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Mid-line Stabilization: Bridging the Gap Between Pre-hab and Training

by, Michael Falk ATC-L, CSCS
Seasonal Athletic Training Intern - Green Bay Packers

Increasingly, athletic trainers are becoming more proactive than reactive to prevent injuries.  This trend represents a significant philosophical shift in sports medicine.

Injury prevention/reduction programs are now common at most levels of sport.  Injuries are often multi-factorial and can include the effects of differing levels of sleep, nutrition, training, practice, etc.  This article will address injury prevention by examining overall movement patterns and teaching athletes the use of proper form to develop better training habits.

Other challenges that athletic trainers face when developing an injury prevention program include operating in an environment with low staff to athlete ratios resulting in a large number of athletes to teach as well as ensuring compliance and with the new regimens.

Injury prevention can be enhanced by teaching athletes proper mid-line stabilization techniques and by training and incorporating proper movement patterns into strength and conditioning sessions.  As athletic trainers, these techniques are areas we are specialists in and we can use our skills to benefit our athletes and compliment a well-designed strength and conditioning program.

Mid-line Stabilization

All athletes need to be able to properly organize their spine and learn how to stabilize their spine while moving their extremities.  This sounds like a simple task and obvious point, but many athletes do not understand proper stabilization techniques.

Our overall goal to optimize training is to enable muscles to function within their design.  Stabilizers need to stabilize so that prime movers can move.  Injuries happen when muscles are required to function outside of their design.  A prime example of this is the hip flexors.  Athletes often use their hip flexors as the primary source of stability for the spine.  This habit leaves athletes resting in a lordotic posture, leaving them susceptible to back injury as well as hamstring strains.  Additionally, in this example the hip flexors are performing a stabilizing activity leaving them less able to function as they are designed - to achieve the proper triple flexion - triple extension position required for running among other things.  Educating athletes on proper mid-line stabilization can help prevent injuries, and can improve performance.  Teaching mid-line stabilization can be difficult, as it is a challenging concept for athletes to understand.  Asking them to use small, deep muscles they can’t see isn’t easy for them to execute.

To begin the process of teaching mid-line stabilization, start by teaching proper breathing techniques.  In order to properly stabilize their spine, athletes must be able to breathe using their diaphragm.  Most people become chest breathers over time, rather than diaphragmatic breathers as humans were designed to be.  Chest breathing is not only inefficient; it also leaves the musculature of the pillar at a disadvantage with the changing length-tension relationship.  Watch for the stomach to rise and fall with each breath, while the chest stays relatively still.  This technique is one that the athlete must practice in pre-hab and in ADL’s.  Next, incorporate spinal stabilization while moving the extremities around a stable spine in an unloaded position progressing to a slightly loaded position.

The table top, or dead bug exercises are perfect for this purpose, because they require the athlete to stabilize the pillar and move their extremities.  Be creative which patterns you have the athlete do, but some examples are:  marching, arms over head, ball squeezes, etc.   These exercises also mimic the primal development patterns from which humans develop.  The two-month-old infant position involves the patient lying on their back with hips and knees bent to 90 degrees.  By tying exercises back to primal development, they can often help muscles function as they are designed.

Bird dog exercises position the patient on their hands and knees following the same principles as the table top exercises in a slightly more loaded position.   The concept of stabilizing the spine is the same, but now the hips, shoulders, and spine must stabilize against gravity.  Moving the arms and legs requires the spine to stabilize against rotation.

Functional Progression

While proper education on a table or in quadruped position is important, it is more important to incorporate the mid-line stabilization strategies into weight-bearing functional movement.

Once proper mid-line stabilization has been achieved in a rehabilitation setting, you must then educate it in a functional setting by teaching athletes how to squat, RDL, dead lift, hang clean, bench press, and row with proper mid-line stabilization.  By teaching proper movement patterns, through full ranges of motion, every exercise and every strength and conditioning session will become a part of your injury prevention program.  This technique will help the athlete feel better, perform better and stay healthier.

No one wants a weak athlete.  They will not perform at the highest level, and weakness leaves the athlete more susceptible to injuries.  Therefore, athletes must be able to safely participate in a strength program.  Athletic Trainers can help bridge the gap to work with the strength training staff to teach athletes to move well.

A deep squat with good technique is a perfect functional exercise for sport.  An RDL with proper technique can help avoid hamstring injuries.  And Olympic lifts are as close to simulating sport activity as possible in a weight room.  These lifts require high speed concentric activation with immediate eccentric load and stabilization.  Done properly, these exercises will help athletes perform better and stay healthier during a season.

Tips on teaching the squat:

  • Use a dowel that reaches from the base of the head to the end of the spine to help the athlete understand their spinal alignment
  • Unload it, or work from the bottom up rather than from the top down
  • Give the athlete a target to squat into, like a bench or stool


Tips on the teaching the RDL:

  • Use a dowel again as in the squat to help the athlete understand their spinal alignment
  • Cue the athlete to be long from their head through their heel on the leg
  • Use the wall as an aiming point to teach a proper hip hinge and posterior weight shift



Often times, athletic trainers view strength and conditioning programs in the wrong light.  They see these activities as an area for their athletes to risk injury.  Instead, Athletic Trainers can use their skills to add to and enhance the current strength and conditioning program.   Working in partnership like this is also an efficient use of a staff’s time and resources.

To get started, athletic trainers and strength coaches should sit down and develop a common language to talk about movement.  Find a screen that both the athletic trainers and strength coaches can use to look for poor movement patterns or imbalances.  Use this baseline work to develop common cues, so that both departments use the same cues to teach an exercise.  This will prevent confusion with the athletes and help reinforce proper movement patterns.

Second, develop a “Pillar control for dummies” course.   On the first day of the strength and conditioning program teach all the athletes about proper mid-line stabilization.  This way they will understand the cues they can use while lifting weights and why they are important.

Finally, always teach a pattern, load a pattern, then speed a pattern up.  Grey Cook says, “move well before you move more often.”  I would expand this to include “move well before you move heavy things.”  Strength training will reinforce patterns, both good and bad.  Proper movement patterns will be reinforced with the strength program.  This discipline will help athletes perform better and stay healthier.



Cook, Gray; Burton, Lee; Kiesel, Kyle; Rose, Greg; Bryan, Milo.  Movement. On target Publications. Santa Cruz, Ca. 2010.

Kolar, Pavel. Clinical Rehabilitation. Rehabilitation Prague School. 2013.

Starrett, Kelly; Cordoza, Glen.  Becoming A supple Leopard: The Ultimate Guide to Resolving Pain, Preventing Injury, and Optimizing Athletic Performance. Victory Belt Publishing. 2013.





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