Category — Soft Tissue Techniques

Below is an article written by Keats Snideman and myself that was originally published on Mike Boyle’s Strengthcoach.com website.

The article goes over some of our ideas regarding soft tissue therapy and looking at trigger points and myofascial lines as a way of working with those in pain.  Included are two video examples - the first one explaining a few basic soft tissue therapy techniques and the second going over some practical application of those techniques.

I hope you enjoy the article.

Patrick
patrick@optimumsportsperformance.com

It Hurts Right Here: The Mystery of Pain
By
Keats Snideman BS, CSCS, RKC, LMT
&
Patrick Ward MS, CSCS, LMT

Of the many reasons people seek out medical (allopathic or alternative) care, the number one reason is usually for some sort of pain, be it from an acute injury or some type of chronic or distressing condition. According to the Centers for Disease Control, the number one prescribed class of drugs is analgesics, which are painkillers. However, since few fitness/S & C professionals are also doctors with a license to prescribe drugs, our focus in this article is on non-pharmaceutical approaches to dealing with pain. Specifically, we are going to be dealing with athletic-type of painful conditions that are quite common in an active and athletic population and even in sedentary populations as well (although for different reasons). We’ll start this article by discussing many of the common reasons people suffer pain (other than the obvious ones like acute, traumatic injury). Then, we’ll discuss how many of the common approaches to treating painful conditions, including limiting treatment to primarily the site of pain, are less than optimal and even counter-productive!

Development of Pain in the Myofascial Tissues

One of the most common sources of many aches and pains in the body are local areas of dysfunction in the musculo-tendonous tissues called myofascial trigger points. This term was originally coined by the late Dr. Janet Travel M.D., who pioneered the entire field of myofascial pain and dysfunction and really spearheaded the entire field of treatment for trigger points. In the second edition of the landmark text by Travell and her esteemed colleague Dr. David Simons M.D., a precise definition was given that we will use for explaining what a trigger point (TrP) actually is:

A hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is painful upon compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomenon.

Since so many fitness/health professionals throw theTrP term around so loosely we thought it was important to make sure we are being accurate with our current scientific understanding of the whole trigger point phenomenon. It must be remembered that much of the following information in only theoretical, the best scientific understanding we have at the current moment. Some of this information is tentative and must not be taken as “gospel.” We only highlight these concepts to stimulate a little deeper thinking on the subject at hand.

Are All Painful Spots Trigger Points?

There are some experts that do not fully embrace the trigger point theory/hypothesis and it should be known that not all tender spots upon palpation are trigger points. Some of tender spots could actually be entrapped, compressed, or overly stretched nerves (sub-cutaneous sensory or even deeper peripheral nerves); in fact, David Butler, the Australian Physiotherapist who has helped popularize and develop the field of neurodynamics, has coined the term AIGS (abnormal impulse generating sites) to signify painful sites on the body that might be related to more of a nervous system dysfunction that just a sore or tender muscle/tendon area. Any way you slice it, pain is a nervous system phenomenon; so speaking just of muscles, fascia, bones, ligaments and tendons without mention of the actual nerves which supply them and relay information to and from the CNS (central nervous system) is missing the boat. AIGS are another way to think of painful sites in the body.

How Do You Know if You’re Dealing with TrP’s?

The basic criterion for the diagnosis of a TrP is a painful/tender area upon compression with a sensation of referred pain to a distant area, often remote from the spot being compressed or palpated. Furthermore, if the person recognizes the referred pain then the TrP can be classified as an active trigger point, and if the referred sensation is new or unknown to the individual, then it is classified as a latent trigger point.

Then, there is the classification of central trigger points and attachment trigger points. The central trigger points tend to develop in the center or “belly” of a muscle and can lead to excessive tension (pulling) on either end of the tendons. Initially, this can lead to tendon problems (i.e. tendonitis and inflammation) and if these tensile stresses continue long enough, eventual calcification and degenerative changes can occur to these tendons (i.e. tendonosis & enthesitis).

