Overactive Versus Underactive Muscles: What Does It All Mean?

Overactive Versus Underactive Muscles: What Does It All Mean?

Posted on August 28, 2014 by nasm

By Kyle Stull, MS, LMT, NASM-CPT, CES, PES, NASM Master Instructor

“Do you suffer from muscle imbalances?” “Is your back pain due to a muscle imbalance?” “Prevent ACL injuries by reducing your muscle imbalances!” What does all this mean? Are muscle imbalances just a marketing craze extending beyond the fitness industry and completely overhyped by social media? Do muscle imbalances even exist, and if so, what are they? This article will help to explain the relationship between muscle imbalances along with understanding more about the implications behind overactive and underactive muscles. What is muscle balance? Efficient human movement and function requires a balance of muscle length and muscle strength around a joint. If muscles are not balanced, then the associated joint is directly affected. For example, a muscle imbalance at the shoulder involving a “tight” pectoralis minor will pull or shift the shoulder forward into a rounding position. Muscle imbalances can be due to poor posture, stress, repetitive movement, or injury. Once this occurs, the body will continue to endure movement, only now the movement occurs along the path of least resistance, otherwise known as relative flexibility (Clark, Lucett, & Sutton, 2012). This pattern can lead to altered reciprocal inhibition, synergistic dominance, and eventual injury (these terms will be further described later). As these patterns of dysfunction continue, the muscle imbalance will lead to muscles on one side of the joint becoming chronically shortened and muscles on the opposing side of the joint becoming chronically lengthened. This is where the terms “overactive” and “underactive” come from. It is generally assumed that an overactive muscle is short, tight, and strong, as opposed to an underactive muscle, which is assumed to be long and weak. While these assumptions are sometimes correct, they may also be misleading for two primary reasons:

1. The sensation of muscle tightness does not always mean that a muscle is short.

2. Just because a muscle is short does not mean that it is overactive and strong, and conversely, just because a muscle is long does not mean it is underactive and weak.

Reason #1 Two important sensory receptors are the muscle spindles and the Golgi tendon organ (GTO). Muscle spindles are receptors within the belly of a muscle that primarily detect changes in the length of the muscle and rate of length change (Magill, 2007). The GTO senses changes in muscle tension and the rate of tension change (Magill, 2007). Located near the origin and insertion of the muscle, when a muscle generates force the GTO becomes distorted and will fire nerve impulses to the central nervous system (CNS) regulating the force and tension developed. When a muscle is rapidly lengthened, the muscle spindles are excited and send a message to the CNS, resulting in the contraction of the lengthened muscle fibers (Clark et al., 2012). Consequently, this results in the sensation of tightness. An example of this is the person with an anterior pelvic tight (excessive arch in the low back). As the pelvis tilts forward, the hamstrings are lengthened. Overtime, these muscles begin to feel “tight.” In most cases, the individual will feel the need to stretch the hamstrings. As the hamstrings are stretched, the GTO will inhibit the muscle spindles (autogenic inhibition) and the hamstrings will begin to feel as though they have relaxed. Yet this altered position of the pelvis causes a lengthened resting position of the muscle, and as soon as the GTO is no longer excited the muscle spindle will begin to signal for the CNS to contract, leading to reoccurring tightness.

Anterior Pelvic Tilt

Reason #2 Sahrmann (2002) stated that the force generation capabilities of a muscle are dependent on the muscles resting length. This is known as length-tension relationship. To state it more simply, a shortened muscle has too much overlap of actin and myosin filaments, and a lengthened muscle doesn’t have enough overlap. This means that both examples could possibly be underactive and test weak compared to a muscle at ideal resting length (Sahrmann, 2002). Therefore, a lengthened muscle could actually become overactive and dominant over another muscle. Let’s further discuss hamstring length and how this affects pelvic orientation. The gluteus maximus is the prime mover during hip extension and the hamstrings provide assistance when needed. In an anterior pelvic tilt position, the hip flexors (iliopsoas, rectus femoris, and tensor fascia latae) may become shortened. According to Sherrington’s law of reciprocal inhibition, if one muscle is contracting then the muscle on the opposing side of the joint must be relaxing (Magill, 2007). If this inverse relationship is altered, as in the case of an anterior pelvic tilt, the hip flexors will be contracted during a functional movement (such as walking) while the primary hip extensors are relaxed. As mentioned previously, the body will find a way to get from point A to point B with the least amount of resistance. In this scenario, the next best muscle to perform hip extension would be the hamstrings. This is known as synergistic dominance, where a mechanically lengthened muscle is overactive and performs the work of the prime mover (Sahrmann, 2002). Conversely, in the case of shoulder dysfunction, someone who is protracted forward with a shortened pectoralis minor also has an overactive pectoralis minor. Therefore, it may be more appropriate to refer to overactive muscles as hypertonic and underactive muscles as hypotonic. A hypertonic muscle is defined as a muscle which exhibits excessive tone or tension (Medical Dictionary, Medline Plus). A hypotonic muscle would be a muscle that lacks tone. Due to the complex nature of overactive and underactive muscles, the fitness professional must begin with a comprehensive assessment. How do I know if my client has overactive or underactive muscles? An assessment should begin with a static postural analysis. Static posture can be thought of as a snap shot of the client’s daily habits. The fitness professional should always consider the five kinetic chain checkpoints: feet, knees, hips, shoulders, and head. If any of these are out of alignment there is a good chance overactive and underactive muscles will be found. A movement assessment should be performed following the static assessment. The overhead squat assessment (OHSA) is one that incorporates active range of motion of the ankles, knees, hips, and shoulders, and requires optimal stabilization from the trunk in order to be performed correctly (Bell et al., 2012). During the OHSA, the same five kinetic chain checkpoints should be viewed as the client squats down with an end goal of having the hips parallel with the ground. A client with overactive and underactive muscles will usually demonstrate predictable patterns of dysfunction (Page, Frank, & Lardner, 2010). In addition to movement assessments, more specific assessments, such as passive range of motion and manual muscle testing, can be performed by a licensed professional. More information on these and other assessments can be found in the NASM Essentials of Corrective Exercise Training textbook.

