S B Coaches College - Prehab Your Program, Program Your Prehab




		Prehab Your Program, Program Your Prehab *Joe Bonyai, CSCS* Share \|

Prehabilitory and corrective exercises have become as important to program design as any other element. They help to decrease pain and restriction, which leads to more efficient movement patterns and greater strength gains in the long run. However, even prehab exercises are vulnerable to abuse. Prehab exercises become ineffective when, like anything else, they are over-programmed and under-coached.

I think the more relevant side to the rule is that prehab exercises can be under-coached too easily. I doubt there are too many coaches over-programming prehab in a numbers sense. However, any part of training that is under-coached, is over-programmed.

Even the most basic isolation or “activation” exercises require multi-segmental coordination to ensure that movement is being produced at the right place, by the right muscles. Band walks, side-lying abduction, prone trap raises, and the thorn in my coaching-side, quadruped hip series, can all be massacred if you don’t watch your athletes closely.

Here are some examples of “simple” prehab exercises commonly performed incorrectly:

Side-lying Abduction (Top Left) – It’s very common for the hip to slide into flexion, decreasing the contribution of the posterior fibers of the glute medius.

Quadruped Abduction & Co. (Top Right) – I use quadruped exercises with caution and only when I have enough PVC tubes handy to lay across the athletes’ backs. In the picture above, Glenn demonstrates how some athletes are not able to dissociate their torso from hip action.

Prone Trap Raise (Middle Left) – Hyperextension of the cervical spine and medial rotation of the humerus will increase the contribution of the levator scapulae and rhomboids and decrease the contribution from the middle and lower traps. Although this picture isn’t the best, you can see Glenn is shrugging, instead of focusing on relaxing the upper traps and retracting.

Serratus Push Up (Middle Right) – Like the prone T, the demonstration in this picture is dominated by core instability and upper trap dominance. The hips should be elevated, securing the torso and allowing the scapulae to track properly along the rib cage. The head position should also be corrected to be in line with the torso.

Elbow to instep (Bottom Left) – I’m throwing dynamic flexibility or corrective mobility exercises into the prehab category as well. A more effective version of this movement would require full extension of the back leg and trunk so that there would appear to be a straight line from the ankle to the shoulder. This coordinates the hips and torso in a way that effectively transfers to efficient movement.

Hip Flexor Lunge (Bottom Right) – I’m picky about this one, and I’m not sure that picture does justice to the point I’m trying to explain. It is very easy for most athletes to extend through the lumbar spine during this type of stretch, which again, inhibits the coordination between the torso and hip that we’d expect to transfer to movement. This position may also compromise the anterior hip capsule and other ligamentous restraints in the front of the hip. Normal range of motion for hip extension is between five and ten degrees. Some texts report up to fifteen, but I’d say with all the time we have to spend working on hip extension with our athletes, it’s probably less. Even though this may feel like a stretch, we have to be careful of the tissue that is being stressed. Better execution of this stretch would ensure that the torso and pelvis remains stabilized and that hip extension of the back leg is active, requiring the hip extensors to fire and the hip flexors to relax.

Do we really have to prehab, prehab?

Yes. I’m not against prehab at all; however, I do think it can be programmed poorly, especially in a large-group setting. I don’t know how far poorly executed prehab will go to further exacerbate dysfunction, but nothing is more dysfunctional than a waste of time. Two ways to adjust your program are to either manipulate the exercises you’re already using, or choose new exercises. Here are some ways to get the most out of prehab, including some ideas that I “stole”, and additional exercise progressions that incorporate most of our prehabilitory goals.

1. Organize better

For exercises like prone Ts, and glute activation, use sets of 3-5 second iso-holds during warm up. This gives you a chance to keep your eye on more athletes performing the same exercise. This also gives the athletes a better chance to feel what muscles are supporting the position you put them in. Ask them, “Who feels this in their _______?” Whoever answers with some muscle other than the one you’re hoping for, fix them.

Isolate, then integrate. We’ve heard this before when it comes to prehab. But normally this means strengthening a muscle through isolation prior to integrating it into a multi-joint movement. In this case, isolate prehab by putting it at the beginning of a session, and once you feel your team has a handle on it, integrate those exercises into the workout later on in the program.

2. Choose different exercises

Band “Skater” – I’m borrowing this one directly from an article written by Anthony Lomando, of Athletes’ Performance. All credit goes to the staff there, but I liked the exercise so much, I thought it deserved further recognition.

Med Ball Elbow to Instep w/Rotation – This exercise is derived from a Gray Cook progression, except we don’t have Core Boards, so I substitute a med ball. It puts the athlete in a more applicable position than the elbow to instep shown earlier (above).

Start Begin “crawl”

Mini-Band Wall Crawl: More larceny. This exercise is extracted straight from Shirley Sahrmann’s text (1). It’s designed to improve shoulder flexion range of motion by activating the serratus anterior (by pushing into the wall). The mini band requires the lateral rotators of the rotator cuff to fire and fulfill their role as humeral depressors as the arm is elevated.

