Injury Protocol

Originally Published in Techniques Magazine

Provided by: USTFCCCA

Recent years have shown that NCAA athletics is leaving the transitional period from the old school 'No Pain, No Gain' era to the 'Student-Athlete Wellness Era'. The wizened coaches' perspective that 'these kids aren't as tough as they used to be' may linger but we as a profession need to move onto an athlete-centered approach in regards to injuries that meets the needs of the contemporary student- athlete and thus will extend the duties and responsibilities of the collegiate coach.

The very nature of every event group within track and field is to create a training program in which we are trying to create 'micro- injuries' in order to stimulate super compensation of physiological systems. However, with the demands for higher levels of performance, both coaches and athletes push the boundaries, toeing the line of individual human limitations in order to drop that extra fraction of a second or get that extra centimeter of effort. As a result, that line can accidentally be crossed and as a result a student athlete can become slightly hurt, or when warning signs are missed, injured for an extended time.

The key to successful injury management is to move from a reactionary standpoint to one of prevention, with the hope of putting the workload of addressing injuries prior to, rather than after they happen in rehab. Everyone understands that injuries will occur despite your best preventative efforts due to bad luck, genetic inclinations, or structural and anatomical reasons, but a large number can be avoided by addressing deficiencies in the muscular systems early on. However, even preventative measures and rehabilitation will not meet all the needs in this era.

Whether due to increased litigation of civil action lawsuits in athletics or an intellectual awakening of sorts, the publication of documents by the NCAA such as Mind, Body, and Sport and the proliferation of the NCAA Sports Science Institute have pushed student-athlete wellness to a position of importance next to or near actual team performance at some institutions. Thus, there is more than just a diagnosis and recovery that will be necessary when regarding injuries, rather a coach needs to work from a holistic standpoint when evaluating the needs of an injured student-athlete.

PREVENTATIVE MEASURES:

In the world of distance running, overuse injuries are the most common, however, they are usually a symptom or magnification of other issues at play such as strength imbalances, muscles weaknesses, inflexibility or structural deficiencies which can also lead to more acute injuries. In order to prevent many of these injuries, one needs to focus on developing both strength and flexibility from the core to extremities and from big muscles groups to small.

The goal of your flexibility program should be to increase range of motion, specifically in a manner that allows the stride to move unhindered through its natural cycle in order to allow for proper ground contact. The biggest thing to watch out for is tightness in the hip and pelvic area as this inflexibility can lead not only to injuries in the hips and upper legs due to the large muscle groups trying to power their way through a resisted movement, but can also lead to pain and injury that manifests itself in the knee or lower leg area due to incorrect foot strike brought about by the lack of ability to get to ground contact in an appropriate position. Unfortunately, if there is one area on a daily basis in which athletes go through the motions, it is usually during the daily stretching routine as it becomes a time in which socialization can take over and at times linger in a manner that negates the warm-up. Adding structure and accountability to this portion of your practice can lead to a significant decrease in injuries while increasing the desired range of motion

In addition to stretching for flexibility, incorporation of mobility programs that attack different points on the body will also not only increase range of motion, but increase strength in specific areas of concerns. Once again, the highest emphasis is on the core of the body, so creating dynamic strengthening routines such as a hip mobility series (example: straight leg raises, fire hydrants, donkey kicks, etc.) or hurdle walks increase the functional range of motion while simultaneously increasing strength without damaging the stretch reflex capabilities.

The incorporation of formal strengthening programs moving from simple body weight exercises to more traditional strength training that focus on the core moving towards the extremities can create strength in the abdominal region and lower back that can have a significant impact on pelvic tilt, hip extension and the resultant knee lift from improving anterior pelvic tilt. Most coaches have moved on from the traditional crunches to a larger scope of core strength that addresses the full scope of the core from abdominals to knees on the front and hamstrings to mid-back on the posterior side. In addition, the focus on the core of the body from the beginning sets the body up better for the introduction of formal strength training and far larger loads. Once again, working from the core towards the extremities, building lower leg strength from knee to ankle can help prevent shin splints, tendinitis and various other annoyances and a dedicated foot strengthen program can help prevent arch injuries and plantar fascistic.

Once the basics have been addressed in regards to strength and flexibility the next logical step is to move into the weight room. While there are great variations in strength programs, facilities, and the possible presence of a strength coach, there are a couple factors that should remain constant. First, one should address mobility through the three major joints of the legs as the inability to move through a full range of motion through the hips, knees, or ankles can prevent the body from being in the proper position through the full lift, thus putting one at risk of injury. Therefore, a mobility assessment under a light load should be done before lifting and no progression in terms of load should be done until the athlete shows proper range of motion through all three joints and lift can be performed with correct form.