Two other classifications of TrP’s that need to be understood in this article are the concepts of “key” and “satellite” trigger points. The basic theory here is that until key TrP’s are released, which are usually in larger more proximal muscles, the satellite TrP’s will not release or will return rapidly after treatment. So what this also means is that often, just by effectively treating the key TrP’s, the satellite ones will diminish or go away completely without any direct treatment. A good example of this would phenomenon would be TrP’s in the lateral hip musculature, the gluteus medius or minimus. If a key trigger point were treated in the Quadratus Lumborum (QL for short) prior to treating the glutes, the therapy would be more effective and longer lasting. If the QL and lumbar muscles were not treated, the TrP’s in the lateral hip area might not diminish their TrP activity and referral patterns. This concept of key and satellite TrP’s can also be effectively applied to the fascial connections or “train” theories of Rolfer Thomas Myers. But before we dive into the fascia, let’s review in a video, the many different techniques that can be used (from a soft-tissue perspective) to effectively treat myofascial pain and dysfunction.

Soft Tissue Techniques:

Applying Trigger Point referrals to myofascial lines

Now that we have a fundamental understanding of what trigger points are, how they work, and how to treat them, we can begin to apply this information to myofascial lines and attempt to trace some of our mysofascial tension back to its origin.

Oftentimes clients come in and we perform soft tissue therapy on the area that they complain of pain.  However, our results may only be temporary - the individual reports feeling better for a couple of days only to have the pain return.

This is where having an understanding of myofascial lines and knowing your trigger point referral patterns can help you in searching for the source of soft tissue pain and dysfunction instead of just treating the site.

Thomas Myers, a Rolfer by trade who was trained by Ida Rolf, brought the concept of myofascial lines, or what he called “trains”, to popularity.  Myers proposed several fascial lines that connect the upper and lower extremity and show how dysfunctional patterns in the lower extremity could potentially have a negative impact on the upper extremity.  The fascial lines are:

The Superficial Back Line
The Superficial Front Line
The Lateral Line
The Spiral Line
The Deep Front Line
Back of the Arm Lines
Front of the Arm Lines

We encourage you to check out Myer’s work in order to gain a better understanding of all of these lines and how they affect movement of the body. For the purposes of this article, we will use the lateral line as an example of how to investigate soft tissue to decrease pain and improve overall function.

The lateral line begins at the foot with the peroneal muscles that travel up the outside of the lower leg to attach onto the fibular head and share a fascial connection to the IT-band. The IT-band then travels up the outside of the leg and forms into the gluteus maximus, tensor fascia latae and partially the gluteus medius. These muscles serve as the attachment for this line into the iliac crest. From the iliac crest, the lateral line continues into the internal and external obliques and the QL which all attach to the lower ribs. From the lower ribs, the lateral line blends into the fascia of the intercostals and continues up the body until it reaches the fascia of the splenius cervicis, SCM and scalenes.

Now that we see the connection that these muscles share, we can begin to piece together a treatment plan for an individual who may be experiencing lateral ankle pain or coming back from an inversion ankle sprain.

An inversion sprain is one in which the individual rolls their ankle – think running and slipping off the sidewalk and rolling over your ankle. This injury can range in severity and the pain (and possibly inflammation) this injury causes can inhibit our movement as our body figures a new strategy to move that is less painful.

The peroneal muscles, the muscles on the outside of our lower leg, functional primarily to evert or pronate the foot.  During an inversion sprain, these muscles are rapidly placed on stretch and subject to a high amount of trauma.

It has been documented that following an ankle sprain, individuals may be subject to hip abductor weakness.  This is especially true if the individual is placed in a boot to stabilize the ankle and prevent movement while healing takes place. Our main hip abductors are the gluteus minimus, TFL, and gluteus maximus – the three muscles that make up the IT-band and three of the muscles that share a fascial connection to the peroneals in Myer’s lateral line. 

Moving further up the lateral line, the Quadratus Lumborum (QL) can house trigger points or increased tone following an inversion sprain because it is recruited to help move keep pressure off the injured foot when walking – this is especially true in individuals who are placed in an immobilization boot.

