CONDITIONING THE AUTHOR
Ian Jeffreys is currently director of Sport Science and Athletic Performance at Coleg Powys in Brecon, Wales. He is the strength and conditioning coach for the Welsh Schools’ Rugby Union national team at Under 16 level, as well as working with athletes from a range of sports. Ian is an accredited member and director of the United Kingdom’s Strength and Conditioning Association, and a registered strength and conditioning coach with the British Olympic Association. He is a certified strength and conditioning specialist re-certified with distinction, a certified personal trainer and coach practitioner with the National Strength and Conditioning Association.
References 1. Bompa TO. Total training for young champions. Human Kinetics 1991. ISBN 073600212X 2. National Strength and Conditioning Association. Youth resistance train- ing: position statement paper and literature review. Strength and Conditioning Research 1996;18(1):62-75 3. Faigenbaum AD. Age and sex related differences and their implications for resistance training. Chapter in: Essentials of strength training and con- ditioning. Human Kinetics 2000. ISBN 0736000895 4. Bailey D and Martin A. Physical activity and skeletal health in adoles- cents. Pediatric Exercise 1994;6:330-347 5. Faigenbaum AD. Strength training for children and adolescents. Clinical Sports Medicine 2000;19(4):593-619 6. Blimke C. Resistance training during pre-adolescence. Issues and contro- versies. Sports Medicine 1993;15 389-407
7. Falk B and Tenerbaum G. The effectiveness of resistance training in chil- dren. A meta analysis. Sports Medicine 1996;22:176-186 8. Westcott WL and Faigenbaum AD. Clients who are pregnant older or pre- adolescent. Chapter in: NSCA’s essentials of personal training. Human Kinetics 2004. ISBN 0736000151 9. Pearson D, Faigenbaum A, Conley M and Kraemer WJ. The National Strength and Conditioning Association’s basic guidelines for the resistance training of athletes. Strength and Conditioning Journal 2000;22(4):14-27 10. Conroy B, Kraemer WJ, Maresh C et al. Bone mineral density in elite junior weightlifters. Medicine and Science in Sports and Exercise 1993;25:1103-1109 11. Faigenbaum AD and Schram J. Can resistance training reduce injuries in youth sports. Strength and Conditioning Journal 2004;26(3):16-21 12. Smith A, Andrish J and Micheli L. The prevention of sports injuries of children and adolescents. Medicine and Science in Sports and Exercise 1993;25(S8):1-7 13. Committee for the Development of Sport of the Council of Europe. Conclusion of an international seminar for children, Norway. CDDS 1982 14. Falk B and Mor G. The effects of resistance and martial arts training in 6-8 year old boys. Pediatric Exercise Science 1996;5:339-346 15. Faigenbaum AD, Westcott WL, Loud RL and Long C. The effects of dif- ferent resistance training protocols on muscular strength and endurance development in children. Pediatrics 1999;104(1):e5 16. Stone and Wathen. Roundtable discussion: Machines versus free weights. Strength and Conditioning Journal 2000;22(6)18-30 17. Faigenbaum AD, Milliken LA, Loud RL et al. Comparison of one and two days per week of strength training in children. Research Quarterly in Sport and Exercise 2002;73(4):416-424 18. Balyi I and Hamilton A. Long term athlete development update. FHS 2003;20:6-8
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SET 2 ■ Rehabilitation for Patellofemoral Pain Syndrome
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■ Anterior Cruciate Ligament Rehabilitation ■ Rehabilitation for Shoulder Impingement ■ Hamstring Strain Rehabilitation
WWW.SPORTEX-MEDICINE.COM Hamstring rehabilitation
Quadriceps stengthening ladder PRACTITIONER PROMPT
PATIENT ADVICE
Patellofemoral pain syndrome rehabilitation
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Closed chain exercise progression Correct lower limb alignment must be emphasised at all times. The exercises should be pain free at all times. The patients should carry out 3x15 repetitions. The exer- cise should only be progressed when the patient can carry out 3x15 repetitions pain- free with correct lower limb alignment. The patient should start at the level they are able to achieve on assessment without pain and with correct alignment.
