Quad Pain, Injury & Science

For the previous five years I have been treating Troy for the injuries he sustains playing soccer/football. Troy is more prone to injury. And unless he's very diligent with his rehab, the more injuries he endures, the more inclined he is to sustain new ones. This is because of the “flow on effect that happens when a body part is not sufficiently mobile or strong to control the forces involved in the client’s chosen activity. Science based chiropractic injury specialist, Dr. Alexander Jimenez discusses the study.

Troy plays goalkeeper, for which he must move quickly in any way after long periods of relative inactivity. He takes goal kicks, which require him to create large amounts of muscular torque, too frequently after comparatively relaxed intervals.

In one match, Troy hurt his right quadriceps muscle after a goal kick really early on -- but he had, he promised me, warmed up before the beginning. Of interest was what Troy reported had been happening in the days before the game. He has a sedentary occupation, and he'd had some low back pain in the previous week. This was likely postural pain caused by a poor sitting position, but in these cases of prolonged sitting plus pain, I am always curious to look at what might be going on with the muscular system. Then, on the day of the game, Troy had undertaken a two-hour car travel, coming only 30 minutes before the warm up.

Following The Trail

The kicking action deploys muscles which stabilize the back, foot and knee together with the ones that provide the power for the approach and kicking of the ball. Since Mark Alexander has reported, the kicking action follows a certain timing and specificity of muscle recruitment.

One of people who have lower back pain, one quite common muscular imbalance is that the failure to recruit gluteus maximus at the right time (if at all), in its function of stretching the hip and strengthening the pelvis when standing on one leg.

The part of psoas major can be to keep the normal lordosis of the lower spine, especially when people are sitting, but also to stabilize the front of the hip joint to prevent injuries such as labral tears. On the football pitch, it is also very active in the approach to the ball and also the effect phase of the kicking action. It is reasonable to assume that the hip flexors may reflexively shorten if they are weak or not able to work throughout their whole selection. Table 1 shows which muscles may overwork or compensate for the reduction of activation of those stability muscles.

In case the psoas is feeble, the athlete may over-recruit rectus femoris to flex the hip, putting extra load with this muscle. What's more, if the hip flexor doesn't have adequate length, it cannot be properly lengthened in the preparation stage of the kick. This may lead to inadequate coordination of the through swing, resulting in poor performance -- and potentially injury.

This was certainly the mechanism behind Troy's muscle injury, as Table 2 shows.

Troy was unable to stand on one leg for any length of time, especially when he had to swing the opposite leg, as from the kicking action. Correction of this was all a part of his house exercise program.

I originally gave him exercises only to trigger the gluteals while lying supine, then standing and sitting. Then we progressed this into the stance leg at the kicking actions.

Gluteal exercises

1. Single leg stance glute activation

• Stand on affected side with good alignment and contract gluteals

• Perform three sets of 10 contractions, holding for 10 seconds each time. The athlete should not recruit the hamstring or adductors, but keep them relaxed.

2. Single leg stability against contralateral movement (Fig 1)

• Keeping stance knee facing forwards, turn contralateral side of pelvis away and back (counter and clockwise hip rotation) towards the front, using the gluteals. This strongly isolates gluteus medius on stance (affected) leg.

• Perform three sets of 10 reps under control.

3. Hip flexor strengthening (Fig 2)

• Loop x-band around ankle with weak hip flexor; secure the other end behind client.

• Standing on opposite leg, flex hip against the band resistance.

• Return leg, keeping it bent so that the foot stays off the ground, and repeat the raise.

• Avoid hitching hip on swing leg side.

• Perform three sets of 10 reps.

The principle which you're only as strong as the weakest link is indeed true here. Troy sustained the rectus femoris strain because of muscular weaknesses away from the injury site. Core muscle control is essential for all sports and it ought to be prioritized in every athlete's health program. It must also be specific to the sport: that is, speed and direction-specific. So that the therapist needs sound understanding of the technical aspects of the client's game and has to relate that back into the joint range and muscular control needed to reduce injury episodes and enhance functionality. In the end, a drop-off in performance is often the first warning sign that something's wrong.