Overhead Squat Assessment

What are the next steps? After the assessments have been performed, a corrective exercise program can be developed. Corrective exercise is defined as “the systematic process of identifying a neuromusculoskeletal dysfunction, developing a plan of action, and implementing an integrated corrective strategy” (Clark & Lucett, 2011, p. 4). NASM’s Corrective Exercise Continuum consists of first inhibiting the overactive muscles with self-myofascial release (SMR), lengthening the muscles which were identified as being shortened, then activating the underactive muscles with strengthening exercises, and finally, integrating back into a total body movement pattern. As an example, let’s continue with the client that has the anterior pelvic tilt. Based on the assessment, it is known that the hip flexors are overactive and shortened. Therefore, these muscles would need to be foam rolled and statically stretched. As we mentioned earlier, in most cases the hamstrings are also overactive but they are not shortened. This means that we could foam roll the hamstrings but do NOT stretch them. Then, the client would need to activate the gluteus maximus and core stabilizers with floor bridges and planks. Finally, finish up with a squat to row on a cable machine for integration.

Inhibit (SMR)

Lengthen (Stretch)

Activate

Integrate

Conclusion Overactive and underactive muscles are usually reflections of muscle imbalances and posture. Overactive muscles are not necessarily strong or tight, but are hypertonic or have chronic increased tone. Whereas underactive muscles may not always be weak and lengthened, but are hypotonic or have chronic decreased tone. The CNS regulates the length of muscles and basis much of its information from the input of different types of receptors. When developing an exercise program, a health and fitness professional must not let the sensation of tightness be the only guiding force, but to also utilize the information provided by a comprehensive movement assessment. Muscle imbalances do not cause all dysfunction in human movement, but in the presence of muscle imbalances many of the supportive tendons and ligaments may be at higher risk for overuse injuries.

References

Bell, D.R., Vesci, B.J., DiStefano, L.J., Guskiewicz, K.M., Hirth, C.J., & Padua, D.A., (2012). Muscle activity and flexibility in individuals with medial knee displacement during the overhead squat. Athletic Training & Sports Health Care, 4(3), 117-125. Clark, M.A., & Lucett, S.C., (2011). NASM Essentials of Corrective Exercise Training. Lippincott Williams & Wilkins, Baltimore, MD. Clark, M.A., Lucett, S.C., & Sutton, B. (2012). NASM Essentials of Personal Fitness Training (4th ed.), Lippincott Williams & Wilkins, Baltimore, MD. Hamilton, N., Weimar, W., & Luttgens, K., (2008). Kinesiology: Scientific Basis of Human Motion (11th ed.). McGraw Hill, New York, NY. Magill, R. (2007). Motor learning and control: Concepts and applications (9th ed.), McGraw-Hill, New York, NY. Medical Dictionary: Medline Plus. (n.d). August 19, 2014. Page, P., Frank, C.C., & Lardner, R. (2010). Assessment and Treatment of Muscle Imbalance: The Janda Approach. Human Kinetics, Champaign, IL. Sahrmann, S. (2002). Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, St. Louis, MO.

This entry was posted in CEx, Newsletter by nasm. Bookmark the permalink.

Profile

Sign in with Twitter

Sign in with Facebook

or

Name

Email

Not published

Website

Comment

Search

RECENT POSTS

▪ Overactive Versus Underactive Muscles: What Does It All Mean?

▪ Detoxification- What Do You Have to Lose?

▪ Motivational Interviewing-Steps to Behavior Change

▪ Urbanathlon Phase 2

▪ Urbanathlon Phase 1

CATEGORIES

▪ 12 Days of Fitness

▪ Exercise Programming

▪ Fitness Tips

▪ Recipes

▪ Certified Personal Trainer

▪ CEx

▪ Fitness

▪ Fitness Professionals

▪ Fitness Week

▪ Golf Fitness

▪ Holiday Fitness

▪ Inspirational

▪ LA Fitness

▪ MMA

▪ Newsletter

▪ Nutrition

▪ OPT

▪ Q & A

▪ Research Study

▪ Senior Fitness

▪ Sports Medicine

▪ Sports Performance

▪ Thanksgiving

▪ The Training Edge

▪ Training Benefits

▪ Uncategorized

▪ Urbanathlon

▪ Weight Loss Specialist

▪ Winter Sports

▪ Women's Fitness

▪ Workout Plans

To Ice or not?? Great article.

Why Ice Delays Recovery

In a recent study, athletes were told to exercise so intensely that they developed severe muscle damage that caused extensive muscle soreness. Although cooling delayed swelling, it did not hasten recovery from this muscle damage (The American Journal of Sports Medicine, June 2013). A summary of 22 scientific articles found almost no evidence that ice and compression hastened healing over the use of compression alone, although ice plus exercise may marginally help to heal ankle sprains (The American Journal of Sports Medicine, January, 2004;32(1):251-261).

