Building a Strong Base in the Lower Extremities: Using "Rehab" Exercises for the Uninjured Athletes
During my clinical rotation, I was placed at a location with close ties to physical therapy's greats such as Dr. Chris Powers. Dr. Powers taught a closed workshop over the weekend to clinic staff. In most PT clinics, therapists will not get to do actual "strength and conditioning" due to insurances stopping authorization if a patient has met their "functional goal". Instead, we should educate patients on how to incorporate our exercises everyday in a practical manner. Dr. Powers runs a cash-based PT clinic where he is not limited by insurance.
His 2-day workshop was about lower extremity progression. Since other similar work by him is publicly accessible via peer-reviewed journals, I will be discussing how integrate and apply his findings into high level sports performance, rather than repeat what he said. Below are the 5 levels of lower extremity progression from injury to athletic performance by the man himself.
Most clinicians will only get to see Levels 1-3, rather than more traditional core lifts such as deadlift, squat, lunges, etc. On the opposite side, most lifters, athletes, and general public are ONLY doing traditional core lifts and maybe a few from Levels 4-5. In addition, it's probably with poor muscle recruitment (Don't assume all athletes have great form and understanding! They've got other things to put effort into such as the actual game plans). They rarely do anything from Level 1-3.
***CLINICAL PEARL: Dr. Powers suggested fixing the hip before the foot. Although the impairments may be seen on the foot as well, the hips have larger musculature and therefore giving you more bang for your buck in treatment. The foot is still important, but may be fixed if the glutes are addressed. This is different than common belief that injury should be addressed from the bottom up. With that said, keep this pearl in your head, but it is not meant to address every single case.***
The Significance and Application
For the athlete, lifter, general public: You may already be doing Levels 4-5 in addition to bigger core lifts, but it's important to still do certain exercises in Level 1-3. This helps reinforce proper muscle recruitment, and ensures the wrong muscles don't dominate a movement when instability is present. For example, many athletes squat heavy, but when I ask them to recruit their glutes during testing, they end up compensating with their erector spinae, TFL, and quads. This leads to eventual injury, pain, less time on the field, and reduced performance. Do not assume Levels 1-3 are for the weak, but rather those stages are filled with exercises for "prehab" or injury prevention. I recommend choosing 2-3 of these exercises to do at the end of all your workouts, taking no longer than 5-10 minutes (Most athletes only have 1 hour lifts, and as short as 30 minutes during the season). Below is a example template for a 1-hour session for a football player on leg day in-season.
- Hip Flow Warm-Up - (6 min)
- Double KB Cleans (3x5) - (3 min)
- Hang Clean (3x3; 60% max) - (4 min)
- KB Squat (5x5) - (4 min)
- Romanian Deadlift (3x5) - (5 min)
- Reverse Lunges (2x15) - (3 min)
- Side Squat w/ slider (2x15) - (3 min)
- Standing Fire hydrant (2x1 min hold) - (3 min)
- Sidelying Hip Abduction (2x1 min hold) - (3 min)
Notice this total work time is roughly 34 minutes. This accounts for time to re-rack or change weightts and other logistics that occur; final time should be roughly 1-hour even with partners and supersets. As athletes advance, more work time can be added. For in-season athletes we reduce volume significantly, and loads are heavier than hypertrophy and endurance. They are already getting volume at their practices, so overuse and volume need to be addressed in the weight room. No need to run them to the ground. People forget the secondary goal of a strength and conditioning coach is to keep players on the field year around.
***STRENGTH AND CONDITIONING PEARL: During workouts, look at things such as ankle mobility. Always be assessing to see if workout and practices are taking a toll. Stiffness is an indicator that future workouts need to be adjusted.***
For the physical therapist and trainers: We need to educate our patient's on how to program for injury prevention alongside their strength work. Most physical therapists either forget, or do not know how to program exercises. Certified Strength and Conditioning Specilists (CSCS) have it memorized: Warm-Up, Power, Strength, then accessory. The accessory portion is where most PT's live as far as treatment goes, so it's where we have to shine. Cue your patients for good pelvis and scapular stabilty on core lifts, and remind them to include these in their programming even when discharged. Of course you will need to talk to the strength coaches to implement this rather than the athletes; the strength coaches are on your side.
Thanks for reading,
CSCS, USAW-1, ACSM-CPT
What You Should Watch
Mike Reinold is a well-known physical therapist in the sports world, and always produces great content. Below is an older video of his, but is a basic cue and concept most people forget or get lazy with.
For trunk stabilization, we always move from the middle out to our limbs; the trunk must be stable while the limbs move. Once a athlete can keep their pelvis steady in a regular bridge, the next progression is to fire those abs and glutes while moving a foot or an arm. Here are some key points in developing progressions for the bridge:
- Pay attention to where you feel it. You should feel it in your glutes and abs. If you feel it primarily in your back, or hamstrings, then reset at the bottom and fire your glutes and abs before going up.
- It's important to move arms, legs, or both eventually to learn shoulder dissociation and hip disassociation for trunk control. Depending on the sport, one may be more applicable than others, but all should be attempted eventually.
- When moving an arm or a leg, a fully extended limb will tax the trunk more than a bent limb. This is because a longer lever can crank harder.
- For the REALLY advanced person, move one limb from bent to extended repeatedly and quickly to test your stability during high velocity actions. Only go as quick as you can maintain trunk and pelvis stability. Reminder that sports transferability will always triumph sports specificity.
What You Should Read
This month I followed the Strength and Conditioning coaches over at Cal Poly San Luis Obispo led by Chris Holder. If you don't know who Chris Holder is, a quick google will tell you he is the man with a plan. He may be most known for his introduction of kettlebells to pro and college teams, but he is all-around strength and conditioning genius when it comes to programming and mindset.
Below is a article he wrote for Breaking Muscle on his foundations to his programming that have kept his athletes on the field and performing at an unstoppable pace. See article here.
Vien is Doctor of Physical Therapy Student and also a Certified Strength and Conditioning Specialist through the National Strength and Conditioning Association. He has 6 years of experience training youth, college, and pro athletes in 1-on-1 and team settings. He has shadowed several Strength and Conditioning Programs in a addition to having clinical rotations in sports settings.