Hamstring injury rehabilitation Hop
One leg minisquat with weight
One leg minisquat without support
One leg minisquat with support
Bilateral minisquat with weight
Bilateral minisquat without support
Bilateral minisquat with support
Isometric squat against wall
Signs
Aggravating factor Pain
Tenderness Crepitus Giving way Effusion
Click/clunk Range of movement
PFPS Patella
Running, stairs, Jumping, landing, Standing, Quads activity, Musculo- eccentric quads eccentric quads knee ext Retero-patella
tendonitis Infra-patella Peripatella
Occasional With quads inhibition
Inferior pole
None None
Occasional small Tendinous/ thickening
Older patients None
syndrome apophysitis Hamstring strain
Infra-patella Pole patella, tibial tubercle
Fat pad
None None
Posterior
compartment None
Fat padIschiogluteal bursitis
None Decreased flexion, Decreased flexion, Decreased
Patella mobility Decreased medial Decreased caudally
cephallic
Quadriceps strength
Decreased/ inhibited
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Decreased/ inhibited
Decreased
The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for special- ist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negli- gence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.
Figure 6: Clinical signs of main causes of anterior knee pain Normal None
particularly squat particularly squat extension and rectus femoris length
Piriformis syndrome
Decreased
caud/ceph caud/ceph pathology
Lumbar spine
Sacroiliac joint pathology
Adverse
Decreased/ inhibited
tibial tubercle None
syndrome of thigh Tibial tubercle
Hamstring syndrome Ischial Pole patella,
thigh
Accurate diagnosis Establish correct diagnosis, differentiate between: ● Hamstring muscle strains ● Posterior compartment syndrome of the thigh ● Hamstring syndrome ● Ischiogluteal bursitis ● Adverse neuromeningeal tension ● Piriformis syndrome ● Lumbar spine pathology ● Sacroiliac joint pathology
Step down
Step up with weight
Step up
Treat pain and inflammation ● PRICE
Patella mobilisation ● Patella in groove/Ober’s position
● Mobilise into resistance Condition Fat pad Traction
Step down with weight
Flexibility ● ITB
Hamstring strengthening Progression of force application: ● mid-range isometric contractions ● mid-range multi-angle isometric contractions ● mid-range concentric-eccentric contractions, slow to fast velocities of contraction
Step-to (side to side)
● Rectus femoris ● Hamstrings ● Gastrocnemuis/Soleus
Control of lower limb alignment ● Gluteus medius coactivation
● outer-range isometric contractions ● outer-range multi-angle isometric contractions
Meniscal rehabilitation
Hamstring flexibility ● Appropriate healing time (14 days post-injury)
● outer-range concentric-eccentric contractions, slow to fast velocities of contraction
● Start partial weight bearing (maximum visual cues) ● Increase limb load ● Decrease visual cues ● Uneven/mobile surfaces ● Use of orthotics to control pronation
● Electrotherapeutic modalities ● Specific soft tissue mobilUisatise fons ● Transverse frictions
●
Patella taping r pain relief
● closed kinetic chain and sport specific actions ● application of force in functionally specific patterns
Menisectomy Phase 1: Maximum protection (3-7 days) Goals ● Protect wound ● Control inflammation ● Full knee extension ● Regain quadriceps control
● for biceps femoris a combination of hip exten- sion, abduction and lateral rotation along with knee flexion and tibial lateral rotation
● Use to facilitate quadriceps activation ● Check for allergic reaction ● Correct patella position
Site of pain on palpation
Plica
increasing intensity knee flex/ext knee flex/ext hamstrings
tendinuous hamstrings hamstrings None
IschialRarely tuberosity
Present
Decreased flexion Normal Piriformis
muscle Normal Lumbar spine Normal
Sacroiliac joint
neuromeningeal tension
(pain medial glide)
None None
Repetitive Effect of SLR Iliotibial band Repetitive
● for semitendinosus/semimembranosus a combination of hip extension, adduction and medial rotation along with knee flexion and tibial medial rotation
● Restore normal gait (elbow crutches first 1-2 days)
● Isolation of stretch to hamstring muscle
● Appropriate direction of stretch
● For biceps femoris a combi- nation of hip flexion, adduc- tion and medial rotation along with knee extension and tibial medial rotation
Onset of symptoms Effect of hamstring Effect of activity
syndrome friction syndrome Positive for
Medial patella Lateral patella Positive for
tuberosity Medial plica Lateral condyle femur/tibia
Tight posterior Negative Present
Positive for hamstrings
Rarely None Decreased extension
Positive for neural
Normal
Positive for neural
Positive for Gradual
The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for special- ist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negli- gence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.
