Recently the Journal of Sports Sciences published a Systematic Review detailing the factors associated with injury in Elite Junior Tennis players. It is important that coaches and parents of such athletes are aware of the findings (Oosterhoof et al, 2018).
Risk Factors for Lower Back Injury
Previous Lower Back Injury:
Previous injury is often a good predictor of future injury. Why? That is not clear, but one reason may be that rehabilitation of injuries is often not done to the level that it needs to. Rehab is often done adequately to get a player back on the court, but functional deficiencies can remain. This can predispose the athlete to recurrence, or to injury of another part of the body due to compensation. Elite Junior Tennis players should undertake their rehabilitation under the guidance of a Physiotherapist and Exercise Physiologist that are experienced in this field.
Training Loads > 6hrs p/wk:
Elite Junior Tennis players will be training and playing at least this amount. So how do we mitigate against this as a risk factor? For one, the athlete needs to have a good recovery repertoire and be diligent with it. A recovery program should be personalised for the athlete, but some common features of an athlete recovery plan are; adequate sleep; good diet, hydration and nutritional support (protein especially); massage; stretching and cold-water immersion. Secondly, Functional Resistance training can help build strength in muscles and tendons, mobility in joints, stability in movement, balance and spatial awareness. If your child, or an athlete under your guidance does not have a recovery plan, and/or is not undertaking a quality, personalised functional strength program I would speak to a qualified and experienced Exercise Physiologist to help them build one.
Risk Factor for Upper Extremity Injury
Fewer Years of Playing Experience
The authors do not specify what it meant by ‘fewer years of experience’ so we can only speculate. But generally speaking, when a young person starts at a new sport, their body is going to be exposed to forces that they may not be conditioned to deal with. I recommend that young people new to tennis undertake an overall movement capacity assessment, such as the ‘Movement Screen’ (Movement Screen ). This will identify any functional limitations that can be corrected through a functional strength training program. We use the Movement Screen with all of our young athletes at iNform.
Risk Factor for Lower Extremity Injury
Interestingly, in the studies included in the aforementioned review players that regularly stretched the muscles of the lower body had an increased risk of injury than those that didn’t. This is counterintuitive for most, as stretching is supposed to be good for us, right? Stretching can be useful for increasing the mobility of a restricted joint. However stretching can also acutely reduce our muscles responsiveness and power. So there are pros and cons to stretching for athletes. If an athlete is going to be prescribed stretches, they should be recommended only for areas that display movement restriction (and have shown a positive response to stretching) and should be timed so that performance is not impacted negatively. The Exercise Physiologists at iNform can easily identify whether a young tennis player would benefit from stretching, and recommend when is best to do it.
Whilst there are injury risks associated with playing Elite Level Tennis at the junior level, they can be mitigated by taking an intelligent and strategic approach to the young athletes programming. The Exercise Physiologists at iNform have extensive experience helping Elite Young Tennis players stay strong and healthy and on the court.
Jacobien H.F. Oosterhoff, Vincent Gouttebarge, Maarten Moen, J. Bart Staal, Gino M.M.J. Kerkhoffs, Johannes L. Tol & Babette M. Pluim(2018)Risk factors for musculoskeletal injuries in elite junior tennis players: a systematic review,Journal of Sports Sciences,DOI: 10.1080/02640414.2018.1485620
Our list of the 3 best core exercises offer the perfect way to keep your spine health and your abdominal muscles strong and functioning well – no matter where you are!
Those of you who have had some previous ‘iNform experience’ would be fully aware that we tend to stray away from traditional abdominal exercises like crunches, for those movements that train the core in a more movement specific manner.
Now, first and foremost, a bit of a disclaimer – these traditional exercises are unquestionably anatomically correct.
With this I mean that they do indeed train the abdominal muscles – although they certainly don’t really train them in a manner that replicates how they work in the real world.
You see, the muscles of the trunk (AKA, your core) make up a seriously complex system that plays a multitude of roles which are dependent upon the scenario in which they are placed.
With this in mind, they act to stabilise the spine and pelvis during high force and high velocity movements, they transfer force from one limb to another (for example, from the hip to the arm during throwing movements), and can also initiate movement of the trunk itself.
Which should make it pretty obvious as to why traditional abdominal exercises really don’t do enough.
But don’t worry – we have got you covered.
