Rehab Never Ends

Previous injuries are the greatest predictor of future injuries.

I recently published 20 Hacks for the 24-Hour Athlete, a book written to help players with their overall talent development. Below is a chapter I wrote, based on previous newsletters, but decided not to include.

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I walked into my first practice as the head coach of a professional team as players warmed up and shot around informally. I saw our starting wing shooting free throws on the far basket. From behind, I could see him leaning to one side as he shot. I walked down to his basket and asked when he had hurt his ankle. He looked at me quizzically, as I had met him the previous day and barely knew his name. He said he had hurt it two years ago, but it did not hurt anymore.

He may not have felt any pain, which is normal two years post-injury, but his previous injury hurt his performance. Pain is a construct of the brain, according to Dr. Adriaan Luow. The initial pain is a perception of a threat; the ankle signals danger. Something is wrong. Abort! Abort! The pain dissipates when the danger or threat recedes, but its absence does not indicate health. Pain has little to do with the biology of or the recovery from an injury. The absence of pain simply signals the removal of the threat.

Additional shooting practice would not have improved his shooting without addressing his compromised ankle range of motion (ROM) first. A treatment has not worked until players return to their pre-injury performance, according to Peter Viteritti, DC. Instead, players too often base their recovery on pain, not the strength or health of the joint, returning to action when the pain dissipates and the swelling subsides. They develop new movement patterns when not fully rehabilitating their injuries, which increases their injury risk and reduces performance, according to Clare Frank, DPT. My wing needed to improve ankle ROM and flexion/extension, as his lingering injury created a new movement pattern and suboptimal performance.

Should you Ice an Ankle Sprain?

Nearly every team will lose players to an ankle sprain during a season. Ankle sprains contribute to over half of the time missed due to injury in basketball (McKay et al., 1996). The biggest risk factor is a previous ankle sprain, as players are five times as likely to sprain an ankle after a previous sprain (McKay et al, 2001). Pain fades quickly and many players never strengthen or recover proper ankle mobility. They return to play in a weakened state or with tightness due to the trauma. Most never notice, but they alter their movement pattern to protect the joint. The altered movement pattern stresses the system, and the joint never returns to full health, causing frequent re-injuries.

Players must return to their pre-injury performance levels or perhaps exceed their pre-injury levels, as weakness, tightness, poor proprioception, or subpar motor control may have contributed to the injury (Eils & Rosenbaum, 2001). They need to address their balance, control, coordination, mobility, stability, strength, movement quality, conditioning, and ultimately skill as part of their return-to-play protocol. As previous injuries increase injury risk, rehabilitation should not end once players return to play. Training equals rehab, and rehab equals training, as Charlie Weingroff says. Players should continue the exercises and tests to maintain health and performance. Rehab never fully ends, but becomes your training.

Single-leg balance has been shown to predict future ankle injuries, as those who demonstrated poor balance had nearly seven times as many ankle sprains as those with good balance (McGuine et al., 2000). Players who cannot stand on one leg with the other knee raised to hip level, close their eyes, and balance for 10 seconds are two-and-a-half times more likely to sprain an ankle, according to Men’s Health (February 2007). A study of 700 basketball and soccer players found those who performed the following exercises for 30 seconds on each leg suffered 38% fewer ankle sprains, according to Men’s Health.

Exercises

• Single-Leg Balance: Stand on one leg for 30 seconds. Harder: Close your eyes.

• Single-Leg Dribble: Dribble while balancing on one leg. Harder: Throw chest passes to a partner.

• Unstable Balance: Stand on a balance board. Harder: Rotate your hips from side to side while standing on the balance board.

• Single-Leg Unstable: Stand on one leg on a balance board. Harder: Close your eyes.

• Unstable Dribble: Hard: Stand on one leg on a balance board and dribble. Harder: Stand on one leg on a balance board and pass to a partner.

Furthermore, a 10-week, eight-minute warmup routine with a barefoot, eyes closed single-leg balance, plank, and calf stretching improves ankle dorsiflexion ROM and center of pressure displacement, which are important to ankle injury prevention in basketball players (Padua et al., 2019).

These are common rehabilitation exercises, and players with a history of ankle sprains should incorporate some of these exercises beyond their return to play to maintain their range of motion, balance, and ankle stability. These exercises alone may not be sufficient, as players have not recovered fully until they return to pre-injury performance. Additional training may be required to prevent the continued impact on their basketball and movement skills.