Single Arm Supine “Y” –Using the floor as a “guide”, the athlete is required to control the movement throughout the diagonal pattern. Once the athlete reaches the ball, they apply light pressure for 3-5 seconds and then repeat the pattern, maintaining “awareness” of the scapula stabilizers that should be felt against the floor throughout the movement. Preceding prone Y’s with this exercise generates better feeling, awareness, and control for the muscles the athlete should be strengthening. The ball can be replaced by a foam roller, or dyna-disk depending on the athlete’s level of restriction.

3. Use Prehabilitory Progressions

Another way to increase the corrective nature of your program, without decreasing the physical demand is by using “prehabilitory progressions” (I know, real creative). For the most part, the old-school program design parameters such as “stable to unstable” and “easy to difficult” get thrown out the window.

Exercises that are used early in a program should challenge as many of your “prehabilitory goals” as possible. These include: improving multidirectional trunk stability, active hip separation, scapular stability, active dorsiflexion, and so on. Exercises progress from an unstable stance (not surface) to a stable stance by the time strength and power development is the primary goal.

Dumbbell Bench Press Progression

DB Hip Bridge Bench (Top Two Pictures) – This exercise steals the concept of a Physioball DB bench and instead places the athletes shoulders on a stable surface. Have the athlete sit on a 12 inch plyo box, aerobic step or something that works. The athlete will lean back (Top Left), bridge their hips (Top Right) and perform the set in the bridge position.

DB Single Arm Bench (Bottom Left) – In this picture, Dan slides his body to one side until the edge of the bench is aligned along the midline of his torso. It’s a great anti-rotation exercise that, like the hip bridge bench, teaches the athlete the importance of hip and torso stability when attempting to transmit force through their upper body.

DB (Alt) Bench (Bottom Right) - Alternating DB and traditional DB bench exercises are programmed as maximum strength development becomes more important. By this time, your athletes should be locked into how to utilize their lower body and stabilize their torso in order to put up respectable weight.

Dumbbell Row Progression

Start Finish

Single Leg DB Row Supported (Top Two and Bottom Left) – This is a great exercise that will reveal a lot about an athlete’s movement capacity. The undermining definition is that it’s a horizontal row that will help build shoulder stability and improve single leg balance. The integrated view is that it evaluates active hip separation, hip stability, extensibility of the lateral hip and leg soft tissue, and the ability of core musculature to stabilize against rotary posterior-anterior force. Each single leg progression (top and bottom left) will help to build linkage between the hip and opposite shoulder.

DB Row (Bottom Right) – Just like DB bench progressions, as the program moves into strength and power development and away from corrective emphasis, athletes are allowed back on two feet.

Lunge Variations

Single DB Lunge Variations – Single dumbbell lunge variations challenge trunk stability in the coronal plane and are more challenging than you might expect. Researchers have suggested that deficits in neuromuscular control of the trunk in the coronal plane may predict risk of knee injury in females (2). I don’t normally jump to conclusions over one research study, but I did feel that adding a bit more single-dumbbell work early in a program would lead to cleaner movement later on. I like transitioning into single-leg balance (bottom right) between each rep with both lunge and single leg dead lift movements. Any additional opportunity to cue hip flexion to 90 degrees and active dorsiflexion should be utilized. It transfers nicely to movement mechanics during warm up, agilities, wall drills, etc.

Single Leg RDL Progression

PVC RDL RDL w/ PVC Y

I love single leg dead lift variations using heavy weight and low reps. However, most athletes generally don’t have the coordination to perform a body weight single leg dead lift well. Variations using a PVC (top two) will help to teach linkage between the torso and free leg. Dumbbell versions carry many of the same benefits of single leg rows (see above). As with lunges, I cue to finish each rep into single leg balance.

Question against this type of progression

“How do you expect an athlete to get stronger when so many of your progressions use single arm, single leg versions, and body weight?”

1) I think the real question is the definition of strength.

2) These are supplementary lifts that are included in a program with double and single leg plyos, med ball throws, Olympic lifts, clean pulls, front and/or back squats, and pull ups.

3) These lifts challenge myofascial linkage and subsystems that stabilize the body from the inside out and in each plane. Utilizing force in all three planes will help to evaluate dysfunction, which once corrected, will improve performance in your core lifts.

Conclusion and Perspective on Program Design

Program design is much like life itself. Where you are now should depend on where you’ve been and prepare you for where you are going. What exercises you’ve chosen in the past and your goals for the future give context to your programming. Whether you are evaluating someone else’s program or your own, make sure you first understand the context into which everything is placed.

References

1) Sahrmann, S. (2002). Diagnosis and Treatment of Movement Impairment Syndromes. Mosby.

2) Zazulak, B. T., Hewett, T. E., Reeves, N. P., Goldberg, B., & Cholewicki, J. (2007). Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. The American Journal of Sports Medicine. 35, 7.

Joe Bonyai, CSCS is currently completing his Master’s degree in strength and conditioning at Springfield College in Springfield, MA. At Springfield, Joe works as the strength and conditioning coach for five varsity teams. Please contact Joe at jjbonyai@hotmail.com