Sport Massage by Elizabeth Wieldling (2010)


Alright well thank you guys very much for coming today I really appreciate it, especially because massage therapy I think is something that’s still not utilized to its full potential there’s a lot of questions about it being fluffy or it being sort of yeah I guess fluffy is the word. There’s also a lot of people who still associated with kinky stuff and it’s definitely not a tool that gets full credit for the potential that it can have for athletes. So my talk today is going to be not really a scientific, its going to be based much more on practical information about sports massage and what I see and the kinds of questions that I get from most of my clients. I work with both youth and adult athletes and I have some very high level elite athletes that are swimmers and gymnasts and I also work a lot with professional triathletes, soccer players, football players. And then we also have novice down from very small children who are just learning to swim up to beginning triathletes who have never had any kind of a sports background, so there’s a huge gamut of people who come in to utilize massage and really no matter what your level is, it’s a tool that will help you perform better. Just to give you a little bit about my background in the perspective that I’m coming from with massage therapy I started swimming at a very young age and when I was five started with a little summer team and then although I was never a very fast swimmer I did swim through college and have gotten into more endurance sports now with running and triathlon. So I kind of massage therapy with an athlete perspective I’ve used it since high school and as a coach I used it with my kids and with the adults that I coach for both swimming and for triathlon. In addition to that I am a licensed massage therapist, studied sports massage at the American Institute of Massage Therapy which is in Hawaii which is a great Mecca for sports, so I had a lot of access there to working with the Honolulu marathon world championships for triathlon I mean that is your Mecca for athletes. So it gave me a lot of exposure to see how athletes can work with all different level or how massage can work with all different levels of athletes.

Lets see I’m sure, so what I want you to get today out of what I’m going to talk about is practical information, not necessarily scientific, so what I’m going to go over is what is a massage therapist and who is a massage therapist, it’s still a field that’s being defined, there are a lot of different people who will throw in massage therapy like a PT or a physical therapist chiropractors, so it’s not always clear and it’s still not clearly defined who is a massage therapist and what the academic requirements are for that. So it’s important to understand both what a massage therapist is and what they’re not, so that when you go into somebody you’re going to understand what your expectation should be and what you need to get from them. I get a lot of clients who are confused about where massage therapy fits in with their treatment plan as an athlete. So it’s important to understand that so that you can be very specific and direct with whoever you’re working with. I’m also going to talk a little bit about the anatomy and how massage therapy is specific to swimmers. Most of the clients that I have who are swimmers come in because of shoulder issues so I’m just going to talk a little bit about the shoulder and how massage therapy will help with shoulder issues and then the last two things I’m going to talk a little bit about are kids and massage.

That’s something that I have seen growing more and more, about a year ago I moved into a pediatrician’s office who I don’t know if you guys are familiar with swim teams in Kansas city but he is the team doctor for the Kansas city Blazers which is a large program in Kansas city, it’s a well established program that’s produced a lot of really top notch athletes. So this pediatrician works with that team and has juts recently started incorporating massage therapy for kids that are very small all the way up through their most elite senior swimmers and I know from his perspective he was very skeptical in massage at first it took a lot of convincing but we’ve had a lot of luck with being able to get at some of the problems that initially that doctor thought were bone issues or are coming from nerve stuff. So it’s starting to grow but you do need to know what to, how to handle kids with massage because it is an intimate touch and it needs to be comfortable and it must be professional over the top professional. And then in the last thing I’m going to talk a little bit about is, things that you can do to help with muscle recovery. One of the things that I see with triathlon that I don’t see a lot with especially age group swimming is talking about nutrition and how nutrition will support muscle recovery. So if you’re going to a massage therapist because you want to enhance muscle recovery which is one of the main things it does, you really need to be looking at the nutrition aspect of it as well and timing that both as far as when you’re eating after practice and what you’re eating and how that will support muscle recovery. Because that is a biggest thing you can do in addition to massage therapy to increase how fast you’re going to recover and be ready for your practice the next day.

So with that we’re just going to briefly touch on massage therapy as a tool what it is and what it’s not. Massage therapy is soft tissue manipulation, that means you’re dealing with muscles and you’re also dealing with ligaments and tendons which are just like little connectors, you’ve got ligaments and tendons which connect bone to muscle and then also bone to bone. So when you hear somebody talk about tendonitis, it’s just an inflammation of the tendon and so that is soft tissue with massage you are going to get in there and affect both the muscle and the tendons and ligaments. The last thing you don’t hear people talk a lot about is the fascia, fascia is if you’ve ever cooked chicken, you pull it out of the package you’ve got that white sort of casing that’s around it and that’s fascia. Fascia is connective to tissue, it incases all of your muscles in the body and you have one sheet of connective tissue throughout your whole body. So what that means is that if you have a little piece of your fascia some place that starts to catch that it’s just going to keep magnifying its like if this is my fascia in my body and it started to catch here it’s just going to keep catching and catching and catching. So it’s just going to stop pulling in and creating problems that are not just in this specific spot but eventually it’s going to pull over here. So you’re going to get referred pain patterns and all of that kind of stuff. And the way you do with fascia is a little bit different than how you would deal with muscle fiber.

So I’m going to talk about that in a little bit but it is a huge part of effective massage therapy. What massage therapy is not, massage therapy is not bone manipulation. You’re not going to go to your massage therapist and have them adjust your spine, they’re not going to adjust your hips, they’re not going to adjust any part of you that deals with the bone. Now if you go to a chiropractor you may get a chiropractor that will also do a little bit of massage therapy. Your physical therapist may do a little bit of massage therapy so because of the scope of practice and the amount of training that different disciplines have, massage therapists do not manipulate bone, they do not do physical therapy, they do not diagnose. That is not legally within our scope of practice and that’s important to understand. Even if your physical therapist is doing a little bit of massage work, it’s fine for it to go that way it’s not fine for it to go the other way. And it’s important as an athlete that you have a massage therapist that is willing and able to communicate with other health care practitioners, they need to understand the muscles, they need to be able to use the names of the muscles, they need to know the muscle function because they need to be able to call the doctor that you’re seeing and say “can you tell me a little bit about what’s going on and is massage therapy something that we should do?”