Healing Requires Inflammation
When you damage tissue through trauma or develop muscle soreness by exercising very intensely, you heal by using your immunity, the same biological mechanisms that you use to kill germs. This is called inflammation. When germs get into your body, your immunity sends cells and proteins into the infected area to kill the germs. When muscles and other tissues are damaged, your immunity sends the same inflammatory cells to the damaged tissue to promote healing. The response to both infection and tissue damage is the same. Inflammatory cells rush to injured tissue to start the healing process (Journal of American Academy of Orthopedic Surgeons, Vol 7, No 5, 1999). The inflammatory cells called macrophages release a hormone called Insulin-like growth Factor (IGF-1) into the damaged tissues, which helps muscles and other injured parts to heal. However, applying ice to reduce swelling actually delays healing by preventing the body from releasing IGF-1.

The authors of one study used two groups of mice, with one group genetically altered so they could not form the normally expected inflammatory response to injury. The other group was able to respond normally. The scientists then injected barium chloride into muscles to damage them. The muscles of the mice that could not form the expected immune response to injury did not heal, while mice with normal immunities healed quickly. The mice that healed had very large amounts of IGF-1 in their damaged muscles, while the mice that could not heal had almost no IGF-1. (Federation of American Societies for Experimental Biology, November 2010).

Ice Keeps Healing Cells from Entering Injured Tissue
Applying ice to injured tissue causes blood vessels near the injury to constrict and shut off the blood flow that brings in the healing cells of inflammation (Knee Surg Sports Traumatol Arthrosc, published online Feb 23, 2014). The blood vessels do not open again for many hours after the ice was applied. This decreased blood flow can cause the tissue to die from decreased blood flow and can even cause permanent nerve damage.

Anything That Reduces Inflammation Also Delays Healing
Anything that reduces your immune response will also delay muscle healing. Thus, healing is delayed by:
* cortisone-type drugs,
* almost all pain-relieving medicines, such as non-steroidal anti-inflammatory drugs like ibuprofen (Pharmaceuticals, 2010;3(5)),
* immune suppressants that are often used to treat arthritis, cancer or psoriasis,
* applying cold packs or ice, and
* anything else that blocks the immune response to injury.

Ice Also Reduces Strength, Speed, Endurance and Coordination
Ice is often used as short-term treatment to help injured athletes get back into a game. The cooling may help to decrease pain, but it interferes with the athlete’s strength, speed, endurance and coordination (Sports Med, Nov 28, 2011). In this review, a search of the medical literature found 35 studies on the effects of cooling . Most of the studies used cooling for more than 20 minutes, and most reported that immediately after cooling, there was a decrease in strength, speed, power and agility-based running. A short re-warming period returned the strength, speed and coordination. The authors recommend that if cooling is done at all to limit swelling, it should be done for less than five minutes, followed by progressive warming prior to returning to play.

Our Recommendations
If you are injured, stop exercising immediately. If the pain is severe, if you are unable to move or if you are confused or lose even momentary consciousness, you should be checked to see if you require emergency medical attention. Open wounds should be cleaned and checked. If possible, elevate the injured part to use gravity to help minimize swelling. A person experienced in treating sports injuries should determine that no bones are broken and that movement will not increase damage. If the injury is limited to muscles or other soft tissue, a doctor, trainer or coach may apply a compression bandage. Since applying ice to an injury has been shown to reduce pain, it is acceptable to cool an injured part for short periods soon after the injury occurs. You could apply the ice for up to 10 minutes, remove it for 20 minutes, and repeat the 10 minute application once or twice. There is no reason to apply ice more than six hours after you have injured yourself.

If the injury is severe, follow your doctor’s advice on rehabilitation. With minor injuries, you can usually begin rehabilitation the next day. You can move and use the injured part as long as the movement does not increase the pain and discomfort. Get back to your sport as soon as you can do so without pain.

For more information, please email us at info@stroudsportsclinic.com or to book an appointment, visit us online or call 01453 762369.

Running Pain, an overview from NaSM.

Running tops the charts as one of the most popular fitness activities. According to Running USA, women are out-participating men in road races at every distance except the full marathon. Even for teens it is one of the most participated in sport. But as runners increase their mileage, the chance for injury increases, especially if they have underlying kinetic chain dysfunctions. Here we’ll explore the more common overuse injuries fitness professionals should be on the lookout for and what can be done to help their running clients prevent them from happening. For committed runners, rest is a four-letter word, and the last thing they want to do is stay off their feet.

Some of the more common running related overuse injuries include patellofemoral pain syndrome (PFPS), IT-band syndrome (ITBS), shin splints, and plantar fasciitis. We’ll take a look at what they are and what can be done to help prevent these mileage stoppers. As you’ll see, performing an overhead squat assessment or single-leg squat assessment will help identify the clients that could be at risk for these injuries along with corrective strategies to apply (1). Key identifying compensations will be knees that move inward and feet that flatten, but each client may have additional kinetic chain dysfunctions that will still need to be addressed to run straight.