At this point, the old school high rep, low weight endurance methods have been replaced with focus on strength and power in most strength training programs. If one's school does not have a strength and conditioning coach and thus the responsibility falls on the event specific coach, please take the following into consideration:

• Lifting should focus on power and strength development, not endurance

• Focus on major lower body compound lifts first (squats, leg presses, etc.)

• Use specific muscle lifts (leg extensions, leg curls, etc.) to addressed identified muscle imbalances

• Periodize your strength training like you would your running training portion in terms of volume and intensity

• Strength training needs to be monitored to be highly effective and safe

• Lift after workouts in order to take advantage of the release of hormones and to keep recovery days a day to recover

The final classification of preventative measures falls in the therapeutic realm using a variety of modalities that from an anecdotal standpoint sometimes have more value than the research may or may not support. However, with the psychology of the student-athlete a big part of their success, if they feel that the following methods work for them or you believe they are having a significant effect anecdotally, continue on with those methods. In regards to research regarding foam rolling (self-myofascial release), while it does not increase athletic performance, it may affect both short-term and long-term flexibility and range of motion while reducing the effects of delayed onset muscle soreness. Sports massage and deep tissue therapies show similar results in increasing range of motion and soreness reduction. Finally cold water immersion also has its opponents and conflicting research, however when used correctly (mid to low 50-degree range of temperature) it may have an effect on muscle soreness as well.

GOING BEYOND THE DIAGNOSIS:

The diagnosis of an injury is only the starting point, not an ending point or conclusion as one needs to investigate what was the underlying cause of the injury. While overtraining played a part into the equation, it most likely magnified an existing structural issue or imbalance. Beginning from the core of the body out, go through each joint looking for flexibility issues in regards to the range of motion and strength of muscles, tendons and ligaments associate with the movement. After flexibility and mobility, look at the muscle groups from big to small, looking for dramatic weaknesses in a large muscle group that may be causing a smaller muscle group to take on more load than it should. Or identify any large scale muscle imbalances between complimentary muscle groups (i.e. quadriceps and hamstrings).

Sit down with the student-athlete and talk about their nutrition at length. Walk them through their daily caloric needs and then take a look at the type of meals that would help them meet those needs. Be sure to address amounts of carbohydrates, proteins, and 'good fats' they need to be eating and provide samples of 3,000, 4,000 and 5,000 calorie diets. Have them track their calories for a few days using a phone based app to get an idea of where they are at before a diet modification and for a few days after. In most cases student-athletes are far below what they need to be without an eating disorder being present.

Ensure that there is a proper chain of communication occurring between all parties involved. A coach needs to be at the center collecting information regarding rehab and physical therapy from team doctors, athletic trainers, and specialists in order to relay that information to the student-athlete, event coaches and strength coaches to ensure that it is consistent and concise. One cannot rely on the "grapevine" method of getting information from a student-athlete as they may misinterpret the information or in some cases not reveal the whole story in hopes of getting back quicker. If necessary, work with the sports medicine department to have them develop a formal injury report listing injury, current physical therapy, next evaluation or milestone and projected timeline for return to running.

DURING THE INJURY:

When a student-athlete is injured, it is easy to let them slip through the cracks as your focus is on those student-athletes who are currently competing. However, it is important to note that during this time frame, the student-athlete can be in a fragile state of mind as many times their self-worth and self-identification is as being the one thing they cannot be, "a runner.' As a result of not being able to fulfill that portion of their life, athletes can become frustrated, depressed and at times drift towards risky behaviors.

Sit down with the student-athlete and create a formal recovery plan, much like you were creating an individual training plan, as this will give the student-athlete a focus that is necessary to fulfill that missing aspect of their self-identity. Focus on milestones they should be aiming for and give them a realistic timeline of recovery, as it may be easy to discuss optimistic timelines try to err on the realistic side as not to falsely create the illusion of a setback when the optimistic timeline of reaching a milestone is not met. Rather than 'banish' them to the pool or bike during practice time, give them a role at the beginning of practice that helps the team such as setting up equipment, helping athletes identifying the paces for the workouts, keeping splits or encouraging the moral of the team. This will keep them engaged with the team aspect and allow them to feel like they are making a contribution to the program.

Obviously during this time period, depending on the injury, the studentathlete will be completing some sort of cross training program in order to maintain their fitness. Depending on the timeline of the injury one can expect a certain amount of detraining to occur. For a rough point of reference; nothing is impacted at five days of non-training, at about 10 days of complete non training you begin to see significant decreases in metabolic activity, followed by significant decreases in VO2 max starting at two weeks, and at four weeks significant reductions in cardiovascular adaptations. Years of training experience can contribute to a slower process of reduction as can the inclusion of cross training. In regards to cross training, both aqua jogging and cycling research has shown both can similarly maintain the general aerobic fitness from running, but cannot reach the race specific endurance one requires at the 5,000 meters or below. Elliptical training research has been shown to only reduce VO2 max over a four week time span by less than two percent when complete non-training reduced VO2 max by over four percent in the same time frame.