As a massage therapist I would never initiate the treatment program, I’m going to complement what a physical therapist is doing or what a doctor is doing and take that direction from them because I don’t diagnose. So you need to make sure that that part is clear, let’s see, the impact of massage therapy is going to vary a lot depending on what kind of technique is applied. And this is especially important for athletes because you have athletes going through macro periods with their training if they’ve got meso period they’ve got micro periods. And the kind of massage therapy that you want in each one of those periods is going to be different. If you are 24 hours out from your race, the kind of treatment you’re going to get is much different than what you’re going to get two weeks from an important race. Very generally massage therapy and the impact it has it’s going to relax muscle tissue which helps, it helps recovering and it helps muscle function. So it’s really important in terms of getting the most out of your body. It’s going to help improve circulations, both the strokes are used during massage and also the heat that’s created will move blood in lymph. Moving lymph is you’ve got lymph fluid throughout your body you have a lymph system, it’s basically what flushes out your system for illness. So you’ve got lymph nodes that’s where you’ve got a lymph system throughout your body and you have lymph nodes.

All of different fluids will move through your body they go to lymph nodes where it filters out illness and that kind of stuff, that’s why a lot of times if you do get a massage you may feel a little bit gunky the next day, sometimes people will come down with a cold because it’s going to stir up a lot of stuff that may be sitting in your body. So that’s another really important reason why we have to time when you’re going to get sports massage. The last thing you want to do is go in two days before your biggest race of the year and you come down with a cold because you’ve stirred up something that was kind of nesting in your body. So it’s important to know when to get it. The thing about massage like I said in the beginning is that it is becoming it’s a field that’s not necessarily really clearly defined right now and it’s a field that’s slowly but surely gaining credibility, I still get a lot of people that make jokes about what I do in my massage room and rest assured it’s always professional. They’ve started a massage therapy research institute but because it’s some thing that is still gaining traction as far as being legitimate tool the research that’s been done on it and the impacts that it may have on an athlete there’s still a lot to learn. So you can say there’s obviously you can take anecdotal stories, there are things that in my mind are very clear when I see an athlete what the effects are going to be. As far as the hard research there’s still a long way to go, so you need to make sure you’re paying attention to who you’re seeing, what they’re doing I mean what your experience is with it because that’s all legitimate and the science just isn’t there yet.

Some of the things that they are looking at as far as the impacts of massage, neuro imaging and looking at what happens in the brain when you do have massage therapy enhancing neuro reception, which is body awareness. I’m sure as coaches you guys have those athletes that get in the water and they get it like that, they can get in they are seven years old somehow they just get freestyle. You can give them a verbal command and all of a sudden they are going to pick it up. They have good body awareness it’s a type of intelligence we all vary in terms of that, some kids bless their hearts they’re just not going to get it, but they do think massage therapy may start to increase that body awareness a little bit. In terms of mental stress, decreased disassociation with problems and that kind of stuff there’s definitely thoughts that massage therapy will help with that kind of thing. I get a lot of questions about cramps especially from my triathletes more so endurance, cramping is actually something they don’t know whole lot about, it’s super common I’m sure you guys see it with, someone is pushed off the wall they get in their cuffs they get into their feet most of the time. The two main sort of schools of thought with cramping is that either it’s muscle fatigue or it’s electrolyte imbalance, there could be a lot of other reasons as well, as far as fatigue the muscle get used especially a sport like swimming it’s repetitive use, repetitive use over and over, the muscle gets fatigued and sometimes the things are just start firing wrong, it may just get over stimulated and the neuron just aren’t traveling right. So it starts to cramp it just gets over stimulated.

Massage is going to help intercede with that with those I guess firing of those neurons and help calm that muscle down a little bit. Electrolytes, that’s something that has to do with hydration there’s not much massage can do about that but it certainly can help with cramping. We’ve talked about who does massage therapy, it still like I said a field that’s been defined and it’s actually each state is going to have different requirements. Missouri other than Kansas and Missouri there’s two right on state line Missouri you have to take the national exam in order to be certified at practice. Kansas is the most unregulated state in the US which is a little scary, there’s only one city in Kansas right now that requires any kind of actual certification and that’s because they had a prostitution ring that was being run under the veil of massage therapy and so I guess they learnt their lesson and decided they should implement some kind of certification requirement. So hopefully that is changing but you should definitely check Hawaii has state exams so you need to know in your state what the certification requirements are you can call your city but figure it out so that you know who you’re going to certified especially if you are taking kids I just can’t overstate that.

So what I’m going to talk about now is types of massage if you Google sports massage and try and figure out exactly what it is, it’s pretty vague, it’s really a type of massage that incorporates a lot of different modalities so I’m going to cover it is kind of some, when I do treatment very the types of massage that I use most. Just to start out Swedish massage is the fundamental massage if you’ve ever gone to have a massage like at a spa, pretty much any place unless you’re requesting a specific type of massage the Swedish is what you’re going to get, it’s the long strokes it’s used for relaxation and that’s sort of your building block for massage that’s the basic what you’re going to learn in school and everything else from there kind of moves up. Deep tissue massage utilizes Swedish massage but in different way, you’re going to go a little bit deeper with the muscle it involves a lot of stretching. It’s usually not relaxing it’s probably going to be a little bit painful. The thing about deep tissue massage is that most people or at least a lot of people come me want deep tissue massage and they don’t really know what it is. And a good therapist is going to be able to feel on the muscle the kind of pressure that’s appropriate for that person and you can feel when the nods in the muscle you can feel them react and you can feel the response of the persons body and a good therapist needs to be able to work with that. So if you have somebody that is really uncomfortable or you’re not comfortable with, your sense about that is probably right. Deep tissue is very effective but it has a specific place and it needs to be applied correctly.

