Category — Injuries

I recently had the pleasure of being interviewed by Joe Heiler for his website, www.sportsrehabexpert.com.

The interview mainly centers around the concept I refer to as the “Physiological Buffer Zone” which is discussed in the DVD I did with Joel Jamieson and Charlie Weingroff, Strength in Motion.

To listen to the interview CLICK HERE.

Patrick
patrick@optimumsportsperformance.com

I recently had the opportunity to attend two courses from the Postural Restoration Institute – Myokinematic Restoration and Pelvis Restoration.

The basic premise of the system that is taught by the Postural Restoration Institute is that the body is asymmetrical and, in order to optimize human function, we need to try and restore as much symmetry needed in order to have balanced reciprocal function (while appreciating the asymmetries of the body and acknowledging that we will not change them). Basically, we have a liver on the right side, the crural attachments on the right lumbar vertebrae are thicker than on the left, the right lung has three lobes while the left lung has two, etc (we can go on and on with these sorts of asymmetries), thus we tend to orient ourselves over the right leg which places us in a pattern of right mid stance, referred to as a Left AIC.

Left AIC

The main pattern discussed and the backbone of their system is the Left AIC (short for Anterior Interior Chain). The Anterior Interior Chain is a chain of muscles which connect the torso to the knee and consists of the diaphragm, psoas, iliacus, TFL, vastus lateralis, and biceps femoris. We have two AICs in the body, one on both sides, however the Left AIC tends to be more dysfunctional than the right. Additionally, individuals may find themselves in other patterns but underneath those patterns is always a Left AIC due to the natural asymmetry of the human body as discussed above.

In this Left AIC pattern the main findings include things such as:

• Anterior pelvic rotation on the left
• Increased hamstring length, tension, and tone on the left
• Pelvis rotated to the right side
• Right ischial tuberosity sitting lower than the left
• Left femoral head is not received as well by the acetabulum as the right is
• Right side is more in a position of adduction, internal rotation, and extension
• Left side is more in a position of abduction, external rotation, and flexion
• Decreased trunk rotation to the right side
• Decreased right apical expansion and left diaphragm opposition
• Increased left rib flare (poor left zone of apposition)
• Decreased left mediastinum expansion

All of these things are actually “normal” and are due to the natural asymmetry we all posses; however, some people – with proper training – can control this position better than others and thus perform at a higher level. Other individuals may not control this position well and end up compensating in such a way that they themselves in a position of PEC – short for posterior exterior chain – where they exhibit many of the things above on both sides, bilaterally.

PEC

The Posterior Exterior Chain consists of our latissimus dorsi, QL, Posterior Intercostals, Serratus Posterior, and Ilicostalis Lumborum.

Being in a PEC position is characterized by attributes such as:

• Stiff looking gait mechanics
• Bilateral hyperlordosis
• Both hips in a position of flexion, external rotation, and abduction (people tend to walk with their toes out)
• Butt gripping (tight gluteus maximus bilaterally)
• Flat and stiff thoracic spine
• Bilateral compression of the SI-joints
• Sagital plane dominant individuals who have lost optimal function in the frontal and transverse planes
• Pelvic floor in a descended position, bilaterally, causing the muscles of the pelvic outlet to be stiff and inflexible leading to issues with constipation
• Poor zone of apposition bilaterally
• In a state of hyperinflation, lacking the ability to exhale and allow the diaphragm to dome up

Goal of PRI

The goal is to use a battery of tests to determine what sort of position the individual is in and then what type of control they actually have. To do this, the Postural Restoration Institute has a number of tests – some are tests of position while others are tests of function – to help understand the person in front of you and make informed decisions about exercise prescription. To take it a step further, the tests are also used, in an algorithmic sort of way, to differentiate between individuals displaying one of these patterns versus individuals displaying one of these patterns but considered to be “pathological” and displaying a certain amount of ligament laxity – referred to as a  Patho Left AIC or Patho PEC. This information further drives exercise choices as those that are pathological may need a different set of exercises or exercise regression to ensure they are performing the movements in the right position and feeling the correct muscles working.

PRI can get extensive with the exercises as they have over 100 in their catalog although there are a few exercises that would be considered “big money” exercises for each of the possible patterns one may be in. If you understand the patterns and use the testing approach effectively you will understand which structures/muscles you are looking to facilitate and which you are looking to inhibit and can pretty much use any permutation of the “big money” exercises as long as they achieve the intended goal and improve the testing when you go to re-test, which should be done frequently to know if what you are doing is working and if you are helping re-position the individual.

