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Archive for the ‘Stretching’ Category

Using the foam roll as method of massage and myofascial release is common in the strength and conditioning field as well as in the fitness and personal training industry. It probably isn’t as common in the athletic training setting, particularly in the injury rehabilitation venue. However, as athletic trainers, w need to become more knowledgable of this modality and how it can effectively help those in our care.

Probably, the first step is understanding what foam rolling actually does. A great way to gain understanding of this process is through the use of analogy.

I’ve heard Mike Boyle speak on this topic and he addresses it in his book Advances in Functional Training. One of the primary roles of the foam roller is to serve as a self massage and self myofascial release. Foam rolling will help to reduce knots within the muscle and prepare it for effective stretching. Mike uses the analogy of a knot in a band. If you don’t roll and remove the knots beforehand, stretching will simply cause the knot to tighten. Rolling removes the knots and allows one to effectively stetch. This is a great analogy and the premise makes sense to me.

However, a colleague questioned this when I shared this analogy with him and he aksed how knots get formed in a muscle to begin with. When you think of a band or a rope, a knot is formed by the strands actually being tied and twisted together. Instead of adhering to each other, a knot actually becomes entangled into each other. Think about your garden hose. The only way to remove the knot in this instance is to feed one part of the band, rope, or garden hose back through the loops until the the knot is completely unwound. Compressing that knot would not really relieve the knot, it may actually make it tighter. This is not really possible to separate muscle fibers and feed them through each other.

So, my colleague’s question caused me to think a little more – while we can’t deny the knots and increased tissue density in these areas, is there another analogy that possibly fits this process better.

So, as I was thinking about this – does a “knot” in a muscle as it relates to the relationship between foam rolling and stretching more closely resemble a ball of dough.

A ball of dough is made up of fibers and is initially tight, dense and inflexible. Stretching a ball of dough in it’s round state is pretty tough and really won’t do much in the way of lengthening the dough. However, as you roll and knead the dough, it becomes more pliable. Adhesions break down and the dough ball begins to become more accepting of change. Once the dough becomes less dense and pliable enough, it can now be stretched and lengthened. Rolling, in this instance doesn’t necessarily “remove a knot” in the tissue in the technical sense but it breaks down aherences, restores muscle density and function, and realigns the fibers into a more workable state. Rolling the dough makes the task of stretching or lengthening the dough much more easier to accomplish.

Ultimately, the point remains the same – foam rolling improves tissue quality, restore normal tissue density and prepares the body for stretching and activity. This is merely a question of semantics. As we explain this strategy to our athletes and patients, does this analogy drive the point home a little more?

This is more of a thinking out loud post. What are your thoughts? Does this analogy work a little better? Do you have another analogy you use altogether? I’m curious to hear your thoughts.

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The March-April 2010 issue of the Journal of Sports Health has several insteresting studies. This particular study compared the effectiveness of stretching vs. stretching with joint mobilization for posterior shoulder tightness measured by internal rotation loss.

Now for starters, the hypothesis was interesting. Going into the study, the researchers hypthesized:

Shoulder internal rotation range of motion will not change with either of 2 interventions: cross-body stretch alone and cross-body stretch plus posterior capsule joint mobilization”

So going into the study, the researchers were not convinced either of these two methods would effectively produce a change in internal rotation range of motion. As the pursuit of evidence based medicine continues, studies like this that prove to provide evidence with which to base our treatment decisions is important.

A second point of interest was the underlying premise that the posterior capsule is responsible for the loss of internal rotation. There is growing belief that this is not necessarily the case. Can this paper-paper thin structure be responsible for interal rotation ROM loss? The authors did not and I won’t answer this question but an interesting side note nonetheless.

The study measured 39 asymptomatic individuals who had a minimum of a 10 degree loss between the “treated” shoulder and the “control” shoulder. Twenty shoulders were treated with stretching only and 19 shoulders were treated wtih stretching + joint mobilization.

