sessions start with either a dynamic warmup or an agility ladder and conclude with foam rolling and stretching.

MONDAY

Drills:
•Seated Arm Swing 1×20
•Standing Arm Swing 1×20
•Walking Arm Swing 2×20
•Pillar March 2×5
•Split Stance Acceleration 2×10 meters

Plyometrics:
•Jump Squats 4×6 @ 30%

Abdominals:
•Rope Reverse Crunch 2×20
•Off-Bench Obliques 2×10

Conditioning:
•Sprints (1:12)
…..3×80 yds
…..5×20 yds
…..7×10 yds

TUESDAY

Drills:
•Standing Arm 1×20
•Swing 1×20
•Walking Arm Swing 1×20
•Jogging Arm Swing 2×20
•Pillar Knee-Ups 2×5
•Ball Drops x2 (split stance)

Plyometrics:
•Pitchers: Split Jumps 2×5
•Others: Lateral Box Jumps 2×5

Medicine Ball Routine:
•Close Overhead Throw 3×8
•Chest Pass 3×8
•Front Facing R/L Twist Throw 3×8
(Pitcher in split stance)
•Side Facing R/L Twist Throw 3×8
(Hitters in stride step; slappers in split stance)

Conditioning:
•Slide Board: 4×0:30/0:60
•Bike Sprints:
…..3×0:10/0:20
…..3×0:15/0:45
…..3×0:20/0:40

WEDNESDAY

Drills:
•Walk-to-Jog Arm Swing 2×20m
•Pillar Single Exchange 2×5
•1-Leg High-Knee Walk 1×20m
•Alternating 1-Leg High-Knee Walk 1×20m
•Lateral Starts x2

Plyometrics:
•90-Degree Box Jumps 2×4
•90-Degree Hurdle Hops 2×4

Abdominals:
•Same as Monday

Conditioning :
•Hill Sprints (1:12), 10×30 yds

THURSDAY

Drills:
•1-Leg High-Knee Skip 2×20m
•High-Knee Skip 2×20m
•Defensive 1-2 Stick x2
•Cross-Over to Base-Position x2
•Number Ball Drops x2 (with lateral start)

Plyometrics:
•Same as Tuesday

Medicine Ball Routine:
•Same as Tuesday

Conditioning:
•Slide Board: 4×0:30/0:60
•Bike Sprints: 6×0:15/0:45

Victor Brown III, MS, ATC, CSCS, NSCA-CPT, is the Associate Strength and Conditioning Coach at Boston University. He can be reached at: vbrown@bu.edu.

The amount of research on ankle injuries is expansive—but maybe too expansive for a busy athletic trainer to read. That’s why we’ve compiled it into one comprehensive article.

By Dr. Rod Walters

For over 100 years, medical professionals have been conducting research on the prevention and treatment of ankle injuries. Way back in 1895, V.P. Gibney published an article in the New York Medical Journal titled, “Sprained Ankle: a treatment that involves no loss of time, requires no crutches, and is not attended with an ultimate impairment of function.� Gibney was talking about taping ankles in his article—by wrapping the ankle with strips of rubber plaster.

Although Gibney devised this technique for treating ankle injuries, we now know it as an option for prevention. We also know that ankle braces have a role in warding off the ever-prevalent ankle injury. But what is the best way to prevent an initial or recurring ankle sprain?

There is not one simple answer. But there is a plethora of research on the topic that gives some direction. For this article, I have analyzed research on ankle injuries from over 80 published manuscripts and textbooks and put it together into one comprehensive piece. From “The effect of ankle wrapping on motor performance,� published in 1972 in Athletic Training, to “First-time inversion ankle ligament trauma: the effects of sex, level of competition, and sport on the incidence of injury,� published in the American Journal of Sports Medicine last year, when pieced together, the many studies reveal some interesting advice.

BACKGROUND
Some of the research reveals no surprises. For example, the foot and ankle are among the most commonly injured body parts of recreational and competitive sports participants. An estimated 25,000 ankle sprains occur daily in the United States. Though recovery from the initial injury is likely, re-injury often results in moderation or discontinuation of sports activity.

The ankle joint comprises the tibia, fibula, and talus, and results in the motions of plantar flexion and dorsiflexion. The stability of the joint arises from the bony articulations combined with ligaments and muscles working together. The motions of inversion and eversion occur distal to the ankle joint at the subtalar articulation. The fibula extends more distal than the tibia, and thus prevents excessive eversion. The mechanism of injury for the lateral ankle sprain is characterized by the classic plantar flexion and inversion.

The extent of injury to the ligaments determines the severity of the sprain. A mild sprain is characterized by microscopic tears with no loss of ligamentous integrity. The application of additional forces may produce partial tears of the ligament, or a moderate sprain. Such injuries are significant, even though the tear is not complete. Severe sprains involve complete disruption of the ligament and associated functioning properties. While the American Medical Association uses the terms mild, moderate, and severe to classify the degree of injury, some programs refer to the degree of injury as a Grade I, Grade II or Grade III sprain.

The inversion sprain is more common than the eversion sprain because of the bony anatomy on the lateral side of the ankle, which tends to limit eversion. The most common mechanism of ankle sprains are plantar flexion and inversion. A single ligament tear usually involves the anterior talofibular ligament as it is stressed with plantar flexion. The anterior talofibular ligament has the weakest tensile strength of the lateral complex. The addition of inversion to the plantar flexed ankle may further affect the calcaneofibular ligament.

Intrinsic risk factors for sprains of the lateral ankle ligaments include a history of ankle sprains, generalized joint laxity (increased talar tilt), and delayed muscle reaction time. The most common risk factor for ankle sprains, however, is a history of sprains. Athletes with a previous ankle sprain have a 500-percent incidence of re-injury.

Therefore, a key factor in preventing and treating ankle injuries is understanding chronic ankle instability, which can result from mechanical instability or functional instability. Mechanical instability is easier to diagnose and treat because it involves a measurable degree of laxity. The ligaments no longer effectively support the ankle joint, making repeated sprains and instability more likely in normal daily activities. The athlete is aware of his or her symptoms and avoids any risky activity.

