From Turf to Table

Well, I'm working my own practice now.

After four years of school, a national exam, and a hell of a lot of prep work, I finally opened my new clinic. As business grows, it's coming with its rewards..and lessons.

During the majority of my time in school and the couple years that followed, most of my work experience was on the sports field. In essence, my scope of practice between the field and clinic are the same. Respond to the injuries, treat the pain, rehab the injuries, and progress my clients to their return to activity.

The work life on the field is high-paced and demanding. You would think that moving to the clinic would be a refreshing change and much easier job. Yeah, no. The clinical life comes with many of its own challenges. I wouldn't call either job necessarily harder than the other, but that's just it; "easier" really doesn't exist.

Time Constraints

Firstly, yes, the fast-pace lifestyle of the field can be stressful. When you have a 10-minute intermission and seven players in line to see you, you need to be on your toes to give them what they need in a restricted amount of time. Often, you have to make some tough calls and prioritize the injury needs of some players over others in order to get your team back on the floor in as optimal order as possible. Bad bruise on your arm? Sorry, I have a thrown-out back and two fresh ankle sprains to manage. Come back to me after the game.

Pictured: The third blown-out knee in the game, probably.

On the flip side, now that I'm in the clinic, I have nothing but time to spare with my clients. However, this puts a different kind of pressure on. Athletes on a team are so eager to get back on the floor - adrenaline rushing in their veins in higher volume than blood - and half the time they'll feel better the moment you put your hands on them, even if you haven't done anything yet. (A lot of them don't seem to feel pain.) Clients in the clinic, on the other hand, have just as much time to think as you do, and so all their own focus is on their pain and sensations. With that being said, there's the extra stress of missing something or not being maximally effective with a treatment technique; stresses that you realize weren't there before when none of your athletes ever had the time to think about it.

Motor Patterns and Compensations

Yup, so athletes get injured. A lot. Every game, there's going to be something new happen, and it often feels like you're in a hopeless loop of never-ending accidents and players in pain. Arrggh, why doesn't it stop!

That's the nature of sport. Crap happens. However, the good thing about all of these constant injuries happening in your presence is that you can do something about them immediately! I'm talking within five minutes of them occurring. Do I get that convenience in the clinic? Not at all.

When an acute injury occurs, there is the traditional, tried-and-true protocol of RICE: rest, ice, compression, and elevation. You can minimize the secondary tissue damage by minimizing excessive swelling, ensure that a player isn't going to hurt themselves more by discontinuing activity, and get them on early rehab exercises as early as the next day. Range of motion, proprioceptive training, and strengthening in those first few days does amazing things for recovery by making sure that damaged tissue heals and reorganizes itself in the proper patterns and line of pull immediately.

When it comes to clients who book in at the clinic, it's once in a blue moon that someone books in for an injury that was sustained just the day before. More often than not, these people have been in pain for months - if not years or decades. Their injured tissue has healed in haphazard directions, they've developed poor motor habits around their conditions, and muscles have become strong, weak, tight, and loose in compensation. It's not longer a matter of simply getting the injured joint moving; now we have to pick apart months and years of improper motor training. A sprained ankle four years ago can cause a limp, resulting in a hip weakness on the opposite side, compounding into knee and back pain and so on.

That toe sprain has completely mangled your neck.

Never Easy, But Always Fun

As you can see, both the field and clinic worlds have their challenges that contrast but don't trump one another. You can't call either job easier. However, I love both sides of my professional life. The slow, controlled pace of the clinic as well as the exciting, non-stop action of being on the field. A healthy balance keeps things interesting, and my job is definitely a lot of that!

How Do Pain and Spasm Work?

I had a client this week ask me why the body seizes up so violently when it experiences injury, even when the muscles that are seizing up weren't the ones that were damaged. You've sprained a ligament at your AC joint, so why has your entire upper back and neck become so tight and restricted?

As I've mentioned before, the body has this fantastic mechanism when it comes to protecting its joints. Normally, when it detects instability around a joint, the brain signals the muscles to tighten and tone in order to guard the joint from harm. However, when the instability is severe or when the body experiences an acute, traumatic injury, this tension becomes spasm.

Spasm is an involuntary muscle contraction and is how we define this "seizing up" of muscles when we experience injury. The body is desperately trying to do whatever it can to maintain the integrity of the joints by minimizing any further harm. Unfortunately, this spasm is very often even more debilitating than the injured structure itself. Why is that?