Return to Run Protocol:

Once the athlete is ready to return to running, one needs to take into account various factors when creating a return to run program to ensure that there are no setbacks. These factors should include:

• Severity of injury
• Injury history of athlete
• Timeline within the competitive season
• Goals and desires of the student athlete

It is important to note, that two athletes that may have the same exact injuries may not follow the same return to training program. Regardless of what you devise, there is a need to remain athlete-centered during this part of the process. If a student-athlete is not comfortable with the vigor of the return to training program, you may want to downgrade it a bit even if you have higher goals than the athlete. Throughout the process you will need to listen to or 'read' the athlete to figure out how they are feeling and make adjustments to the protocol. It will also be important to look out for the health and well-being of the athlete from the perspective of protecting the athlete from themselves. As is the nature of the sport, most student-athletes are highly motived individuals that tend to err on the side of too much rather than too little, so it may be necessary for you to regulate what they are doing in order not to suffer a setback.

For impact related injuries (i.e. stress fractures and stress reactions) the first step we take is simply to progressively add weight by first taking away crutches followed by removing the walking boot for a portion of the day, and finally removing the walking boot all together. From there we progress to alternating jogging and walking, slowing increasing the duration of the running intervals while decreasing the walking intervals, a period that can happen over one to two weeks depending on the aforementioned factors. From there we begin a hybrid running, cross training program where total time of activity is equal to their max in season volume, and over the course of six to twelve weeks increase running volume while decreasing an equitable amount of cross training volume.

Comparatively, soft tissue injuries can have a more abbreviated timeline in terms of a return to run protocol, but can linger if not properly accounted for. Adding in volume versus intensity can differ relative to actual nature of the injury, with some allowing for a full return to volume quickly with a slower return to intensity and others allowing for quick incorporation of intensity but a much lower volume.

ADDRESSING RECURRENCES OF INJURY:

As frustrating as it is for a coach to have an athlete re-injure themselves, it is necessary to be empathic to the fact that the "injury-prone" athlete will be far more frustrated. Some athletes will be battling injury for all four years of college and simply walking that tightrope of being injured takes a mental toll via the anxiety that accompanies it and the depression that occurs immediately following an actual injury. These "injury-prone" athletes will need the most care and attention as they will require the assurance that there is a way to be healthy and have a positive experience, but that way may require modifications from the whole group training. Once again working with the athlete-centered model, begin to develop modified training plans that limit total volume, or increase cross training days, or increase off days. Find strategies that work and eliminate ones that do not, unfortunately, this will require trial and error, which may take months or years to figure out an optimal plan.

While a single injury may be brushed off as a fluke or outlier for that student-athlete, two injuries especially if similar, would suggest taking deeper looks into physiology of the student athlete. When returning from injury with a prolonged timeline of recovery, this is an optimal time to work on changes in form. Using the same methods as before in injury analysis begin from the core out starting with the core region and work your way towards the extremities. Considerations and observations should include pelvic tilt, hip drop, mobility of swing through, position at ground contact, position at toe off, hip extension, and foot strike to name a few. There are multiple phone apps that allow you to do effective rudimentary analysis of form in addition to more complex form analysis soft-ware that are beginning to propagate themselves at sports medicine clinics. However, before you begin, do your research in regards to what to look for and what are the underlying factors that lead to the 'suspect form' before making any changes.

With "injury-prone" athletes it's necessary to create and maintain a professionally close relationship as the student athlete will need to be comfortable enough to be open to bring up and discuss topics such as depression, eating disorders, amenorrhea, etc.. This is not an easy relationship to develop and in all situations this requires a lengthy build-up of trust in order to speak openly about such topics, especially when the coach-athlete relationship is made up of opposite genders. At times, conversation topics regarding depression may go beyond your expertise so an established relationship with campus counseling services is helpful when one needs to elevate the help needed. This trusting relationship is also helpful or necessary in order to consider one-time or regular testing of slightly invasive testing such as iron/ferritin blood testing, bone density scans, calcium and potentially hormone level measurements.

In the end, an exorbitantly large number of our student-athletes are not going to end up as professional track and field athletes. As such when the number of serious injuries begin to pile up over the years, it may be necessary to have the conversation regarding long time physical effects and short term mental effects of battling through such injuries over time. At times, it may be necessary for you as a coach to step-in on the athlete's behalf and discuss options beyond competing in college in order to prevent long term lasting physical effects and create better immediate mental health. Obviously the inclusion of college scholarships into the equation makes it a more complex discussion regarding `retiring' but this is a topic that appears near the top of the NCAA's student athlete welfare agenda in the coming years.