Functional instability is harder to understand (and there is less research on it) because of its subjective nature. Symptoms include lateral pain, difficulty walking on uneven surfaces, a feeling of weakness in the ankles, swelling, stiffness, and tenderness. Individuals have the sense that their ankles will give way if they take a wrong step. Functional instability has more to do with lost or diminished proprioception in the ankle. This type of ankle instability is the most difficult to diagnose and the most challenging to treat.

Hans Tropp, MD, PhD, is the foremost researcher on functional instability in ankles, and has found that decreased postural stability is not a function of mechanical instability, thus supporting functional training. He found soccer players with poor postural sway had a higher incidence of injury, and further reported improved postural sway in subjects with functional ankle instability following training on a balance board for six weeks.

To treat an ankle sprain, complete rehabilitation of all muscle groups is important, since eccentric invertor strength deficits may contribute to the symptoms of functional ankle instability. Weak invertors may contribute to functional ankle instability because they are less able to assist in controlling lateral displacement of the shank over the weight-bearing foot.

Overall, the gold standard today for preventing chronic ankle dysfunction is multifaceted. It includes an accurate and complete assessment, aggressive treatment and rehabilitation, addressing any underlying problems, and implementing a balance program to train proprioceptively.

TAPE IT UP
Prophylactic ankle taping has become one of the primary methods used to protect the lateral ligament complex. A review of the literature reveals prophylactic ankle taping techniques are warranted in high-risk sports. Interestingly, the literature is mixed regarding the exact mechanism through which these devices work and the effect they have.

Several studies point to the effective use of non-elastic tape to assist in the control of excess motion, to enhance performance, and for injury prevention. Authors also report athletic tape to be critical in the control of excess motion after an acute sprain.

Elastic tape has been found to have such characteristics as well, but with some conflicting studies. Most research looks at the use of taping in two key areas: First, does it provide mechanical resistance? And second, does it enhance or diminish performance?

At least five recent studies have found that ankle taping provides effective mechanical resistance to sprains. It does so by pulling from an area of strength along the proximal anchor across the weakened or injured area of the ankle back to the area of strength. Two papers explain that taping externally stabilizes the ligamentous structures and prevents joint hypermobility without significantly interfering with normal joint mechanics. Another finds that taping helps prevent the ankle joint from exceeding its physiological and biomechanical limits of motion. And two others say that prophylactic ankle taping decreases ankle motion against forces sustained during activity. Several authors found taping effective in controlling motion. One other said that taping specifically restricted plantar flexion and inversion motion, two frequent hallmarks of sprains.

Further studies say that taping provides support and stability to the ligaments and joint specifically in the chronic stage when the athlete returns to his or her sport. The research suggests that both mechanical and functional stability of the ankle can be improved with taping (both athletic tape and cloth wraps were used with success).

Other studies have looked at the ability of tape to function well over time. A 1997 paper found taping to be virtually ineffective after periods of just 40 minutes. Four others felt ankle taping provided little support because the tape loosened with exercise. In 1973, The Journal of Sports Medicine discouraged taping due to the mobile nature of skin, the moisture that accumulates beneath tape, and disuse atrophy of ankle musculature. However, several authors felt that even though the restrictive effect of athletic tape may be lost over time, the neuromuscular and sensory mechanisms remain effective—ultimately, they may be of greater importance than the mechanical restriction of movement.

In terms of performance, most studies look at the effect of taping on the ankle’s proprioception. In 1995, Robbins and colleagues assessed ankle proprioception and found the ability to determine the foot position of subjects with taped ankles was greater than over subjects with untaped ankles. Taping in particular helped mitigate decreases in proprioception brought about by wearing athletic shoes. Several factors likely contribute to this increase in proprioception. Taping appears to facilitate dynamic muscle stabilization of the ankle at least in part by improving peroneal muscle activation. Foot position sense is also improved by the deceleration of inversion provided by taping.

However, other studies have found different results. In 1972, two articles found that ankle taping decreased agility compared to no protection or using laced ankle stabilizers. The research also found ankle taping to restrict running and jumping activities.

A 1992 study reported that motor performance in taped and untaped subjects was not significantly different. In 1996, Verbrugge compared the effects of ankle taping and bracing on performance of agility drills, sprinting, and vertical jumps. Neither treatment affected the test results.

BRACED FOR THE WORST
Ankle braces are very popular today and come in many different styles. These various models are designed to provide external support and allow normal biomechanical motion and function.

In terms of acute injuries, a long list of studies have found orthotic devices effective as a chosen modality for treatment. More specifically, in 2002, Konradsen reported that orthotic braces used to treat acute Grade III lateral ankle ligament sprains were as effective as cast mobilization.

Many studies have found that ankle braces are effective at preventing ankle sprains and do not affect athletic performance. Tropp and colleagues evaluated the effect of an ankle orthosis on ankle injury incidence and concluded that bracing is effective at preventing ankle injuries. A group headed by Surve evaluated the effect of a semi-rigid ankle orthosis and found that it significantly lowered the incidence of sprains. Sitler, et al., evaluated the effect of a semi-rigid ankle orthosis and found a 3.5 times greater injury rate in un-braced subjects. This study also found that subjects had a generally positive attitude toward use of the braces. Further, Ubell reported braces are effective when landing on an object with one foot unexpectedly, forcing inversion.

Hughes and Stells found bracing combined with taping to effectively restrict foot and ankle motion. Various authors reported that brace utilization and high-top shoes combined with prophylactic taping results in fewer injuries. Others reported bracing combined with taping restricts motion, although these limitations did decrease force production and total work.

Rovere retrospectively reviewed laced ankle stabilizers with ankle taping over six years and found more than twice the number of initial sprains among the taped group—the effectiveness of the lace-up ankle brace in sprain prevention was statistically significant. Greene and Hillman compared the relative effectiveness of athletic tape and a semi-rigid orthosis in providing inversion-eversion range restriction before, during, and after a three-hour volleyball practice. There were maximal losses (41 percent) in taping restriction for both inversion and eversion 20 minutes into exercise.