Linking science to practice

Following rehabilitation from an ankle sprain, it may be common for the individual to have residual pain or movement dysfunction.  As we have just shown, the pain in the lateral ankle and the accompanying movement dysfunctions may be caused because of trigger points or fascial tension which were initially developed to help the body move safely in a time of injury; however, are no longer needed or desirable as the individual is prepared to move back to sports activity.

Instead of treating the site of pain – the ankle – we propose that the therapist start further up and begin by investigating the QL, then the hips (paying special attention to TFL, Gluteus Medius, and Gluteus Maximus), move down the IT-band, into the peroneals and finally the ankle, which you may find no longer is painful after the work performed higher up.  In addition to tracing the fascial lines higher up the chain, by working proximal to distal in this manner you also are able enhance blood and lymph flow.  In the case of a chronic ankle sprain, working the ankle directly may be contraindicated due to swelling, inflammation, and pain.  While you are allowing the tissue around the ankle to heal, you can work with the fascial chains higher up to facilitate the healing process and create healthy lymph flow to help the swelling decrease.

Practical Applications:

Conclusions
 
Well, we hope that this article has stimulated some good thought processes on how to approach pain lingering after an athletic injury such as a lateral ankle sprain. We also hope that coaches, trainers, and therapists realize that you can’t just treat the site of pain if optimal recovery and return of function is to occur. As we’ve all heard a million times, the body is “all connected” and is kinetic chain that is linked together mechanically, neurologically, and fascially. Through the theories of trigger point development and treatment, as well as an understanding of the fascial connections of the body, we demonstrated the process that one must take when addressing common injury and pain syndromes. We hope you enjoyed that article and the videos!

About The Authors:

Keats Snideman is the owner of Reality Based Fitness.  Patrick Ward is the owner of Optimum Sports Performance.  Together they own the Reality Based Fitness/Optimum Sports Performance Training facility in Tempe, AZ, where they offer sport conditioning and soft tissue therapy to athletes and clients of all levels and abilities.  In addition, they both host the Reality Based Fitness Podcast.

References

Myers T. The Anatomy Trains Part 1. J Bodywork and Movement Therapies 1997; 1(2):91-101.

Myers T. The Anatomy Trains Part 2. J Bodywork and Movement Therapies 1997; 1(3):134-145.

Chaitow L, DeLany J. Clinical Application of Neuromuscular Techniques Vol. 1: The Upper Body. Churchill Livingstone. 1st ed. 2000.

Chaitow L, DeLany J. Clinical Application of Neuromuscular Techniques Vol. 2: The Lower Body. Churchill Livingstone. 1st ed. 2002.

Friel K, McLean N, Myers C, Caceres M. Ipsilateral Hip Abductor Weakness After Inversion Ankle Sprain. J Athletic Training 2006;41(1):74-80.

One of my favorite things about the internet is that I get to communicate and discuss ideas with colleagues in this field that I may not have otherwise ever met.

One place were great conversation has come up is Twitter.  Recently, several of us had a brief discussion about Carpal Tunnel Syndrome, which inspired me to write this article and give some of my ideas about how soft tissue therapists can work with this issue that affects many.

What is it?

The carpal tunnel is the tunnel formed by the carpal bones of the hand and the transverse carpal ligament.

Carpal Tunnel Syndrome refers to the compression of the median nerve at the carpal tunnel in the wrist.  The median nerve is the nerve that feeds our first three fingers and half of the fourth finger (so our thumb, pointer finger, middle finger and part of our ring finger).  Often times, the median nerve can be compressed by the flexor tendons that share the space within the carpal tunnel.

When the space within the carpal tunnel is compromised, the median nerve can become aggravated and individuals will commonly complain of tingling, paresthsia (pins and needles), burning, shooting pains or numbness into the hand and typically the thumb, pointer finger and middle finger.  In addition to these various sensations, individuals will often display weakness, a loss of muscle function and possibly atrophy.

How does it happen?

