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Hamstring Training and Injury Management in Team Sports, Episode 3: Conversation with Kostas Chatzic

After baseball and football we are going to look at what happens into professional basketball with one of the most successful teams in recent years in Europe.

I have the pleasure to introduce Kostas Chatzichristos, currently Director of Performance at CSKA Moscow, for the third episode of the hamstring management series.

AR: Kostas, you've been working with the CSKA Moscow for 4 years now. Can you explain how your role has evolved over time and how you actually manage all the aspects related to performance of your players?

Kostas Chatzichristos: I think that the biggest change throughout my years in coaching has been the increasing need to act, not only as a coach, but also as a manager and team builder. At CSKA, starting this season, I assumed such a role, being named Director of Performance, as there was a profound need to better organize and coordinate the medical and performance teams and also, to improve the communication with the coaching staff. We implemented many changes regarding role assignments, decision making and emergency procedures. One of the most important tasks was to bring all of us to function under a unified philosophy, which takes time and effort since we all come from different cultures and educational backgrounds. We also improved communication with the coaching staff, so that the head coach receives accurate and timely information regarding the condition of the players. There is still a lot of work to be done, as the department needs to grow by adding more experts in the areas of sports nutrition, sports psychology etc. Our vision is to become a point of reference in sports medicine and performance in European Basketball.

Managing all these duties during a long season that involves a lot of travel and many games needs organization and a great team that works efficiently. It takes frequent meetings with the medical staff to discuss our players’ needs and to decide on their training and treatment programs. It also involves long hours in the gym and on the court, since we often must group athletes according to their fatigue levels and playing times and train them separately. For example, after a Euroleague game, some players will do only treatment and recovery work, some will only lift and shoot, some will practice harder etc. For better communication between us and also for faster and more meaningful data analysis, for the first time this season, we are using an athlete management system (Athlete Monitoring) as a centralized location to share and analyze information.

AR: Hamstrings injury in basketball seems to have a lower impact than in other team sport like football, baseball or rugby however they represent a problem. Do you think there is still the need to emphasize hamstrings training over a more comprehensive performance program? What is your approach in pre-season and during season?

Kostas Chatzichristos: It is true that hamstring injuries are no so prevalent in basketball as in other sports. In our team, based on our statistics in the last five years, the more prevalent injuries are ankle sprains and lower leg muscle injuries.

I am a big believer that injury reduction in general is a matter of a more comprehensive, “holistic” like you said, approach. Injury prevention is not about one exercise or one method. It’s about a well-designed, personalized, multifaceted program that is consistently implemented and adjusted to the athlete’s changing physical condition Any intervention must be tailored to each athlete’s individual characteristics, mainly age, injury history, training history, position and performance needs. Although it makes sense to focus on a specific muscle or muscle groups that have been shown to have a higher prevalence of injury, this by no means should be the only focus of a training program. A hamstring injury can be the manifestation of a problem elsewhere in the chain, for example the hips or the feet, so we must look at the general picture and then work on each athlete’s needs.

Obviously, training differs a lot according to the various seasons. Our competition schedule is very strenuous, as we play around 80 official games in eight months, with a frequency of two to three games per week. This means that there is very little time to rest, let alone train. Despite the logistical difficulties, every week we try to have one “heavy” lifting day for each athlete. The focus of such a workout is mainly strength and power development, which, besides the obvious positive effects on performance, has been shown to have potent injury prevention effect. Then we try to schedule individual sessions according to each player’s fatigue levels and playing times. The goal is to get them in the weight room as often as possible, even for a short time, as I think consistency and constant monitoring is the key in maintaining health during such a demanding season. Although strength and power development using multi-joint lifts is a major focus of the program, in each workout we include a lot of individualized exercises on mobility, stability and muscle activation, all based on the player’s current condition.

© CSKA Moscow

Since we are talking about injury prevention, I think that it’s worth mentioning that during the season, apart from exercise, load management can have a profound effect on players’ health. Balancing work and rest, taking every opportunity to unload some key players are as important as exercise in terms of injury reduction. Too make such decisions, we look at things like individual playing time, practice loading, subjective feelings of fatigue and energy levels and of course, our upcoming playing schedule. At this point, communication with the coaching staff and especially with the head coach is vital. I like to say that in any team, the head coach is the Chief Injury Prevention Officer, as he is the one that has the final word on programing, on whether the team or a specific player will rest, or practice and he eventually decides on practice intensity and volume.