FINAL FACTORS
Clearly, there is an expansive body of research on the use of ankle tape and braces in the prevention of athletic injuries. And the research continues to evolve. It is evident that taping and bracing (or both) can protect an ankle from initial or subsequent injury. But which to choose and when should still be based on the individual athlete and provider preferences.

A question often arises on which is more cost efficient: tape or braces? Olmstead applied the “Numbers Need to Treat� analysis to previous ankle injury research and found that to prevent one ankle sprain in a game among athletes with ankle sprain histories would require taping 26 ankles. Further, 143 ankles would need to be taped among those without a history of ankle sprain to prevent one sprain. Based on these numbers, ankle bracing involves 50 percent the cost of taping over the course of a season. Thus, the use of ankle braces is usually a significant time and money saver for athletic trainers.

However, the choice must still come down to what works best in a specific situation. Braces can be effectively recommended for athletes during individual workouts when athletic trainers are not available for taping, while taping allows a more hands-on approach that can ensure the athletic trainer and athlete connect every day. Either way, the research supports supporting the ankle, however you choose to accomplish it.

To access references for this article, visit: www.AthleticSearch.com/anklerefs.

Rod Walters, DA, ATC, is Director for Sports Medicine and an Instructor in Athletic Training at the University of South Carolina. He served on the NATA’s Board of Directors from 1997-2003 and was inducted into the NATA Hall of Fame in 2005. He can be reached at: rwalters@gwm.sc.edu.

If your recurring dream is to add more staff to your college athletic training room, you’re not alone. If you want to know just how to fulfill that dream, read on.

By Greg Scholand

Brian Coble was reaching the end of his rope. As the one-man athletic training staff at Carroll College, an NAIA school in Helena, Mont., he was spending 12 hours or more a day at work Monday through Saturday, then covering contests and holding treatment time for the football team on Sunday. Coble had heard that his predecessor was known for working 16-hour days, but as a new dad with a young family, that kind of schedule wasn’t sustainable for him.

Not long into his first year on the job, he decided something had to change. “We were hosting one of the first volleyball games of the year, and I was going to be traveling with the football team,� recalls Coble, MS, ATC, PES, CSCS. “The volleyball coach came to me and said, ‘We need somebody here tonight.’ And all I could say was, ‘Well, you need to help me find someone.’�

The two called physical therapists and high school athletic trainers in the area, scrambling to come up with coverage for the event. “I decided then: We clearly need another staff member,� Coble says.

By effectively lobbying his administration, Coble got his wish, and athletic training at Carroll today is much better for it. With another full-time position in the department, event coverage is reliable, injured athletes receive more attention and better treatment, and teams take part in revamped conditioning programs that help prevent injuries in the first place. What’s more, Coble finally has time for life outside the athletic training room.

For college athletic trainers, long hours and daunting workloads have traditionally come with the territory. But in recent years, more and more are questioning the status quo and strategizing about how to change it. Both collective and individual efforts are making headway, with the ultimate goal of keeping the profession strong.

CHANGING TIMES
If you feel like the problem of too much work and not enough personnel has gotten worse in your college program, you’re probably right. Many new demands have been placed on athletic trainers in recent years, mostly without corresponding staffing increases.

“Athletic training involves a heavy workload—it’s always been that way, and most people know it when they enter the profession,� says Josephine Lee, MS, LAT, ATC, Assistant Director of Sports Medicine at Georgia Tech and President of the College Athletic Trainers’ Society (CATS). “But the fact is, the workload has increased in the last several years. Athletics is a year-round operation now, and as teams have gotten more sophisticated, there are many more workouts and practice sessions that need coverage.�

Lee adds a harsh truth: Not all administrators sympathize with overworked athletic trainers. This summer, CATS invited a well-respected former NCAA Division I athletic director to speak at its annual meeting, and he talked frankly from the administrator’s point of view. “He said that when some athletic directors hear a person complain about long hours, they think, ‘If you don’t like it here, you could easily be replaced by another athletic trainer, maybe even for less money,’� she explains. “They see others in the department putting in a lot of hours—the coaches and their assistants, the academic counselors—and decide it just comes with the territory.�

Dennis Miller, ATC, PT, Head Athletic Trainer at Purdue University, believes this trend may be harming the profession in the long-term. “When we have college athletic trainers putting in 80- and 90-hour weeks, it’s no surprise a lot of quality people choose to leave the job entirely. They can make the same money in a different setting and have a better quality of life,� he says. “That’s bad for the athletic training community, and it also means college programs miss out on a lot of great athletic trainers who do excellent work but don’t want the heavy workload. It’s a very legitimate issue for us.�

At Dowling College, Mark Rodman, MSEd, ATC, Assistant Athletic Director for Sports Medicine and Wellness, has noticed a marked decrease in the number of applicants when he posts athletic training positions. “When I had an opening 10 years ago, I would hear from 50 or 60 people, at minimum,� Rodman says. “This year, I heard from two. One of them had no experience at the college level, and the other had taken the last 10 years off. That tells me either people aren’t as interested in athletic training as they used to be, or people don’t want to enter the college setting because they’re worried about the long hours, stress, and burnout.�

GROUP HELP
At the national level, several groups have efforts underway to help increase athletic training coverage on a broad scale. Last year, CATS surveyed college administrators to find out what they weigh most heavily when allocating resources. The group focused on NCAA Division I, but sought input that could be useful across the board.

“We asked how athletic trainers can improve their position in the department,� says Lee. “We also asked what factors athletic directors pay most attention to when making judgments about coverage—how they weigh the head athletic trainer’s recommendations, staff evaluations, coaches’ and athletes’ evaluations, and so on.�

From the 25 administrators who responded, CATS noticed a few trends. When assessing requests for more resources, several athletic directors said key factors are how the request would increase overall quality of care, and whether the head athletic trainer appears to have a coherent, creative vision for his or her program. Also important was whether the athletic trainers appear to understand the athletic department’s financial “big picture.�

“Administrators said we need to realize we’re not the only ones asking for more staff,� explains Lee. “We’re often vying with coaches, academic aids, the strength program, and sports information, and everyone sees their department as not having enough people. If the administrator can’t clearly see how more resources will tangibly improve the quality of care, we’re probably not going to win that battle.�

The NCAA, too, has taken a recent interest in the state of college athletic training, looking primarily at ways to ease the burdens created by heavy workloads. Ron Courson, ATC, PT, CSCS, Director of Sports Medicine at the University of Georgia, sits on the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports and the association’s task force that is studying work/life balance issues, and he says many new ideas are being brought to the table.