Similarities with other Approaches

Whether it is PRI or any other system (DNS, FMS/SFMA, Janda, Osteopathic approaches, etc) there should be some similarities in the message as all of the systems are dealing with the human body. It is the similarities between all these things that I care the most about because it helps me see the big picture and be aware of more things when I look at an individual.

One thing PRI does is go heavy into the anatomy of the body with regard to how muscles function and they do a good job of differentiating between which attachments are moving and which are stable. For example, we can have femoral acetabular rotation (a femur rotating on a pelvis) and we can have acetabular femoral rotation (a pelvis rotating over a femur). This is similar to the idea of punctum fixum and punctum mobile in the DNS methodology. While some may consider looking at things like this as being a bit excessive, I truly believe that understanding these concepts can be extremely helpful to understanding function and programming exercise.

PRI has a large focus on breathing and talks extensively about the “zone of apposition” (ZOA) – the aspect of the diaphragm that apposes the chest wall. The ZOA is influenced by the position of the rib cage. When the rib cage is flared upward, ribs in external rotation, the ZOA is not in a position to function and allow for proper diaphragmatic breathing. In DNS this same position is referred to as on “open scissor position” where the rib cage is angled upward and the pelvis is angled downward (anteriorly tilted), causing increased erector spinae tone and a lengthened abdominal wall which posses a high amount of tension. Individuals with an inefficient ZOA or the open scissor tend to be more upper chest breathers, stuck in a hyperinflated position, and recruit the neck musculature (SCM, Scalenes, Levator, Upper Trap) to assist with respiration.

I see a bit of an Osteopathic influence in the PRI system which is cool because I have read a lot of Osteopathic texts. The whole approach to re-positioning the pelvis in PRI is similar to self Muscle Energy Techniques where the individual is using muscular force to drive the pelvis into a certain position (which is great because you don’t have to put your hands on the person for these techniques to be useful and can allow the client to feel empowered by performing the activities on their own).  The interesting thing is that the common pattern in PRI, the Left AIC, is opposite that of the common pattern in Wolf Schamberger’s text, The Malalignment Syndrome, which states that everything is happening on the right side (right pelvis in anterior rotation rather than the left) and this is similar to some of the other Osteopathic things I have read in the past. The instructor gave some answers as to why this is and in the end it comes down to a visualization thing as most of the other approaches were looking at anatomical landmarks with the person either supine or prone on the table and because of this they can be flawed as anatomical landmarks can change when someone lies down on the table (Schamberger does talk about some of these changes in his book on pgs. 43-44). Thus, PRI recommends tests of position and function rather than static tests of anatomical landmarks. The instructor of the course also talked about how the Muscle Energy Techniques used in those Osteopathic approaches achieved a similar result a lot of the time, even though their understanding of the position was incorrect, because they were activating the correct muscles to drive the pelvis into the correction position. Who’s right? Who’s wrong? Does it really matter? At the end of the day the goal is to make a positive improvement and if you did something that had a positive influence, even if your explanation or thought process wasn’t 100% correct, I don’t know if it matters all that much. Another thing that I would add is that the Osteopaths discussed breathing and the autonomic nervous system pretty extensively so perhaps their holistic approach achieved many of the similar results that those using PRI achieve. Regardless, there are a lot of similarities between these two approaches to pelvic movement and correction which is interesting to look at and be aware of. The Osteopathic similarities with PRI also show up with regard to the discussion on the diaphragm and viscera as the Osteopathic techniques on visceral manual therapy/massage discuss similar relationships between the diaphragm and the liver on the right side and the diaphragm and the spleen on the left.

Finally, the PRI patterns, particularly the PEC, is where I see some similarities to Janda and Travell and Simons. This pattern is very similar in appearance and function to the Upper and Lower Crossed Patterns from Janda. Many of the muscles which are discussed as needing inhibition in PRI (and in Janda) are also those that are either needed to keep us upright throughout the day (anti-gravity muscles) or those that help assist with respiration when the diaphragm is not functioning properly. So, it makes sense that things you want to inhibit in some of these patterns are the lumbar erectors (we live in a world of extension) and the glutes (particularly in the PEC pattern). Additionally, the vastus lateralis is a muscle which is part of the Anterior Interior Chain and one that can function significantly in these patterns to help provide stability. It comes as no surprise that this muscle is also one that is frequently riddled with trigger points, particularly in the lateral side under the IT-band (which lies over the vastus lateralis, biceps femoris, and is influenced by the TFL – all three muscles which are part of the Anterior Interior Chain).

