Injuries are a part of every sport.

Whilst we will never be able to fully prevent injuries from happening, we are in a stronger position than ever to understand and minimize known risk factors. At its most fundamental level, injury risk profiling can be characterized as a balance between demand and capability, where:

Demand – Represents all of the varied demands associated with sporting movements (e.g. the force demands imposed when rapidly changing direction).

Capability – Represents an athlete’s abilities to tolerate these demands (e.g. an appropriate level of lower limb strength to deal with the ground reaction forces in said change of direction activity).

“Risk is heightened and injuries occur when the sporting demands imposed significantly outweigh an athlete’s capabilities to tolerate them.”

Hockey is a high intensity, multi-directional and highly reactive sport, all of which contribute to very high demands being placed on the ankle complex. This is often reflected in the high prevalence of ankle injuries that players experience as a consequence (Manaf et al 2021; Barboza et al 2018; Murtaugh 2009).

In order to best cope with these demands, training programmes that address a range of capabilities around the ankle are a powerful tool for helping to lessen the potential injury risks.

Three of the most important capabilities are:

• Static Balance

• Hopping (Dynamic Stabilisation)

• Calf Strength
  

Balance

A common component of programmes designed to either decrease lower limb injury risk or rehabilitate athletes that have experienced an injury is single leg static balance work. There is evidence to suggest that athletes with poor balance are at elevated risk of developing ankle injuries (e.g. Bliekendaal et al 2019). And there are a range of studies suggesting that training programmes that include balance work may lessen injury risk in a range of sports (Petersen et al 2013, Kaminski et al 2019). These studies often show that balance work is more effective in lessening the risk of re-injury in athletes that have had prior ankle injuries, likely due to it helping to retrain deficits in proprioception and reaction time that can arise after an initial injury.

Balance training programmes with the highest risk reduction are often shown to be those that create progressive overload from a sensorimotor and proprioceptive system perspective, and so often include perturbation through either standing on unstable surfaces or adding secondary tasks such as reactive throwing and catching (Ellis et al 2010, Wedderkopp et al 1999).

A series of balance progressions could look something like this:

1. Standing Single Leg Balance on flat ground – building up to 3-5sets of 30seconds continuous balancing

2. Standing Single Leg Balance on an unstable surface – Progression as per the above

3. Standing Single Leg Balance on an unstable surface throwing and catching a ball for additional perturbation.
   

Hopping

Alongside static balance, the ability to express stability and neuromuscular control in dynamic scenarios is a crucial consideration when looking to reduce ankle injury risk, likely due to its higher level of specificity to the demands of sporting movements. Athletes who demonstrate poor dynamic stability in hopping tests are often found to be those with functional instability and elevated risks of developing ankle injuries (Delahunt et al 2007).

Likewise, studies such as that of Akasaka et al (2019) suggest that regular exposure to hopping training over a number of weeks can help to significantly lower future injury risk.

Hopping is inherently a very high force activity for the ankle, with the plantarflexors reaching comparable levels of muscle force to top speed sprinting, up to 10 times bodyweight (Kulmala et al 2016), making it a powerful conditioning tool if used appropriately. It also challenges the neuromuscular system to effectively self-organize and coordinate itself in dynamic movement tasks, that can be scaled to different levels of intensity, allowing athletes to build up control and stability in simpler variations before progressing to single leg, multi-directional tasks.

A series of hopping progressions could like something like:

1. Double Leg Vertical Pogo Jumps (3-5sets of 8-12reps) – I would suggest building volume of these at a submaximal intensity (80% effort) initially before increasing intensity

2. Single Leg Vertical Pogo Hops (3-5sets of 8-12reps) - Progression as per the above

3. Single Leg Side-to-Side Pogo Hops (3-5sets of 8-12reps) - Progression as per the above
   

Calf Strength

Calf strength cannot be overlooked in programmes looking to reduce the risk of ankle injuries. The soleus and gastrocnemius play a big role in propelling the body in all directions, producing very high forces in a range of sporting movements. Alongside this they also have a major role in frontal plane stabilisation of the ankle, making calf strength a priority for any running-based athletes (Liu et al 2021).