Individuals who seem to be most prone to getting carpal tunnel syndrome are those that sit at a computer with their hand/wrist in the same posture for extended periods of the day or those who perform repetitive tasks everyday (musicians and especially guitar players can fall into this category).

While it is basically an overuse injury, overweight individuals or pregnant women can be prone to carpal tunnel syndrome as well due to increased edema (fluid retention) compromising the space in the carpal tunnel or even a traumatic injury in which one of the carpal bones is sublexed, causing it to move out of place and impede on the carpal tunnel.

Women may be more prone to carpal tunnel syndrome because they have a smaller carpal tunnel.

Additionally, others have noted the possibility of poor posture in those showing symptoms of carpal tunnel syndrome.

What can we do about it?

Traditional approaches to carpal tunnel syndrome have focused on the site of the pain (at the wrist) and often overlooked potential factors coming from higher up the chain (IE, forearm, upper arm, and neck).

As noted above, poor posture may play a role in carpal tunnel syndrome.  A 2009 study published in the Journal of Orthopedic and Sports Physical Therapy evaluated the correlation between forward head posture and cervical spine range of motion and carpal tunnel syndrome.  The researchers concluded that, “Patients with moderate carpal tunnel syndrome had greater forward head posture and decreased cervical range of motion when compared to healthy subjects.  Greater forward head posture was associated with a reduction in cervical range of motion.” The researchers, however, did state that, “no cause-and-effect relationship could be inferred from this study.”

I find that last statement interesting.  The researchers state later in the discussion that a cause-and-effect relationships cannot be drawn from this study because it is unknown if the forward head posture is the cause of the problem or if it is a consequence of the problem, as a way for the patient to attempt to move out of pain.

I will say that investigating these structures can be extremely important when working with clients suffering from carpal tunnel syndrome, as a forward head posture can place certain muscles on prolonged stretch and other muscles in a shortened position (obviously creating the reduction in range of motion as shown in this study and others), leading to possible trigger point formation and myofascial pain and dysfunction (as we will see later).

The researchers in the study above did hypothesize that, “Perhaps treatment directed at the cervical spine may enhance the outcome of patients with carpal tunnel syndrome.”

Addressing these issues may offer the client significant improvements in pain and function when other, more traditional approaches, have failed.

Soft Tissue Therapy Ideas

Several non-surgical approaches to carpal tunnel syndrome can be taken and depending on the therapist you see, that approach may be different.  The point of this paper is not to show that one approach is better than another, but rather to highlight some of my ideas with regard to soft tissue therapy when working on individuals suffering from carpal tunnel syndrome.

Altering habits of daily use is a typical starting point for those suffering from carpal tunnel syndrome.  By doing so, the individual breaks the cylce (so to speak) and gives the injured hand a break in the action and a little bit of rest.

Massage was also shown to help decrease signs and symptoms of carpal tunnel syndrome in a 2003 study in the Journal of Bodywork and Movement Therapies, with patients improving in function and decreasing symptoms after seeing a therapist for one 15-minute session once a week for four weeks (the patients were additionally given self-massage treatment plans, as a means of self-care, to be completed in between their weekly appointment)

Additionally, neural mobilization may be effective in decreasing the signs and symptoms of carpal tunnel syndrome, by decreasing neural tension and improving the normal and physiological state of the nervous system.

Looking elsewhere

While clients commonly complain of the pain down at their wrist, thumb and hand, the site of the pain may not always be the source.  It is important to rule out other factors higher up the chain that may be adding to or, in the case of trigger points, creating the symptoms.

Trigger points, myofascial lines and carpal tunnel syndrome

Several muscles may house trigger points that can mimic carpal tunnel syndrome.  In addition, the area that these muscles refer pain to can house satellite trigger points.  So, you may be treating a trigger point down near the wrist and the client may feel better temporarily, only to have the pain return after several days.  It is then that the therapist should look for trigger points in other muscles, usually more proximal to the body, which may be complicating the treatment process.  Evaluating the myofascial lines of the arm can be extremely useful in treatment and may give you a better idea of the source of pain for a particular client.