Integration & Conclusions

I have enjoyed the courses thus far and look forward to taking more of them. I think that they underpin things I already do in practice very nicely and can fit well within the FMS model as another tool that can positively impact the results in some of the tests. Also, I have found that when there are a number of things going wrong in the FMS using some of the PRI approach can be helpful to reposition the individual and then retest to see what sort of improvements have been made. I have been using some of the exercises in my own warm ups and in the warm ups of a few people I have been working with (based on what we have found in testing) and the results have been very positive.

I don’t think any one system has all the answers and I don’t think any system will ever have all the answers as there are so many things that influence the body and so many things we don’t quite know. What I will say is that I really enjoy when different philosophies line up and share many similarities. The PRI approach is one more tool in the toolbox to help understand human function and their courses are some of the most fun I have had during a con ed course in a pretty long time.

patrick
patrick@optimumsportsperformance.com

Crossfit is an incredibly popular training system at the moment for a variety of reasons one of which being that the workouts are extremely challenging and demanding. A study recently published in the Journal of Strength and Conditioning Research set out to evaluate the fitness adaptations that take place during a 10 week Crossfit training program (Smith MM, et al. Crossfit-based high intensity power training improves maximal aerobic fitness and body composition. J Strength Cond Res 2013. Published ahead of print.).

Subjects

The study began with 54 healthy participants of varying fitness levels; however, only 43 completed the study (23 males/20 females) and were able to return for the post training re-test (more on that later).

Methods

The subjects body composition and Vo2max were tested at the start and end of the study to evaluate for changes.

Following the initial testing the subjects performed a 10 week, periodized, CrossFit training program at a CrossFit affiliate gym. The program utilized basic gymnastic activities (handstands, ring work, etc) and multi-joint exercises such as the squat, press, deadlift, and Olympic lift variations. The training program had some variation to it, adding an element of periodization, where some exercises were performed as a time trial (best time) and others were performed in an as many reps as possible style for  a prescribed time domain (E.g., 10 or 20min).

Results

The subjects who completed the entire 10 weeks (43 of them) all experienced significant improvements in both VO2max and body composition changes (decreases in body fat percentage) leading the researchers to conclude, “Our data shows that high intensity power training (which is what they refer to CrossFit as in this study) significantly improves Vo2max and body composition in subjects of both genders across all levels of fitness.”

My Comments (The Nitty Gritty)

First I’ll begin by making some obvious statements which, may not be so obvious given that marketing and hoopla tend to cloud rational thinking:

1. CrossFit is not that novel. Circuit training and calisthenics have been around for hundreds of years.  Training over a broad range of mixed time and modal domains is certainly not a new thing.

2. What CrossFit did do is create and environment and a culture that made that stuff cool and exciting for people, “Hey, it really sucks to suffer when I work out hard but if I suffer with a group of my friends it really isn’t that bad!”  In that regard, I think CrossFit has done a great job motivating a lot of people to get off their butts and exercise. This is a good thing.

3. High intensity interval training or really hard aerobic power type activities, which make up the brunt of the energy system demands during a CrossFit workout, have been shown to improve things like VO2max and Body Composition so do these results really come as a surprise? This stuff has been looked at in hundreds of studies by now.

Now to the not so obvious stuff – the devil is in the details

While the fitness and body composition results seen in this study are certainly impressive, as they are in many studies on high resistance interval training (as I alluded to in point number three above) the most concerning thing about this study and the biggest thing that concerns me with CrossFit is that of the 54 original subjects only 43 were able to complete the study. Nine of the subjects dropped out citing overuse or injury (two of the 11 dropouts cited time restriction as a problem in completing the study).

This sort of dropout rate is a bit hard for me to handle and I believe it has to do with the type of activities chosen from CrossFit workouts, the intensity with which those activities are performed, and the frequency of high intensity workouts within the training week (IE, poor sequencing of training intensities over the week). We don’t see this sort of dropout rate in traditional High Intensity Interval Training studies (usually performed on a bike, treadmill, or rower) and yet we similar exercise benefits. This sort of stuff makes me question the utilization of CrossFit as a training system because the risk seems to outweigh the reward.