The stretch that was chosen for both groups was the cross-body stretch. Traditionally, there are probably three common self stretches that are chosen to address internal rotation loss. These stretches are: the towel stretch, the sleeper stretch, and the cross body stretch. A study by McClure et al compared the cross body stretch and the sleeper stretch and research determined that the cross body stretch was superior. Hence, this stretch was chosen for the purposes of this study.

As far as the study was concerned, the stretch in both groups was done on their own at 5 sets x 30 seconds each. This was done a minimum of 3-4 times a week for 4 weeks.  This stretch was done in a sitting or standing position without concern for stabalizing the scapula.

As far as the joint mobilization, posterior capsule mobilizations (grade III and IV) were performed for a total of 10 minutes at a minimum of 2 sessions per week for 4 weeks. Again, the stretching and joint mobilization groups included both interventions while the stretching only group used the stretching only strategy.

Overall, both the stretching and stretching plus joint mobilization groups resulted in increased internal rotation range of motion – both at the end of the 4 week period and at 4 weeks post-intervention. The conclusion of the study  was as follows:

The cross-arm stretch with joint mobilization and the cross-arm stretch along can significantly increase shoulder internal rotation following 4 weeks of intervention in a group of asymptomatic college age students.”

One further point about the study results that stuck out: the stretching plus joint mobilization resulted in greater gains at 4 weeks than the stretching only group but the results at 4 weeks post appear to be pretty comparable between teh ROM gains.

Now the authors did note some limitations with the study. The limitations noted were: asymptomatic participants, a convenience sample, measurement error, and a 10 degree difference in internal rotation between shoulders. Probably the biggest of which, in my mind, is the fact that the subjects in this study were asymptomatic – they simply had bilateral motion differences between shoulders for internal rotation. Whether or not this particular strategy would be effective for someone presenting with internal rotation loss while symptomatic remains to be seen.

However this does give us a starting point to begin our treatment planning.

Number one, as an injury prevention strategy for those who have ROM limits but are asymptomatic, a 4 week stretching program using the cross body stretch is probably a good starting strategy.

Regarding symptomatic patients with loss of internal rotation, this may be a part of the treatment strategy package. As we plan our strategy, this study gives us some considerations.

If some already presents with IR deficiency accompanied by pain, a towel stretch behind the back probably is not going to be very comfortable. It is very common that this motion is painful for patients to begin with. Having them to push through pain to increase ROM in this method makes little sense. So if the towel stretch is currently a common staple of your treatment protocol in these particular cases, there very well could be a better strategy.

The sleeper streth is another common method of stretching. This stretch certainly has it’s place. To restore range of motion in an injured shoulder – may or may not be effective. Again, whether or not the stretch causes pain is a chief consideration. Some patients cannot tolerate this stretch real well early on in the rehabilitation process.

The cross arm stretch, studied in this particular research piece, is shown to be effective in asymptomatic individuals. Again, when applying with symptomatic individuals, working within a pain-free is very important. 

The other consideration, especially with this particular stretch, is stabalization of the scapula. Again, working within a pain-free range, stabalizing the scapula is a better technique than simply the cross body stretch while sitting or standing.

To stabalize, one can lie on their side and use body weight to help stabalize the scapula. (Eric Cressey demonstrates this stretch on his blog here.)For the clinician-assisted stretch, this stretch can be done with the patient supine and you can use your under hand to stabalize and provide medial pressure to the scapula while using the opposite hand to horizontally adduct the arm and provide that cross body stretch. (Mike Reinold demonstrates this technique in one of his posts – scroll to the bottom of the post). To enhance the stretch, you can take the arm being stretched straight across or add a little internal rotation component as well. Again, all within pain-free limits.

In the symptomatic patient, if these stretching techniques cannot be done without pain, then some gentle joint mobilizations may be a places to start.