“With the work/life balance task force, we’re hoping to come up with some specific recommendations on how to improve the quality of life for everyone in the athletic department,� Courson says. “For instance, one thing we’ve talked about is encouraging more schools to offer childcare on campus. For people trying to balance being an athletic trainer with being a parent, that could be a real help.

“We’re also discussing ideas like mandatory days off for athletics staff,� Courson continues. “We require that for student-athletes because we see it as important to their health and well-being. So why shouldn’t the same be true for someone in athletic training who might be working non-stop for entire months at a time?�

Courson says the task force’s work could eventually result in a set of NCAA-sponsored best practices athletic departments could apply program-wide, which would help athletic trainers in everything from creating more personal time to attracting more quality people to the profession. “I think we’re realizing more and more that examining these issues is in everyone’s best interest,� he says. “And if we want to keep the athletic training profession healthy, it’s a discussion we need to be having.�

The most direct effort at increasing athletic training coverage, however, has come from the NATA. In 1998, the association formed the Appropriate Medical Coverage for Intercollegiate Athletics (AMCIA) Task Force and charged it with creating a comprehensive formula for determining how much medical coverage a college or university should have to fully meet student-athlete needs. The result of their work, released in 2000 and updated in 2003, was a set of guidelines based on all the important variables related to sports-medicine coverage and student-athlete welfare.

“Every year, it seems like coaches and athletic departments ask more from athletic training, and we’re striving to keep up with those demands and constantly improve,� says Miller, who chaired the AMCIA task force. “But clearly, the amount and quality of health care we can provide is linked to the amount of manpower available to do the job. The guidelines are an attempt to translate all of that into some numbers a program can use to evaluate itself.�

Miller says the AMCIA guidelines are the centerpiece of the NATA’s effort to help college athletic trainers advocate for more staff, so they’ll be revised and improved on an ongoing basis. “We’re just starting the process of re-evaluating the formula a second time, and we’re seeking feedback from athletic trainers who have used the AMCIA document so we can find out what has and hasn’t worked,� he explains. “We’re currently sending out a questionnaire to our entire membership about that, and hopefully next year we’ll make some new recommendations to the board of directors about altering the guidelines so they’re even more useful.�

USING THE GUIDELINES
How can you apply the AMCIA formula to your program to see whether your coverage level meets the recommendations? First, you must understand how the formula assesses coverage demands, using a system of points called Health Care Units (HCUs). Each sport is assigned a base-level HCU score between zero and four, depending on its injury rate, the number of treatments typically required per injury, and the potential for catastrophic injury. A school takes the HCU score for each of its sports and applies a formula that incorporates roster size, number of active days (practice and competition), length of season, the team’s travel schedule, and athletic trainers’ administrative duties associated with the sport.

From there, a total number of HCUs for each sport is determined, and when all sports have been calculated, the HCUs are added up. The formula says a full-time athletic trainer can be responsible for 12 HCUs per year, so dividing the department’s total HCUs by 12 reveals the number of athletic trainers recommended for appropriate medical coverage department-wide.

“One central goal of the AMCIA is to provide a measure of how much time an athletic trainer actually spends on each sport,� Miller explains. “Sometimes when athletes have minor or nagging injuries, they won’t miss any practices or games, but treating them takes up a lot of health care time. If the head athletic trainer talks about needing more help, the athletic director may look at rosters and say, ‘How can that be? We only have three people out this week!’ The HCUs give a more accurate picture of the demands athletic trainers face on a regular basis.�

Since the AMCIA formula uses hard data about a department’s athletic training services and the demands of each sport, it can add a new dimension to an argument for adding more coverage. One way not to use the formula, however, is as a “standard of care� to assess legal liability. Miller says that was never the intention, but acknowledges some misconceptions have arisen since the formula was first released.

“It’s one thing for an athletic trainer to explain to the athletic director that there isn’t enough coverage in the department,� says Matt Mitten, JD, Professor of Law at Marquette University and Director of the National Sports Law Institute. “But it’s quite different to say, ‘Here’s what we need to do to avoid legal liability.’ That is a much more complicated issue, and it’s not an argument I think athletic trainers ought to be making.

“The basic legal standard is that you must use reasonable care to protect against foreseeable harm—the interpretation of that depends on your resources, the plans in place for emergencies, and several other factors,� continues Mitten, a former chair of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports. “The law simply doesn’t require X number of athletic trainers for a school to be protected.�

That said, Mitten does believe the AMCIA guidelines can still be a useful tool in evaluating a program’s level of coverage. And Miller feels the formula has succeeded in helping athletic trainers present a case that’s more data-driven. “The NATA has fielded a lot of questions about the document, so we know people are using it,� Miller says. “I think for the most part, when you lay the numbers on the table, administrators around the country have said, ‘Okay, let’s see what we can do to improve our program.’�

GAINING SUPPORT

Along with using the AMCIA formula to advocate for more staff, another effective strategy is to line up support from those you work with. When Coble first arrived at Carroll, he quickly noticed that in the past, some injuries hadn’t been appropriately dealt with, especially outside of football. “I talked to coaches in some of the other sports and they agreed with me,� he says. “They understood immediately how their athletes would be better off with more coverage, and they supported me in my request for more staff.

“When coaches speak up and say, ‘My athletes aren’t getting the same care as someone else’s,’ that catches a lot of people’s attention,� Coble continues. “I also got the backing of our dean of student life and our athletic director after I talked with them about how it would benefit the athletes to hire another athletic trainer. Their support was critical in convincing the senior administration at our school to make room in the budget for a new position.�

Athletes’ parents can be a powerful ally, too, as they have a larger voice than ever in their children’s college experience. At Dowling, parents aided in Rodman’s campaign to add two full-time assistant athletic trainers to his staff in the past two years. “I keep athletes’ parents in the loop whenever there’s an injury or a rehab situation, and I talk to them every chance I get at contests,� he says. “If parents see the value of athletic training, maybe they’ll notice at the next away game if there isn’t an athletic trainer traveling with the team. Then they’ll start asking, ‘Why isn’t someone there, and what can I do about it?’