Preseason is strenuous by default, because of the volume, intensity and frequency of training. If the combined load from basketball practice and our conditioning/ “strength” sessions is not properly controlled and adjusted to the players’ capacity, then there is an increased risk of injury. At this phase, my primary focus is the health of the neuromuscular system. I make sure to make some basic tests in the beginning of each season and then adjust my program to each player’s needs. When it comes to training in the weight room, I really can’t say that I follow a specific protocol for the whole team. I take an individual approach with everyone, since we got players that show up at training camp prepared after working hard during the off season, players that are somewhat prepared, guys I see for the first time (new transfers) and players that are out of shape. Some guys can train harder that others, but in all of them I place a big focus on dealing with muscle weaknesses and imbalances from previous injuries, on maintaining joint mobility, on building basic strength with medium intensity and volume and on teaching basic techniques (especially for the new comers), thus setting the base for working harder in the future. This may sound oxymoron, since it’s thought to be hard to increase strength and power during the season, when the games start I get more opportunities to train my players, since we practice only once per day.

AR: Most performance and rehab professionals doesn't make a proper distinction between training for hamstrings health and training for hamstrings rehab. The different situation in muscle physiology between a previous injured and a non-injured athlete leads to different methods and training variables. How do you manage the rehab process and what baseline testing and metrics you use for return to play decision?

Kostas Chatzichristos: When training an injured athlete, we must always consider the time course and healing process of the involved tissues (collagen, muscle tissue etc), their current loading capabilities and the available range of motion. Generally, in the early stages after trauma, an injured muscle needs much lighter loads and careful exercise progression. After the initial diagnosis, along with any therapy modalities applied to the athlete, I start loading the non-injured part of the muscle and its synergists using positional isometrics. The goal is to preserve as much strength and function as possible. In a next stage, I will start loading the injured muscle, again by using isometric contractions and gradually we add low-speed, low-load weight bearing exercises as well as non-weight bearing exercises. For example, we will do various marches, partial lunges, body weight squats, hip extensions, always being careful to use non-painful range of motion. Generally, I use the same exercises that I would use with a healthy athlete, making sure that the selected variation and load, will do no harm to the injured tissues. For example, I will have the athlete do an SRDL without any added external weight and for a limited, pain-free ROM. If he can complete the exercise with no pain, then I will increase the load by adding weight or changing the lever arm. Following this phase, we place an increasing emphasis on strength and higher velocity exercises, until we can bring the athlete to perform all sport specific movements at 100% speed. The final step in rehab is to have the player complete at least two team practices without feeling and pain or discomfort. Another point I would like to stress, which I think doesn’t receive enough attention, is that even a small injury can cause muscle inhibition (cortical or peripheral) , which in turn can affect the rehabilitation outcome, by preventing strength and muscle mass gains.

The return to play decision is made collectively with the doctor and the rest of the medical staff. Our criteria to clear a player to fully participate in official games are mainly absence of pain or discomfort during and after practice, full range of motion of the involved limb and absence of pain on palpation at the injury site. As far as metrics go, I always test muscle activation and isometric strength using manual muscle testing and compare pre-post injury performance metrics, using tests like the squat jump, single leg jump etc. Although the later are not hamstring specific assessments, they do give us a picture or the general condition of the player.

AR: An holistic approach to hamstrings training seems to be supported by some recent researches as well as what we see in daily practice. How important is a proper speed and coordination training into the hamstrings conditioning process?

Kostas Chatzichristos: As I mentioned before, I believe in a more “holistic” approach when it comes to injury reduction and performance enhancement. Speed and agility are important components for hamstring conditioning and general neuromuscular training, since they closely simulate game conditions. During the in-season we don’t do much – if any- extra agility training. We do add one or two drills in some days right after our pre-practice warm up, but most of the COD training comes from playing basketball in a competitive intensity. I believe that training as close to game intensity as possible, keeping the volume of training low and giving appropriate recovery time plays a crucial role in reducing hamstring and other neuromuscular injury to a minimum. Speed and coordination must also be an integral part of training in the later stages of rehab before an injured athlete return to full action. I always start working on acceleration and COD mechanics at low speeds as soon as possible after an injury, to improve coordination, movement quality and active range of motion.

© CSKA Moscow

AR: Eccentric strength and fascicles length are two fundamental parameters related to the risk of hamstrings injuries. Nordic exercise as well as flywheel eccentric can have their place into a training plan but overemphasizing a single exercise or method is a big problem in professional sport. What is your opinion about the way eccentric exercises are being used today?