Some muscles that can refer trigger point like symptoms:

• Latissimus Doris
• Infraspinatus
• Scalenes
• Subscapularis
• Pectoralis Major
• Pectoralis Minor
• Subclavius
• Brachialis
• Brachioradialis
• Pronator Teres
• Flexor Carpi Radialis
• Flexor Pollicis Longus
• Adductor Pollicis
• Opponens Pollicis

It is important to note the muscles in the above group that may be put under greater stretch in a forward head posture, referring to the research cited earlier.  The scalenes, pectoralis major and minor can be prone to shortening in this type of posture.  In addition, the latissimus doris is both an internal rotator and extentensor of the arm, which puts it into a position that can cause greater tension on the brachial plexus (the bundle of nerves in the cervical region, where the median nerve begins its journey down the arm).  This internally rotated position is one common to those who hold office jobs and work on computers all day, causing these muscles to develop trigger points as a means of energy conservation.

Many of these muscles also share a common myofascial connection, as noted by Thomas Myers in his front of the arm line, which has two different tracks.

The first track starts at the pectoralis major, latisimus doris and teres major.  From there, the fascial connection moves to the medial intermuscular septum and then to the medial epicondyle (the attachment site for the pronator teres and several of the flexor muscles).  From the flexor tendons, the fascial connection ends at the palmer side of the hand and the fingers.

The second track begins at the pectoralis minor and draws a fascial connection to the coracobrachialis and short head of the biceps.  The biceps then connect to the radius, where the fascial connection continues with the flexor compartment and finishes at the thumb.

Obviously all of these connections are important to look at when palpating the tissue of someone suffering from carpal tunnel syndrome.  The forward head posture noted above may also create dysfunctional breathing, causing the scalenes to become over active and compress down onto the brachial plexus, creating carpal tunnel syndrome symptoms as well as other possible neurological symptoms.  This over activity of the scalenes in this instance may cause them to house trigger points which can also refer symptoms of carpal tunnel syndrome.  Because of this, it may be critical for the therapist or trainer to  re-teach proper breathing patterns and enhance core function as part of a possible long lasting treatment strategy for those suffering from carpal tunnel syndrome.

Conclusions

When assessing individuals complaining of hand, wrist or thumb pain, it is important to also evaluate other structures more proximal to the area of pain in order to form a more comprehensive treatment approach that provides the client with sustained relief.

The objective of this article was not to argue which treatment method is the best, but rather to offer some ideas for therapists to consider when dealing with carpal tunnel syndrome.

The information in this article is not to be used in place of a full medical evaluation.  If you are suffering from any of these symptoms, please consult a medical professional for a thorough examination.

If you would like information about Optimum Sports Performance and how we can help you, please email me at patrick@optimumsportsperformance.com

References

Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. Mosby. 2002.

De-La-Llave-Rincon A, Fernandez-De-Las-Penas C, Palacios-Cena D, Cleland JA. Increased Forward Head Posture and Resricted Cervical Range of Motion in Patients with Carpal Tunnel Syndrome. J Orth Sport Physical Therapy Sept. 2009;39(9):658-664.

Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles: Testing and Function with Posture and Pain. Lippincott Williams & Wilkins. 2005. 5th ed.

Fields T, Diego M, Cullen C, Hartshorn K, Gruskin A, Hernandez-Reif M, Sunshine W. Carpal Tunnel Syndromes are Lessened Following Massage Therapy. J Bodywork and Movement Ther 2004;8:9-14.

Kostopoulos D. Treatment of Carpal Tunnel Syndrome: A review of non-surgical approaches with emphasis in neural mobilization. J Bodywork and Movement Ther 2004;8:2-8.

Davies C. The Trigger Point Therapy Workbook. New Harbinger Publications, Inc. 2004. 2nd ed.

Chaitow L, DeLany J. Clincal Application of Neuromuscular Techniques Vol. 1: The Upper Body. Churchill Livingstone. 2000. 1st ed.