The 3 great core exercises outlined in this article provide a simple way that you can train the muscles of the trunk in an effective and efficient manner. These can be performed at home, and offer a fantastic means of enhancing your ability to stabilise the spine and transfer force – ticking all of the boxes for us.
3 Best Core Exercises You Can Do at Home
So, onto our exercises.
The first cab off the rank is the deadbug.
Extremely simple in premise, this great exercise offers one of the most effective ways to improve core strength and improve spinal stability, while also enhancing the trunks ability to transfer force between the upper and lower limbs.
Moreover, it can be performed anywhere and at any time.
Start by lying on your back with your feet and hands in the air. Your knees should be bent to 90 degrees (you should ultimately look like a ‘dead bug’). In this position brace your abdominals and press your lower back flat into the ground.
Proceed to drive one leg out, while simultaneously lowering your opposite arm back. Extend both out as far as you can without your lower back raising off the floor. This movement should be slow and controlled.
Return to the starting position and repeat on the other side – this is one repetition.
We can thank well known coach Tony Gentilcore for the perfect demonstration
An oldie but a goodie!
When performed appropriately the side plank trains the muscles of the trunk and the hip in a manner that teaches proper spine and hip control. This means a healthier spine, and a stronger trunk – both of which are pretty important of you ask me!
Start lying on your side with your elbow directly under your shoulder. You should be able to form a straight line from the bottom of your feet to the top of your head.
Lift your hips and trunk off the ground, ensuring that they are held in a straight line and completely rigid.
Hold this position for 20-30 seconds, and then repeat on the other side.
Here is a perfect demonstration by super coach, Dean Somerset.
Our third and final option is a specific plank variation that aims to correct the unwanted postural deviations we see as the result of prolonged periods of sitting. I really like this plank variation for a couple of reasons.
Firstly, it is seriously brutal. As a result, you only need to do sets of 15-20 seconds to get a decent effect, and get your abdominal muscles working overtime.
Secondly, it’s really hard to perform incorrectly. Once you get yourself in the proper position, if you ‘lose it’ you will feel it straight away. As a result, you can be sure that this exercises is doing exactly what its supposed to – which is building essentially building a strong and resilient human!
So, without further ado:
Start in a traditional plank position, with your elbows placed directly under your shoulders while you are up on your toes.
Shift your hips up so that they are slightly elevated, and squeeze your glutes as hard as you possibly can (imagine you are trying to crack a walnut…).
While in this position, actively ‘drag’ your elbows towards your knees (your elbows shouldn’t actually move, this should simply increase tension).
Hold this position with maximal tension for 15-20 seconds.
And another excellent demonstration provided by Dr John Rusin
Putting it all Together
So, doing these in a single (very short) session at home might look something like this.
Deadbug 20 reps either side
Side plank 20 seconds either side
RKC plank 20 seconds
Then rest for 1 minute and repeat the cycle 3-4 times, for a grand total of 10ish minutes.
Simple, and effective.
Take Home Message
I appreciate that you may not have the time available to get in a solid gym session every single day – but to say you don’t have the time to do anything is inexcusable. The program provided using the 3 core exercises outlined can be performed in as little as 10 minutes.
Not to mention it can be done literally anywhere, offers the perfect way to promote back health and enhance trunk strength, and allows your burn a little energy in the process.
I often get asked how does the brain deal with pain? The brain is a highly complex organ so lets not think of the brain regions as an entity; more like a highway of networks communicating. To understand how the brain makes pain, I will use the analogy of networks like a map. You may come to have some gratitude towards your brain, as your brain is only doing it’s absolute best to protect you.
So how does your brain deal with pain? Here’s an everyday analogy
Keeping to the network analogy: lets say you are meeting a friend for a coffee at a new unbeknownst location. You lock in the coordinates in your mobile app, and away you go. You start briskly walking and come across a busy pedestrian crossing. Of course you wait until the green logo flashes for you to safely cross.
As you continue to walk a cyclist rings their bell to notify you of their passing. The initial noise was alarming, which caught you by surprise. However the cyclist speeds on by, and you are back to absorbing the beautiful sunshine.
Further up the road you notice a branch impeding the footpath from the previous days storm. You decide to live a little, and jump over the branch thanking your exercise physiologist for the strong bones. Your heart rate settles back down, and your mobile app notifies you that you are five minutes from your destination.
