Cricketers and Side Strains

Cricketers and Side Strain Injuries

Cricket fast bowlers have long been punished for taking up one of sports most demanding tasks. Bowlers under the age of 22 are one of the most injured sports groups in Australian sport. At any given time 1 in 4 fast bowlers under the age of 22 will be restricted by an injury and 64% of bowlers will have a back/trunk injury during their life.

The most well known and debilitating injury to the fast bowler is the lumbar stress fracture. And rightly so, keeping many young bowlers out of the game for up to 12 months and high incidence of repeated injuries through their career. It is important that young fast bowlers get the rest they need. 

But what about the more hardened younger adult bowler, still in their 20’s who rely on constant workload to be effective. Adult fast bowlers still have a 60% injury rate but only 14% of these are in the back. 

What gets injured instead and do they need this break?

Can a break produce a break?

In Australia, we are afforded a break over the Xmas / New year period where all games and training tend to cease, and other commitments and weather often reduce attendance at training. In some cases we see fast bowlers go for 4 weeks without bowling a ball before getting straight back into it – often at full tilt.

Does this time off lead to being vulnerable to other injuries?

My observations in managing cricketers is a sharp increase in side strain presentations in the January period in the first 2 weeks back from the break. Many of the people I see follow a specific trend. They tend to be young fast bowlers in their early 20’s who have had some niggles in the side or their hips during the first half of the season. They tend to push through then comes the break and then the “break”.

What is the side strain?

The side strain especially in cricketers is usually a tearing of the deep abdominal muscle, specifically the internal oblique (IO) and more likely on the opposite side to the bowling arm. This muscle runs from the outside of the pelvic bone (iliac crest) to the front part of the bottom 3 ribs and rectus abdominals on the same side. The muscle rotates and bends your trunk towards the same side.

The injury can occur suddenly and often prevents the person from being able to continue to bowl. Other cases can develop gradually and eventually impairs the ability to develop force in this phase. Pain and/or reduced speed often result in attendances in the clinic of the Health Professional.

The other causes of side strain aside from the IO tear including

  • rib stress fractures
  • impingement of the ribs into the pelvis with associated soft and bony tissue changes
  • stripping back of the tissue connecting the IO to the rib (periosteal stripping)
  • tears to the lats, intercostals, or tendinopathy to the quadratus lumborum
Anterior Abdominal Wall
Image 1: Picture of internal oblique from [https://www.slideshare.net/rongon28us/anterior-abdominal-wall]

How do I know that I have a side strain?

Simple one here – you bowl and as you pull down your arm you feel a strain in your abdominals, usually on the non-bowling side. It will hurt to stretch (twisting and bending to the other side). It may hurt to cough or sneeze and will be tender to touch just under the outside of the ribcage.

Although diagnosed well clinically, MRI can help in ruling our stress fractures and bony changes to the ribs or pelvis which do account for some side strain symptoms. This can be important as these ones tend to develop over a longer period and take a longer to get better. 

Why do side strain injuries happen?

The side strain is the second most reported injury in fast bowlers, accounting for 12.3% of all time-loss injuries but increasing (Nealon et al 2016). Although more common at the start, they are seen through the whole cricket season. It would not be too farfetched to think that when a bowler returns from the break that they may have lost some conditioning, especially in high demand muscles such as the IO and like all of us could be a little sluggish on return to work!!

Most of these injuries occur during the phase of bowling once the front foot comes into contact with the ground and the front arm pulls the body through. At this stage, the front arm is pulled from a high position while the trunk is usually bent and/or rotated towards the other side. This places the IO under maximal stress from a maximally stretched position – the perfect ingredients for any muscle tear. 

At the phase between front foot contact and ball release the activity of the IO increases to 97% of its maximal isometric voluntary contraction (Shorter 2011).

It is also interesting to note that bowlers have up to 10% more muscle bulk in the IO on the non-bowling side compared to the other side (Hides et al 2008).

Picture of muscle activity during phases of bowling:

Muscle Activity During Phases Bowling
Image 2: Showing the increase in IO activity in mixed action bowlers from when the arm starts to pull down through to front foot contact. Image from Shorter et al 2011

Ultimately this leads to a few keen observations:

  1. We need to build bigger, better and faster working internal oblique
  2. It may be best to keep some degree of bowling going over the Xmas break or work on abdominal muscles during this time
  3. We need to be mindful of bowling actions for at-risk players.
  4. It is important we measure other contributors such as
    • Hip and trunk mobility
    • Arm extension strength
    • Hip strength, stability and control

How do we measure IO strength?

Truth is there has been no reliable way to measure this muscle. A series of tests have guided the way this muscle could work including side plank endurance. A rather novel test has been developed to assess lower trunk rotation as a guide for measuring appropriateness for meeting the demands of bowling. 

