A Balanced Approach to Rehabilitation and Sports Performance

A Balanced Approach to Rehabilitation and Sports Performance

Author: Gina Shaw/Friday, March 11, 2016/Categories: December 2014

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By Gina Shaw
When watching the teams of elite athletes march into the stadium during the 2014 Sochi Olympics, you might have assumed that all of them were paragons of strength, coordination and balance. After all, how could they get to this level if they weren’t? But of the more than 2,500 athletes who competed in the most recent Olympic Games, 11.2 percent reported suffering injuries.

A significant number of those injuries, say chiropractic experts, might well have been prevented with the right kind of training and rehabilitation.

Proprioception and Balance

“You’d be amazed at how many professional athletes lack coordination and balance,” says Guillermo Bermudez, DC, CCSP, who practices in Oregon and is a past president of the American Chiropractic Association’s Council on Sports Injuries and Physical Fitness (ACASC). “They have such tremendous natural gifts and have trained so much that they compensate for it. But the focus is so often on training the major muscles in the body that we neglect the smaller, synergistic balance and control muscles. That leads to injury and decreased ability to perform at the optimum level.”

Dr. Bermudez points to pitchers who experience injuries like a SLAP tear or a rotator cuff tear. “The throwing shoulder may be very powerful and strong, but when you test for stability, you’ll find that it’s actually very unstable.”

Injuries and Balance Training

A substantial body of research has demonstrated that impairments in balance and proprioception are significant contributors to injuries among athletes and that balance training can help reduce injury risk.

For example, one study prospectively tested nearly 300 male and female NCAA athletes for core proprioception, then followed them for three years.1 Among the women, for each degree increase in average active proprioceptive repositioning error, there was observed a 2.9-fold increase in the odds ratio of knee injury, and a 3.3- fold increase in the odds ratio of ligament/meniscal injury (P <or=>
A recent meta-analysis of randomized controlled trials found that proprioceptive training significantly reduced the rate of reinjury among athletes who had suffered an ankle sprain.2

Balance training can be particularly important when athletes have other factors that predispose them to injury — elements that may not be as amenable to change. One of the biggest considerations predisposing high school football players to ankle sprains is a high body mass index. “Linemen can’t drop weight, certainly not in the middle of a season, and that’s not really your goal,” notes Jay Greenstein, DC, CCSP, who practices in Maryland and is the team chiropractor for the Washington Redskins Cheerleaders.

But in a 2007 study of football players with high body mass and a previous ankle sprain or both, those who underwent balance and proprioceptive training using a foam stability pad saw a 77 percent reduction in their incidence of ankle sprains.3

Another study used the Functional Movement Screen™ tool (seven movement tests designed to easily identify restrictions or alterations in normal movements) to predict lower extremity injuries, particularly ACL tears, in female college athletes.4 “The maximum score on the FMS is 21 — most athletes don’t score that high,” says Dr. Greenstein. “The researchers found that the athletes who scored 14 or less on the FMS were six times more likely to sustain an ACL tear than those who scored higher. Screenings like these allow you to find the biomechanical fault and work to improve it and reduce the risk of injury. There are performance improvement plans using proprioceptive training and dynamic warm-up techniques that have a significant impact on reducing those injuries.”


Doctors of chiropractic are positioned to be the premier preventive and wellness experts for rehabilitation and performance, Dr. Greenstein says. “We provide truly functional solutions to patients’ problems, instead of just medicating symptoms.”

The first thing any DC should do with an athlete in need of rehabilitation is assess for an underlying predisposition to injury, says Sherri LaShomb,

DC, immediate past president of the ACASC, the head athletic trainer and DC for the Buffalo Bandits men’s professional lacrosse team and the team chiropractor for the athletes at Niagara University. “In addition to balance and proprioceptive problems, you may identify a kinetic chain issue, a biomechanical issue or a nutrition issue that’s putting them at risk for injury, especially if they’re coming to you for a chronic or recurrent problem.”

To assess an athlete’s balance control, Dr. Bermudez has begun using a new system for movement analysis and functional assessment known as OptoGait.5 It measures flight time of one leg vs. the other, and step length. “If you’re spending more time on one leg than another, that’s a problem.” OptoGait also facilitates jump testing, once again measuring contact time, flight time and location of landing.

Many chiropractic practices may not have access to costly technology like this, but you may be able to work with a local sports team or university athletics program on shared access. Dr. LaShomb also says that an experienced chiropractic physician can often discern almost as much from close observation. “If a patient comes into my office who sustained a back injury while playing golf, I’ll watch their swing to see how much motion they have at the shoulder, for instance. Maybe it’s not that their back muscles are weak; instead, maybe their core is weak, maybe they pronate at the foot and ankle or maybe they favor the right or left.”


One of the simplest forms of proprioceptive training is to have patients balance on one foot, with eyes open, and hold that pose for 20 seconds. Then, ask them to close their eyes and do the same thing. “Now they’re relying solely on the proprioceptive system; you’ve gotten rid of the visual ocular reflex,” Dr. Bermudez says. “Most athletes can’t do it and start hopping around within a few seconds.”

“But if you practice that for a few minutes, three or four times a day, it’s amazing how quickly your body will adjust,” Dr. Bermudez adds. “After an athlete improves balance with this exercise, we move to a soft pad that’s a little unstable and then to something like a BOSU ball. We also have them do squat balance training, using more of their hip and gluteal muscles rather than the knee.”