Myers T. Anatomy Trains part 2. J Bodywork and Movement Ther 1997; 1(3):134-145.

Instead of foam rolling, when I can I like to get my hands on the athletes and do more specific work.

This is a little video compilation we got of me working on one of our amateur golfers prior to his training for the day.  He originally came to me after spraining an ankle and being put into a boot for several weeks.  We have been working together for a couple of months now and he is back competing again and his training has been progressing nicely.  I got some videos of him warming up and training as well, but have not uploaded them yet.  In this video I am working on his hip and lower leg.

We lift 2-3x’s a week and prior to lifting I either do a little soft tissue work (like in the video) or he foam rolls.  In addition to the lifting, he comes in once every two weeks (especially a few days prior to the first round of a competition) for more comprehensive soft tissue therapy where I work his upper and lower extremity.

Patrick

patrick@optimumsportsperformance.com

I just received a call from a gentleman who was referred to me because of some issues he was having with his running.  He informed me that he had a calf strain (gastrocnemius) for the past 3-months and has not be able to properly train.  He said that physical therapy did not help and he really doesn’t know what to do from here.

I asked him many questions and came to the conclusion that he was working towards optimizing his performance (5K runner) with lots of bad information.  The unfortunate part is that the bad information came from three sources that we would consider to be “professionals”, yet they all dropped the ball:

The Coach (I use that term lightly)

He told me that while he was training he informed his running coach several times that his hip and knees were hurting (6-days a week of running tends to do that to people).  His coach replied, “If you want to be a great runner, you need to get used to that.” I will go out on a limb here and say this coach doesn’t understand the stress of training or how to appropriately progress a training program and develop an athlete.  That is horrible advice!

Being in pain is different than being sore.  If you are in pain you need to determine what you are doing wrong.  If you are overly sore, then you need to address your recovery and regeneration strategies.

The Doctor

After he strained the calf, he went to the doctor who found nothing wrong under MRI.  So, the doctor’s recommendation was to “do nothing and rest”.  Unfortunately, when we do nothing with this sort of injury, two things happen:

a) We become deconditioned.  I would have been trying to train the upper body and trying to maintain work capacity instead of sitting around.  The one thing I know about runners is that when they get injured they do nothing.  When they come back from the injury, in their deconditioned state, they try and jump right back in at the intensity and volume that they were doing previous to the injury.  No good can come of this!  Maintain work capacity.  Find a way to train around the injury or (more importantly) train some of the possible factors that caused the injury as the site and the source of the problem are rarely the same thing.

b) The strained/torn muscle starts to lay down scar tissue and becomes stiff.  This doesn’t mean that you should go in and start doing tons of direct soft tissue work or trying to get the muscle to move agressively.  You should however do some light soft tissue work to get the lymph and blood flow moving, do more specific soft tissue work on other areas up or down the chain (remember, the site and the source of the problem are rarely the same thing) and encourage pain free ROM once inflammation and swelling have come down.  Don’t just sit there and let the tissue get stiff and allow a mass amount of scar tissue to form.

The Physical Therapist

After meeting with the doctor and doing nothing for awhile, he decided to try out physical therapy.  He told me that all they did were some exercises that made the area more irritated and painful.  I asked him if they did any specific soft tissue work and he said after he had been going there for 3-weeks they started to do some soft tissue massage and then told him that he could just go out and start running a little bit.  So of course (see above about runners coming back from injuries) he took that to mean he could start training normally again and jumped right in running 5-days a week.  Because of this he has not be able to do anything for several weeks due to pain.  Why the physical therapist did not start with soft tissue therapy right away, I don’t know and why the therapist did not instruct the guy on proper progression back to running is totally beyond me (my best guess would be the therapist has no clue about running, periodization, program design or training in general).

Long story short, he has a long road back.  I know he can get there, but it will take some time to undo what has already been done.  We talked a bit about some of the things that I do at my facility - sports specific strength and conditioning, soft tissue therapy, etc - and how I think I could best help him out with his program design.  We’ll see what happens.