Patellofemoral Pain Syndrome (PFPS)

PFPS occurs due to a variety causes, ranging from overuse to direct trauma. Clients with PFPS typically complain of pain when going down stairs or squatting, even driving or sitting for long periods of time may illicit pain (1,2). A larger Q-angle (the pull of the quadriceps and the axis of the patellar tendon, from the hip to the tibia) is typically associated with the anterior knee pain of PFPS (1,2). This larger Q-angle and increased knee valgus leads to abnormal lateral tracking of the patella in the femoral trochlea and increased loading on the medial side of the knee (1,2).

Other issues to address with PFPS include hamstring tightness, weak hip musculature (abductors, external rotators, and quadriceps), and altered muscle activation (1,2). This was shown in a meta-analysis highlighting the contribution of muscle recruitment timing between the vastus medialis obliquus (VMO) and vastus lateralis (VL) as a factor to anterior knee pain (3). The conclusion being that there was a trend of delayed VMO relative to VL in those with anterior knee pain (3).

Since most muscles that act on the knee also act on other joints of the lower body, dysfunction can come from either above or below the joint, or both. Consider knee valgus which is influenced by weak hip abductors and external rotators (gluteus medius/maximus) accompanied by overactive hip adductors biceps femoris short head, tensor fascia latae (TFL), VL, and the lateral gastrocnemius (1,4).

IT-band Syndrome (ITBS)

The iliotibial band (IT-band) is the ligament on the outside of the thigh that runs from the hip to the tibia. It can become inflamed and irritated as it rubs against the lateral femoral condyle causing ITBS. This pain on the lateral side of the knee, also referred to as Runner’s Knee, is an overuse injury most commonly experienced by long distance runners, cyclists, and triathletes. Typically it is associated with an increase in training volume and/or abnormal running mechanics (1,2,5).

Research has indicated weakness of the hip abductors, tightness of the TFL, increased internal knee rotation, and low hamstring strength compared to the quadriceps in ITBS (1,6,7). During assessments such as the overhead or single leg squat, clients at risk of ITBS may display an inward knee compensation. Tightness of the IT-band is also associated with PFPS (8).

Shin Splints

Shin splits (or more clinically, medial tibial stress syndrome) is an overuse injury typically experienced by beginning runners, but also by more seasoned runners as they increase their mileage, training, or even change running surfaces. It is an irritation of the periosteum in the tibia, causing pain and tenderness along the medial tibia, typically the distal third, during or after activity. Caused by too much running too soon, overpronation has been linked as a risk factor, as has increased passive inversion and eversion range of motion at the ankle joint and internal and external rotation at the hip (1,5).

Plantar Fasciitis

The plantar fascia runs along the bottom of the foot, from the calcaneous to the metatarsal heads, supporting the medial longitudinal arch. Plantar fasciitis occurs when this tissue becomes inflamed and irritated. It is a common cause of heel pain- especially in the morning when first stepping out of bed. Pronated feet and a lack of ankle dorsiflexion have been associated with plantar fasciitis, as has a high BMI. Corrective stretching strategies for plantar fasciitis focus on the gastrocnemius and soleus, and recent research indicates hamstring stretching as well (1,2,9).

Though most of these common running issues can be addressed with rest, reducing mileage, and or cross training, preventing them is a better approach. By taking your client through a series of postural and movement assessments, you’ll be able to identify potential risks for running injuries and utilize corrective strategies to keep them on their feet!

References

1. Clark M.A., Lucett S.C. (2011). NASM Essentials of Corrective Exercise Training. Baltimore, MD: Lippincott Williams & Wilkins.

2. Bahr R. (2012).The IOC Manual of Sports Injuries. Oxford, UK: Wiley-Blackwell.

3. Chester, R., Smith, T., Sweeting, D., et.al. (2008). The relative timing of VMO and VL in the aetiology of anterior knee pain: a systematic review and meta-analysis. BMC Musculoskeletal Disorders 9:64.

4. Neumann, D.A. (2010). Kinesiology of the Musculoskeletal System, Foundations for Rehabilitation 2nd ed. St. Louis, MO: Mosby Elsevier.

5. Gotlin, R.S. (2008). Sports Injuries Guidebook. Champaign, IL: Human Kinetics.

6. Messier S.P., Edwards D.G., Martin D.F., Lowery R.B., Cannon D.W., James M.K., et al. (1995). Etiology of iliotibial band friction syndrome in distance runners. Medicine and Science in Sports and Exercise. 27:951–960. doi: 10.1249/00005768-199507000-00002.

7. Noehren B., Davis I., Hamill J. (2007). Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clinical Biomechanics 22:951–956. doi: 10.1016/j.clinbiomech.2007.07.001.

8. Hudson Z., Darthuy E. (2008). Iliotibial band tightness and patellofemoral pain syndrome: a case–control study. Manual Therapy 2:147–151.

9. Bolivar Y., Munuera P., Padillo J. (2013). Relationship betweentightness of the posterior muscles of the lower limb and plantar fasciitis. Foot & Ankle International 34(1):42-48.

Shoulder Pain overview.

Shoulder Pain Prevention

By Brian Sutton MS, MA, PES, CES, NASM-CPT

Is shoulder pain stopping you from, playing your favorite sport or achieving your personal fitness goals? Chances are, if you are experiencing shoulder discomfort or pain, you’ll have to alter your lifestyle to accommodate this dysfunction. Shoulder pain can occur in a multitude of ways and is prevalent in 21% of the general population with 40% of that population having injuries persisting for at least one year.