The Pain-Spasm Cycle

What happens is this delightful process known as the pain-spasm cycle. First, your body experiences pain. As we know, the body now tightens and spasms up in response. However, this tension has made the pain even worse. As a result of the increased pain, the body throws in even more spasm, and the cycle continues.

This is essentially the physiology of any injury and the reason why it's so hard to find relief. This cycle can be an extremely debilitating process and is tough to break. But it CAN be broken, and that's where I come in to do my job.

Breaking the Cycle

How do you break a cycle? Well, you remove one of its pit stops, of course. Through whatever means are used, if you can reduce either the pain or the spasm, its counterpart, by principle, will become alleviated as well. This is the purpose of modalities that therapists use. Massage and needling, for instance, help to relieve muscle tension and decrease the amount of pain that a client has. On the flip side, electrical stimulation machines are also used solely to block the pain signals from the tissue to the brain, causing the brain to allow the muscle to relax and cease its spasm.

However, these modalities are often not enough. Even IF the symptoms can be completely alleviated through a treatment (spoiler: most often, they're not), the symptoms can easily return. The way that I explain to my clients is this: Regardless of muscle tension and pain, there is going to be some degree of dysfunction or joint instability remaining from the injury. By not correcting these issues or by leaving behind even a small amount of pain and spasm still, the symptoms are likely to return full-force.

And how do you correct that? Movement. Athletic Therapists recognize that treating the tissue ourselves is only half the battle and that the rest of the work is up to yourself to stop the problem from coming back. Strengthen the muscles around the joint. Create stability. Rebuild the trust between the brain and the muscles that movement can be done safely and pain-free. This is only way to truly correct a dysfunction and prevent this painful boomerang effect.

The most useful medical tools.

These principles are well-known to most medical practitioners, but it seems that it's often missed by the public. By offering this understanding on how exactly pain and spasm work and how to correct them, hopefully it will prove to be a valuable resource to motivate people as they move through their recovery process and back to health.

Case Study: Why Not To Over-Mobilize

I've got a case study for you, and it's a great example of why we need to be careful to not take mobility principles out of context. (Look at me, kicking that horse again. Get used to it.)

The Client

In this instance, I had an adult recreational hockey player in to see me for treatment. He had a history of shoulder injuries, some shoulder pain, and ongoing neck tension and headaches following his weekly hockey game. He exercises regularly, but doesn't often workout his upper body at the gym due to his lifestyle demands not requiring it.

In short, my plan of attack was to do some moderate soft-tissue release through his traps and neck, give him some self-mobility exercises to do before hockey, and some stabilization movements to strengthen his scapular and deep neck muscles. From the rehab side of the world, basic basic.

We tried this approach for two sessions in a row, a week apart. In both cases, my client felt great all week.

Oh wait, except for the two days after his weekly hockey games. Then the pain was like none other.

What Went Wrong?

I'll tell you what went wrong. My client was very responsive to the stabilization exercises and could feel himself standing taller and his shoulder sitting back much better all the way through. However, by increasing his shoulder and thoracic mobility (both through the treatment and through his home exercises), we inadvertently created instability that his muscles weren't yet ready to fully compensate for. 

He described the pain after the second hockey game as "piercing straight from the back to the front" of his thorax. Essentially, after we freed up his joints and increased the movement happening through his thoracic spine and ribs, we created a need for the muscles in the area to work harder to maintain stability, Unfortunately, the strength and endurance in those muscles weren't yet there, and pain resulted for the days after the demand was placed upon them.

So after puzzling this one out, our third session was spent exclusively on strengthening exercises. We purposely avoided doing any hands-on soft-tissue release or joint mobilizations (aside from his self-mobility drills) to try and create a better foundation for stability first. After that treatment, he went to his hockey game and reported, finally, a relief in pain in the days following.

The Takeaway

This is a great reminder to be cautious with the amount of mobility and soft-tissue release that we're providing to our clients (whether you're an Athletic Therapist, a chiropractor, or personal trainer) or even to yourself. Rapidly releasing muscles and freeing up joints does not automatically translate to good health. It must be balanced with proper strengthening to allow the muscle to compensate for the increase joint movement, and those muscles will continue to need further conditioning in order to endure any extended workload demands. Even the best of us will still overshoot when it comes to these principles, but all's good as long as we can take care to reevaluate and not try to maximize range of motion in too short of time.