So while this study admittedly doesn’t answer all of our questions, particularly in relation to our symptomatic patients, it does gives us a frame of reference we can start with when addressing the issue of internal rotation loss of motion.

What are your thoughts? What strategies have you effectively employed to restore internal rotation ROM?

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Efficiency is defined as the following: “Skillfulness in avoiding wasted time and effort”. If we can accomplish two or three things at once with a drill, a stretch, and exercise or a treatment –  this would be considered efficient.

I was reading The Essential Eight – Eight Mobility Drills Everyone Should Do by Mike Boyle. Leg swings were listed as one of the essential eight mobility drills. Here is what Mike wrote about side-to-side leg swings and it really speaks to the efficiency of this exercise:

“Leg swings are an interesting exercise. I used to think of leg swings as a hip mobility exercise and a dynamic adductor stretch… Physical Therapist Gary Gray made me realize that leg swings are actually a great transverse plane mobility exercise for the ankle. Yes, I said ankle. Watch an athlete with poor ankle mobility do leg swings and you will see the foot move into external rotation ( turn out) as they swing. The key to leg swings is to keep the foot in contact with the floor and to drive rotary motion into the foot and ankle. The action of the leg swinging creates mobility at the ankle in the transverse plane.”

Efficiency on clear display.

So whether you work with:

  • athletes and are looking for a way to make more efficient use of the stretching and warm-up time
  • patients in a rehabilitation setting and want to incorporate an effective drill to prepare someone for his/her rehabilitation exercises
  • employees in an industrial setting and are looking for an efficient and effective pre-work warm up drill
  • (enter your specific situation here)

Leg swings can be an excellent choice and are able provide a lot of value in a single exercise.

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The final part of this series will briefly address the mental aspect in relation to functional flexibility. As has been discussed in this series, Functional Flexibility is being used as a bridge. It allows the body to ramp up and progress from one series of events to another. This progression also helps the mind as well prepare for the next stage in the process.

In anything we do, the mental aspect is very important. We go out into our cars on a snowy day and most drivers would begin thinking something like: “The roads are going to be slippery.  I need to drive more slowly, brake a little earlier, and keep my eye out for reckless drivers.”  All systems are on go and ready. The posture is a little more upright, the feet are more ready, and we have a tighter grip on the wheel. Why? We are mentally prepared and this also allows our body to respond appropriately as well.

So, let’s go back to the example of the halftime intermission. Any coach will tell you that many contests are often won and lost within the first few minutes of third quarter. Coaches stress coming out strong to start the second half and yet most teams are sitting down in a relaxed position while listening to their coaches.

I’ll go back to the refereeing example. I mentioned in my last post that at the beginning of the third quarter it is often difficult for me to focus. Again I go from activity to 10 minutes of inactivity and sitting and then back to activity again. The body has physically slowed down, the heart rate is decreasing, and all signals are that we are calling it a day. Then all of the sudden we have to resume what we were doing with no significant lead in. The mind now has to refocus and get in sync with the body. I often find that it takes a few minutes to “get back into the flow”. For an athlete or someone in your care, those few minutes can be the difference between winning and losing or between performing safely and sustaining injury.

Functional flexibility can play a significant role in many facets. It is a bridge from stretching to activity. It can be used to progress that injured athlete, industrial athlete, or patient back into activity. It can be utilized during intermissions or breaks to keep the body prepared for additional activity. And finally, functional flexibility can also help individuals become more mentally prepared for additional activity requirements.

If you haven’t already, please take the time to view the video on Functional Flexibility and then your next task is to see how you can use this strategy in whatever setting you work. As we continue to strive to better serve those in our care, I hope this series has challenged you to develop some new ideas and strategies.