My Take Away Conclusions

1. Hard workouts are great. Hard workouts are fun. Pushing yourself is awesome. But, you need to do so with safe exercise selection and have a training program that takes into account your abilities to adapt. This means you need to look at the training week and sequence things properly to ensure that you aren’t killing yourself in the gym everyday and training yourself into a rut. A training program should make you a healthier person, not crush you and deteriorate your body.

2. Olympic lifting exercises should not be used as exercises to be performed “as many reps as possible”. They are highly technical exercises and the athlete should have adequate rest before performing their set.

3. Things like deadlifts and exercises that place the spine in a compromised position as fatigue sets in should not be performed for “as many reps as possible”. This is just asking for trouble.

4. Qualify people to do certain exercises. Sure, gymnastics skills are great and can be a fun addition to a workout; however, not everyone is immediately qualified to perform these activities – just like not everyone is immediately ready to squat, deadlift, or olympic lift. Make sure you have some sort of way to qualify individuals to perform these exercises. This goes beyond skill and technique and should first include ensuring that they have the requisite joint ranges of motion and stability to handle the exercises. Once they are qualified then spend time on technique. Once technique is solid then condition. Do not just throw people to the wolves.

5. Structure your training in phases so that you don’t go high intensity all the time and run the risk of breaking down. The body can only tolerate so much high intensity or maximal effort work. All high intensity interval training programs should have phases where that intense stimulus is removed or minimized to allow the body to not only recover but to also work on developing the aerobic system, which can be helpful in moving the lactate threshold further to the right and allowing the individual to tolerate greater amounts of high intensity work once you get back into that phase of training.

Patrick
patrick@optimumsportsperformance.com

I just finished reading the book Allostasis, Homeostasis, and the Costs of Physiological Adaptation edited by Jay Schulkin. The book is fantastic and while it is not written specifically about physical preparation for sport the information contained inside has everything to do with physiological preparation for sport.

Homeostasis and Allostasis

Homestasis is a term most are familiar with and generally the word gets thrown around when we talk about training – “The goal of training is to disrupt homeostasis and force the body to adapt and get stronger.” There is, however, a difference between homeostasis and allostasis and understanding that difference may help us better understand the ramifications of our training program. While the authors who contributed chapters in Schulkin’s book all seem to agree there is a difference between homeostasis and allostasis they do have subtle differences in regard to how those terms are applied and the physiological processes they are applied to. Rather than getting so focused on those subtle differences I think that just grasping the basic concepts would be helpful before I try and put this into the context of physical preparation for sport.

Homeostasis

The concept of homeostasis dates back to Walter Cannon’s work (1935) and for a broader understanding of Cannon’s work I suggest checking out his book, The Wisdom of the Body, as  it is a classic in the field of physiology. Cannon used the term homeostasis to refer to the processes needed to preserve constant conditions within the body which are centered around specific set points and governed by negative feedback loops.

A common example of homeostasis often cited is the thermostat in your home. If you set the air conditioning to 80 degrees in the summertime the thermostat does not kick on until the temperature in your home rises above 80 degrees (the set point), providing negative feedback to the thermostat and requiring it to take action and regulate the temperature back to normal, achieving homeostasis. Of course, if you opened a window in the house the temperature would rise and be constantly above the set point of 80 degrees causing the theromstat to remain on for a significant period of time, as it attempts to maintain the homeostasis, until you finally either close the window or the thermostat breaks down because it has overworked itself.

One of the issues with the homeostasis model in health is that the medical community takes body set points very literally and thus we end up with a large number of medications being prescribed to help people maintain specific numbers considered to be “normal”. This issue was confronted by Sterling and Eyer in 1988 when their research led them to coin the term allostasis. 

Allostasis, Allostatic State, & Allostatic Overload

Schulkin notes three distinguishable features of allostasis (pg. 7):

1. Allostasis – The process by which an organism achieves internal viability through a bodily change of state
2. Allostatic State – Chronic overactivation of regulatory systems and the alterations of body set points
3. Allostatic Overload - The expression of pathophysiology by the chronic overactivation of regulating systems

Noted stress physiologist, Bruce McEwen, goes on to further differentiate between these features of allostasis and homeostasis by making the distinction that homeostasis applies only to a few physiological systems that are essential for life – pH levels, body temperature, and oxygen tension. These systems are so essential to human survival that slight fluctuations for a brief period of time could lead to death.