“No one is more concerned about student-athletes’ welfare than their parents, so they’ll go right to the athletic director or even the president of the school with their concerns,� Rodman continues. “If enough people start doing that, you can bet it will have an impact.�

Of course, the biggest obstacle in most college programs isn’t that administrators want to settle for less coverage—it’s simply the cost. So another powerful argument can be made by demonstrating how, under some circumstances, employing more athletic trainers will actually save the athletic department money.

At Dowling, the vast majority of student-athletes’ injury rehab used to be performed at private clinics and other out-of-house settings. But since adding more staff, the school has brought 90 percent of its rehab in-house, resulting in major savings. “When our insurance carrier realized that we would be handling more of our own treatments, they reduced our premiums and changed some things in our coverage,� Rodman says. “We ended up saving around $135,000.�

At Syracuse University, Head Athletic Trainer Tim Neal, MS, ATC, argued for a larger staff by explaining how it could enhance treatment in significant ways. “We’ve always been very good at conventional care, but with more people on staff we’ve expanded our repertoire and become even better,� says Neal, who has converted three part-time positions to full-time and created a new position all in the past six years. “Recently, two of our athletic trainers became certified in Active Release Technique, and since we incorporated it into our treatments, we’ve cut down on time lost to injury and helped athletes manage chronic injuries more effectively.

“And just last summer, all of us took an online course in sound-assisted soft-tissue mobilization, which we’ve had great results with,� he continues. “The net effect is, as the staff has grown in numbers, we’ve been able to branch out and expand what we can do for our athletes.�

For Coble, the common thread in all these persuasive tactics is getting administrators to see the many ways athletic training is a wise investment. “It’s part of our nature in this profession to work behind the scenes, out of the limelight,� he says. “But when it comes to proving your worth, sometimes you have to step up and tell your athletic director about those 16 athletes you treated this morning, or how you were in the athletic training room until midnight last night. If we don’t talk about that stuff, no one else will.

“It’s just like the coach who has to prove he can win before he gets a contract extension or another assistant,� Coble continues. “We have to show that we’re doing a great job, and that we’re really helping the department succeed. If everyone sees that, it’s a lot easier to make the case.�

THE SPOILS OF VICTORY
Athletic trainers who have successfully advocated for more staff agree on one more thing: The benefits justify the effort. From quality of care in the program to quality of life for themselves, the positive effects are numerous and worth lobbying for.

“Since we’ve added another athletic trainer, we’ve been able to formulate new strength and conditioning programs for several of our teams,� Coble says. “Not only has that addressed their performance needs, but it’s also resulted in fewer injuries because we’re taking more preventative measures. When the athletes are healthier and we’re spending less time treating injuries, everyone wins.�

Coble is also finding it much easier to balance his job with the rest of his life. “Sometimes it’s just knowing there’s someone else here if I need to go pick up the kids, or get a hair cut, or take half an hour to work out,� he says. “I have more time now for everyday things that come up, and I’m not worried about being burned out all the time. That’s made a huge difference.�

Sidebar:
TURNED DOWN
The truth is, not all requests for more athletic training staff will be successful. What should you do when there simply isn’t room in the budget for another position, but your workload is reaching overload?

One solution worth trying is to shift certain administrative duties to others in the athletic department. “A lot of things athletic trainers end up doing, like filling out insurance forms, handling the paperwork for doctor’s visits, and conducting drug testing, don’t need to be exclusively our responsibility,� says Mark Rodman, MSEd, ATC, Assistant Athletic Director for Sports Medicine and Wellness at Dowling College.

“If you can designate someone else to handle insurance issues, or to make sure outside doctors get paid, that can save a huge chunk of time,� he continues. “As more of the job has become administrative work, we have less time to treat athletes, and that’s not ideal for anyone. It’s worth stepping back to look at whether some of those duties should be reassigned.�

Creating a paper trail of your unsuccessful personnel requests is also a good idea. “Anytime you ask the administration for more staff, you need to put it in writing,� says Josephine Lee, MS, LAT, ATC, Assistant Director of Sports Medicine at Georgia Tech and President of the College Athletic Trainers’ Society. “If there’s ever a lawsuit because something bad happens, someone could ask why the head athletic trainer didn’t make sure there was more coverage. If you can show you were raising concerns about gaps in coverage on a regular basis, you can prove you saw the problem and did what you could.�

Greg Scholand is an Assistant Editor at Training & Conditioning. He can be reached at: gs@MomentumMedia.com

Since 2005, government rules have prevented Medicare from paying for physician-supervised treatment unless provided by a physical therapist, occupational therapist, or speech and language pathologist. As a result, athletic trainers, kinesiotherapists, and other allied health professionals have been left out of the Medicare picture. Now, a Senate bill aims to change those rules, to the benefit of athletic trainers and Medicare beneficiaries alike.

The bill, introduced in September by Sen. Craig Thomas (R, Wyo.), is called the Access to Physical Medicine and Rehabilitation Services Improvement Act of 2006 (S. 3963). It would change rules enacted by the government’s Centers for Medicare and Medicaid Services, allowing Medicare reimbursement for doctor-recommended therapy provided by certified athletic trainers and certain other professionals.

“This crucial piece of legislation ensures that the maximum number of qualified therapy professionals are available to provide Medicare beneficiaries with the quality care they need and deserve,� Chuck Kimmel, ATC, President of the NATA, said in a statement. “We believe that physicians are best qualified to determine the type of therapy treatments prescribed and to choose the best qualified professionals to deliver those services.�

The bill’s supporters note that in addition to improving the quality of care for Medicare users, the policy benefits taxpayers. Recent reports from the Medicare Payment Advisory Commission and the General Accounting Office indicate that physical medicine and rehabilitation services provided in a physician’s office (such as those performed by athletic trainers) are more cost effective than comparable services provided in other medical settings, such as skilled nursing facilities.

