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low back flexibility, chronic shoulder injury, female athletes

Low back flexibility & chronic shoulder injury: two case studies of female athletes

Case study 1: the rugby player whose low back will not flex

A rugby player (England Women’s Squad) I work with has some flexibility problems, specifically in the low back and hips where she is very restricted (see also page 7). You can see this inflexibility when she attempts a “touch toes” movement with her knees almost straight. Firstly, she hardly gets near her toes, which suggests her hamstrings are tight. Secondly, and more important for the low back, you can see that as she bends forward her lumbar spine is completely flat, with all the flex coming in the thoracic spine. In a normal adult you would see a smooth curve throughout the whole spine as all the segments flex a little. The problem with the rigid, flat lumbar area is that the thoracic spine will over-flex to compensate, reducing its stability and producing the round shouldered posture. This is known as a relative flexibility imbalance. The player and I have decided that her rigid lumbar spine and tight hips are reducing her agility and mobility on the pitch, particularly the ability to sprint, tackle and move with the ball in low positions.

Treatment

This season she is including the following dynamic mobility routine to her daily training.

Knee rolls. 20 reps

The athlete lies on her back, with knees bent, arms out to the side. With feet and knees together she rolls her legs from side to side. She takes her knees as far as they will go until the opposite shoulder starts to lift from the floor. This exercise flexes, lateral flexes and rotates the lumbar spine.

The Cat. 20 reps

Kneel on all fours, with hands below shoulders and knees below hips. Breathe in and arch your back, tilting the pelvis up, pulling the shoulders back and finally the head up and back. Hold this concave back position for two counts. Then, breathing out arch the back the other way, tilting the pelvis under, pushing the belly- button up as high as you can and letting the head and neck relax down completely. Hold this convex back position for two counts. This exercise flexes the lumbar spine and extends the thoracic spine.

Knees to chest. 10 reps.

Lying on your back, grab both legs behind the knees and pull them up towards your chest as much as you can, as if you are curling yourself into a ball. Hold the position for five counts and then release. Use your arms to pull on the legs, but also use your stomach muscles to pull on the lower back, sucking in the belly-button and making the lumbar spine flex as much as you can. This exercise flexes the lumbar spine and hips.

Dynamic hamstrings. 20 reps each side

Stand with feet hip-width apart but one foot in front of the other. Keeping the back straight, flex forward from the hips and run your hands down the front leg. Keep the front leg straight but allow the back leg to bend at the knee. Do the exercise slowly, focusing on the hamstring stretch in the back of the front leg. Do not reach with your arms or flex your upper back as you bend forward. This exercise stretches the hamstrings and helps with co-ordination of learning to bend from the hips and keep the back stable.

Deep squats. 20 reps

Stand with feet shoulder-width apart. Holding on to something in front for a little support, squat down as far as you can, flexing your knees and hips. Ideally, you can squat very low, with your knees and hips completely flexed. Hold the bottom position for three counts and stand up. This flexes the hips and low back in a functional manner which requires the athlete to bend as low as he/she can.

It is hoped that by performing this routine on most days each week, the player will improve her range of movement in the hips and low back, and her mobility and agility on the field will improve. To ensure that the increased range of motion is supported by increased strength throughout the whole range, the player is performing squats and lunges in her strength programme. These are being done not as heavy as she can lift, but with 100% focus on moving through a full range, flexing correctly at the hips and keeping the back stable, especially in the upper spine.

Case study 2: the rugby player with a chronic shoulder injury

Another England Women’s rugby player I work with had shoulder problems over the whole of last season. This prevented her from upper-body strength training, which, of course, is essential. The injury was an impingement of the supraspinatus tendon, which is a common rotator-cuff injury in athletes who perform lots of upper body lifts, especially the “press” and “overhead” types. After a period of treatment, the athlete performed regular rotator-cuff strengthening exercises. These included external rotations of the shoulder and limited-range lateral raises, both with light dumbbells. In combination, these two exercises work the whole of the rotator cuff muscles very effectively.

External rotations

Lie on your side with your top arm holding a dumbbell and bent at the elbow. Have your elbow fixed into your side and rotate the hand up and back, using the rear shoulder muscles. Do not rotate your back or lift your elbow.

Lateral raises (limited range)

Lie on your side with your arm straight down your side, holding a dumbbell. Lift your arm up until it makes a 45 deg. angle. Lower slowly. The player also performed exercises for scapula stabilisation. This means the ability of the scapula to stay in place (as part of the back) whilst the arm moves at the shoulder. A great way to train this is with the seated row exercise.

Seated row

Sit upright in the machine with perfect posture. Grasp hold of the weight and pinch your shoulder blades down and together slightly. Keeping your back perfectly still and maintaining the pinch in the shoulder blades throughout perform the row exercise. The only part of your body that should be moving is your arms. You will get the feeling that the elbows are being pulled back, while the shoulder stays in place.

With all three of these exercises, the initial focus must be on lots of reps and low weights, because stabilising muscles are trained more effectively with lower force movements.

Towards heavy lifting sessions

The final part of the rehabilitation process involves the athlete building up to being able to perform heavy lifting sessions twice a week. Ideally, the athlete will be able to bench press close to body weight as a 1 RM maximum lift, and in training she will be completing sets of 5-8 reps at relatively heavy weights. This requires a more demanding rehab progression than your normal adult, who would not need to strength train at such advanced levels. We decided that the best approach was to build up the “press” exercise loads, very slowly. The reason: while her big shoulder muscles may be capable of taking large weights, the tendons, ligaments and stabilising rotator-cuff muscles need to get used to the high forces gradually. It has been shown that tendons gain strength with training just as the muscles do, but it takes longer. The player performed the Dumbbell Bench Press exercise twice a week. This exercise was chosen as the weights are free, require stabilisation from the rotator cuff and the athlete can focus on moving through a full range of motion without being restricted by a bar or machine.

For the first month the athlete performed 3 sets of 20 reps at 10 kg. When this became very easy, she increased the weight to 15 kg and reduced the reps to 3 sets of 15. When this became easy, she raised the level to 17.5 kg for 3 sets of 12 and then 20 kg for 3 sets of 10. She is now lifting 25 kg for 3 sets of 8 completely pain free. This took a period of four months. Her technique and stability are much better than last season and so the risk of the injury recurring is reduced. She also performs lots of “row” and “pull” type exercises in her programme to ensure she has a balanced strength at front and back of the shoulder. This will also prevent injury in the future.

Raphael Brandon

low back flexibility, chronic shoulder injury, female athletes