If you feel you are in the same boat as this gentleman and looking to optimize your performance on the field of play, feel free to shoot me an email: patrick@optimumsportsperformance.com

Patrick

I have worked with a number of clients over the past two weeks, each with different problems and issues.  One thing that I feel is incredibly important is not just performing soft tissue therapy, but getting the clients up and moving and developing some sort of capacity to function.  In addition to that, performing some exercises following soft tissue work can be a great time to ensure that the soft tissue re-models, deforms and complies properly so that you can start to normalize the areas that feel “unhealthy” or “not normal” (which I realize is somewhat subjective to the therapist; however it can also be confirmed by the clients feedback as to how the tissue feels - tender, painful, referral pain, etc…)

My last post on Movement in Athletics got some great comments and I thought I would touch on the idea of preparing the tissue to move first and then developing the pattern.

There are basically two types of people that come into my office:

1) People that need a whole lot of soft tissue work (their tissue quality is really poor or they may have a lot of pain and soft tissue dysfunction) followed by a little bit of movement re-education

and

2) People that need a little bit of soft tissue work (just to get mobility) and then a lot of movement training (basically we are getting them back to function or reconditioning them to prepare for a more specific training program).

Obviously the goal is to progress from group 1 to group 2, as group 2 is moving towards developing their overall capacity to a much greater extent.

Soft tissue therapy is great for helping us to achieve mobility.  We free up the soft tissue, then apply a stretch and/or some sort of joint mobilization (either manual or self-mobilization) and regain or re-develop joint mobility.  Once mobility is gained, it is then time to train for stability and make sure that the joint is stable in its new range of motion.  Physical therapist Gray Cook uses the analogy of “giving you WD-4o to loosen up the joint (IE, manual therapy) and then duct tape to fasten it down (IE, training/corrective exercise).”

I had the pleasure of meeting Charlie Weingroff, a physical therapist and strength coach from New Jersey, this weekend.  We talked shop for a good 3 or 4 hours.  It was awesome.  One of those real “wow” type of moments.  Charlie was giving me some ideas and concepts he uses in the treatment room to assess athletes and determine where their limitations lie.  He then talked about gaining mobility first followed by stability.

Basically, he looked at my hip joint and determined that my hip mobility was poor (which it was…horrible actually).  Then, he asked if I was satisfied with this amount of mobility and if it was something that I could live with.  Obviously I said “no”, since I am not a 90-year old man who doesn’t care about being active (no offense to any extremely mobile 90-year old men out there).  What he told me was that if I was satisfied with my (poor) hip mobility then we could go ahead and train for stability in that (poor) range of motion.  However, since I wasn’t happy with that range of motion, the goal would be to first go and get more mobility, and then once that has been gained, start to train for stability.  That sequence would basically continue on until I was at a range of motion that was adequate enough to meet my activity level and training goals.

There was obviously a lot more to the discussion and Charlie had a ton of great info on assessments and determining where dysfunctions lie.

The idea of doing soft tissue work followed by some movement/exercise is the way that I always set up my sessions - and that mantra should be nothing new to those who are regular readers of this blog.  The take home message is more about coming up with a systematic way to evaluate your clients in order to get an understanding of where the greatest restrictions are.  By correcting those first you can sometimes correct a lot of other issues that may be going on.

So to recap:

1) Assess

2) Get mobility where range of motion is restricted

3) Once mobility is gained, make the joint stable in the new range of motion

4) Rinse and repeat until satisfied

One thing I would add is to try, as hard as you can, to not bias your assessment in anyway.  We often get so caught up in things like weak glutes, anterior pelvic tilt, overpronation of the foot, etc., that we expect to see it with everyone that walks in the door and sometimes this expectation almost forces us to see things that may not actually be there.  I try and approach each client with the mentality that they have no issues and I am hoping to not find anything majorly wrong.  This (hopefully) allows me to treat each person as an individual and determine where their individual dysfunctions lie, and not just lumping them into the mold of what we typically see or what is common.

Patrick

patrick@optimumsportsperformance.com