So Swedish and deep tissue are kind of part of what goes into sports massage, sports massage like I said is not clearly defined, I have a couple listed here that couple types of massage listed here that goes into sports massage, you’ve got Swedish, deep tissue, trigger point myofascial neuromuscular. Those are all, I’ll kind of cover those in a minute and briefly explain what each of those are but the mind frame with sports massage that I use is that its geared at a function. You want an athlete to recover, you want an athlete to be ready for performance you have an injury and it needs, you’re a part of some kind of recovery program. Sport massage you’re not really going to go in for like a nice day at the spa, I have a couple of clients that call my, when they come in they call it Liz’s house of pain. So it’s not really something that like always feels great, which is another reason why its important to handle it correctly with kids which I’ll get to in a minute.

Sports massage has a couple of specific parameters, one is your timing, if you’re going to have sports massage and you want deep work you’re not going to have it 24 hours before. If you want deep work and you have a big race coming up you need to have it minimum of four days out, really the week of is not a good time for a deep work. Pre-massage is going to be pretty quick it’s going to use a lot of fast movements just to stimulate the nervous system and to kind of get things fired out. You don’t want to sedate yourself when you’re getting ready to go out for a big race. Post race massage you’re going to use a much different pressure than you what if you wanted if you are going to get a deep work, the muscles are going to be pretty sore especially if you’ve just finished something like a marathon or an iron man, for swimmers it might be a little bit different because 50 even a mile long race you’re not going to get out and be excessively sore but right at that point you want your body to have time to use its own defense mechanisms to clear out like lactic acid and all that kind of stuff. So a post race massage is going to be a fairly light just kind of flush of the body. An acute injuries is another time when you’re not going to use massage, if you have I had a soccer player last week that had an enormous bruise on her leg from a ball that got knocked into her leg, she needed to wait at least three days before she came to see me just because the body needs to be able to take care of itself before you put in before you stimulate it with more massage.

Maintenance massage, if you’ve got an athlete that doesn’t have a lot of problems but they’re going to come in over the season every three weeks is going to be fine and maybe they don’t need a lot deep work but it’s just to help with muscle relaxation and muscle function. Alright so sports massage also the duration are you going to 30, 60, 90 minutes, a lot of my clients in fact the majority are probably 30 minutes because we’re working on a problem and we’re going to focus on one specific area maybe it’s the shoulder maybe it’s lower back hips glutes are a big one 60 minutes might be maintenance or it might be sports massage. 90 minutes you’re going to be doing that’s a recovery massage. You’re not going to be go in to somebody for 90 minutes and have them grind on one area of your body, it would just not produce good things. So then the technique kind of how the movements you’re using and the speed of the movements and then the pressure is also going to be all component of sports massage. Myofascial is a specific type of massage that I incorporate into sports massage you’re working with the fascia that I talked about with the chicken, the white stuff that kind of encases the muscle myofascial release is a much different type of massage it’s very slow its kind of unwinding of that casing of the muscle, so it might be something I’d put my hand on a clients lower back and I might stretch up the skin and just hold it there and you can actually see the fascia unwind its pretty fascinating.

Shins plants it works pretty well with kind of stretching of that shin, you can use it over the scapular all different places buts it’s just unwinding of that fascia that’s then going to allow you to actually get in and work with the muscle a little bit more. Trigger point therapy there’s a lot of debate about what trigger point is or isn’t without getting into the big debate about it it’s basically a spot in the muscle that is going to kind of unlock the problem. So maybe you’re having a pain, I get a lot of pain the people get in their hips and it’s a lot of times coming from something that’s happening in the lower back and it may you have a lot of referred pain involved with trigger points so what you’re trying to do with that is find the point in the muscle that’s creating the pain. In a lot of times the point that’s creating the pain is not where the pain is felt. So you need to figure out what point that is and trigger points occur over time with repetitive motion. That’s why with something like swimming and endurance sports, trigger points are going to become really important.

If you think about a swimmer’s shoulder and a 5,000 yard practice depending on how many strokes they take, they’re going to rotate their shoulder 5,000 times. So if you’re doing something 5,000 times in one practice, there’s a lot of opportunity there that kind of continues to create a problem area and build it up. So trigger point you’ve to find a point in the muscle that’s causing the problem and then work it out and unleash it. Hot rocks is not something that I hear lot about with sports massage therapists but it’s extremely effective. If you are going into a sports massage therapist, they may not use hot rocks necessarily but they will use heat. It just allows for a deeper penetration into the muscle. It’s just like stretching after you are done with a workout instead of beforehand. The muscles are a lot more receptive to being stretched out and to being moved. So I use a lot of heat with my clients and hot rocks are so easy and accessible. You can get into really isolate the spots that you want to make, that you want to bring the heat to. So that’s kind of sports massage in a nut shell. This technique that I’m going to talk about now is soft tissue manipulation but it’s not sports massage.

This is a technique. It’s called active release therapy. It’s a very specific type of soft tissue massage. You have to be certified in, in order to do. It costs about $10,000 plus to get certified in it. If someone is an active release therapist you will know it. They will have the label all over the place and it’s one of the most effective soft tissue therapies that I have ever found and if you guys are of the belief that massage therapy is a bunch of hooey, then this is the modality you want to go and try. Hands down it’s the best out there. It’s a therapy that’s endorsed by Iron Man. If you guys are not familiar with Iron Man, it’s a triathlon that consists of a two and a half mile swim followed by a 112 mile bike followed by a 26 mile run. It’s extremely hard on the body. And this, I was just at Iron Man last week; I had a huge room set up with active release. It’s phenomenal stuff. The basic idea behind active release therapy is dealing with scar tissue. When you use muscles as all swimmers do and any others do, your body goes into repairs it. You’re going to have scar tissue build up. You do not have an injury; you don’t need to have an injury in order for scar tissue to build up. It just happens naturally.