Stephen Curry’s career nearly was upended by persistent early-career ankle injuries and surgeries. He was mired in a cycle of injury and rehab and injury. Keke Lyles, then the new Director of Performance for the Golden State Warriors, shifted their strategy. “We wanted to teach Steph how to load his hips to help unload his ankles,” he said (Torre, 2016).

Curry’s new training initially emphasized the hip hinge and trap-bar deadlifts to emphasize the hips. Reduced ipsilateral hip abduction strength has been associated with chronic ankle sprains (Friel et al., 2006) as well as a delay in activation of the gluteus maximus in hip extension (Bullock-Sexton et al., 1994). Rest does not improve these weaknesses, nor does reducing swelling and pain. Players need to train and focus on the entire kinetic chain.

The kinetic chain is the sequenced and coordinated activation of body segments that puts the terminal/distal part at the optimal timing in the optimal position with the optimal speed to perform the required athletic activity (Almansoof et al., 2023). Isolating muscle groups, as is common in physical therapy for the general population, does not improve the sequencing and coordination of complex movements. Athletes need more full-body exercises and more time to transfer these gym gains into sport-specific movements.

Curry took to the training, which emphasized stability, as roughly 90% of his lower-body strength work is single-leg exercises: Reverse lunges, rear-foot elevated single-leg squats, single-leg dead lifts (Torre, 2016). Teammate Klay Thompson said, “The man was always in the gym. Steph just stuck with the routine. He works on his body just as much as he works on his jump shot” (Torre, 2016). Curry’s father, 16-year NBA vet Dell Curry, added, “Steph became more aware of how he needs to take care of his body” (Torre, 2016). His training moved beyond the initial rehab exercises, but has never moved too far from the rehabilitation concepts of training balance, stability, core strength, and ankle ROM.

The general population simply needs pain and swelling to subside to return to normal daily living. Athletes need more. Previous injuries predict future injuries not only because of the lasting effects of the trauma, as well as compensations, but because something caused the initial injury that also must be corrected or improved. Recovering from injury is not just a time to get back to the court, but to improve basic movements, balance, stability, and coordination. Some may need primarily ROM exercises; some may need more single-leg balance exercises; others, such as Curry, may need greater hip strength to shift their movement strategies. Regardless, athletes should not discontinue these exercises once they return to the court. These should become part of their regular training, potentially as a pre- or post-practice routine.

References

McKay, G.D., Payne, W.R., Goldie, P.A., Oakes, B.W., & Stanley, J.J. (1996). A comparison of the injuries sustained by female basketball and netball players. Australian Journal of Science and Medicine in Sport, 28,12–17.

McKay, G.D., Payne, W.R., Goldie, P.A., & Oakes, B.W. (2001). Ankle injuries in basketball: injury rate and risk factors. British Journal of Sports Medicine, 35, 103-08.

Eils, E. & Rosenbaum, D. (2001). A multi-station proprioceptive exercise program in patients with ankle instability. Medicine and Science in Sports and Exercise, 33(12), 1991-98.

McGuine, T.A., Greene, J.J., Best, T, & Leverson, G. (2000). Balance as a predictor of ankle injuries in high school basketball players. Clinical Journal of Sports Medicine, 10(4), 239-44.

Padua, E., D’Amico, A. G., Alashram, A., Campoli, F., Romagnoli, C., Lombardo, M., ... & Annino, G. (2019). Effectiveness of warm-up routine on the ankle injuries prevention in young female basketball players: A randomized controlled trial. Medicina, 55(10), 690.

Torre, P.S. (2016). How Stephen Curry got the best worst ankles in sports. ESPN the Magazine, February 29.

Friel, K., McLean, N., Myers, C., & Caceres, M. (2006). Ipsilateral hip abductor weakness after inversion ankle sprain. Journal of Athletic Training, 41(1), 74.

Bullock-Saxton, J.E., Janda, V., & Bullock, M.I. (1994). The influence of ankle sprain injury on muscle activation during hip extension. International Journal of Sports Medicine, 15(06), 330-334.

Almansoof, H.S., Nuhmani, S., & Muaidi, Q. (2023). Role of kinetic chain in sports performance and injury risk: A narrative review. Journal of Medicine and Life, 16(11), 1591.