Shoulder injuries have many different mechanisms or pathologies ranging from acute trauma to chronic overuse injuries. Acute trauma typically comes from a direct force, such as falling directly on the shoulder, or from an indirect force, such as landing on an outstretched hand. Either of these mechanisms may result in fractures of the humerus, clavicle, scapulae and glenoid fossa, or dislocations and tears of the capsular ligaments or labrum. However, the most commonly seen injuries in athletes or the active population stem from overuse syndromes.

Overuse Injuries

Overuse injuries (aka cumulative trauma disorders) are any type of muscular or joint injury caused by repetitive stress that surpasses the body’s natural repair processes (i.e., tendonitis, stress fractures). Overuse injuries of the shoulder are common among athletes who consistently perform overhead movement patterns (i.e., throwers, swimmers, tennis players) and individuals who repeatedly work with their arms raised (i.e., painters, construction workers). Among the overuse injuries, shoulder impingement is the most prevalent diagnosis accounting for 40-65% of reported shoulder pain.

Common symptoms of shoulder overuse injuries include (11):

▪ Minor pain during activity and at rest

▪ Pain observed at the top or front of the shoulder during overhead activity (i.e., overhead presses) or during chest activities (i.e., incline bench press)

▪ Tenderness on the lateral aspect (outside) of the shoulder

▪ Loss of strength and range of motion (ROM)

▪ Pain during throwing motions

Poor Posture
In addition to overuse injuries, individuals who exhibit poor static posture of the upper body are at risk for shoulder dysfunction. A common postural distortion of the upper body identified by Janda is the Upper Crossed Syndrome (UCS) and is characterized by protracted shoulders and a forward head. UCS generally involves tightness (overactivity) within the anterior chest region (pectoralis major/minor), latissumus dorsi, and cervical extensors (sternocleidomastoid, levator scapulae, scalenes), coupled with lengthening and weakening (underactivity) of the mid-and-upper back muscles (mid/lower trapezius, serratus anterior, rotator cuff) and deep cervical flexors. Individuals who sit for extended periods working on a computer may be at risk for developing upper body dysfunction and poor posture if certain precautions are not made such as taking frequent breaks and working at an ergonomically sound work station.

Exercise Selection
Similar to overuse and poor static posture, improper exercise selection can also contribute to shoulder dysfunction. For example, if a baseball pitcher tries to increase velocity of his pitches by only strengthening the superficial muscles of the shoulder (prime movers) that produce internal rotation (pectoralis major, latissimus dorsi) more than the stabilizers/external rotators of the shoulder (infraspinatus, supraspinatus, teres minor), these stabilizers become reciprocally inhibited (underactive) and fail to stabilize the glenohumeral joint during the throwing motion. Without adequate stability the athlete may develop a subacromial impingement, leading to subacromial bursitis, rotator cuff tendonitis, and possible tears of the external rotators.

Another example of poor exercise selection involves the over reliance on uniplanar, isolated resistance training exercises. Athletes and fitness enthusiasts oftentimes place too much emphasis on uniplanar exercises strictly focusing of concentric force production (e.g., presses and pulls) while neglecting total-body movements that integrate the entire kinetic chain (lower body, core, upper body) in multiple planes of motion (sagittal, frontal, transverse). Everyday activity occurs in all three planes of motion (front-to-back, side-to-side, and rotational) and only training in one plane (predominately the sagittal plane) will not effectively improve the individual’s ability to move in a coordinated fashion in the frontal and transverse planes. This form of program design may lead to muscle imbalance and faulty movement patterns increasing the individual’s risk of injury and/or joint dysfunction.

Using these two examples, fitness professionals should design exercise programs from an integrated (all-inclusive) perspective. An integrated exercise program encompasses both uniplanar and multiplanar movements; single, compound and total-body exercises; and adequately targets on all muscle groups (prime movers and stabilizers).

Shoulder Injury Prevention Strategies
If a client presents pain or dysfunction the fitness professional should never attempt to diagnose the problem but rather refer his or her client to a qualified medical professional. However, utilizing various movement screens, fitness professionals should assess their clients to identify potential muscles imbalances (muscle weakness and muscle tightness) and faulty movement patterns and subsequently implement a corrective exercise strategy to proactively address these concerns. For a list of comprehensive movement screens and corrective strategies for the shoulder complex see NASM’s Corrective Exercise Specialist.

Following a comprehensive fitness assessment (including a battery of movement screens), fitness professionals should implement a corrective exercise program that is individualized for their client:

▪ Step 1: Inhibitory techniques (self-myofascial release) should be used to decrease tension and effects of latent trigger points of the overactive muscles surrounding the shoulder complex.

▪ Step 2: Static stretching should be performed for a minimum of 30 seconds on identified overactive muscles to help facilitate optimal joint ROM and muscle extensibility.

▪ Step 3: Isolated strengthening exercises should be used to facilitate the underactive muscles of the scapulae. Auditory and tactile feedback while performing these exercises can also help develop neuromuscular activation with proper kinetic chain positioning and control.

▪ Step 4: Lastly, exercises are progressed by incorporating activities that integrate the entire kinetic chain (multijoint, compound movements). During these exercises clients should be instructed to maintain scapular retraction, depression, and posterior tilting while limiting winging by keeping the scapula on the costal surface.

Patient consent Form.

STROUD SPORTS CLINIC Ltd.