And the muscle fibers in your body are going to lay parallel to each other. So you’ve got all these little muscle fibers that are going this way. And when you break them down and your body goes into repairs, scar tissues are just going to lay in whatever direction it wants, it’s just going to build up and it’s sticky. It’s a lot like that that fascia that’s between the chicken. So if you’ve got muscle fibers that are laying next to each other and they’re moving along, moving along and all over sudden you throw on a bunch of scar tissue or sticky stuff that’s laying in every single direction it’s going to really inhibit your muscles ability to move like it should. What active release does is it goes in and very specifically isolates the muscle and the location on the muscle where scar tissue is built up and then it releases it. It’s called active release because you will actually move the muscle through a series of motions in order to get that scar tissue to break down. I have found over time that a lot of injuries that athletes will come in with feel like their bone; feel like their nerve, they’re going to see orthopedic doctors. They’re seeing all of these different people. They’re diagnosing anything but soft tissue and I just cannot overstate how much pain that soft tissue can create in an athlete, I mean I thought that I had a stress fracture and it was all soft tissue.

Active release is something to look into and it’s something I have not seen a lot in the swimming community and will be well worth your time to try figure out if there is a practitioner in your area. And I’m unfortunately not an ART specialist yet, but I certainly hope to be ‘cause it’s just phenomenal stuff. ART will also deal with nerve entrapment. You’ve got nerves that run all the way through your body. You’ve got muscles all over the place. These nerves are running through the muscle, muscles get tight; they’re going to impinge the nerve. Again it can be excruciating pain, it can be diagnosed as a lot of different things and sometimes it’s just going to be as simple as relaxing a muscle. I had a lady that came in last week and have been dealing with itching like for a year, itch, itch, itch all over the place, didn’t have a rash, they’d done all the tests they could have possibly think of to diagnose whatever was going on with her and it ended up that she had one trip to an active release therapist and she has not itched at all because it was, had to do with he nerves just being kind of squished between the muscles ‘cause she was stressed out all the time.

A lot of ART practitioners are also chiropractors. So if you’re looking for an ART therapist, chiropractic is a good place to start with that. I will say I go to an ART practitioner on a regular basis who is a chiropractor never does chiropractic work on me. You know chiropractic sort of work on its own special deal. If you’re not comfortable with that you do not have to get chiropractic done when you go to see an ART therapist. But chiropractors do have the ability to diagnose and they are very familiar with the body, so having them be a chiropractor and doing ART I knew was not a bad thing at all. Alright, so with that the last thing I’m going to talk about is Kinesio tape. Kinesio tape is something that is relatively new in the US. It was first seen the Olympics a couple of years ago with volleyball players which I pointed to here, you can see it on their shoulders there. Kinesio tape is a very, it’s fascinating; it’s basically tape that works on a narrow muscular level. It will either help relax a muscle or it can actually help facilitate a muscle and help it fire if you have a muscle that is not firing correctly.

You can also use Kinesio tape as a correction tape, but it is not like the white athletic tape that you see on people. Its function is very different and used in different ways. The way the Kinesio tape works depends on how it’s applied, whether you are applying the tape from, each muscle has two ends. You have an origin where it starts and you have an insertion where it ends. When muscles move, they always move insertion to origin. So it affects their movement and how you apply Kinesio tape, whether you start at the origin or the insertion, it will affect how the Kinesio tape works. So one is for relaxation, one is to actually help the muscle fire. It also depends on how tightly you stretch the tape. If you’re putting it on with a total stretch you’re going to actually be helping correct a movement. Like a lot of times we’ll use it on if you get patella tracking, you have your knee cap that’s not tracking right you can actually use the tape to hold the knee cap in place. Otherwise how much stretch you put on it is going to impact what it’s helping that muscle do.

This would be a tape that I use a lot for my swimmers. Over the shoulder, we’re looking at the deltoid which is the pink, kind of right around here, that deltoid muscle is key in helping swimmers bring their arm around. The way this is taped here, is actually helping that deltoid muscle relax a little bit. It starting at the insertion and bringing and pulling it down. Allowing that deltoid muscle to relax a little bit. The black tape that you see in that second picture is over one of the top rotator cuff muscles. Its called the supraspinatus is one of the most common muscles that creates pains in shoulders for swimmers. They get the impinged a lot, it gets squished between the bones and it also gets a lot of tendonitis. So the way that tape is applied there is just creating a lot more space ad relaxation in that shoulder. It’s taking a little bit of stress off the muscles that the swimmer will be using. You can use the tape in water. You can leave it on for three to five days. You can do anything with it that you would normally do. And either people will feel nothing with it or will feel good. If you do have a swimmer that uses Kinesio tape and it’s uncomfortable, they need to take it off, plain and simple. It may just not been applied right or may have been applied to the wrong muscles. You need to give it another try. This is just a picture of a swimmer in the water with the Kinesio tape.

[audience member]: Is there something that we as coaches can do or it’s just a technique that even somebody else can do?

[EW]: There are people who, she asked if you can take it to a professional or as coaches you guys can use Kinesio tape. I’ll tell you there are lots of opinions about that. There are definitely people who are not certified who do put on Kinesio tape. Having been through the courses to be certified, it’s a little bit more complex than it looks like. What I would recommend is finding somebody who is certified and who knows how to apply it and seeing if after you’ve gone to them three or four times and it’s working for you, ask them to show you how to put it on. You can buy Kinesio tape, different sports stores will have it I know like some of the endurance running sports will have it, sports stores will have it. You can order it online but I would really recommend understanding what you’re doing before you start applying it. You’ll see some crazy applications out there and maybe they work but it’s probably worth your while to look into it.