As you see the coffee shop in the distance you close down the app taking your eyes briefly off the footpath to put your mobile phone away. Within a matter of milliseconds a car pulls out of the driveway while your head is still down. You put on your own breaks, by contracting your muscles with great force to prevent walking into the red jeep.
The driver gives you a wave in courtesy, and takes off. Still feeling a little startled, a memory comes up of your one and only bike accident. Five years ago with a red sedan, while you were training for your maiden triathlon. You consciously rub your right shoulder. Your friend meets you with a warm smile and hug. You both sit down, and your friend notices that you look a little ‘stiff’.
Breaking down the perceive threats so that we can understand how your brain deals with pain
The following analogy contains many contexts that I am going to break down with you, and most importantly reduce the threats. In my analogy I constructed a few events during the walk to the coffee shop that all have contextual meanings that the brain must process. Most are safe, with a couple having more meaning, can you guess which ones?
The pedestrian crossing is a safe means to cross the road. Although the crossing is busy with traffic. The brain likes the safety of the green light. What about the speeding cyclist? Although the cyclist bell would have been initially startling- fast acting areas in your brainstem enable you to respond quickly, the cyclist was also being courteous, while speeding off, which your brain processes the comforting visual information of safety.
What about the branch on the footpath? Haven’t you been strength training with your exercise physiologist? and feeling confident and strong? The quick jump activates the fight and flight system to release adrenaline to contract your muscles quickly, the brain enjoys these types of acute stress.
Now, how about the red jeep pulling out in front of you without any warning? Now here is an acute threat. However there are some added contexts to consider. The colour of the jeep is significant (remember the red sedan?), along with the colour red meaning: stop, hot and danger! And what about the significance? Weren’t you training for your first triathlon before being knocked off- with a subsequent right shoulder injury?
That is a pretty significant event that your brain ought to remember with great detail to protect you. However, the accident happened five years ago. Still, every time you see a red car, you notice that you hold onto your breath.
Lastly, your friend used the word “stiff” to describe your seated posture. What comes to mind when you think of stiff? Stiff can be in reference to your muscles tightening up reducing mobility, and maybe activating that neat fight and flight response again. But do you need it this time?
Can you see how everyday events can trigger the networks in the brain to communicate on: sound, vision, memory, colour and muscle tone? And how the significance of the event, even though it happened five years ago, can still alarm the brain to protect you?
Now understanding what pain is and how it protects us is useful, but now I would like to use this information to give some practical tips to reduce pain.
In Part 1 of this blog series we learnt that we need pain to survive, to avoid danger and protect us from injury. However in Part 2 we learnt that the protective response from an injury, such as muscle tightness and weakness can persist long after our tissue has healed. This can lead to pain being present for much longer than needed.
So if your pain has persisted for longer than the usual tissue healing time (around 3-6 months), then it might be useful to read below:
Tips to reduce pain:
Find movements that you feel comfortable with and progress slowly.
We know that pain is the result of our brain feeling as though we’ve pushed our tissue tolerance above a certain threshold (Butler & Moseley, 2013). So it’s firstly important to know where that threshold is at and gradually challenge this over time. For example, if your back gets sore after 10 minutes of continuous walking, start with less. Then you gradually build this up minute by minute until you get to an amount you’re happy with.
Now please understand, you will experience flare ups from time to time. However, it’s important not to worry about this. Unless there has been another injury/trauma (you will generally feel this at the time), these flare ups in pain are just a way of your brain telling you that you need to pull it back a bit. Go back to what was previously comfortable and then progress slowly once more.
Train your brain before you train your body
At times movement may be too much. You may know what types of movement give you pain. Quite often these movements are very similar to the movement that may have created your injury in the first place. So why not start with imagining the movement?
Motor skills studies show that just by imagining movements you can improve them. One in particular showed that basketballers who imagined free throws improved just as much as those that physically performed the task (Richardson, 1967).
Now when it comes to pain it’s important to imagine the movement pain free and in a relaxed state. Sometimes just thinking about an aggravating movement can make you feel anxious. It may bring up emotions that you need to recognise to move on. In this case you may need to relax yourself once more before you return to imagining the movement.
Distraction can be a great way to reduce pain
Our levels of pain are amplified in the brain when we focus on them. It makes sense that when we add other stimuli it gives your brain more to process therefore it decreases the pain stimuli (Schreiber et al, 2014).