The architecture of the calf musculature shows us that the soleus has a disproportionally large physiological cross-sectional area (PCSA) to fibre length ratio, meaning that it has a very high number of muscle fibres are packed into a small space, which makes for a very high force production capability (Lieber and Ward 2011). And likely due to this impressive structure the plantarflexors are relied upon heavily in all forms of locomotive tasks, often operating at a very high percentage of their capacity (Kulmala et al 2016, Dorn et al 2012, Schache et al 2011).

Calf raises are an effective way to train the soleus, gastrocnemius and a number of smaller lower leg muscles and can be performed in a variety of ways. When looking to facilitate the most potent strength stimulus, you should look to choose exercises with a high level of stability which you can progressively add load to overtime and aren’t limited by things like grip strength or balance. Three great options are:

1. Leg Press Calf Raise

2. Seated Calf Raise Machine

3. Standing Smith Machine Calf Raise
   

All can be performed either single leg or double leg. A suitable loading scheme for any of the above would be in the range of 3-5 sets of 5-10 reps.

References

Akasaka, K.; Ono, K.; Otsudo, T.; Hattori, H.; Hasebe, Y. Effects of deep hopping training on ankle sprain in junior high school basketball players: a clustered randomized control trial. International Journal of Sports Physical Therapy . Dec2019, Vol. 14 Issue 6, pS4-S4. 1/3p.

Barboza SD, Joseph C, Nauta J, van Mechelen W, Verhagen E. Injuries in Field Hockey Players: A Systematic Review [published correction appears in Sports Med. 2018 Feb 14. Sports Med. 2018;48(4):849-866.

Bliekendaal S, Stubbe J, Verhagen E. Dynamic balance and ankle injury odds: a prospective study in 196 Dutch physical education teacher education students. BMJ Open. 2019;9(12):e032155.

Delahunt E, Monaghan K, Caulfield B. Ankle function during hopping in subjects with functional instability of the ankle joint. Scand J Med Sci Sports. 2007;17(6):641-648.

Dorn TW, Schache AG, Pandy MG. Muscular strategy shift in human running: dependence of running speed on hip and ankle muscle performance [Page//published correction appears in J Exp Biol. 2012 Jul 1;215(Pt 13):2347]. J Exp Biol. 2012;215(Pt 11):1944-1956.

Kaminski TW, Needle AR, Delahunt E. Prevention of Lateral Ankle Sprains. J Athl Train. 2019;54(6):650-661. doi:10.4085/1062-6050-487-17

Kulmala JP, Korhonen MT, Ruggiero L, et al. Walking and Running Require Greater Effort from the Ankle than the Knee Extensor Muscles. Med Sci Sports Exerc. 2016;48(11):2181-2189.

Manaf H, Justine M, Hassan N. Prevalence and Pattern of Musculoskeletal Injuries Among Malaysian Hockey League Players. Malays Orthop J. 2021;15(1):21-26.

Murtaugh, K. Field Hockey Injuries, Current Sports Medicine Reports: September 2009 - Volume 8 - Issue 5 - p 267-272 doi: 10.1249/JSR.0b013e3181b7f1f4

Lieber RL, Ward SR. Skeletal muscle design to meet functional demands. Philos Trans R Soc Lond B Biol Sci. 2011;366(1570):1466-1476.

Liu K, Delaney AN, Kaminski TW. A review of the role of lower-leg strength measurements in ankle sprain and chronic ankle instability populations. Sports Biomech. 2022;21(4):562-575.

Petersen W, Rembitzki IV, Koppenburg AG, et al. Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg. 2013;133(8):1129-1141.

Schache AG, Blanch PD, Dorn TW, Brown NA, Rosemond D, Pandy MG. Effect of running speed on lower limb joint kinetics. Med Sci Sports Exerc. 2011;43(7):1260-1271.

Wedderkopp N, Kaltoft M, Lundgaard B, Rosendahl M, Froberg K. Prevention of injuries in young female players in European team handball. A prospective intervention study. Scand J Med Sci Sports. 1999;9(1):41-47.