Thus, allostasis is not so much focused on constancy as homeostasis is, but rather, is able to fluctuate and alter set points in order to meet demands that are placed on the body. Additionally, rather than only being dependent on negative feedback loops, the allostasis model indicates that the body can be predictive and anticipate stress and react based on feed-forward information.

High blood pressure is a good example to use when trying to understand the difference between allostasis and homeostasis and how this has influenced the medical community, as I alluded to earlier. “Normal” blood pressure is often cited as being 120/80. If a patient presents at the doctors office with a blood pressure of 160/90 they are classified as being hypertensive and prescribed medication to try and bring their blood pressure back down to the “normal” 120/80. One of the issues with taking this homeostatic approach to blood pressure is that this individual’s blood pressure set point may have shifted for a reason. Perhaps they live an incredibly stressful life, they sleep only 4 hours a night, and they keep a poor diet. Their blood pressure is simply adjusting its set point in order to try and still be effective and get the job done. Prescribing medication means that you are not acknowledging all of those other important things going on with the individual’s health and well being and attempting to focus on the adaptation (allostatic state) that is rightfully taking place in the presence of these stressors rather than addressing the true problem – life stress, sleep, and diet. Additionally, the medication which is being used to treat their high blood pressure may do so at the consequence of other physiological systems, as there are often side effects and other systems need to adapt to the medication, placing these other systems into an allostatic state. Of course, if this allostatic state of high blood pressure goes on for a considerable period of time the individual may find themself in a state of allostatic overload – potentially life threatening.

Limitations of Selye’s General Adaptation Syndrome

Hans Selye, whom many consider to be the “Father of the Stress Response”, defined stress as a nonspecific response by the body to any demand whether it is pleasurable or non-pleasurable (eustress or distress). Selye broke stress down into three phases – alarm, resistance, and supercompensation:

The Alarm phase takes place when we encounter a stressor, causing the body to break down. The Resistance phase is our bodies attempt to combat this stressor in order to not only restore homeostasis but to actually put our body in a better position to resist that same stressor should it happen again, thus reaching a state of Supercompensation. Of course, if we continually breakdown and do not provide the body ample time or opportunity to resist the stress we are placing on it we reach a state of Exhaustion.

This model was revolutionary at the time as Selye literally discovered the stress response on accident by making some errors in his lab with the way he handled the mice he was studying. However, like most things, the picture is a bit incomplete and many stress physiologists look at adaptation in a different way. This stereotypical, non-specific response to all stressors, pleasurable or non-pleasurable, in no longer considered accurate. Rather, different situations and different stressors can mediate allostasis in different ways depending the response needed and the body’s ability to cope with the stress. Thus, there is a degree of specificity that stress has on the body and the perception that the body has to this stress will help to determine how it reacts.

Physical Preparation and Allostasis

Similar to the discussion regarding General Adaptation Syndrome, it is important to note that stress can have positive or negative outcomes depending on the amount of stress applied to the body and how the body adapts to that stress. While not discussed in the book, the term hormesis comes to mind. Hormesis is a term of biology used to explain how low levels of a toxin can produce a favorable biological adaptation to the cells while high levels of that same toxin would lead to cell death. This concept can apply to training, much like the model of allostasis discussed in the paragraph above, where a little bit of training can produce a favorable adaptation to the body – the appropriate amount allows the body to cope with the stress of the training session – but, if we push too hard and overload the individual they may achieve an allostastic state, where the biological systems become overactive as they attempt to adjust set points in response to the stress. If we then continually apply training stress we end up with a negative result and force the individual into allostatic overload – the toxin, in this case training, when applied at a low level led to favorable adaptations, however once we did too much it ended up becoming toxic and damaging to the system.

An allostatic state, where the body systems become overactive and adjust their set points in response to training stress, may not be such a bad thing. This would probably resemble a brief period of overreaching and, provided we monitor the athlete appropriately and do not push them over the edge, would lead to favorable gains as the increased set points for things like hormonal output, cardiovascular function, and central nervous system firing would result in the athlete getting stronger, faster, bigger, and more fit.