Along
courseWWW.SPORTEX-MEDICINE.COM of sciatic nerve neural
Gradual Gradual Decreased medially
Positive for neural
Gradual
and slump test (sudden/ traumatic contraction or gradual)
Sudden/traumatic Gradual
ROM - 0o - Pain free range (At 1 week, approximate range 0-120o) Treatment ● Heel slides ● Quadriceps sets, trophic stimulation as required ● Non weight bearing hamstring/gastrocnemius/soleus stretches ● Single leg raise - 4 planes ● Hip abduction/extension ● Patella mobilisations ● Non-operative leg/abdominal circuits ● Isokinetics non-operative leg
● For semitendinosus/semi- membranosus a combination of hip flexion, abduction and lateral rotation with knee extension and tibial lateral rotation
● Progess from sustained static stretches to controlled ballistic stretches
● Single leg raises - 4 planes ● Patella mobilisations ● Hydrotherapy at 4 weeks ● CPM pain free range (up to 0-90o)
Sudden or gradual Gradual
Phase 2: Moderate protection (7-21 days) Goals ● Increase lower extremity strength and ROM ROM - No limits Treatment ● Continue Phase 1 ● Angle specific isometrics knee flexion/extension (30o steps) ● Hydrotherapy, lower limb exercises ● Isokinetics (High speed > low speed) ● Bike ● Swimming, no breaststroke ● Closed kinetic chain exercises (initially bilateral > unilateral) ● Open kinetic chain exercises 0-90o (initially bilateral > unilateral) ● Step ups > step downs ● Calf work ● Proprioceptive work ● Commence jogging > running (pool>trampet>sand>grass) Weak, no pain
Decreased strength Pain increases with and painful
activity No effect No effect No effect
Sitting aggravates, movement eases
Increases with activity, decreases immediately with rest
Very specific activity will
aggravate, relief not immediate on cessation of activity
No effect (occasional, sudden)
Pain increases with activity
Advancement criteria Necessary strength, ROM, endurance and proprioception + no patellofemoral symptoms
Increases and decreases
with certain postures and activities
Weak, no pain (occasional, sudden) Weak no pain Increases and decreases
The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for special- ist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negli- gence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.
Phase 3: Minimum protection (21-42 days) Goals ● Safe and gradual return to activity ● Initiate isolated hamstring work ● Improve ROM, strength, endurance and proprioceptive Treatment ● Continue phase 1 and 2 ● Stairmaster ● Hamstring 0-60º ● Sprinting-acceleration/deceleration ● Agility work ● Sports-related drills
with certain postures and activities
Increases with activity, relief not immediate on cessation of activity
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Phase 2: Moderate protection (6-10 weeks) Goals ● Restore normal gait ● Avoid overstressing the repair ● Increase lower extremity strength and ROM ROM - No limits Treatment ● Continue Phase 1 ● Closed kinetic chain exercises 0-60o flexion ● Open kinetic chain exercises 0-90o (45-90o if associated cruciate involvement) ● Calf work ● Proprioceptive work
Advancement criteria Necessary strength, ROM, endurance and proprioception + no patellofemoral symptoms
Phase 3: Minimum protection (10-16 weeks) Goals ● Safe and gradual return to activity ● Initiate isolated hamstring work ● Improve ROM, strength, endurance and proprioceptive Treatment ● Continue phase 1 and 2 ● Stairmaster, stationary bike ● Hamstring 0-60o ● Swimming no breaststroke ● Commence running programme ● Commence functional progression
The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for special- ist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negli- gence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.
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Meniscal repair Phase 1: Maximum protection (0-6 weeks) Goals ● Protect repair ● Control inflammation ● Full knee extension ● Regain quadriceps control
ROM - 0-90o Treatment ● Heel slides 0-90o
● Quadriceps sets, trophic stimulation as required
● Non weight bearing gastrocnemius/soleus stretches, hamstring stretches
R PRACTITIONER PROMPT
ACL reconstruction rehabilitation – Part 2 2) Strength, fitness
PRACTITIONER PROMPT
and function Progressive resistive strengthening exercise ● Quadriceps - closed and open chain exercises (in appropriate
range of movement) ● Hamstrings - outer range strength and strength at high veloci- ty contractions ● Gastrocnemius ● Hip adductors & abductors - inner range strength to maintain joint alignment
training ● Static bike ● Rowing, stepper, cross trainers ● Challenge cardiovascular system - monitor heart rate and set appropriate targets ● Running at 12 weeks post op (if proprioception and dynamic control adequate) ● Sport specific training (if passed functional tests) 20-24 weeks post op
3) Functional testing
Screening criteria for functional performance testing ● No pain ● No effusion ● No crepitus ● Full active range of movement ● Symmetrical gait including stair ascent and descent
Progressive cardiovascular and functional
● Lower limb extensor muscle strength (isokinetic eccentric and concentric) LSI > 85% ● 1RM single leg press LSI > 125%
● Isometric 1/2 and 1/4 squat > 45 seconds with eyes closed or open
LSI = Limb symmetry index, divide mean of involved leg by mean of uninvolved leg x 100
M O B I L ISE
● ESIPAREHT Aim - 85% LSI
Error scoring Landing
Balance
Hop tests ● One leg hop for distance - stand on leg, hop as far as possible ● Timed one leg hop - time to hop 6m ● Triple one leg hop for distance - stand on leg hop for three hops as far as possible ● Cross over hop - stand on leg hop for three hops as far as pos- sible, crossing a centre line with each hop
●
N A L Y S E
Multiple single hop stabilisation test Set a 2.5cm target in a diagonal distance set at 50% of patient’s height. The patient must land onto the mark and hold the posi- tion for 5 seconds with hands always on iliac crests.