Patient Consent Form and Data Protection Policy

Payment for services provided

• We accept cash and all major credit and debit cards. Patients are politely requested to settle their fees after each visit. 
• We regret that unless 24 hours notice is given in cancellation, a full charge may be made. 
• Most medical insurance policies will cover Chiropractic/Physiotherapy and Sports Therapy treatments offered by this clinic. As each company has its own criteria we politely request that the patient settles treatment fees after each visit and make their claim in the appropriate way direct to the insurer for reimbursement. It is helpful to know, however, if you do plan to claim through private insurance. Please tell your practitioner if you are planning to do so. 
• I agree to the terms above and conditions for fees.
  Data protection
  Under the Data Protection (1998) Act, we are required to advise our patient(s) on our Data Protection Policy.
  As part of the Patient Record, this clinic is required to retain information for the purpose of the consultation for treatment, recording subsequent treatments, and for use by third party medical practitioners only, at the request of the patient, in writing.
  Upon completion of the Patient Details Form, Data Protection and Consent Form, all paper files and information therein may be electronically scanned and stored on a computer file for as long as the patient remains a patient of the clinic, and thereafter a period of 7 years. Alternatively paper records will be retained for the same period.
  All the information provided will be treated as confidential, and will not be given to any other person(s)/organisation(s) without written consent of the patient concerned.
  Information held both manually and electronically in files is accessible only by staff of the Clinic that are directly involved in the data entry and processing of patient records.
  I the undersigned* acknowledge that I have read the Data Protection Policy (above) and do hereby give consent to the Practitioner to maintain records for the purposes outlined within the policy. I also consent to the sharing of my treatment records with other practitioners at Stroud Sports Clinic Ltd if they become involved with my ongoing treatment.
  Consent to examination and treatment:
  Occasionally it may be necessary to contact your GP and inform them of findings for which your permission is needed. I consent to an appropriate physical examination and give authorisation for my GP to be contacted as necessary.
  I have been given my Report of Findings regarding my condition. I have been advised of, and understood, the possible risks of treatment and had all my questions answered to my satisfaction. I consent to treatment as outlined.

Name (PLEASE PRINT)

.............................................................................................................................................................

Date .....................................................................................................................................

Signed .....................................................................................................................................

Please print and provide this signed form to your practitioner.

A fantastic article on Ice and its use in sport.

Ice application and its use in sport 

by Peter Thain

Before I discuss the different modalities, it is important to mention the rationale for ice application. Within the sports medicine environment, cryotherapy (just another name for ice application really) is a widely used therapeutic modality for both the treatment of acute soft tissue injures, and during rehabilitation. The immediate application of ice aims to provide a cold induced analgesic effect, thereby reducing the appreciation of pain. The magical skin temperature frequently reported in the literature to produce local analgesia is between 10 and 15°C, and this is readily achievable with most ice modalities.

Pain relief is the main reason you should be applying ice to a musculoskeletal injury, and there are numerous scientific papers that will support this. However, if we were playing family fortunes, and “we asked 100 people to name a reason to apply ice”, you can almost guarantee that ‘reduce swelling’ would earn you a star prize (probably a washing machine or cross trainer!). However, you may be surprised to learn that there is currently no research involving human subjects which supports this. So why not…?

Studies have examined the effect of ice application on metabolism (which is what the ice needs to supress) in animal studies and identified the target tissue temperature to be between 5 and 10°C. At first you may think this is achievable, however, this temperature reduction needs to be reached at depth rather than at the surface. No study to date has achieved this at 2cm below the adipose tissue. So… what does this mean for the future of ice?!

Well firstly make no mistake; ice is a fantastic modality at reducing pain. As far as reducing metabolism, for me the jury is still out. Although having said that, whilst it may not be possible to reduce the tissue at depth to 10°C, you could argue that even if the temperature declines by 1°C then that is of benefit. If you are interested in reading more on this, I would recommend the brilliant article by Dr Chris Bleakley entitled “Is it possible to achieve optimal levels of tissue cooling in cryotherapy?”

So onto the main question: “Which modality?”

The answer to this all depends on the stage of injury. I currently work in semi-professional football so forgive me for these examples, but I think the three different scenarios help to explain the rationale and are applicable to any sport.

Scenario One: Acute setting – Return to play.

The athlete has received a trauma to the ankle/ foot complex but there is no significant structural damage. Here the aim of the ice application is to provide quick pain relief before the athlete returns to activity. The best modality to use is an ice bag containing crushed ice, as it has been shown to reduce temperatures to critical levels required for analgesia within 5 minutes (Jutte, Merrick, Ingersoll & Edwards, 2001; Merrick, Jutte & Smith, 2003). You should consider the use of wet-ice application, where ice is applied through a fabric bag; this porous material provides a barrier to stop potential ice burn, whilst the residual water is in contact with the skin. As cryotherapy modalities absorb heat through conduction and evaporation, wet ice exhibits greater thermal conduction than that of its dry ice counterpart (Belitsky, Odam & Hubley-Kozey, 1987; Merrick et al., 2003).

As I am not just a researcher but a practicing sports therapist, I appreciate the need for the recommendations to be practical. I therefore use a mixture of crushed ice and water mix in a plastic bag and apply pitch-side, as wet ice applications can be messy and impractical. However, during half time, many players will receive crushed ice enveloped in a thin wet cotton cloth to their ankles for fast pain relief following contusions and heavy tackles.

Scenario Two: Acute setting – Remove from play.