Kostas Chatzichristos: Certain exercises or pieces of equipment periodically receive a lot of attention and are being promoted as the solution to all our problems. Unfortunately, there are no magic bullets when it comes to rehab, injury reduction or performance enhancement. Too many coaches fall into that trap of overemphasizing on certain methods or exercises, instead of initially looking the body as an interconnected machine. The Nordic curl as a form of eccentric exercise is a piece of the puzzle, not the whole puzzle. I like to think about all types of exercises from a biomechanics point of view: What is the direction of the external forces, which muscle or muscle fibers are activated (internal forces analysis), which is the center of rotation in each move, how does the lever arms change throughout the movement? There is nothing magic about one exercise or the other. Regarding the Nordic curl we must also consider a few basic questions: How many players can really perform a proper full ROM Nordic curl? What are the progressions one must follow? What if an athlete cannot perform this specific exercise due to injury? How can we design biomechanically similar exercises? A coach must always think about all the above parameters and make proper decisions on which exercise is best for a specific player. I have nothing against Nordics, but for the body type of an elite basketball player, other exercises with a strong eccentric component, for example variation of RDL’s, might be more beneficial and easier to progress.

I can’t say much about the use of eccentric exercise specifically, but I want to stress a couple of points about exercise in general. The first one is proper exercise loading. Too often I see coaches working in what I call the “Empty Zone”, which basically means that the weight and/or speed of movement is not sufficient to cause any adaptation along the force-velocity curve. For example, I see professional soccer players working on “strength” doing body weight squats and step ups with 10 kilos, which is clearly not enough to cause any meaningful adaptation either for injury prevention or performance enhancement. The effect of an exercises depends mainly on loading, not its “choreography”! Second, many coaches don’t pay enough attention to proper technique. I admit that coaching every athlete is hard to do in a team setting, but there is no other way, since even a minor change in the technique can alter the loading pattern of and exercise and stress a completely different body part than of that intended. It’s also dangerous. I believe we must organize our sessions (for example, split the team in many small groups) so that we are able to coach every set and every rep, even to athletes that are experienced and have being with our programs for many years.

AR: Technology application is growing today and professional teams are starting to invest in high-end equipments to best assist the health of the players. Neuromuscular diagnostics systems as well as eccentric strength asymmetry testing are growing in popularity both in USA and Europe. What is your approach to monitoring hamstrings condition during the season?

Kostas Chatzichristos: There is a lot of excitement about all these new technologies that are becoming available to us. I always keep a critical mind regarding any new product that comes along. I try to answer some basic questions like, how accurate and reliable is the new device? Are the data relevant and useful in injury prevention or performance enhancement? How can the analysis of all the data help me make better decisions? As far as hamstring monitoring, we are currently not using any specific device, mainly because hamstring issues are not so prevalent in our world. We do monitor our athletes almost daily, looking for red flags and possible risk factors. We use manual muscle testing to identify inhibited muscles after games or extensive travel, we use specific exercises like the squat jump to periodically measure power and left/right asymmetries amongst other things and importantly we pay attention to personal clues and subjective feelings of stress and fatigue. This year we are experimenting with a force plate attached to a flywheel device to check for asymmetries, measure strength (in all its forms) and get information on contraction profiles of selected athletes. Again, we must see how all this data correlate with injury rates and our performance metrics, so we can make better decisions for our athletes.

© CSKA Moscow

AR: The last topic i want to address is the difference between weight-bearing and non weight-bearing exercises for hamstrings function. Muscle activation as well as timing and coordination are highly influenced by foot strike dynamics and overall foot/ankle function: what is your opinion about the ratio between weigh-bearing and non weight-bearing hamstrings exercises in a specific training program?

Kostas Chatzichristos: I don’t think that there is a specific ratio between these two types of exercises. They both have their role in training and I guess their use depends on the desired outcome. I like low force, isometric non-weight bearing exercise in the early stages of rehab and during pre-practice, “activation” work. I also like to use both types in every strength program varying their loading profiles. For example, during the warm up we may do single leg RDL’s with a lighter load and then later in the workout, we will include a full glut-ham raise or single leg swiss ball curls. Or, we may do some variation of hip extension (e.g. single leg bridge, non-weight bearing) during our low intensity prep phase and then load the athlete using RDL’s (weight bearing). Now, foot strike dynamics and foot function I think play a major role, not only in hamstring health, but also in the whole function of the kinetic chain. Overuse, taping and minor or previous injuries can cause inhibition of important muscles causing various problems, as is the case with plantar fasciitis or destabilize the whole body, when for example, a minor ankle sprain inhibits the peroneus longus. That’s why we systematically assess and train the intrinsic muscles of the foot, as well as all the muscles that cross the ankle joint which are also related to proper foot mechanics.


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