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Today we’ll continue with part III of our four part series discussing the topic of Functional Flexibility. If you pay close attention in the video, Gary Gray, PT alludes to what takes place at halftime during athletic contests that he’s involved in. He implies that during this “break time” , his athletes are still going through functional activity and staying loose and active during halftime. The end result often is that his team is better prepared than the opponent to start the 2nd half and is able to use that advantage to jump out early in the second half while the other team is still “waking from it’s slumber”.

 I can attest to this 3rd quarter phenomenon with my refereeing. I’ll finish up running up and down the court for a 30 or so minutes and at halftime, my partner(s) and I go into the locker room and discuss what took place during the first half and what we expect to transpire in the 2nd half. Sounds reasonable, right? The only problem is that we sit down for 7 or 8 minutes while doing this. As a result, the body is more than a little surprised when it has to get back up after resting and then run up and down a basketball court again. The first few minutes of the second half are always a challenge for me and quite honestly I often find myself wishing I wouldn’t have stopped. The two halves lacked a bridge to help prepare me for that transition back into activity after rest.

The principles that we discussed for implementing functional flexibility prior to the contest and at halftime are very similar. At the beginning of the contest, we go from stretching to warm-ups to game activity. At halftime, we are going from full throttle activity to stopping and then ramping right back up again with little to prepare us. In both situations, functional flexibility can serve as that connection between the two extremes and gives the body a better opportunity to recover from the first activity and at the same time, prepare and transition for the second.

With a full slate of basketball games over the next two months,  I’m going to implement this strategy and I’ll report back. Stay tuned.

Finally, in the last part of the series, we’ll just briefly look at the mental aspect that is involved and how functional flexibility can possibly help sharpen us mentally for our contest.

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In my last post, I discussed the importance of bridging the gap from stretching to activity with some Functional Flexibility as illustrated and discussed by Gary Gray, PT. Otherwise, without this safe and progressive ramping up, aren’t we essentially allowing our athletes, industrial athletes, and patients to jump from one side of the river to the other and hoping they don’t get hurt? The bridge of functional flexibility allows those in our care the opportunity to safely build to the point activity.

Now the second part of this discussion is the injured athlete or employee or patient who is going to return to activity. Let’s use a football player with a hip flexor strain as our example.

Prior to activity, we spend plenty of time stretching this athlete out and get the athlete ready for the next step in the process. Do we then let them go out and do some light jogging and additional warm-up activities immediately following stretching? Or would we take them through several minutes of functional flexibility?

  • We can take them through some closed chain sagittal, frontal, and transverse plane activity. One example as shown in the video is to place one leg on a bleacher and begin to move in all three planes starting with a low range of motion and progressing in the process. Then switch legs and you’ll get a different range and differing progressive effects.
  • We can then advance with some arm drivers as Gary discusses to add an extra element of challenge. It is one thing to move forward in the sagittal plane and another to move forward with the shoulders going into flexion and the torso going into extension. Totally adds a different element.
  • The next step would then be some closed – open – closed chain activities such as the stepping/lunging with no arm drivers at first and then adding the arm drivers.
  • Then you could finish with single leg actitivities that would further test our proprioception, etc.
  • From this point (after several minutes of this routine tailored to the individual with respect to the activity they are getting ready to participate in) the individual should now be ready to move on to more specific warm-ups that are sport, work, or activity specific.

So in review – In part I we discussed starting off with some stretching, then do some functional flexibility suited to be activity specific, followed by warm-up at an increasing level of intensity so that by the time the individual needs to be ready to participate, they are raring to go. Bridging the gap. Same thing with someone who is injured. This technique also provides us a little better window to monitor their progress. We have an opportunity to see any potential problems in this progressive approach.

Again, please share your thoughts. Have you used this strategy? What benefits or negatives for that matter, do you see from implementing this  strategy with those in your care?

In my next post, we’ll explore the third part of this series and discuss what can be done in the middle of activity (halftime, breaks) in order to stay in tune with the game and allow those in our care to continue to be sucessful after the intermission.

Photo Credit, Niklas Hellerstedt

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