Distraction is a great way to do this. Some things to consider while you exercise are listening to music, changing your visual input (closing your eyes or using mirrors), performing cognitive tasks (like crosswords/sudoku), adding balance (standing on one leg or moving on an unstable surface), and changing your environment (try outdoors, indoors or in water).
Find an aerobic exercise that suits you and perform it regularly
Now I understand that sometimes when you’re in pain it’s hard to find an aerobic form of exercise that is tolerable. However, research shows that if you can tolerate it (even if it produces a 6/10 pain level), doing it regularly will reduce your pain. This is because aerobic exercise has been shown to reduce your central immune response via the glial cells (Cobianchi, et al, 2017). People with chronic pain can quite often have a hypersensitive central immune system. When this system is always on it creates an inflammatory response, even when it’s not needed. So when you exercise is down regulates this response, leading to less inflammation and in turn reduces pain.
Choose fun, enjoyable activities with people you love!
Finally, one of my favourite pieces of advice is to find activities and movements you love! Not only will this help you reduce pain, we know that people who have hobbies and activities they enjoy typically live longer (and happier) than those who don’t (Fushiki et al, 2012).
In our brainstem we have certain areas that pick up pleasure and displeasure. Interestingly the area of displeasure is closely associated with areas of the brain that detect and produce pain. The pleasure centre does not have this relationship but is closely related to movement and attraction. So let’s use this to our advantage and find activities you actually want to do. It may even help you stay motivated to doing things that aren’t as pleasurable (such as the homework exercises your exercise physiologist gives you), so long as you can relate it to the activity you love (for me this activity is trail running!).
So there you go. Hopefully I’ve given you some practical ideas to reduce your pain and help you get back to doing the things you love doing. Obviously if you need any help with any of the tips above, we are alway here to help you with your journey free of pain.
Cobianchi, S., Arbat-Plana, A., López-Álvarez, V. M., & Navarro, X. (2017). Neuroprotective Effects of Exercise Treatments After Injury: The Dual Role of Neurotrophic Factors. Current Neuropharmacology, 15(4), 495–518. http://doi.org/10.2174/1570159X14666160330105132
Fushiki, Y., Ohnishi, H., Sakauchi, F., Oura, A., & Mori, M. (2012). Relationship of Hobby Activities With Mortality and Frailty Among Community-Dwelling Elderly Adults: Results of a Follow-up Study in Japan. Journal of Epidemiology, 22(4), 340–347. http://doi.org/10.2188/jea.JE20110057
Following on from the great work from my colleague Dr. Nathan Harten’s last blog; I will continue educating you on the latest neuroscience on persistent pain.
You may have been allluded to our brains wonderful capacity to protect to a ‘perceived’ threat.
Perceived you say?
Lets delve into this further…
There needs to be credible evidence of danger over safety for a pain experience (1).
Let’s pause and reflect on that for a moment…
Danger or safety in pain circumstances
It is advantageous to have fast acting danger messages to make us pull our hand away from a hot pan right? Danger over safety is highly relevant here. What about an ankle that had been sprained ten months ago? That ankle is still hurting to load, difficult to localize the pain, and you have exhausted Google & the pharmacist for an answer. Not advantageous at all is it?
Pain is not a true marker of tissue damage…
Let’s pause and reflect again on this statement…
Pain is an output constructed by the brain (1), by many contextuals. Contextuals ranging from:
Is this pain going to interrupt my job?
Is this what an ankle sprain feels like?
Can I still play in the football grand final?
How long am I going to be out for?
Should I just rest?
All of these constructs add to a pain experience (3); storing memories, emotions and motor patterns in a highly organised network, AKA your central nervous system. Even your immune cells (microglia) and endocrine system (HPA axis) are activated! (3) plus more!
Persistent pain is more than just where it hurts
So you see pain isn’t all just about where it hurts. Especially persistent, chronic pain (1). Somehow, your brain is still warning you. It still wants to protect you from a perceived threat and make you hurt.
This may sound like a rhetorical question, but is this protection advantageous at all?
Please take the time to reflect on your own experiences of pain…
Maybe the threat of losing your job is adding to a pain experience?
What if you are a professional athlete, trying to protect your pain from the coaching staff, perhaps because your contract is up at the end of the year?
Are you still blaming the driver who hit the back of your car?
All of the highlighted words are ‘threats’, and thus the brain will scrutinise all of the aforementioned and will decide whether it’s important or not to let you know; and to make you hurt.