The Senate Committee on Finance received the bill in late September and has not yet scheduled a vote. The NATA, the American Academy of Physical Medicine and Rehabilitation, the American Medical Society for Sports Medicine, and many other professional groups have announced their support and have formed an ad hoc coalition to advocate for the bill’s passage.

As high school sports participation continues to rise, injury rates have fallen in the past decade, according to new research. Yet while this data is encouraging, one high school athletic trainer says more information is needed before drawing any conclusions.

The latest numbers come from a study published by the Centers for Disease Control and Prevention (CDC). The authors, led by Dawn Comstock, PhD, of the Columbus (Ohio) Children’s Hospital, looked at injury rates from 100 high schools nationwide in nine different sports—football, wrestling, boys’ and girls’ soccer, boys’ and girls’ basketball, girls’ volleyball, baseball, and softball—for the 2005-06 academic year. They compared their results to the findings of a 1999 study that used data from the mid-1990s and found that in every sport except girls’ volleyball, the injury rate was cut at least in half.

“While part of the decrease is due to a different definition of injury, we know that sports-related injury rates are decreasing because of rule changes, improvements in protective gear, and in the diagnosis and treatment of injury,� Comstock told the HealthDay News Service. She said scientific advancements and greater awareness in areas like heat illness and concussions are prime examples of these effects.

Jon Almquist, ATC, Athletic Training Program Specialist at Fairfax County (Va.) Schools and Chair of the NATA’s Secondary Schools Committee, says the study’s results are important but cautions against reading too much into them. “We have to look at larger amounts of data before we can make any real claims about a nationwide trend,� he says. “With improvements in athletic training in recent years, hopefully there has been a decrease in injuries. Now there is some evidence of that, but it should be viewed in perspective. It’s one study, and while it’s a great start, there’s still a lot more research to be done.�

The study, “Sports-Related Injuries Among High School Athletes: United States, 2005-06 School Year,� was published in the Sept. 29 issue (Vol. 55) of the CDC’s Morbidity and Mortality Weekly Report. To view the full text, go to: www.cdc.gov/mmwr/preview/mmwrhtml/mm5538a1.htm.

The practice of interval training—alternating short bouts of high-intensity exercise with longer periods of recovery—has been a mainstay among competitive athletes for years, since it replicates the brief and intense bursts of energy required in most sports. But how does it compare to standard cardio exercise for promoting muscle health to improve performance? A new study suggests the two are essentially equal.

In the study, led by Martin Gibala, PhD, Associate Professor of Kinesiology at McMaster University in Canada, college-age males exercised on stationary bicycles three times a week over a two-week period. One group worked out at peak intensity for 30 seconds, followed by four minutes of slow pedaling for active recovery, during a 20-minute session. The other group rode at a steady, moderate pace for 90 to 120 minutes per session.

After the two weeks, researchers tested each participant’s muscle tissue for an enzyme that indicates how efficiently the muscle is using oxygen. To their surprise, both groups exhibited roughly the same increase in enzyme level—around 25 to 30 percent. This suggests interval training offers the same benefits as less intense, more prolonged exercise in only a fraction of the time.

“You can think about [interval training] as being able to produce energy more efficiently, being able to go at a faster pace and exercise longer,� Gibala told the Los Angeles Times. “We’re still wrapping our heads around the magnitude of improvement in the interval group.�

California is one of only six states that doesn’t regulate or officially recognize the title of athletic trainer. And after an October veto by Gov. Arnold Schwarzenegger, that won’t be changing for now.

The Athletic Trainers Registration Act, which passed convincingly through the California legislature this summer, would have established certification for athletic trainers in the state and imposed penalties on any uncertified person who represented themselves as an “athletic trainer,� “certified athletic trainer,� “registered athletic trainer,� or “ATC.� It was introduced by State Sen. Alan Lowenthal on behalf of the California Athletic Trainers Association (CATA), which warned that under existing law, anyone could pass themselves off as an athletic trainer regardless of their education and skill level.

In Schwarzenegger’s veto message, he explained his decision in terms of small-government conservatism. “There is no evidence that the existing unregulated status of athletic trainers poses any threat to public health and safety,� he wrote to the state senate. “While there may be a benefit to consumers by providing a distinction for certified athletic trainers, this bill would place unnecessary regulatory burdens on the athletic training profession.�

CATA President Mike West, while disappointed by the veto, vows to continue the fight for recognition. “Have faith that though disappointed, your leadership is not discouraged,� he wrote on the CATA Web site in October. “Much was learned along the way that will ultimately assist us with whatever our next move might be.�

As more and more sports medicine professionals become frustrated with traditional approaches to hamstring care, they are coming up with new ideas on how to treat this bi-articular muscle group.

By Dr. Daniel Cipriani

In virtually every sport, hamstring injuries account for a larger percentage of lost time than any other musculotendon injury. Not surprisingly, a great deal of research has been devoted to understanding predisposing factors, intervention approaches, and preventative measures involving the muscles of the posterior thigh.

Yet, for the most part, these injuries still perplex us. Despite all that we’ve learned, we still repeatedly see athletes clutch the back of their thighs in pain and hobble off the field, court, or track. And once they’ve suffered one hamstring injury, there is a good chance they’ll suffer another.

In response, some sports medicine professionals are starting to think outside the box about the treatment and prevention of hamstring injuries. They are taking a more holistic approach to the hamstring and trying out new ideas and techniques. They are asking themselves: What is unique about this muscle group? Does its dual innervation lead to different types of injuries? And how does training the quadriceps affect the hamstrings?

In this article, I will review the most widely accepted predisposing factors of hamstring injuries as well as innovative approaches to intervention and prevention. I’ll examine the role of the quads and hip flexors in hamstring function, and explain how to train this muscle group in its position of greatest tension.

A LOT OF MUSCLE
The hamstring consists of four muscle bellies originating on the pelvis and inserting below the knee on the lower leg. On the lateral side of the posterior thigh is the biceps femoris component of the hamstring, and on the medial side are the semimembranosus and semitendonosus. These muscle branches are bi-articular in that they cross two joints: the hip and the knee.