[audience member]: This is interesting. [indiscernible] [0:29:55] kids 12 and under are not allowed to use it [indiscernible] [0:29:57]

[EW]: That would be something to look into for sure that is interesting. I did not know that. He said down if you guys could hear and he said 12 and under are not allowed to use it.

[audience member]: [Inaudible] [0:30:08] we were at junior nationals this summer they didn’t come out and talk about this [inaudible] [0:30:11].

[EW]: Yeah.

[audience member]: I think they also said no additional taping.

[EW]: Okay.

Next speaker: Because it may not be legal, I don’t know for sure but that was his message at junior national.

[EW]: Which would be, he said at junior nationals they were saying no taping. So I did not…

[audience member]: For training purposes there is no [inaudible] [0:30:28]

[EW]: For training purposes it’s not, for me it’s you know, obviously look into that and you know whether that is enhancing performance or just you know allowing performance to a full potential, hard to say it’s a fine line. So better air on the side of caution and maybe not wear it during competition unless you’re pretty sure it’s okay. But certainly for training it’s an effective way to get through training. Alright, so we’re going to talk a little bit about massage therapy, the shoulder, if you guys were just in here for the anatomy talk, some of this maybe redundant and I didn’t hear what he talked about. But I’m just going to cover a little bit about what U.S. Coaches are dealing with in terms of the shoulder and then show you what kind of massage therapy we’ll do for that. So I think I’m not, oh okay, I’m going to show you a little video clip that I think really explains it well but she, it’s actually a video that’s done by June Quick which is the late Richard Quick’s wife.

She worked a lot with Stanford swim team. She does a very good job of explaining the anatomy of the shoulder; I mean how it ties in the core and that kind of stuff. But she uses a lot of words if you’re not familiar with it’s easy to get lost in the video so I’m just going to briefly kind of explain some of the words that she is going to be using so that it makes more sense. She’s going to talk about swimmer shoulder which I’m sure as coaches all of you guys have heard of. It seems to be kind of a catch all phrase for things that hurt the swimmer’s shoulder and I know as a coach you know it’s kind of, you don’t really know what’s going on. You don’t know the kid’s telling the truth, if does hurt, you don’t know what it is and it’s really hard to know what do about it. You know physical therapy seems to work half the time and then other times not. So swimmers shoulder a large percentage of the time is going to be rotator cuff tendonitis. Rotator cuff is going to be four muscles I’m going to talk about in a minute. It’s in the shoulder, it basically means that there’s a little piece of the shoulder muscle that is inflamed and it’s uncomfortable.

Bursitis a bursa sack is a little fluid filled sack that you have all over your body. It basically provides a cushion all the times it’s between two bones. It’s just so the bones don’t rub together. Bursa sacks can become inflamed and it’s uncomfortable, maybe Bursitis which this means inflammation of the Bursa sack. Impingement syndrome, that muscle that I showed you back here that runs along the top of the shoulder where that black tape is, that muscle that they’re taping along there can get squished between two bones in the shoulder and so it’s just impinged and obviously that’s uncomfortable if you’ve got the muscle the muscle that is squished between the shoulder bones and then the subluxating shoulder just means a loose shoulder joint. If you’ve got kids where the shoulders are always popping in and out and it just seems to have high hyper flexibility that’s subluxating shoulder. So it’s nothing that you know super complicated, it just means you got part of you shoulder that’s pinched, something that’s inflamed or your shoulder is a little bit loose. Kind of a catch all first swimmers shoulder.

This is just a picture, if you can see there, that little sack there, that’s your Bursa it’s preventing those two bones from rubbing together so that it can just become inflamed, and then that’s just a little end of the muscle there that’s gotten inflamed maybe from being rubbed or just from repetitive use. Shoulder is a complex joint but very simply it’s not a strong joint because of the way that it’s constructed I guess you’d say you’ve got, let’s see we’ve got [inaudible] [0:34:02] here. You’ve got three sort of shoulder bones if you want to call it. This is very basic informational but you have your clavicle which is your collar bone, you’ve got your shoulder blade and then you’ve got your humerus which is your arm bone. Basically those three bones kind of make the shoulder joint. Now none of those bones are fused together. So all of those bones are held in place by muscles. So that means you’ve just got three floating bones that are held together by four muscles that are pretty small muscles that are called the rotator cuff muscles. You have two that run kind of along in the back side here of your scapula and then you’ve got one that runs along at the top of your shoulder and then one that actually runs underneath your scapula.

So kind of a sandwich between your shoulder blade and then one that runs on top and those four little muscles are what hold those bones on your shoulders together. So it’s good because it allows for all of the movements that your shoulders make to swim but having auto-mobility it means that it is not very stable. So she’s going to explain kind of a little bit more about where those muscles are in the body and how they fit together. She’s also going to talk about the core muscles which are extremely important in swimming. I know over the years there has been a lot of debate whether you power your stroke from your arms versus your core. Your shoulders are kind of where the power transfer happens between the arms and your core. So she’s going to just talk a little bit about that. Core strength is another really important way to prevent shoulder problems. It just kind of helps to holds everything in place so that you don’t constantly have things that are moving in the wrong direction and creating a problem. So I’m just going to… if I can try and show this video real quick.

[audience member]: It is a vital part of our team here at Stanford. She is a physical therapist, athletic trainer and Certified Pilates instructor. She’s been working with world class athletes in swimming for over 20 years and I know from personal experience that she’s helped some of our athletes win even Olympic gold medals. Summer Sanders does not win her Olympic gold medal in the 200 butterfly in 1992 without the help of June Quick. June is going to share some of her expertise on shoulder rehabilitation today and more importantly shoulder injury prevention in swimming.