- not covering tape mark - stumbling on landing - foot not facing forwards - hands off iliac crests
Rehabilitation of the sporting back A
1. Analyse - techniques, training, coping strategies ● Gait analysis ● Orthotics ● On-site assessment
Mechanism of injury
Contributing causes Pain
Congenital defect
Rehabilitation of brachial plexus injury PRACTITIONER PROMPT
A
Differential diagnosis of nerve root versus brachial plexus lesions Cervical nerve root
Brachial plexus
2. Therapise - anti inflammatory and pain relieving measures ● NSAIDS ● ice packs ● ultrasound ● massage
Parasthaesia Tenderness
3. Mobilise - physiotherapy, osteopathy, chiropractic ● Restricted and dysfunctional segments
Range of movement Muscle power Reflexes
Provocation
- touch down with non-weight bearing limb - non-weight bearing limb touching weight- bearing limb
● Barrow zig-zag run Run right and left handed for timed symmetry score. Aim 85% LSI. STABALISE Start
- non-weight bearing limb moving into excessive flexion, extension or abduction - hands off iliac crests
4. Stabilise - core stability and sclerosant injection ● General exercise ● Specific exercise
5. Customise - sports specific exercise programmes
Specific myotome affected May be normal
Side flexion, rotation and extension with
Prolapsed disc, stenosis, degenerative disease, osteophytes, trauma
Sharp, burning dermatome distribution Dermatomal distribution Cervical spine Decreased
Congenital canal stenosis R
Treat pain ● Local ● Interferential ● Acupuncture ● Ice/heat
compression +ve. Neural tissue provocation increase symptoms. Neural tissue provocation test +ve
● Spinal ● Mobilise ● Stabilise ● Tape
● Trigger points ● Myofascial techniques ● Positional release ● Acupuncture
The key components in cervical spine rehabilitation are ● Prevent re-occurrence
The sporting back pain vortex
Training errors Poor technique Postural imbalance
●
CUS T
Finish 5m
The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for special- ist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negli- gence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.
M ISE
O
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Lumbar segmental dysfunction
3m
● Increase flexibility of the cervical spine and surrounding soft tissue ● Increase the functional strength of the stabilising muscles of the respective joints ● Improve proprioception of the cervical spine ● Correct abnormal mechanics ● Teach functional specific exercise relative to the individuals sport ● Provide psychological support
1 Prevention ● Full neuromuscular assessment of the cervical spine and shoulder girdle
Pain, burning in all dermatomes, +/- trapezius Can be all dermatomes of the arm
C O
Cervical spine and along nerve trunk 1st rib Decreased initially but may return as spasm settles Transient, all myotomes affected May be depressed
N Side flexion with compression or stretch may
test will be +ve and is an important part of the sub-acute stage of assessment
4. Proprioception ● Re-education of the normal feedback
mechanism for local joint control ● Use of ball to assist feedback training
● Neurological deficits require appropriate further investigations ie. x-ray, MRI, EMG ● Differentiate between spondylytic changes in cervical spine versus brachial plexus lesion
● Medical team supervising the player is happy that a full rehabilitation programme to cervical spine, thoracic spine and shoulder girdle has been completed ● Analyse any predisposing factors in technique for that particular sport
2 Improve flexibility ● Manual therapy to cervical spine, thoracic spine and upper limb biomechanical chain
DYSFUNCTION/ PAIN
Ligamentous LOW BACK
● Muscle techniques to maintain range of movement in the scalenii, sternocleido mastoid and trapezius muscles
Tonic muscle inhibition and antalgic postures
insufficiency and segmental instability
3 Increase functional strength ● Local stabilisation of cervical spine before global stabilisation
Muscle wasting and imbalance
The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for special- ist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negli- gence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.