The athlete has received a significant trauma to the ankle and there is significant structural damage and must cease activity. Here the ice application aims to provide pain relief, but more importantly, compression needs to be applied. In an effort to reduce the oedema from building up, the compression with shut down the available space for the fluid to accumulate. As a result, wet ice application is no use here as the compression will not be consistent as the water escapes the porous bag. Instead, the dry ice method of crushed ice should be applied in a plastic bag and attached with a compression bandage. The ice is not the most important criteria here, it is the compression.

Apply the ice for 10 minutes on, and then remove for 10 minutes. In the rest period, reapply the compression bandage. After the 10 minutes rest, reapply the ice application. Continue this cycle of 10 on, 10 off, 10 on for as long as possible. Once finished icing and before you return home, place the compression wrap back on the area.

The rationale for 10 minutes on, 10 minutes off, not only allows the skin a rest period from constant cold, but more importantly, the modalities ability to absorb heat is at its maximal for at least 10 minutes, before the modality temperature may begin to rise. Additionally, a thermal gradient is created between the skin and the intramuscular tissues, which allows cold to be reached at depth. When the ice is reapplied for a second 10 minutes, the tissue temperature at depth has not risen to pre-treatment levels and therefore can reach a lower temperature still. So, rather than the traditionally 20 minutes continuous, where the modality may start to warm after 15 minutes, here you still receive a combined total of 20 minutes ice application, but the tissueis maintained at a lower temperature for over 30 minutes.

Scenario Three: Rehabilitation

You may not be aware, but the use of cryotherapy during rehabilitation can potentially promote your recovery by using cryokinetic protocols (cryokinetics simply means cold and motion). In the instance of an ankle sprain, the athlete immerses their foot into an ice and water mix (1-4°C) until their foot becomes numb. The typical sensations you can expect to feel are burning, stinging and aching before a period of analgesia occurs after approximately 10 to 20 minutes of immersion. After this, the athlete begins to perform their rehabilitation exercises, so in the early stages simple non-weight bearing range of motion work. Continue to perform the exercises until the period of analgesia is diminished (typically 5 minutes), before immersing your foot again to achieve another period of analgesia. As you progress through the rehabilitation stages, right up to return to activity, you can still use the cryokinetic protocols. So why are we doing this…?

The ability of cryotherapy to provide an analgesic effect enables exercises to be performed earlier than would normally be possible (Bleakley, McDonough & MacAuley, 2004; Knight, Buckner, Stoneman & Rubley, 2000). The beauty of cryokinetics is that it allows the muscles to contract, and therefore they will actively pump the swelling out of the area via the lymphatic drainage system. So by applying the ice application, you can perform simple range of motion exercises early than normally would be possible, and thus reducing swelling quicker. You may have read the recent work by Bleakley, Glasgow and MacAuley (2012) who recommends calling the POLICE, where optimal loading is required. If you haven’t read this article I would recommend it, as cryokinetics allows for this optimal loading to occur sooner.

Some of you may be concerned that by performing exercises under a period of analgesia you will not be able to appreciate pain, and therefore will not know if you are causing any further damage to the tissue as a result of the exercise being too advanced for your stage of rehabilitation. This is not the case, as the ice application does not remove the pain-sensing mechanisms, but rather removes residual pain such as that caused by pressure from swelling on nerves and damaged tissue. (Hayden, 1964; Knight et al, 2000; Pincivero, Gieck & Saliba, 1993). So, if you do perform an exercise that is too advanced that will cause further damage, you WILL still perceive this pain and should therefore regress the exercise.

Ice immersion should be the chosen modality here rather than wet ice bag application as it provides a longer period of analgesia. We are not concerned with how fast it takes to cause pain relief, but rather how longit lasts. The longer the period of analgesia, the larger the window of opportunity to perform exercises.

Cryokinetics is not only effective with joint injuries but also muscle strains. I have found it to be particularly useful in the treatment of lateral ankle sprains. Pincivero et al. (1993) presented a case study and conclude that cryokinetic protocol hastened the return to activity.

So in summary:

1. Athlete return to play: crushed ice in a damp cotton bag
2. Athlete cease play: crushed ice in a plastic bag with compression wrap applied
3. Rehabilitation: immersion to facilitate exercise

Some other considerations……

What about cold spray?

When I took up my current position, I was given a box of cold spray. I must say, it has come in very useful… I use it as pest control to kill the flies and gnats in my therapy room! I personally see no use for the spray in the field of sports medicine. Often you see therapists run on pitch side and administer the cold spray or vapocoolant. Yes, it may act as a counterirritant, but you have to question the accuracy of application. Often the spray is administered over socks and better still most of it may fly away on a windy day! You are far better applying a crushed ice and water mix.

What about instant cold packs?

Commercially available gel packs have a pre-application temperature of -14°C and therefore remain prevalent in sports clubs, with first aiders believing colder is best. However, a modalities capacity to absorb heat is far greater if required to overcome latent heat of fusion (turn from a solid to a liquid) which is not required in the already liquid gel pack. To put this to the test, when I teach undergraduate students thermal treatments, at the start of the lecture we play pass the parcel. I pass around a bag containing a crushed ice and water mix, and an instant ice pack. No sweets here I’m afraid just the gift of cold hands! This will pass 40 pairs of hands in approximately 10 minutes. When it reaches back to me we repeat it again. During the second round, the crushed ice and water mix is still as cold as it was at the beginning, yet the instant cool pack is room temperature (if not warmer after passing 80 pairs of hands). The evidence also conclusively shows that regardless of application duration, ice based modalities are superior to gel packs at reducing skin temperature (Chesterton et al., 2002; Kanlayanaphotporn & Janwantanakul, 2005; Kennet et al., 2007).