[EW]: Thank you Richard for that gracious introduction. I hope all of you swim as fast as Summer Sanders but don’t have to endure a shoulder problem. Although the statistics will show that about 80% of you will at some point in you career have to endure a shoulder problem to some degree. Usually what is involved in swimmer shoulder is inflammation of the rotator cuff and or the long head of the bicep tendon or you could have a loose shoulder joint. A doctor may give you a diagnosis of impingement syndrome, rotator cuff tendonitis, Bursitis or subluxating shoulder which means a loose shoulder joint, he also may tell you, you just have a swimmers shoulder which is kind of the catch all term for a problem in a swimmers shoulder. Let’s go ahead and review briefly the anatomy and how the shoulder joint works so that you will understand why you’re doing each one of these exercises. We’re going to start off by looking at your back. The drawing here shows your head along with your spine, your pelvis, your shoulder blade. This ridge on your shoulder blade comes up and forms the roof of your shoulder. This is the acromion part of the roof of your shoulder. The humerus bone, the upper arm bone, your collar bone is drawn in with dotted lines because it is in front of you and then of course your shoulder blade lays right along these ribs in the back.

The first muscles we’re going to talk about are the rotator cuff muscles. There are four rotator cuff muscles, the first one your supraspinatus lay on top of your shoulder blade. The tendon of the supraspinatus comes underneath the acromion or the roof of your shoulder and lies right on top of your humerus. The infraspinatus muscle lies on the back of the shoulder blade, the posterior part of the shoulder blade and again its tendon blends with the supraspinatus forming that rotator cuff. The teres minor a smaller muscle next to the infraspinatus, it also blends in with that rotator cuff.

Now the fourth rotator cuffs, the subscapularis, we actually need to look at you from the front. Here’s your head, your breast bone, your spine and again your pelvis. Your collar bone coming out from your breast bone, here’s that end of that acromion that forms the roof of your shoulder and here’s your humerus bone. The ribs here I’ve drawn one rib in black and one in white. The other ribs will take off so you that can see the shoulder blade that lies in the back. That’s the dotted line again outlining your shoulder blade. The subscapularis, it lies in between your ribs and right on top of your shoulder blade and again its tendon comes right into the front of the humeral head and blends right in with the supraspinatus which is on top and the infraspinatus and teres minor that are in the back. They literally form a cuff around the top of your shoulder joint.

The other muscle that we’re concerned about in the front is called your biceps. The biceps lies right in front of your arm and it has two tendons. It has a short head that we’re not so not worried about and then it has a long head the tendon that comes up into the joint and attaches onto the shoulder blade in the joint itself. There is a lot of functions that these muscles do for our shoulders but one of the main functions is that it depresses the humeral head or it keeps this arm bone from pinching up against the roof of the shoulder. The way that works in swimming when you’re raising your arm above your head a lot, which we do a lot than swimming, you’re going to have a momentum force going up with that arm and if the rotator cuff doesn’t pull down to keep your shoulder down then it’s going to pinch the rotator cuff muscles. The long head of the biceps does the same. It helps to pull that humeral head down, literally so that the shoulder rotates right in the middle. You can imagine the shoulder being a titter totter and when you raise one end, the rotator cuff and the long head of the biceps better be pulling down the other end to keep you from pinching that rotator cuff or from pinching the long head of the bicep tendon.

The other muscles we need to talk about are your core muscles. Your upper core muscles are your serratus anterior muscles along with the lower trapezius muscles. Let’s try on your serratus anterior first. Serratus anterior helps to stabilize your shoulder blade and where it attaches, it start off at the tip of your shoulder blade and runs along what we call the medial or the inside border of your shoulder blade. It’s best to see it from the front since that’s where it lies. So it originates right on that inside edge of your shoulder blade and the tip of your shoulder blade. It runs around your ribs in front of your shoulder blade and actually attaches into your ribs. If I’m drawing it from the back it comes from underneath the shoulder blade, wraps right around along with your ribs till it gets to the front side of you and inserts into those ribs. Now the main function of the Serratus anterior muscle is to pull your shoulder blade wide across your back. It also help to rotate your shoulder blade right in the middle of the shoulder blade so this scup that the head of your humerus sits in will rise up.

So again the roofs of the shoulder’s rising up to allow you to rise your arm up without pinching those rotator cuff muscles. Now there is another muscle that helps the serratus anterior, it’s called the lower trapezius muscle. It attaches right a long the ridge of the shoulder blade, comes down and fans out along your spine and again when it pulls down along with the serratus pulling forward, we get this resultant rotation of the shoulder blade to help the mechanics of your shoulder joint be normal. Now the upper core is connected to your power house which is your lower core, your abdominal muscles. Your abdominal muscles come in layers. The first layer is your transverse. They lie across your belly sideways and they really give your whole core a nice firm base of support. The next layer are called your internal oblique muscles. Those muscles run up from your hips towards your ribs towards the center line and then the layer of muscles on top of that are your external oblique’s and those really interlace with that serratus anterior and drop down from the ribs to the hips and that connects the upper core with the lower core. So you can see with Richard Quick in his videos demonstrating swimming strokes wanting you to have a core support to allow the energy to transfer to the upper core and finally to your shoulder girdle to allow you to have a more powerful stroke as well as to have a healthier shoulder.