Looking at Smoking's Effect on Pain

I have a client who is troubled by nerve pain stemming from her neck. We're making some good progress with her rehab, but this week, I called her out on one of her bad habits: smoking.

What does smoking have to do with her neck, though? Well, I'm an educated professional, so I took the time to research and find out.

Nicotine and Pain Research

As I found, research to do with nicotine and pain hasn't been extensive, probably due to "SMOKING CAUSES CANCER" being just about all we realistically should ever need to know about the stuff. 

Regardless, there were many small studies that I could find that examined the relationship on nicotine and pain. Unfortunately, many of them conflict with each other and can't seem to come to a consensus. However, there were a couple conclusions to draw.

Don't People Say Smoking Dulls Their Pain?

It's true that, often, people turn to their cigarettes to deal with pain - both mental and physical. It's true that some studies have found nicotine to bind to certain receptors that potentiate pain and help to block pain signals. However, this effect, from what I can find, is not long-lasting. Also, most of the research done on this subject has used habitual smokers as their tests subjects, meaning that these individuals were already addicted to nicotine in the first place. So that raises the question: Could there be an effect of nicotine on pain outside of the window where this initial pain-relief effect occurs? It's quite possible that pain may have been potentiated in the first place by withdrawal symptoms. Also, it's been suggested that an increased pain tolerance in smokers may actually be due to detrimental damage to nerves, rather than simply being harmless signal blocking.

Nerve Pain

Studies about smoking and neurogenic pain (such as sciatica or whiplash pain), on the other hand, has shown some more definitive conclusions. 

The first study I found wasn't completely reliable, as it only used two individuals as subjects, but it was interesting that both subjects rated their pain to be significantly higher directly while they were smoking. Patients with fibromyalgia and diabetic neuropathy also reported an exacerbation of symptoms when smoking than when not. Finally, one very appealing experiment looked up close at the sensitivity of nerves, using rats as the subject. This one found strong evidence that nicotine very much increased the hypersensitivity of nerves that have undergone injury or irritation, meaning that if a preexisting nerve condition exists, the pain would definitely be more severe.

Conclusion

It's still not easy to say exactly what the effects of smoking on pain are. Like I said, there's strong evidence that pain tolerance in habitual smokers increases when they get their fix, but the mechanism of how it works may be due to some rather unhealthy effects. However, the research definitely seems to agree more when it comes to nerve pain, with nicotine found to increase pain and other symptoms of neurological disease.

To conclude, smoking is bad for you. Go tell everyone.

Stop Snapping Your Gym's Bands From Trying To Stretch Your Shoulders

I was working at the gym tonight, doing my last-minute tidy, and, as is usual these days, had to untie all of our bands from their apparent homes attached to squat racks and cable machines. Not that there are very many of them left. We seem to be going through a lot of them in the past year or so. Do you know why?

"Mobility!"

One of the most seemingly trendy exercises to do these days is to use resistance bands to stretch and mobilize. Unfortunately, (or fortunately, for fitness equipment manufacturers), this means a decreased shelf-life for all the bands in your gym due to consistently being stretched to their maximum elastic length.

But, I'm an open-minded person. Maybe there's some merit to stretching with bands as opposed to other things. Absolutely, I've found some use with joint glides using bands (in the therapeutic setting), but for stretching itself, this is different. After my gym shift, I popped into my clinic to experiment in private.

The Verdict

Ok, mobility peeps. You may not be happy, but, as I concluded, the line of pull for stretching your lats and rhomboids using a band:

...was functionally no different than this:

Gasp!

In fact, using the pillar (or doorway, squat rack, pole, or anything else), actually gave me a better stretch. If you're wondering why, it's because the pillar doesn't stretch as well...like the band does. There's a reason everyone has to take their resistance bands to their end ranges - because that's the point where the band stops stretching. Doesn't it make sense to use something that just won't stretch in the first place for the assistance?

But Wait!

Well, maybe the gentle stretch of using the band is better, because those gentle pulses into the stretch help the muscle relax more.

Except no. Muscle spindles don't work like that. In order for the nerves in your muscles to allow the muscle to relax in a lengthened position, they must be overridden with consistent lengthening, not intermittent.

What About Training Overhead Range Of Motion?