Becoming aware of perceived threats and dangers are so important to understanding your pain (1, 3).
I hope now you think of pain as a biopsychosocial paradigm (Bio meaning the biological tissues, psycho meaning thoughts, feelings and beliefs; social meaning the environment) and not just about the tissue that hurts (2).
So I challenge you to challenge your beliefs on pain. This may be a line in the sand that you are willing to make.
Address what threats are in your life (work, financial). Learn how your stress system works. All of this is great at assisting you in the short term, but it can get a bit much if it’s 24/7 (think of having to listen to your car alarm all day!). However this is a topic for another day and another blog!
Feel free to seek help from someone else! Know that you are safe to move when you are experiencing chronic pain (even better with an exercise physiologist!).
Finally, know that we are neuroplastic and bioplastic… meaning that you can heal!
Now in part one of this blog we learnt that pain is a vital part of our survival but sometimes it can persist for longer than we need. So now I’d like to share with you some of the longer term changes that can occur as discovered by pain scientists (Hodges & Tucker, 2011). These adaptations give us a road-map on how to use exercise and movement to free ourselves from pain.
Pain leads to changes in the way we move
Think of a time when you may have hurt yourself and you were in pain. A very common occurrence is twisting your ankle. Sometimes this doesn’t create much tissue damage but it can have a very significant pain response. What you’ll notice is that you’ll limp, maybe just for a little while, as the pain changes the way we move so that we don’t load the affected area too much.
Our muscles around the area will “splint” to stiffen the area up and we’ll subconsciously take load off of the affected side. Now as I stated in part 1 of this blog, this is really useful during the first few months of tissue healing. But long term this can have other consequences. Some common examples are that if we were to injure a joint (let’s stay with the ankle). It can increase the load in joints further up the chain (such as the knee or hip). Alternately, let’s say that we injured our right ankle, if we don’t correct the way we are limping, we’ll place more weight through our left side making it work harder. This could then make the left leg more predisposed to injury.
Now many of these changes in how we move are subconscious. A lot of people don’t realise they are limping long after their initial injury. So sometimes we need to retrain our body to move freely and more evenly again. This is where specific corrective exercise can be useful.
Pain changes the way our muscles fire!
Not only does pain change the way we move, in doing so it also changes the way our muscles fire.
Some muscles will become facilitated
That is, they increase their tone to help protect and splint a particular area. Again while this might be useful for the first few months, these muscles tend to get tight and overworked in the long term.
They also become over-sensitised to pain to the point where even a gentle stretch, well below the threshold that would create tissue damage, creates a pain response. This is where it is important to get these muscles moving freely again, even if it is a little uncomfortable at first. In doing so we are retraining our protective response. Over time our brain no longer deems the use of these muscles as threatening and our pain will gradually decrease.
Some muscles will become inhibited
Now interestingly, while some muscles increase in tone others will “go to sleep”. These are quite often called inhibitions and the long term consequence of these muscles not firing properly can place undue stress on other tissues.
I don’t know whether anyone really knows why this occurs. Perhaps it is part of our short term protective response to prevent us from using a particular area and allow for healing. However we do know that in the brain the areas that fire a particular area become “smudged”. That is when we try to fire a particular muscle we might get a whole group of muscles firing (quite often the protective facilitated ones).
What we find is that we need to “wake up” these inhibited muscles which are quite often muscles that are important for the long term use of our past injured joints. And it is not until these muscles are firing properly again that our pain will subside.
Everyone’s protective pain response is individual
Finally, and most importantly, what we know is that our response to an injury and pain is unique and individual. How we move after an injury depends on what we were doing to cause the injury. How we splint and what muscles tighten up is very individual. And what muscles go to sleep and lose their capacity to fire can be different as well.
Interestingly, all of these people though may have the exact pain in the same location. So it is important that we don’t just focus on the area of pain. In fact, sometimes this can just feed our pain response as it make this area even more sensitive. We need to assess the way you move to see if you are still protecting an area long after it has fully healed. And we also need to identify what muscles are not firing appropriately and what muscles are still stiff and tight trying to protect.
Now this detective work is not always straightforward, particularly if like many of use you’ve accumulated multiple injuries over the years. But unraveling this tangled rope might be one of the best ways to do this and it is probably why good quality movement and exercise is shown to be one of the best ways to free yourself from pain.