[EW]: So in a nutshell that is the anatomy of the shoulder which does not necessarily seem like you need to know when you’re coming to a talk about massage therapy but if you guys understand a little bit more about what’s going on in the shoulder it’s easier to help, kind of direct your swimmers what they need to do , it’s also a good idea just to know, I mean there’s tons of shoulder problems with swimming. You need to be able to find a therapist for your team that knows what they’re talking about with the shoulder, so if you guys know it just helps a little bit when you’re communicating with a therapist. Okay, so why do you need to use massage therapy for your swimmer, these shoulders and your core need to have a massage because it’s going to help with muscle recovery. Not only is it going to help with muscle relaxation but it is going to flush through your system and it’s going to eliminate some of the build up that happens with scar tissue and especially with repetitive motion. The faster the recovery the less the scar tissue, the less the likely for injury. It’s also going to improve muscle function. When the muscles are relaxed and able to do the job that they’re supposed to do, fatigue is less, you’re going to get less cramping and you’re going to have less chance of injury.

So it’s important that your swimmers use massage both for maintenance before they get hurt and then also once they get hurt to kind of get those muscles to functioning back the way they need to. A 30 minute appointment if you can get that and focus on the shoulders and focus on that lower back and the core is really going to be the most effective. You know massage therapy is expensive; it’s not something that most people can afford to do all the time. So if you’re going to do it know what you need when you go in there and know what kinds of questions to ask your therapist. Going in for half an hour every three weeks is going to be better than not doing anything at all and waiting until you have a problem and then you’re going to have to spend a lot of money. So target your shoulders and target your core muscles when you go in.

The last two things I’m going to quickly touch on and then we’re done is massage therapy and your swimmers as far as kids. When you’re referring kids you need to make sure that you know what their licensing requirements are in your state and that whoever you’re using has them and I’ll call your city and make sure that they’re on record there and that it’s not just document up on the wall. God forbid that something happen to one of your kids when they go in there. Make sure that you’re comfortable with the bedside manner of the therapist especially one that is dealing with kids. They need to be able to talk to kids, it needs to be comfortable and the last thing you want to do is creep out your swimmer and you know maybe the person’s fine but they are not just the connection that you need, switch find somebody else. Don’t put your child into a situation where they are laying on the bed faced down with somebody they’re not comfortable with, not a good situation.

The therapist should leave the room when the child gets on the table. I’m pretty strict about that, I will leave the room even if you know if I’m working on somebody’s back and it’s you know a 12 year old male whose mom is in there and they are just going to get on the table and lay face down. I still leave the room. I never want to leave any doubt at all that it is a professional environment. The kid should never think you are standing there watching while they get on the table. It’s creepy, error on the side of precaution and make sure the therapist you see does that. The other thing is that the parent should be in the room the whole time. Any kid that is under 18, you need to have the parents there and as a coach or as a parent you need to be vigilant about that. There is just too many creepy things that happen and that is one way that you can make absolutely certain that nothing weird is going to happen in there. And it shouldn’t most therapists I know are fine, why put the therapist in that position and why put the athlete in that position.

The other thing is communication with an athlete that is on the table if you have a kid. I work on a pain scale with kids. You know we’ve got one to ten, I tell them we should never go past a five or a six. When we are dealing… your body is going to naturally kick in it’s defense response you know grinding through more pain is gain is not a more no pain no gain whatever is not necessarily true and especially for a kid and they don’t need as much pressure. Their muscles respond much more quickly than adults will and if you have an athlete that you know doesn’t ever complain and kind of sucks it up and just keeps taking it, the pain scale needs to be adjusted. A lot of my gymnasts have learnt that they better not say anything no matter how much pain they are in, so I will deal with them on a level four where some of my other athletes you know it’s a different sport different mentality, I can use a six. So make sure you know your athlete you make the session productive. How to find a therapist, doctors you know, there’s not a lot of doctors that work with therapists just yet but that could be a recommendation.

U.S. coaches might know the best place that I would recommend is looking up who the local triathlon club is and find out who they use. Triathletes are a population both because they can afford it and because they’re completely neurotic about doing the best they can. They will use therapists and they will find good ones. That will be the highest recommendation that I can any personal referral. Additional ways to help your swimmer increase muscle recovery the biggest thing I can talk about is nutrition. You know our swimmers get in and they swim you know little kids, may be an hour but ,we’ve got kids in there that are in there three to six hours a day. You get out, nutrition is not something that I find is focused on a whole lot on age group swimming. I was listening to a coach talking not too long ago, who’s nationally known, very top notch probably one of the best coaches in the U.S. and one of the audience asked well what do you recommend these kid eat. And his answer was he didn’t care I bet fell over and died. I mean that is like you know triathlon nutrition is considered the fourth discipline. Swimming they get out for three hour practice, if they don’t get food in them right away and it’s not good food their body… the faster you get food into your body the faster and better your body will utilize that for recovery. If you want to support muscle recovery, you need to get nutrition in and it needs to be good. You need power protein and you need carbohydrates. You know depending on the age that’s going to vary but I cannot reiterate enough that if you’re not doing this and you are going to see you massage therapist, you are not doing yourself any favors. You might as well as skip the massage therapist and start doing this.

[audience member]: Can you feed the kids…

[EW]: What would that be? She said if I could hand the kid one thing after practice what would it be? I would say probably whole wheat bread with omen butter on it. Naturally ground omen butter omen it’s a good nut it has a lot of good fats in it if you get it naturally ground it’s not going to have a lot of sugar in it.

[audience member]: Not butter and banana?

[EW]: Yeah not butter and banana would be great, perfect. You know keep them away from the sugars and all the processed food and get something natural and it doesn’t need to be complicated but it needs to be good. Last thing with the shoulder injury prevention is a strong core, the stronger your core the more it’s going to hold that shoulder joint in place. So if you’ve got kids doing 5,000 arm strokes of practice and their core is weak every time they take that stroke it’s pulling that shoulder joint a little bit out of whack. You do that 5,000 times a day you know for seven days a week that’s what 35,000 times a day your shoulder is gone like this in a motion that it shouldn’t. Your core is going to help hold that in place it’s going to help alleviate or eliminate some of that [inaudible] [0:51:04] moves that you get with the bad stroke so your strong core is huge. I think that is it. You’ve got any questions?