Isometric Lower Trunk Rotation Test

Isometric Lower Trunk Rotation test using Vald’s ForceFrame. The legs sit off centre with the pelvis raised on the side you are rotating towards. Athlete stabilises with hands and then aims to move the pelvis back to the floor.

Measuring IO Strength Vald Forceframe

Here we use the Vald ForceFrame to look at maximal force and rate of force development the Orange which is rotation to the left (right sensor) has a greater Maximal force (207N) compared with rotation to the Right (Blue line) which equals 162N. The steepness of the orange line represents faster ability to generate maximal force.

Although not studied we have seen that if deficiencies are present when rotating to the non-bowling side in pre-season screening that there may be an increase in side strains.

But often it is not only strength that needs to be measured but also how fast the muscle can generate that force. It would be fair to suggest that the two key things that should be measured here are the absolute force produced and how quickly that force can be reached.

Our expectations for return to sport post-injury and to assist in injury prevention would be to have the trunk scores on the non-bowling side approximately 10% greater than the bowling side. Our observations also suggest 20% of body weight seems about right but more data should be collected. 

How do we get it faster and stronger?

End-stage rehab or prevention exercises look pretty much the same. It is important that when you are addressing a side strain that other contributing factors to the demand on the IO are managed. This can include a thorough assessment of

  • Lumbar spine and hip mobility assessment
  • Hip strength assessment
  • Review of bowling action -> especially when under fatigue

Some cricket specific exercises for Management of side strains

Exercises

Barbell Window Washer

Barbell Window Washer Exercise
Barbell Window Washer

The barbell window washer is an isotonic exercise focussing on lower trunk rotation. The focus is on rolling the opposite pelvis upwards as the athlete rotates towards the injured (or focus) side. The athlete is then given a cue to roll the opposite pelvis back and let the thigh trail behind back to the start position. Weight can be added to the barbell on the side they rotate towards.

Cable Side Bend

Cable Side Bend Exercise
Cable Side Bend

Progression for abdominals into weight-bearing where a focus is more on function as opposed to specificity of the muscle. This exercise will work the lats, the QL and the hip stabilisers along with the internal and external obliques. It can be progressed to have a large stride or step out and can include arm bending through and increasing speed of movement.

Single Arm Horizontal Sled Pull

Split Arm Horizontal Sled Pull
Single Arm Horizontal Sled Pull

This exercise is no integrating higher demand on the pull through phase with emphasise on strength and power development and including more involvement and coordination of the kinetic chain

In summary, side strains are a significant injury for cricket fast bowlers. Strengthening the internal oblique muscle to work harder and faster in bowling specific positions could play a role in reducing the impact of these. It is also important to assess other areas of the body and have a look at how your action may change with fatigue

If you are injured with a side strain best to have the diagnosis confirmed by a qualified physiotherapist that has an interest in cricket specific injuries. They will assist with any imaging or other tests required.

Did you know if you are a registered cricketer and have been injured playing cricket in a registered competition you may be eligible to claim through their Cricket insurance policy covering up to 85% off physio costs? Message Aaron Lewis for more info on your injury and ability to claim.

References

Hides JA, Stanton WR, Freke M, et al. MRI study of the size, symmetry and function of the trunk muscles among elite cricketers with and without low back pain. British Journal of Sports Medicine. 2008; 42(10):809-813)

Humphries D, Orchard J & Kontouris A. Abdominal Wall Injuries at the Elite Level in Australian Male Professional Cricketers. Journal of Postgraduate Medicine, Education and Research, October-December 2015;49(4):155-158

Farhart, P. Management of Cricket Specific Injuries.  Course notes, (2012)

Nealon AR, Kountouris A, Cook JL, Side strain in sport: a narrative review of pathomechanics, diagnosis, imaging and management for the clinician, Journal of Science and Medicine in Sport (2016), http://dx.doi.org/10.1016/j.jsams.2016.08.016

Shorter K, Nealon A, Smith N & Lauder M, Cricket side strain injuries: A description of trunk muscle activity and the potential influence of bowling technique, Portuguese Journal of Sport Sciences (2011)

 Stronach B. Biomechanics, physiology, injury and conditioning for cricket fast bowlers, Thesis Aukland University of Technology (2014)

BAppSc (Phty) Masters (Sports PHTY) APAM

High-Performance Sports & Exercise Physiotherapist, Director

Aaron Lewis is a Physiotherapist with a focus on Achilles tendon, ACL tears, hamstring, and Upper limb throwing and lifting pathology. He is also the founding director and senior consultant Physiotherapist at Performance 360.

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