From a functional standpoint, this bi-articular muscle group can produce and control a multitude of lower-extremity motions. With the leg in a non-weight bearing position (such as during the swing phase of running), the hamstring can shorten concentrically to extend the hip or flex the knee, and it can lengthen eccentrically to control the motion of hip flexion or knee extension.

With the leg in a weight-bearing position, the role of the hamstring becomes even more complex. Not only can the muscles work concentrically to extend the hip and eccentrically to control hip flexion (as with the motion of squatting down), they can also produce motion in the pelvis relative to the femur. The hamstring can produce a posterior rotation of the pelvis concentrically (such as when returning the spine from a bent over position), or control an anterior rotation of the pelvis eccentrically (such as when bending forward at the waist). This movement at the pelvis is often referred to as reverse muscle action.

Even though the hamstring is generally described as a knee muscle, from a torque-producing standpoint, it is actually better designed for actions involving the hip and pelvis. In fact, the hamstring has practically no function at the knee when the leg is bearing weight—any knee flexion in stance is caused by body weight and ground reaction forces. Studies using electromyography (EMG) have documented that the hamstring is more active at the hip than the knee during activities such as forward walking and running, backward walking and running, and cycling. These studies have demonstrated that it is the gastrocnemius, and not the hamstring, that is more responsible for creating knee-flexion muscle force during backward running and cycling.

One argument in support of the hamstring as a “knee muscle� is based on the potential role it plays in preventing anterior cruciate ligament (ACL) injuries. The ACL’s role is to prevent an anterior pull of the tibia relative to the femur. And research has demonstrated that the hamstring can produce a protective posterior pull of the tibia relative to the femur to protect the ACL from tension. However, these studies often miss the fact that the hamstring’s ability to create a posterior-directed force on the tibia depends on the knee being in flexion greater than 30 degrees (which rarely occurs during walking or running). Thus, the ability of the hamstring to protect the ACL may be limited.

Regardless of its potential role at the knee, it is not surprising that most hamstring injuries occur during the late swing phase of running. At this point, the hip is moving through flexion while the knee is extended—the hamstring is generating an eccentric muscle action (lengthening contraction) and being passively lengthened simultaneously—and is at its greatest tension. The hamstring is most responsible for controlling the action of hip flexion during the terminal swing, and this swinging leg certainly creates a great deal of angular momentum that must be controlled.

Given the complex functional demands placed on the hamstring, a number of predisposing factors related to the incidence of hamstring muscle injuries have been identified. They include inadequate hamstring strength, muscle imbalances between the hamstrings and the quadriceps, excessive anterior rotation of the pelvis (which places the hamstring in an elongated position), inadequate conditioning, and possibly reduced flexibility. In addition, it has been found that the leading cause of hamstring injury is the presence of a prior injury—nearly 30 percent of all hamstring injuries will result in a recurrence.

NEW APPROACHES
The traditional approach to preventing and treating hamstring injuries (following the acute treatment phase) has been to focus on isolated stretching of the hamstrings along with isolated strengthening. Traditional hamstring strengthening usually includes exercises that emphasize the hamstring’s role at the knee, such as hamstring curls. However, many athletic trainers and physical therapists have become frustrated with the limited results of these methods, and are starting to experiment with newer ideas that include more function-based exercise.

An interesting theory regarding hamstring injuries was recently posed by Bernie DePalma, MEd, PT, ATC, Head Athletic Trainer and Physical Therapist at Cornell University. He points out that the hamstring is unique in that it is one of the few bi-articular muscles that share a dual innervation. Rather than a single common innervation, the hamstring is innervated by two different levels of spinal nerve roots (the tibial branch and the peroneal branch of the sciatic nerve). This dual innervation may result in coordination issues within the muscle during dynamic, high-speed or high-tension activities.

DePalma further notes that the mode of injury to the hamstring differs based on the division of the muscle that is injured. For instance, the upper-middle portion of the hamstring is more prone to injuries during the terminal sub phase of swing (deceleration), whereas the lower lateral portion is at greater risk during the push-off sub phase of stance, when there is a quick, explosive contraction. Thus, the muscle can be injured when it is working eccentrically as the hip is in flexion, and it can also be injured when the muscle is working concentrically as the hip is in extension.

Another compelling observation has been made by Debra Brooks, PhD, CNMT, CEO of the Iowa Neuromuscular Therapy Center, who says, “It is never just the hamstring.� In her practice, she considers all the muscles that interact with the hamstring, and has identified overdeveloped quadriceps and hip flexor muscles as a critical problem area.

Brooks suggests that in order to fully address hamstring issues, athletic trainers and physical therapists must first address the hamstring’s antagonists: the quadriceps and hip flexors. In her experience, tightness of the quadriceps, hip flexors (psoas, iliacus, sartorius, pectinius, tensor fasciae latae, longus brevis), and gracilis are associated with an increased incidence of hamstring injuries. She points out that this anterior tightness can promote increased anterior pelvic tilt posture, which places tension on the hamstrings even before the hip begins to flex during walking and running. This anterior pelvic tilt can then predispose the hamstring to further increased tension during many physical activities. Because the hamstring functions predominantly with an eccentric action (to control forward hip flexion), this added tension stretches the hamstring to “within an inch of its life.�

IDEAS INTO ACTION
Like many progressive clinicians, Brooks considers the entire lower extremity and pelvis when investigating the cause or nature of a muscle injury. Even though the symptoms of a hamstring injury can be fairly obvious, she knows that the actual cause can be more complicated and multifaceted. Therefore, she includes in her injury investigation a thorough examination of standing pelvic posture to determine the influence of tight hip flexors and the rectus femoris.

She notes that the normal standing anterior pelvic tilt for males is approximately zero to five degrees from horizontal (using the PSIS to the ASIS for alignment), and for females it is approximately five to 10 degrees. Above-normal values suggest that the hip flexors and rectus femoris may be substantial contributors to a hamstring injury.

Of course, Brooks notes there are also common problems associated with hamstring injuries. For instance, sometimes the hamstring simply has limited flexibility, even when the pelvis is in perfect condition.

