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Recently, I had the opportunity to present to a local soccer club and their coaches on injury risk and reduction for the sport of soccer. In order to understand this, a “Needs Analysis” must be done. A Needs Analysis is a two-part analysis breaking down the sport into two components:
Today, our primary focus will be on evaluating the sport itself. This can be further broken down into:
Movement & Physiological Analysis Soccer is a very lower-body dominant sport involving the hip, knee and ankle joints and muscle groups including the quadriceps, glutes, hamstrings and calves. A soccer athlete must be able to run, jump, accelerate, decelerate, land, cut, kick, pass, head, shuffle, tackle – all while handling a ball and avoiding defenders. Oh, they also need the ability to sprint and jog throughout the duration of a 90+ minute game. Now, you’re talking about a dynamic athlete with a sound aerobic and anaerobic energy system. That’s A LOT. Here’s a more thorough breakdown:  Injury Analysis Sports injuries are inevitable. It comes with playing sports – exposure already puts you more at risk. You cannot prevent sports injuries, but you can help mitigate and reduce the risk of them happening – especially ones that are non-contact or overuse in nature. Here’s a breakdown of the most common injuries in soccer:  A study done in 2017 by Khodaee et al. tracked detailed information on injury rates among high school soccer players over a 10-year period (2005 – 2014). You can see those below broken down by gender and injury diagnosis.   Muscle strain, ligament sprain and concussions are highest as expected. What’s most interesting is the girls’ ligament sprain – very high for both practice and competition as compared to the boys’ group. Females are 2-5 times more likely to tear their ACL than males in a similar sport. There are a lot of factors that play into this and nothing is definitive. We do know that strength and neuromuscular control are big modifiable factors from an injury risk standpoint. In another study from 2015, Waldén and company analyzed 39 videos for movements related to non-contact ACL injuries in professional soccer players. They found that pressing, kicking, and heading were the 3 most common movements in relation to ACL injuries.  Pressing  Kicking  Heading (check that right leg in D - ouch) Cool, so now what do we do with all of this? Make some superhuman soccer athletes.
Have a plan in place to address these different components. It’s important to create a program for these athletes to develop these athletic characteristics – i.e. lower body strength, power, repeated sprint ability, cardiovascular endurance, change of direction and reactive agilities. Injuries happen all the time in soccer, but if we know what joints and muscles are most at risk, then we can better prepare these tissues to withstand the stress of the sport and build more resilient and robust athletes. Cheers, Dr. Ravi, DPT Sources: Baechle, Thomas R., and Roger W. Earle. Essentials of Strength Training and Conditioning. Champaign, IL: Human Kinetics, 2016. Print. Turner, E., Munro, A. G., & Comfort, P. (2013). Female Soccer: Part 1—A Needs Analysis. Strength & Conditioning Journal, 35(1), 51-57.
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Breathing While structured breathing work may seem simple-even silly- to some, we know that it is a powerful tool for the pregnant and postpartum woman. Deep breaths have the ability to calm the nervous system which can affect muscle tension, heart rate, and blood pressure. Additionally, the respiratory diaphragm can mobilize muscles in the pelvis and back due to anatomical connections. Muscles, including those shown in the photo below, are big players in midline stabilization and support. A great place to start is the 90/90 breathing drill (seen below). Try this out for 10-15 breaths at the end of your day. Ask questions Many postpartum women do not know all of the details after birthing their baby. Some have told me they were not aware they had stitches down below until the 6-week check-up when the doctor wanted to make sure they were healing well! The check-up at 6 weeks can be quick so arrive with questions. It is helpful to know about any tearing, episiotomies, tools used during the birth, etc. These factors are all great to bear in mind as you return to exercise and daily functioning. Another question to ask-- “Is there a pelvic health PT that you would recommend?” They may know someone in the area or have worked with them prior. However, do not become discouraged if they don’t have a name to offer. A Google search for “women’s health PT” or “pelvic PT” should show professionals in the area. Compare websites and reviews to see if the PT would be a good fit for you and your goals! Pelvic Health Physical Therapy Once you have been cleared by the doctor for “usual exercise” and intercourse, I highly suggest visiting a pelvic health or women’s health PT. They will be able to further answer any questions about symptoms you may experience immediately postpartum and later. A pelvic PT is specialized on evaluation and treatment of the pelvic floor musculature. They can perform internal evaluations to test the strength and endurance of your pelvic floor, check for prolapse, address any soft tissue issues, etc. For the evaluation, the therapist will use a gloved finger to palpate muscles internally. While a great deal of information can be gathered from an internal evaluation, it is not necessary for visiting a pelvic PT. The therapist can then prescribe exercises to help relieve the symptoms and provide hands-on work to hips, back, sacrum and other involved areas. Your PT should be a huge help in getting you back to fitness postpartum! Other areas they can treat and improve are bowel/bladder issues, painful sex, and pelvic pain. Focus on healing and strength rather than weight loss Social media and advertising may be all about “getting your body back” and fixing “mummy tummy,” but that is not the focus when you are postpartum. The first step in returning to fitness is addressing foundational strength and continuing to heal from the pregnancy and birth. Your body will go through so many changes in the months following your pregnancy and the timeline is different for every single woman. Steer clear of programs that say at week 8 you do blank. It should all be self-paced and based on symptoms, your birth story, and prior activity level. Do you need help starting out? This was the number one question I received from women in the clinic. “What can I do? Where do I start?” So I developed programming to recover and rebuild your core after having a baby. Check out the THRIVE: Rebuild Bundle programming HERE.  Find a community for support