[audience member]: [inaudible] [0:51:13] impingement injuries and try to prevent that stuff [inaudible] [0:51:20] this article that was talking about the arm position and then you tie you hands away from [inaudible] [0:51:25]?

[EW]: Yeah, she was asking about the hand position when you’re working with impingement syndrome. Impingement syndrome again is when one of those top rotator cuff muscles get squished between the two bones and the shoulder, the reason the hand position would be important there is because all those four little muscles had to do with arm rotation. So the way that your arm is rotated changes which part of muscle is engaged. So when you are switching that hand position it can make a huge difference if you are doing something like physical therapy.

[audience member]: I have two questions. First one would be if you do a full body massage when you start, you start from the legs upward towards the heart or you start from top going towards the legs? Number two is which one do you recommend before… 24 hours before the swimmer competition?

[EW]: Before the competition? His question was one if you get a full body massage where do you start with it? Like in terms of where on the body do you start and the second question was what kind of massage do you get 24 hours before a competition? If you’re going to get a full body massage, you can really start any place on the body. The key is you that want to be working towards the heart. So I might start on somebody’s legs but all of my motions are going to go towards the heart. If I start on the back it’s the same thing. A lot of times therapists will start with an area where there is a problem. So I might give somebody a full body massage but they have problems with their cuff. So I may spend a third an a half of the time on their cuffs and you just want to make sure that you’re working towards the heart. 24 hours before a competition you want something that is not relaxing and not deep so you might get 30 to 60 minutes of a quick flash and the motions are going to be faster. If you’re 15 minutes before your event you probably want like a 15 minutes massage that’s just fast, it’s going to be like a warm up as if you were in the pool it’s going to increase the heat, the circulation and get the muscles ready to fire.

[audience member]: The video that you showed June perhaps it was several years ago, do you have a title on that?

[EW]: I do, it’s a great video and actually it’s called ‘Swimmer shoulder Prehab and Rehab’ and it’s a championship video. It’s phenomenal. She does a lot of PT stuff in there more than massage stuff therapy but…

[audience member]: I’m a college coach and we really don’t have the funding at hand for [inaudible] [0:53:58] with us and I was wondering if you have any suggestions like maybe there are people [inaudible] [0:54:04] getting their education [inaudible] [0:54:05] hours?

[EW]: They do. As far as having massage therapy be more accessible because it is expensive. Finding a school in your area, they are not usually free, they are very much discounted. Sometimes, like if you have a physical therapist or something that can travel with you, sometimes they’ll throw in a little bit of a massage but the most accessible way financially is to find a school. Some of you have got to dig a little bit and find somebody you like and then they move out so it’s not always convenient but certainly more affordable.

[audience member]: [Inaudible] [0:54:44] go along and take a line up expense is that [inaudible] [0:54:52]

[EW]: Massage and insurance. That’s a great question. It’s kind of hit or a miss. I don’t take insurance right now mainly because dealing with insurance companies is a nightmare. There is coding that’s involved. It really depends on the therapist, the state and what the rules are. The good thing about the active release that I was talking about is that because a lot of chiropractors do active release. Chiropractors are covered by insurance. So sometimes active release is easier to get covered but ask it’s worth asking you know. Anything else?

[audience member]: I would like to hear if you have any comments to talk about. I remember during your meetings the whole thing about the [inaudible] [0:55:30]?

[EW]: She is asking about Dara Torres during the Olympics and her team of people. I know she had a massage therapist. I think it’s a very effective both mentally and physically. You’re going to be doing different stuff. I don’t think she could have been… If she was going to pick one person to be in her team it wouldn’t be massage therapist but I do absolutely hands down think that you know that was a critical piece of what she was doing. For relaxation yeah it helps increase muscle recovery the amount of time. I mean basically ‘cause it relaxes, it allows… it gets the circulation flowing. It works out notes before they set in, it’s a big thing. Anybody else?

[audience member]: I heard a lot about stretching before a work out and that it should be more dynamic. Is that just like static kind of stretching [inaudible] [0:56:28]?

[EW]: Sure. She’s asking about stretching before you work out. Stretching is interesting, I know that there is a lot of debate about stretching and how effective it is and should you stretch, shouldn’t you stretch. I am a believer in stretching. I do think it’s more effective after a work out or once you’ve kind of warmed up the muscle a little bit. If I have athletes especially with injury, I will have them sit in a hot tub or something before to increase that circulation and get that muscle warmed up because then it’s a little bit more receptive to stretching. If you’re going to do a stretch before you work out some kind of I guess dynamic would be the word, the word’s more motion. You don’t want to crank into a cold muscle and hold it ‘cause it’s going to start ripping those muscle fibers. So gentle movements are kind of going to get the muscles and then stretch out a little bit is better than cranking and getting into a long stretch. Anybody else?

[audience member]: What are your thought on the foam rollers?

[EW]: Oh the foam rollers are fantastic. In fact I think foam rolling is more effective than stretching. I don’t know if you guys know what foam rollers are? They are about this tall, they are round. They are ridiculously priced it’s like $30 for a piece of Styrofoam. If you invest in nothing else get the foam roller. You can Google it, just Google foam roller. There are some great videos on how to use it. You can get to all kinds of nicks and crannies and basically what foam rolling is doing is helping, at least on a superficial level stretch out that fascia that I was talking about that encases the muscles. They’re fantastic. That and active release and you take nothing away from the talk today.

[audience member]: Like we can use it?

[EW]: Yes you can use the foam roller. Yes you should be using the foam roller they are awesome. Anybody else? Alright, thanks.

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