In our ever-changing world of sports medicine, we are faced with the challenge of keeping our athletes on the field and at the height of their athletic performance. Physical therapists traditionally have a rehabilitative role in this process. As our profession continues to develop, many of us have combined our clinical talents with sports-training skills. We have learned from many years of experience that a pre-habilitative role tends to elicit more successful outcomes. Proper education and training of our athletes' are a few of the many key roles we may play to significantly improve athletic outcomes. Many times, this intervention reduces the need for rehabilitation. And as most of us would agree, most physical therapists would prefer to assist the athlete's training progression rather than to rehabilitate the athlete. Of course, there will always be trauma in sport and function, but a proactive, pre-habilitative approach is where our focus should be.
Having worked with a multitude of athletes along the athletic spectrum, from the maturing adolescent to the world class Olympic athlete, I have too often seen consistent poor biomechanical movement patterns. Bad habits and mechanics begin early in athletic development and often continue throughout the athlete's development. The common movement problems we see are excessive foot pronation, knee valgus, and low back recruitment. Additionally, we see poor leg drive, poor functional flexibility, and poor core strength. These predisposing factors ultimately result in decreased performance, increased risk of injury, and missed games.
In our progressive sports-training approach, all of our athletes work from the core out. That is, we establish a solid lumbo-pelvic/hip foundation and work out toward the periphery. It all starts from the core. An athlete that properly controls his core during movement is going to be more powerful and, more importantly, more stable. Techniques combining proper warm-up, core development, sports-specific conditioning, and athletic endurance training are essential to elite athletic performance.
Our organization, Train Boston, comprises the strength and conditioning staff for the New England Revolution professional soccer team. We have the benefit of working with some of the top athletes in the league. And like most athletes, our athletes still show many of the biomechanical movement patterns described above that predispose them to injury. Additionally, a key component to minimizing injury is proper conditioning to address the problem of injuries late in competition when muscular and neural fatigue is heightened. In soccer, the more common injuries experienced are probably obvious…MCL sprains, ACL sprains, and hamstring & groin strains. Our objective is to best prepare our athletes to minimize these and any other injuries, while maximizing athletic performance.
In this article, I have chosen four exercises to address the most common injury topics we typically see in soccer. The topics are as follows:
- MCL sprains
- Hamstring Strains
- Groin Strains
- Late Game Fatigue leading to poor performance and/or injury
Of course, this is only a sample of injuries, but it is beyond the scope of this article to address every prehabilitative issue. We have decided to include four pre-habilitation exercises covering the above topics.
1. MCL Sprains
Knee valgus injuries may come from a plant-and-cut movement or from a traumatic blow from another player, among many other scenarios. We try to prepare our athlete to have solid proximal hip stabilization to minimize this occurrence. We try to train proximal stability of the hip rotators to help control the femoral-tibial angle. A great conditioning exercise to address this pre-habilitation is accomplished with a Gambetta Band. Simply have the athlete assume a slightly wider-based squat position, with the band placed directly across the knees. Ask the player to release the knees medially, while increasing foot pronation. 
Next, drive the knees outside the feet, moving the tibia laterally and the foot into increased supination. Repeat this to fatigue. The athlete should maintain a good squat position at approximately a 90-degree hip-to-knee angle throughout the drill. The athlete must maintain the squat position throughout the exercise. We typically like to have our players maintain this position from 20-40 seconds, depending upon the level of the athlete.
2. Hamstring Strains
In regards to hamstring and groin injuries, they typically occur due to weakness or poor flexibility. I have chosen to include a hamstring single-leg-buck progression to address a strengthening component and a dynamic lateral lunge to address the flexibility component.
Hamstring conditioning too often seems to be a mystery in conditioning programs and is not properly addressed. Typically, we just think of exercises such as a basic hamstring curl or the "good morning" exercise. We have found a single leg buck progression to be an integral component to proper hamstring conditioning. Phase I of this progression begins with the athlete beginning in a bridge position with feet up on a 12-16" block.
The start position is achieved after extending one leg up toward the ceiling. The athlete is then instructed to extend the hip while maintaining a neutral pelvis.
We ask the athlete to begin with 5-8 reps, eventually working up to 15-20 repetitions. If this type of motion is new to the athlete, he or she may experience cramping with as few as 3-5 repetitions due to poorly conditioned hip extensor strength.
There is a natural progression of increasing difficulty, as shown by the series of photos. Our single leg buck progression, as designed by my colleague and co-worker BJ Baker (former strength coach for the Boston Red Sox), is as follows: (from least to most intense)
1. 12-16" block
2. floor
3. 1 foot on med ball
4. 1 foot on swiss ball
5. slide board
3. Groin Strains
In regards to the groin exercise conditioning, I have selected a dynamic lateral lunge with forward flexion. I have chosen this exercise to demonstrate the need for a great active dynamic stretch to help properly prepare the groin prior to a match. This movement is also a great exercise for loosening up the lower back and hamstrings as well. Simply instruct the athlete to take a fairly large lateral lunge stride, forward flex as far as possible allowing the non-lunging foot to roll inward, hold for 1-2 seconds and repeat.
The athlete should repeat the same movement pattern 8-10 times in one direction and then repeat similarly in the other direction. This is one of the many dynamic movement patterns we utilize in our active warm-up progressions.
4. Late Game Fatigue (a common cause of injury due to improper conditioning)
So many injuries occur late in competition due to fatigue and/or poor conditioning. This is a well-understood and clearly documented fact. How many times have you watched a soccer match in the 70+ minute and watched a kick sail over the cross bar from a player that could otherwise kick that same shot through a hoola hoop in a non-fatigued state? When conditioning athletes, the emphasis should be to place an athlete in a controlled environment of a fatigued state and then trained. The result should be that when the athlete is involved in competition, he or she is prepared to perform, cutting down on the likelihood of injury and improving late game performance.
Lateral hurdle drills are but one example of exercises aimed at accomplishing enhanced conditioning in a functional manner. Additionally, I have included a drill that I use with soccer athletes including our high school and college teams. It is a good test of multi-directional movement combining footwork, balance, and endurance with an accurate finish on net. If the player does not accurately finish, he or she is instructed to continue on with another cycle until an accurate finish is achieved.
The intent of this article is two-fold; to heighten awareness of the impact physical therapists can have on rehabilitation of the athlete through a pre-habilitative approach and to demonstrate some effective, progressive exercise techniques specific to soccer training. If you are as fortunate as I am to have multiple roles of impact in sports training and therapy, you have surely seen the benefits. I trust that you have gained a few new, progressive training ideas for your soccer athlete or any athlete for that matter. I hope that more of my fellow colleagues will incorporate a pre-habilitative training component to help improve the physical therapy profession.
Tim Brewster, MSPT, CSCS is the founder of TRAIN Boston and is the Strength and Conditioning Coach for the New England Revolution professional soccer team. Tim is a graduate of Boston University, earning a Master's degree in physical therapy and a Bachelor's degree in exercise physiology. He has worked with many professional and amateur athletes including those of the 1996 Olympic Games in Atlanta, the NBA's Atlanta Hawks, and the NFL's St. Louis Rams. Through his many clinical experiences, he has developed his approach of "prehabilitation" and dynamic exercise. His emphasis is on sports performance, explosive power development, core conditioning, and athletic endurance.
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