Ok, I'll concede a bit here. Bands could be used to pulse through shoulder flexion and increase range of motion for overhead work. However, I'm still not a fan. With the band remaining uncontrolled in the lateral plane (moving side-to-side), you're essentially tractioning your shoulders at random angles, which could work out fine, or it could aggravate that old shoulder injury from football ten years ago.

Instead, here's my favourite exercise for shoulder flexion (and t-spine extension) done safely and controlled, via Eric Cressey.

Have I Missed Something?

Again, I'm open-minded. After experimenting, I went home and ran some Google searches on band stretching and mobilization to see if there was just something I was missing or doing wrong. Unfortunately, I couldn't find any source that cited the physiological benefit of bands over stable structures for assisted stretching. The best support for it was Kelly Starrett's videos, but even he seems to prefer the method, to my understanding, for the versatility of stretching different ranges rather than for a "better" stretch itself.

Yet, I do still invite the enthusiasts out there to challenge me on why we should be using these methods (besides just looking cool), and I'll absolutely listen. To this point, however, I remain unconvinced.

Making the Case for Mid-Season Rehab

"I'll just power through the rest of the year and get healthy again during the off-season."

I'm good, Coach! There are three whole ligament fibers still in there!

If you've worked with sports in any capacity with athletes over the age of 18, you've encountered this attitude time and time again. Or maybe you're one of these athletes yourself. You got hurt in the first game but feel well enough to continuing playing the week after with only a bit of pain, so you tape yourself up and consign to go and get rehab after the season is over.

This attitude isn't restricted to the traditional multi-game season either. Maybe you're a runner, body builder, or gymnast with that one, big competition coming up in a month. You're training hard and rigorously; there's no time to for stupid little rehab exercises.

In reality, there's actually a big problem with athletes who won't seek treatment in the midst of their sport season. I understand their thought process - in that they either don't have time or don't want rehab to interfere with their training progress or practice - but I far from agree with it. Just because you have someone to tape your ankle, get your back cracked or massaged once a week, or started wearing a back brace doesn't mean it's ok to neglect the actual rehabilitation and retraining of your injured joints.

So what are the reasons to not wait until the season is over to get better?

You're Going to Get More Injured

This one is an obvious one. Regardless of the fact that you have tape or a brace to support the area that you hurt, the structure that was injured is, by nature, now prone to further injury. Even if the tape is good enough to protect your ankle during the game (pro-tip: there's a likely chance it's not!) what about after the game when you return to work or your family? The chances of you reinjuring something, whether during sport, work, or life, are always multiplied after every injury and even moreso after each reoccurence. With that being said, why risk it if there is something to be done?

You're Developing Bad Motor Patterns

So you finally did make it to through those few more months and to your physique show, despite straining your back earlier. It was thanks to that back brace you had at work and that you wore your weight-lifting belt during even the lighter days at the gym. Now that it's all over, now is a good time to hit the clinic.

Except, now that you've waited so long, you've increased your timeline of recovery due to developing poor motor habits by compensating all this time. Whether it's having that back brace that eventually made your core weaker, that limp that mangled your hip strength, or the fact that you just straight-up stopped reaching over head with that arm to protect your shoulder, the adaptations that your body has made around the injury have only become more and more ingrained the longer you put your rehab off. What once may have been a simple couple weeks of rehab for the ankle sprain is now two months of recovery because your hip weakness has now started causing both back and knee pain.

Look at this photo and try to tell me it's ok to walk around like this.

Rehab Will Improve Performance, Not Interfere

This last one is, again, a seemingly-obvious one, but it still doesn't seem to resonate with people who have a less-than-paralyzing affliction. Honestly, I think it may stem from the belief that there's no point in rehabing something that's just going to get more hurt again the next day, but that's an awful way to think.

Anyhow, I digress; you're performance at your sport isn't exactly going to improve amidst an injury, and it's definitely not going to suffer because you added some daily rehab exercises to your training plan. I'll revisit the whole "power through it" mentality, and while that's an admirable philosophy, it's important to remember that every additional ache or pain is going to affect your performance to some degree - whether it's the ankle sprain from three weeks ago meaning you can't run as fast, the back strain preventing you from lifting as heavy, or the shoulder instability resulting in you having less shots at the hoop before needing to come off and ice.