Returning to group classes or running groups can be challenging because you will not be jumping right back into the level you were previously exercising. Having a group of women who understand your needs and have been or are currently at the same stage as you is tremendously beneficial. If this sounds like something you would be interested in, please join my Back to Fitness Postpartum Facebook page. We have posts nearly every day and a lot of great discussions- some serious and some silly! Once you return to group classes, be sure that the trainer knows you are postpartum and if there are any symptoms with movements. If they offer other movement suggestions that still do not feel great, then modify further! Symptoms (leaking, pain, heaviness in the vagina) are a signal to decrease the workload by resting or modifying or both! Getting back to fitness postpartum can be challenging but it is not impossible! With a holistic plan and support you will be able to recover and rebuild to get back to your favorite activities. If you are looking for help with learning more about postpartum fitness, the pelvic floor and how to reach your goals, then please reach out at Athletes’ Potential. Thanks for reading, Dr. Jackie, DPT  Why is this topic so important to me? It’s because I’ve personally been through this process. Twice. And it’s one of the hardest things I’ve had to do in my life. Successful return to sport after anterior cruciate ligament (ACL) reconstruction requires optimal physical AND psychological recovery. The psychological component is quite often overlooked. Fear, emotion, and poor self-esteem can have profound effects on patients' compliance, athletic identity, and readiness to return to sport. An athlete can be physically prepared for return to sport, but if there is fear or anxiety associated, then this process should be prolonged. If you’re a clinician, parent, or athlete reading this, here are four key areas to consider: 1. Psychological Distress:
 This is where education and setting the expectations is huge. When working with an athlete, it’s important to consider this as a part of rehab. Who wouldn’t have anxiety or emotions when they can no longer play their sport and get their knee operated on. It’s completely normal. Rather than hiding it, have a conversation with your athlete. Educate them on what to expect before, during and after the procedure and for rehab. Assure them that everything will be okay and that they will get back to their sport. When an athlete knows what to expect, there’s less psychological distress associated with the process, which can significantly impact the success of the rehab and return-to-play process. 2. Self-Efficacy:
3. Locus of Control:
4. Athletic Identity:
 In addition to the 4 areas above, an objective measure can be very beneficial to quantify where the athlete stands from not only a physical perspective, but psychological. That’s where the ACL-Return to Sport after Injury scale (ACL-RSI) can be helpful. The ACL-RSI is a great outcome measures to assess athletes' emotions, confidence in performance, and risk appraisal in relation to return to sport.
Recognizing positive and negative psychological responses to injury is the first step in initiating treatment and potentially modifying beliefs through psychological interventions. It is important to identify patients who are at risk for poor outcomes because targeted psychological interventions may be successful. If you know of an athlete going through this injury and recovery process, don’t forget that there’s more to it than just what you can see. Cheers, Dr. Ravi, DPT Sources: - Christino MA, Fantry AJ, Vopat BG. Psychological Aspects of Recovery Following Anterior Cruciate Ligament Reconstruction. J Am Acad Orthop Surg. 2015;23(8):501-9. - Sadeqi M, Klouche S, Bohu Y, Herman S, Lefevre N, Gerometta A. Progression of the Psychological ACL-RSI Score and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Prospective 2-Year Follow-up Study From the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST). Orthop J Sports Med. 2018;6(12):2325967118812819. - Ardern CL. Anterior Cruciate Ligament Reconstruction-Not Exactly a One-Way Ticket Back to the Preinjury Level: A Review of Contextual Factors Affecting Return to Sport After Surgery. Sports Health. 2015;7(3):224-30. -Schub D, Saluan P: Anterior cruciate ligament injuries in the young athlete: Evaluation and treatment. Sports Med Arthrosc 2011;19(1):34-43. Melissa A. Christino, MD, et al  Here’s what we know:
That last bullet point is a HUGE problem. How do we know when an athlete is ready? Traditional return-to-sport criteria are mainly focused on the time after ACLR and knee-specific impairments, while the return-to-sport decision-making process is only made at the hypothetical “end” of the rehabilitation period. When is this “end” point? When the patient runs out of insurance-covered visits? When the ortho clears them based on a 5-minute exam? When there’s no longer a government shutdown? This “end” point is completely made up and very subjective. That is why we need more concrete, objective measures to allow these athletes return to sport at a high level with the lowest risk of re-injury.  Dingenen et al. proposes: “an optimized criterion-based continuous and multifactorial return-to-sport approach based on shared decision making, with a focus on a broad spectrum of individual sensorimotor and biomechanical outcomes, within a biopsychosocial framework.” I could not agree more.  This means that we need to get away from time- and isolated-based assessments and look at this from a holistic 360 degree view, taking into account not only the biological factors of the athlete, but psychosocial factors as well. Since there are many individuals involved in this process, it takes a team to make the outcome truly successful. This team consists of the individual, their family, physical therapist, athletic trainer, orthopedic surgeon, sport coach, strength coach, etc.
Remember – A single component alone (i.e. time) is not enough to determine whether someone is ready. All of the components below could have the box checked except the last one and this athlete would still not be ready. I hope this provides some insight to you if you are going through this process as an athlete, parent, or clinician looking to return to sport.
Cheers, Dr. Ravi Source: Dingenen B, Gokeler A. Optimization of the Return-to-Sport Paradigm After Anterior Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward. Sports Med. 2017;47(8):1487-1500. |
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