Range of Motion

Range of motion is also a critical component of rehabilitation for performance. “If you stand up and kick your leg backward and forward, but don’t have a full 90 degrees of flexion and extension, you’ll make that up with your back,” Dr. Bermudez says. “We’re talking about millimeters, but in an athlete, those millimeters are a big deal because they’re regularly putting a lot of wear and tear on the joint.”

Rehab Modalities

Rehabilitation should not move onto strength training until balance, coordination and range of motion are addressed, Dr. Bermudez says. “The key is to start with simple, basic small muscle groups and progress to bigger, more challenging movements that recruit more musculature, stressing the body and allowing it to adapt. The focus on this is still fairly new, so there is relatively little published outcomes literature. But anecdotally speaking, a lot of professional teams — and I happen to work with one, although I can’t be specific — have gone from a season where they suffered a lot of injuries to one with very few injuries, after initiating a rehabilitation program like this.”

Dr. LaShomb relies on multiple rehabilitation modalities and fine-tunes them for each patient. “I think every athlete and every injury is different,” she says. “I may start with one particular protocol, but what technique I use really varies from patient to patient depending on their injury and their response. For example, Graston Technique is commonly used for athletic rehabilitation, but athletes who are hypersensitive may not respond to that initially very well. I like to change things up based on the patient’s response.”

Of course, the athletes must continue their rehabilitative training at home, not simply in the chiropractic office. Tools for at-home rehabilitation can be simple and low cost, Dr. LaShomb says. “We suggest many low-tech things, like foam rollers, inflatable exercise balls, rehab bands and light weights.”

Dr. Greenstein has trademarked his own set of rehabilitation protocols, called FUNHAB®. “The name implies functional rehabilitation, but we also intend for it to signify fun for both our patients and employees,” he says. “While on the surface FUNHAB® appears to be solely about exercise, it actually is a multidimensional treatment program complete with spinal manipulation, soft-tissue modalities and rehabilitative functional exercises. We wanted to employ not only a biomechanical approach but a neurological approach as well, addressing peripheral and central neurologic responses to both pain and interventions.”

FUNHAB® is a region-specific treatment program, with “pyramids” of treatment aimed at four regions of the body: the Cervico-Thoracic Treatment Pyramid, the Upper Quarter Treatment Pyramid, the Lumbo-Pelvic Treatment Pyramid and the Lower Quarter Treatment Pyramid. The base of each pyramid is treatment of pain and inflammation; it then moves up through a total of 11 levels, such as joint integrity and mobility; gait, balance and locomotion; muscle performance; and specific skills and ADL activities.

Dr. Greenstein and his group published a description of the program in Topics in Integrative Health Care last year, and they are now beginning to collect long-term outcomes data. “We have to do it manually, outside of our electronic health record, because we don’t have the capability to do it with a push of a button now, so it’s taking some time,” he says.

Working with Dr. Alan Sokoloff and Dr. Spencer Baron, the team chiropractors for the Baltimore Ravens and the Miami Dolphins respectively, Dr. Greenstein has also created a nationwide training program called POWERPlay In Sports. It teaches DCs and other related health professionals to give free community workshops to coaches, parents and athletes about four key topics in sports: injury prevention and management, concussion prevention and management, dehydration and sports nutrition.

Educational Opportunities

Dr. LaShomb recommends that any DC interested in working with athletes pursue specialized training. “Education for this is key,” she says. “If you want to focus on this area, becoming a diplomate of the American Chiropractic Board of Sports Physicians and/or the American Chiropractic Rehabilitation Board would be important. If you’re just getting started, there are lots of continuing education seminars that address biomechanical issues in rehabilitation. These include Graston Technique, Active Release Technique, and FAKTR [Functional and Kinetic Treatment with Rehab], which all have weekend programs.”

“It’s all about us being the leaders in education to prevent these injuries from occurring in the first place,” Dr. Greenstein says. “We see young athletes being mismanaged every single day, and they then turn into young adults, middleaged, and older adults with chronic problems. We want to use a multimodal approach to musculoskeletal care to get those patients better, but we also want to teach them to get it right the first time. Improving the patient’s function, as opposed to simply managing the symptoms, can have a significant impact on injury reduction. Chiropractic adjustment makes people feel really good, and that’s wonderful, but at the end of the day, appropriate rehabilitation is essential for long-term positive outcomes.”


1 Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. The effects of core proprioception on knee injury: a prospective biomechanical-epidemiological study. Am J Sports Med. 2007 Mar;35(3):368–373.

2 Schiftan GS, Ross LA, Hahne AJ. The effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: A systematic review and meta-analysis. J Sci Med Sport. 2014 Apr 26. pii: S1440-2440(14)00074-7.

3 McHugh MP, Tyler TF, Mirabella MR, Mullaney MJ, Nicholas SJ. The effectiveness of a balance training intervention in reducing the incidence of noncontact ankle sprains in high school football players. Am J Sports Med. 2007 Aug;35(8):1289-94.

4 Chorba RS, Chorba DJ, Bouillon LE, Overmyer CA, Landis JA. Use of a functional movement screening tool to determine injury risk in female collegiate athletes. N Am J Sports Phys Ther. Jun 2010;

5(2): 47–54. 5 Lee MM et al., Concurrent Validity and Test-retest Reliability of the OptoGait Photoelectric Cell System for the Assessment of Spatio-temporal Parameters of the Gait of Young Adults. J Phy Ther Sci 2014 Jan 6; 26(11):81-5. Epub 2014 Feb 6.</or=>

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