Thinking through this model of allostasis it makes me consider how training influences the three aspects of my Physiological Buffer Zone (which I discussed on the Strength In Motion DVD):

1. Good Movement
2. High Level of Stress Resistance or Stress Tolerance
3. High level of Fitness

All three aspects are governed by the same allostasis model and the amount of training that one can tolerate is highly individual. Some athletes need more focus in one area of the buffer zone than others and collectively, if we can raise each aspect as high as it possibly can be for the individual, we have a chance of developing someone that is highly resilient and able to tolerate a great amount of stress without breaking down. Essentially, their biological set points are higher and their body is able to anticipate stressors that may be applied to it – for example the psychological stress of game day, the physiological stress of the game, the stress of going into preseason where coaches usually run them into the ground, or the stress of travel from one competition to the next – and mount the appropriate stress response without becoming overactive and leading to potential allostatic overload and breakdown.

The Allostatic Model and Pain

As I read through the book I couldn’t help but think about the topic of pain when referencing this allostatic model. Pain is an output from the brain, a perception, based on all of the information coming in from the environment. When an individual suffers from chronic pain sometimes signals can get crossed and the person gets stuck in this state of protection where the brain is extremely hypervigilant and protective of the painful region. Thus, this individual finds themself first in an allostatic state where the system is hyperactive and set points – in this case perceptions of pain – are altered in order to initially protect the area from further potential damage. If this continues for a lengthy period of time the individual may then find themself in a state of allostatic overload where there is chronic overactivation of bodily systems that lead to a pathological state of chronic pain characterized by changes in the nervous system (central sensitization), changes in movement and motor programs, psychological changes (depression), and changes in behavior (fear avoidance).

The Allostatic Model and Hands on Therapies

Another place where it is interesting to consider this model is in various hands on or touch therapies (IE, massage and manual therapy). Touch may be one potential way in which we can help to influence the allostatic state and sort of “pull the person back” in an effort to preventing them from reaching a state of allostatic overload. Massage, when used appropriately, may help some cope with stress-related symptoms by decreasing anxiety and enhancing psychological well-being. Additionally, during periods of intense training or frequent competition (IE, the in season period) massage may be help to increase an athlete’s stress resistance and ability to cope with stressors when used at the right time during the week. This approach is essential during a long season to help maintain the health of the athlete and prevent them from breaking down and not being able to perform at their best during game time.

Conclusion

The allostasis model underpins everything that we do as strength coaches. Understanding this model can help us see the bigger picture when it comes to the training programs that we write and how different individuals may adapt to those programs. By understanding the unique ability of each athlete to adapt to the stress we place upon them we can begin to increase the athlete’s physiological buffer zone by increasing their biological set points and enhancing their bodies ability to be predictive and anticipate potential stressors.

Patrick
patrick@optimumsportsperformance.com

This is the final article in this series. To review the previous articles please click here:

Massage and Acute Injuries – Part 1: The Healing Process
Massage and Acute Injuries – Part 2: The Inflammatory Phase
Massage and Acute Injuries – Part 3: The Regeneration Phase

Just to review, again, what I wrote in Part 1 and my disclaimer:

There may be a number of things affected by an acute injury (labrum, disc, meniscus, fractures, etc) but the purposes of this blog series we will only talk about soft tissue injuries such as ligamentous sprains or musculotendious strains (pulls, tears, etc).

Disclaimer: To be clear, this is not to suggest, in any way, that massage is the only thing that needs to be done – it is only a small piece of the puzzle. The athlete should ALWAYS be encouraged to see a medical professional and then massage therapists should be encouraged to work as part of the team of professionals (Dr., PT, DC, ATC, Strength Coach) to ensure the athlete has a safe and healthy return to sport.

Part 4: The Remodeling Phase

The remodeling phase, which textbooks will often indicate can last anywhere from 21-360 days, is the final phase of the healing process. Similar to the regeneration phase that comes before it, this phase is characterized by scar tissue formation except that type I collagen is now being synthesized, which is much stronger and stable than the type III collagen which preceded it. In this phase inflammation has now been resolved and there should no longer be pain with tissue contraction although sometimes athletes will still report pain with movement or activity. Function may still be limited as the athlete is usually now begging to train to play again.