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● Muscle techniques to maintain range of movement in the rotator cuff muscles ● Neural tissue mobilisation techniques to each neural pathway affected. Care must be taken in the acute stage of brachial plexus injury as this will increase pain
and control ● Glenohumeral joint ● Tape, manual facilitation ● Active joint centring ● Maintenance of alignment in functional retraining
● Scapular ● Tape, EMG, stimulation, manual facilitation
Retrain alignment
5 Correct abnormal biomechanics
● Ensure normal cervical, thoracic spine and shoulder girdle spine movement
● Physiotherapist discuss with player and coach potential faults in technique which may lead to recurring injury
6 Functional exercises ● Exercises must be specific to the player’s
● Increase lower trapezius and serratus anterior activity
● Reduce upper trapezius, rhomboids and levator scapulae activity
● Maintenance of alignment in func- tional retraining
● Re-educate deep neck flexor muscles – use of pressure biofeedback unit ● Local stabilisation of scapula muscles and shoulder girdle ● Increase isometric and isotonic strength of cervical spine - use of ball, theraband ● Maintain full muscle strength of rotator cuff muscles with functional control of cervical spine
● Trunk/lower limbs ● Deep abdominal control
● Gluteal control individual sport
● Exercises must be progressed from non- contact to contact drills
● Exercises must be completed at match- related speeds before return to match situation
● Full, specific fitness test, active and pas- sive before return to match situation
I
7 Psychological support ● Physiotherapist to liaise with doctor
responsible for player regarding poten- tial psychological problems post injury
The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for special- ist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negli- gence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.
● Whole kinetic chain ● Synergy between glenohumeral joint, scapular and trunk and pelvic stabilisers in functional retraining
● Physiotherapist to discuss with coaches potential problem if player suffers a sig- nificant neck injury
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The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for special- ist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negli- gence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.
WWW.SPORTEX-MEDICINE.COM Y U T R
Mobilise ● Spine ● Stiff thoracic spine
● Glenohumeral joint ● Capsulo-ligamentous restrictions
● Pelvis / Hips ● For better pelvic / lower limb control
hardening ● Integration of all of the above boxes
● Specific to sport/ functional activity
● Correction of sporting/ functional biomechanics
I T Functional
diagnoses ● Labral lesions ● Internal impingement ● Disorders of the passive restraints
● Acromio-clavicular joint ● Spinal, neural and cen- tral elements
● Long head of biceps/ biceps anchor
Also consider as possible other
Secondary impingement syndrome PRACTITIONER PROMPT
Stretch to the cervical spine, depression of shoulder, compression of cervical spine
P
O
REDUCE LOCAL PAIN
E X C
I T I
O R S Treatment Flexibility
Rehabilitation Rehabilitation schedule schedule
Phase 1(PRICE) Phase 2 (ROM) - PRICE - Exercise rehabilitation
- active and passive pain free range of movement stretches
Rehabilitation schedule
Phase 3 (Loading) Exercise rehabilitation
- PNF stretches Such as hold relax; contract relax. Or
- Hold, relax, hold, contract relax Endurance - - prone knee bends
- low impact step machine - static cycle - 400m walk
- step machine - static cycle
- rowing machine - hamstring run
Rehabilitation schedule
Phase 4 (sport specific) Exercise rehabilitation
- introduce flexibility exercises as stand alone programme
- teach pre-exercise stretching as part of warm-up programme
- step machine - static cycle
- rowing machine
- hamstring running drills - position running patterns
Resistance -
- seated hamstring curl * - standing hamstring curl * - prone hamstring curl * - leg press *
- dumbbell half squat * - dumbbell Romanian dead lift *
- seated hamstring curl * - standing hamstring curl * - prone hamstring curl * - leg press *
- dumbbell squat * - dumbbell straight leg dead lift * - barbell high pull
- dumbbell squat push press - barbell hang clean - barbell clean
- dumbbell squat jumps - dumbbell alternate single arm high pull
- dumbbell static lunge standing hip dips - dumbbell alternate single arm clean - dumbbell static lunge standing dead lifts - dumbbell dead lift and heel raise - dumbbell alternate leg lunges - dumbbell dead lift and heel raise
Other -
- running drills - trampet
- wobble board - ball skills
- ball skills
- controlled game - fitness testing
Key: * = exercises selected as an example in the exercise programme but can be combined with the additional exercises listed above within the appropriate phase.
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