When it comes to intervention, from a treatment or a prevention standpoint, Brooks strongly believes that pelvic posture must be addressed first if it is outside the norm. Thus, she focuses initial hamstring training on correcting sagittal-plane pelvic posture (PSIS-to-ASIS angle).

She begins by using active isolated stretching techniques to improve the functional excursion of the quadriceps and hip flexor muscles. She addresses both the proximal quadriceps (rectus femoris) and the distal component of the quadriceps (the vasti components). For instance, if the psoas major (hip flexor) is tight, it prevents hip extension and the proximal quadriceps cannot be effectively stretched, so the psoas are also addressed. Improving flexibility of the hip flexors and rectus femoris can help reduce anterior pelvic rotation, and subsequently eliminate some of the tension produced in the hamstring muscles.

Once pelvic posture and anterior muscle flexibility have been examined, Brooks determines if there are any spasms and/or trigger points in the hamstring tissue. She also checks to see if hamstring flexibility is normal. She then initiates palpation to reduce spasm in the hamstring and moves on to strengthening exercises. Here, Brooks once again deviates from the normal approach—she advocates an active exercise program for the hamstring that involves strengthening and predominantly eccentric exercises, rather than stretching.

All too often, the first step athletic trainers take is to stretch an injured or elongated muscle group. But Brooks believes that strengthening may be more important for hamstring recovery than stretching the muscles. Research provides some support for this idea: Previous studies have not found a strong link between the incidence of hamstring injury and muscle tightness.

DePalma also focuses predominantly on strengthening the hamstring muscles. He recommends that training, conditioning, and rehabilitation of the hamstrings involve eccentric action exercises with the hip in flexion and concentric action exercises with the hip in extension.

Further, he believes hamstring training needs to be multifaceted, just like the modes of injury. His hamstring program involves high-intensity exercises with multiple sets and repetitions, performed in multiple hip and knee positions, at both high and low speeds. He places a heavy emphasis on the eccentric component of the muscle action with the hip in flexion and the concentric component of the muscle action with the hip in extension.

TOUGHER HAMSTRINGS
The key to these new ideas is that hamstring conditioning and rehabilitation should focus on the function of the hamstring at the hip, predominantly with an eccentric action. Prone lying hamstring knee curls should be replaced with standing, low- and high-speed hip extension exercises. In fact, to truly replicate the function of the hamstring, and mimic the mechanism of its injury, the muscle group should be strengthened in its position of greatest tension, with the hip in forward flexion and the knee in extension, while engaged in the terminal swing phase position of running.

To exercise this motion, the strengthening emphasis should be on the lengthening muscle contraction (eccentric action). The athlete should focus on controlling a loaded tension as the entire leg is pulled into hip flexion with the knee extended, as in the terminal phase of running. Using the hamstring function at the hip to control this forward pull of the leg trains the hamstring to perform forced eccentric action of the swing leg. This form of eccentric exercise should be initiated with low-speed motions, progressing gradually to greater speed.

Rubber tubing exercises are ideal for this type of hamstring training. The elastic tube can be connected to a fixed location on a wall at hip level, then attached to the athlete’s ankle, with the athlete facing the wall and standing far enough away to place maximum tension on the tubing. The athlete then allows the tubing to pull the leg forward, off the ground, into hip flexion and knee extension, using the hamstring muscles to control this forward pull.

The exercise is performed with slow, controlled repetitions. Eventually the speed of the motion is increased to replicate the high-speed swing phase of running. All of the tension is applied to the hamstring, by the tubing, with the hip pulled into flexion and the knee extended.

Exercises derived from the martial arts also provide an excellent training option. For example, the front snap kick and the long leg kick train the hamstring to control the rapid acceleration of a swinging leg, which creates stress similar to what is encountered when sprinting and jumping hurdles. In particular, these two activities require that the stance (support) leg be in a position of hip extension while the swing leg flexes at the hip, replicating the position of injury for the hamstring during sprinting activities. The hip extension of the trail leg produces an anterior pelvic tilt, which further stresses the hamstring of the swing leg.

The front snap kick exercise is initiated with the “target� leg in a front lunge stance. This target leg is lifted into hip flexion, the knee is sharply extended (front snap kick), and the target leg is then returned to the ground in a front lunge stance. The kicking motion requires the hamstring to work eccentrically with the hip in flexion and knee in extension, and the landing component requires the hamstring to control hip flexion into the lunge.

In the straight leg kick, the target leg begins as the trail leg, is brought forward in a straight leg kicking fashion, and then lands on the ground in a front lunge stance. This exercise can be advanced across the court or field, performing straight leg kicks, alternating between the right and left legs. Because this is a full leg kicking motion, it is more aggressive than the front snap kick.

In order to exercise the hamstring to prepare it for the weight bearing mode of injury (early stance), which may be a result of either a concentric or eccentric hip action, a number of different exercises can be used. I like to use two-leg and one-leg deadlifts, which place an emphasis on the hamstring’s function of controlling and moving the pelvis on the femur. These exercises train the muscles to control the anterior rotating pelvis during the lowering phase of the exercise and to create a posterior rotating pelvis during the raising phase of the exercise. In addition, common exercises such as the forward lunge, two-leg and one-leg squats, and diagonal lunges all force the hamstring to work at the hip, control hip flexion, and produce hip extension in weight bearing.

These exercises can be incorporated into any athlete’s training and conditioning regimen. As with any training program, the goals are generally to improve performance and prevent injury. Exercises such as the leg kicking movements, lunges, and deadlifts ensure the athlete is addressing the unique needs of the hamstring as part of an overall physical training program.

Obviously, conditioning and rehabilitation of the hamstring requires a number of different exercise approaches. Athletic trainers should always keep in mind that hamstring injuries are not just about the hamstring. Attention to the pelvis and recognition of the multifaceted function of the hamstrings in weight bearing and non-weight bearing functions are essential to effective management of this muscle group.

Daniel Cipriani, PhD, PT, is an Assistant Professor in the Department of Exercise and Nutritional Sciences at San Diego State University. He can be reached at: cipriani@mail.sdsu.edu.