Contraindication to ice application

Athletes with a fear or intolerance to ice including Raynaud’s disease and cryoglobulinemia should not be administered cryotherapy. The risk of frost bite is very rare and can be reduced by application periods of less than 40mins (Knight, 1995). A barrier is advisable, such as crushed ice placed in a plastic or fabric bag. Cryogen gel packs should always be avoided as there are superior modalities to achieve the desired effects. Bleakley and Hopkins (2010) identified no cases of skin burns in their review of over 35 laboratory basedcryotherapy studies.

References

Belitsky, R. B., Odam, S. J. & Hubley-Kozey, C. (1987). Evaluation of the effectiveness of wet ice, dry ice, and cryogen packs in reducing skin temperature. Physical Therapy, 67(7), 1080-1084.

Bleakley, C. M., McDonough, S. M. & MacAuley, D. C. (2004). Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. British Journal of Sports Medicine, 40, 700-705.

Bleakley, C. M. & Hopkins, J. T. (2010). Is it possible to achieve optimal levels of tissue cooling incryotherapy? Physical Therapy Reviews, 15(4), 344-350.

Bleakley, C.M., Glasgow, P. & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine, 46(4), 220-221.

Chesterton, L. S., Foster, N. E. & Ross, L. (2002). Skin temperature response to cryotherapy. Archives of Physical Medicine and Rehabilitation, 83(4), 543-549.

Hayden, C. (1964). Cryokinetics in an early treatment program. Journal of American Physical Therapy Association, 44(11), 990-993.

Jutte, L. S., Merrick, M. A., Ingersoll, C. D. & Edwards, J. E. (2001). The relationship between intramuscular temperature, skin temperature, and adipose thickness during cryotherapy and rewarming. Archives of Physical Medicine and Rehabilitation, 82(6), 845-850.

Kanlayanaphotporn, R. & Janwantanakul, P. (2005). Comparison of skin surface temperature during the application of various cryotherapy modalities. Archives of Physical Medicine and Rehabilitation, 86(7), 1411-1415.

Kennet, J., Hardaker, N., Hobbs, S. & Selfe, J. (2007). Cooling efficiency of 4 common cryotherapeutic agents. Journal of Athletic Training, 42(3), 343-348.

Knight, K. L., Brucker, J. B., Stoneman, P. D. & Rubley, M. D. (2000). Muscle injury management with cryotherapy. Athletic Therapy Today, 5(4), 26-30.

Knight, K. (1995). Cryotherapy in Sports Injury Management. Champaign, IL: Human Kinetics.

Merrick, M. A., Jutte, L. S. & Smith, M. E. (2003). Cold modalities with different thermodynamic properties produce different surface and intramuscular temperatures. Journal of Athletic Training, 38(1), 28-33.

Pincivero, D., Gieck, J. & Saliba, E. (1993).Rehabilitation of the lateral ankle sprain with cryokinetics and functional progressive exercise. Journal of Sports Rehabilitation, 2, 200-207.

Sports Massage/How it can help you in your training.

Massage in the Fitness arena.

For those who seek a big-picture view of overall health and wellness, it is important to include the regular use of massage therapy as an integral part of true fitness. After all, fitness is not just the strength of one's muscles, a percentage of body fat, cardiovascular power and mental clarity. Fitness also includes the health and wellness of all the body's systems, as well as one's mental and emotional state--and massage therapy has much to contribute in these respects.

Therefore, when it comes to creating overall fitness—fitness that is present both inside and outside the body, from head to toe—one must consider the value of massage therapy for achieving this goal. It may help to think of massage therapy and big-picture fitness as two sides of the same coin, with that coin being overall health and wellness. As you consider this notion, you should begin to see how massage therapy can serve to complement and bolster nearly any aspect of fitness.

For example, consider the common view or stereotype of fitness as a man with a lean and muscular body. This man most likely lifts weights, performs cardio sessions and eats healthy foods on a regular basis. Now, by bringing massage therapy into the equation, this man could also help his muscles and joints stay in the best possible shape, recover from tough workouts in less time and better prevent potential injuries. As you can see with this example, massage therapy and muscle building can go hand in hand to help create optimal fitness.

Another common notion of fitness might be the cardiovascular powerhouse—perhaps a long-distance marathon runner, cyclist or other type of endurance athlete. These people work hard to build their cardiovascular systems in order to achieve faster speeds or longer periods of activity. This type of fitness typically involves repetitive sessions of cardiovascular training.

In this scenario, the benefits of bringing massage therapy into the picture are similar to the previous example, due to the fact that cardiovascular training also has an impact on the body's muscles and joints. Fortunately, regular massage therapy sessions can help reduce the negative side effects that could come about as a result of intense cardiovascular training. For example, the woman who runs many miles nearly every day would be wise to receive massage on a consistent basis, to keep her legs and hips and entire body functioning optimally.

Essentially, one might think of massage therapy as a vital component of the rest and recovery every athlete needs in order to reach his or her maximum potential in the chosen form of fitness, whether it be lifting weights, participating in triathlons or simply maintaining the ability to move with ease and grace in order to prevent potential injury.

The bottom line is massage therapy can contribute to that big picture of fitness by keeping the body's muscles and joints in good shape, speeding the recovery of overworked areas and helping to prevent or rehabilitate any injuries.

Jason Ford NSAM.