All in all, this isn't a groundbreaking train of thought. I'm pretty sure that all of us - athletes, coaches, parents - know that we're better off seeing help sooner than later, but we get stuck in this mentality of dealing with it later because there's more important stuff in the now. It's a mentality that we're much better off with phasing out, however, for the sake of both your health and your performance. Don't be a hero; be smart.

Is Self-Releasing Your Trigger Points Helpful?

The new cool thing to do in the gym is self-trigger point release. You may be doing this yourself already and, if not, you've definitely seen other people doing it. Before working out, you dig into your muscle using a lacrosse ball, tennis ball, or the like in order to find those points of tension and release them before lifting. There are countless videos on Youtube on how to do this, so that won't be the topic of conversation. In fact, let's talk about why it's probably unnecessary to be releasing your trigger points in the first place.

Firstly, there are two types trigger points that you need to be aware of. The first one is active trigger points. These are the ones that you know you have. They cause the stiffness of the muscle, decreased range of motion, and stabbing, referred pain when you try to stretch or contract the muscle. Often, you will even be able to observe the visible muscle twitch that comes with one of these.

Latent trigger points, on the other hand, exhibit all of these same symptoms, but only with manual pressure is applied to them. This means that, unless you start poking around in the muscle, you're unlikely to ever know you have one in the first place.

Now, this will relate back to when I wrote my scathing article about mobility, as the same principles apply. I talk a lot about "protective tension" of muscles. When a joint isn't completely stable by means of muscular strength, the body will make muscles around the area stiffen up and increase in tension in order to guard the joint from injury, effectively creating the stability that was previously lacking. Trigger points are one example of this stiffness, with the painful, active trigger points typically resulting from more acute injuries or mechanisms that shock the body into needing to guard against injury; latent trigger points, on the other hand, usually sneak up on you due to more of a chronic instability.

I guarantee that you have more trigger points than you realize.

Now, about releasing trigger points. If you have an active one that's causing you pain, decreasing your range of motion, and making daily activity too painful, then absolutely, it's time to do something about it. Whether you self-release it yourself using a lacrosse ball or see an Athletic Therapist of Chiropractor to have it taken care of for you, there's no good reason to not address these.

On the other hand, releasing latent trigger points that weren't previously causing you pain is a different story and is where we can run into trouble. Remember what I said about protective tension? Well, if you have a latent trigger point that's not causing pain or impeding activity, chances are that it's a point that's creating that protective stiffness in a completely functional way. In fact, it could be the only thing that's preventing you from experiencing pain or injury.

So indeed, these latent points are a sign of some degree of instability that we should be mindful of, and they could predispose to later injury for sure. With that in mind, gradual releasing of these points coupled with targeted stabilization training is definitely a healthy practice. However, if you think about the logic of protective tension, consider what may happen if you start releasing too many of these asymptomatic spots of tension too quickly. At best, you won't get much for results at all. If the muscle already more or less had full range and strength, releasing those points might not change anything. At worst however, there could be some less desirable results.

Firstly, what could happen is an acute injury that results from a lack of protective stability. For instance, if you release the upper traps and completely relax them before you do your workout at the gym, you may accidentally injure a ligament while lifting by exceeding your range of motion when, normally, the trap muscle would have been stiff enough to prevent that damaging movement.

So you release the tension and are extra careful during your workout instead. That resolves the issue, right? Well, no. Remember, the body desires stability and knows when it's lacking. If you take away one of the foundations that the body has to create that stability, it will react with more tension in order to make up for it. What this means is that after a day of having that muscle loose and relaxed after digging in with the massage ball, the muscle may bounce back with even more tension than before, with even the possibility of active trigger points developing. And now we come full circle in a chronic loop where we're stuck needing to do those releases before every workout, as now we've created a pain-spasm cycle in our body.

So, should you never touch those trigger points on your own? Mmm..it depends. As I said, if you have painful, active trigger points, then by all means, you should get those taken care of. (And address the issue of why you had it in the first place.) If you have numerous latent ones that don't cause pain or dysfunction, I'll be realistic and say that it's probably fine to leave them be. It's fine if you do work them out once in a while (Hell, getting a massage feels great!), or to release them in conjunction with proper stability exercises for the purpose of properly stabilizing the joint with your own strength, but there's no reason why you should get yourself stuck chronically releasing them before every workout. (Hey, where have I heard that before?) Moral? If you're going to do something, do it carefully and progressively, not blindly and aggressive.