The main goals for massage in this phase are:

1. Assisting in functional scar tissue formation and helping to restore function
2. Assisting in the recovery process following training, practice, and/or return to play protocols

Assisting in Functional Scar Formation and Restoration of Function

As I discussed in the previous article in this series, as collagen fibers are laid down scar tissue begins to form which helps to re-enforce the tissue, strengthen it, and provide stability. Scar tissue, like bone, will model itself along the line or plane of stress. In the previous phase, the regeneration phase, the collagen tissue was less mature and being aggressive with this less mature tissue can mean that it wont form a strong bond and the tissue doesn’t heal with the strength and stability that it needs, leaving the athlete open to another potential injury. In the remodeling phase though the tissue is now stronger and more mature meaning that we can take a much more proactive approach to how we address it and assist it in lining up along the line/plane that we want it to to help assist in restoring function. Additionally, we can take a more aggressive approach to our stretching, exercise, and movement and now work more locally than in previous phases as the tissue is in a stable place at this time. Again, always speak with the medical staff that is part of your team to discuss your goals, their goals, and what you are going to attempt to do in order to get the green light from them.

The techniques that can work well in this phase are:

• General gliding techniques
• Pin and stretch
• Friction
• Muscle Energy Technique Approaches

The frequency/amount/duration that you spend with each technique or the technique you choose to employ the most is really up to how the individual is responding/adapting to the treatment. Gliding techniques are often a good start to the treatment as a way to warm the individual up and introduce yourself to their nervous system and friction techniques can be used at very specific areas of the muscle or tendon. The pin and stretch techniques (either active or passive) are a good way to get the client involved in the treatment and, rather then having them lie there passively, engage their nervous system in the process and introduce movement which may have a positive influence on mechanoreceptors and assist in a quicker return to function. Finally, muscle energy techniques can be used in multiple ways. Contract-Relax or Contract-Relax-Contract Antagonist can be used to help teach the nervous system how to go through newer ranges of motion and restore range of motion that may have been lost by the injury while some of the resisted eccentric techniques can be used to help create a strain/stress on the tissue and assist in collagen formation in a more parallel order, rather than being laid down in a random and messy fashion.

Assisting in the Recovery Process Following Training

During this final phase of healing the athlete is often participating in a variety of return to play protocols, light practices, and more aggressive training in order to prepare their body to get back into the game. Training is supposed to disrupt homeostasis to a certain point and create some inflammation – both are favorable as they begin the healing process and set up the internal environment to adapt to the stress being placed on the body with the ultimate goal of elevating the athlete’s level of fitness. That being said, coming back from a sprain or strain can often mean that there is going to be some stiffness, soreness, or slight pain following training. During the remodeling phase, in this situation massage can be used to help with the recovery process and, as I discussed in the previous phases, can provide a large psychological boost to the individual as their sense of well-being improves from the touch therapy, allowing them to be more comfortable with the increasing volume, intensity, and frequency of training. The techniques would be similar to those above and aside from just working locally the therapist is encouraged to perform more global massage as well to treat all areas that may potentially be stressed due to changes in movement and mechanics as the athlete returns back to play.

Wrapping Up

The main objectives for the massage therapist in this final phase of recovery are to assist in functional scar tissue formation and use other massage approaches to enhance stress resistance and improve recovery as the athlete begins to stress the tissue in the training environment during their return to play.

One thing I should note is that the time domains for each of these phases of healing are rather long. I do believe that if we do everything correctly we can sometimes turn the tables quicker and shorten up the time period for healing (depending on the injury and severity, of course, as that will dictate how quickly things can happen – never try and rush things purposefully and risk the athlete’s health!). As I discussed in Part 2 of this series, there is a huge psychological component to injuries and maybe sometimes, because high level athletes are so hypervigilant and hyper-aware of their bodies some injuries may not be as bad as they are initially perceived. The better we can get into the athletes head the faster their body may take to the recovery process.

Finally, it is important to note all the other stuff! How the athlete balances out the ecosystem of their body and tolerates all of their life stresses (what I call Your Stress Account), for example, things like nutrition, hydration, sleep, life stress, etc. will also play a role in their recovery. Athletes that do all the little things right, stay in shape, eat well, get good sleep, and manage their stress tend to recover quicker, as I talked about in the article Recovery: Athlete vs. Average Joe. Remember, all therapy – like training – is a stress that the body needs to adapt and respond too. If you tolerate stress well then you can adapt at a much easier rate and tolerate more stress. If you don’t take care of the little things, get out of shape, keep a poor diet, and have a poor lifestyle then your ability to tolerate stress and make favorable adaptations to the therapy will slow down the recovery process.

I hope you found this series useful and I do stress that, as a massage therapist, you should seek out a team of medical professionals to ensure you are in the right place at the right time. Do not simply go rouge and take matters into your own hands. Be a team player.

patrick@optimumsportsperformance.com