Mastering Your Craft: Soft Tissue Injury Treatment and Prevention
By Robert "Skip" George, D.C., CCSP, CSCS
Sports science is evolving rapidly today as performance training, rehabilitation and sports medicine are "bridging a gap" to increase performance, prevent injuries and more effectively treat injuries when they do inevitably happen to your athletes or clients. Whether you are a personal trainer, athletic trainer, physical therapist or sports doc, soft tissue injury and effective treatment strategies need to be in your "tool box" for optimal performance and injury prevention.
Manual therapy or soft tissue work is utilized for the prevention of injury and treatment for acute or chronic painful conditions or just simple stiffness that is restricting movement. If movement is restricted, performance will be reduced and the likelihood of injury is increased!
When do many of these initial injuries occur? The answer is not only high school athletics but middle and grade school as well. Since previous injury is the most significant cause of re-injury, are we providing the appropriate training and rehab to our younger athletes? In our training programs, are we piling "fitness" on top of "dysfunction" or previous injury?
Assessment and treatment go hand-in-hand especially when it comes to the numerous soft tissue injuries that occur in athletics, especially contact sports. Whether an athlete is in high school, college or is a professional, they are bigger, stronger and faster than ever before. For many, training cycles are year round with intense strength and conditioning programs that lead into the season’s schedule and perhaps playoffs beyond the regular season. Injury prevention, injury treatment, and especially durability are crucial issues for your athletes. One key player sidelined in any given sport for even a short period of time can make the difference between winning a game or winning the playoffs! Effective soft tissue treatment with a "functional" movement assessment and specific corrective exercise is emerging as perhaps the best approach so far to prevention, treatment and performance.
Soft tissue is defined as muscle, ligament, tendon and nerve. Surrounding the muscle like a slippery sack is an ultra thin but very strong membrane called "fascia". This may be one of the most important structures in the musculoskeletal system and forms a "fascial system" that interconnects throughout the entire body and in many ways holds our muscles and bones together in a complex "functional" chain. This fascial system contributes to posture and movement quality which ultimately results in the ability to generate power, speed and agility. When damaged through direct contact, repetitive motion or traumatic injury it will affect movement and performance even when the pain is gone or the injury is "healed". This repetitive stress or tissue injury insult whether a single acute occurrence or one that happens over time affects the "plasticity" of connective tissue and affects movement patterns, player performance and durability of the athlete.
Injuries and pain to soft tissue can be classified as acute, sub-acute or chronic and refers to how long since injury occurred or the duration of pain. Acute injuries go through three distinct healing phases which include the inflammatory phase, the repair phase and the remodeling phase. Depending on the injury and joint involved treatment in the inflammatory phase may include managing the effects of the acute injury with rest, ice, anti-inflammatories and gentle movement with very light stretching, massage and/or isometric exercise depending on location and severity of injury. In the repair phase, the time to promote healing and developing a "mobile" scar begins with soft tissue work while carefully adding exercise progressions. Scar tissue forms initially in a random pattern and during this phase gentle alignment of scar tissue fibers with a soft tissue technique aids in the healing process. In the remodeling phase, increased strength training and continued soft tissue realignment of scar tissue fibers aids in the healing of injuries and helps decrease risk of re-injury. Ultimately, once an injury has healed, the "regional" effects on other areas of the body, especially through the fascial system, need to be addressed.
Soft tissue work has several benefits. The first is biomechanical including the treatment of tissue adhesions, muscle lengthening and increased joint range of motion. Physiological benefits include increased muscle and skin blood flow and circulation, increase of relaxation hormones and decrease of stress hormones. Neurological effects include a reflex stimulation that decreases neuromuscular excitability, pain and muscle tension or spasm. The psychological effects cannot be underestimated and include an increase in relaxation and decrease in anxiety. Plain and simple, there is a healing effect with hands-on therapy!
Manual soft tissue treatment can include traditional massage for biomechanical, physiological, neurological and psychological effects. For focused attention to specific structures there are several approaches widely used in sports medicine.
Today there are several excellent approaches to soft tissue management including the latest in fascial manipulation. Several of these techniques are used in all major professional sports, Ironman competitions and the Olympics. These treatments include Active Release Technique (A.R.T.), The Graston Technique (GISTM), Fascial Manipulation (FM), Functional and Kinetic Treatment with Rehabilitation Provocation and Motion (FAKTR-PM) and Osteopath Guy Voyer’s work on treating fascia especially as it relates to sports.
Active Release Technique (ART) is a hands-on treatment that addresses muscular or soft tissue problems. One of the key premises of A.R.T. and all of the soft tissue approaches mentioned in this article is to reestablish normal motion in and between fascial planes thereby reducing the adhesions that occur in the fascia and muscle while restoring the normal "gliding" and range of movement of these structures. The practitioner determines where the scar tissue or "adhesion" is located. Then, he/she uses the appropriate amount of manual force to lengthen under tension in the direction of the fascia, muscle, tendon, or ligament. Essentially, the muscle and fascia is first shortened then lengthened under manual tension slowly and held at the end of the movement for maximum therapeutic benefit. The experience of the person treated is most often "That’s a good hurt, do it again!". This shortening and lengthening provides a free and complete movement of the structure treated, releasing adhesive tissue restrictions, increasing blood flow and restoring a more complete range of movement. An example would be the treatment of Ilio tibial band syndrome that can cause pain into the lateral thigh region into the knee or a shoulder with scar tissue or limited movement. Spinal pain and dysfunction can be treated in addition to tendonitis of the hand, wrist, elbow, shoulder, hip, knee, ankle and even plantar fascia. A.R.T. was created by Michael Leahy, D.C..
Graston Technique is widely used in amateur and professional sports. David Graston suffered a knee injury to several ligaments in his knee. After extensive surgical reconstruction, he was left with limited range of motion and function. He used a technique known as cross friction massage as described by Cyriax. The problem cross friction massage or any hands-on technique is that it can be hard on the hands including being very fatiguing for the practitioner! Graston developed specific stainless steel tools of different shapes that are used in many different directions over a fibrous "lesion" or scar tissue. This soft tissue technique is designed to mobilize, reduce and reorganize fibrotic scar tissue or restrictions and can be very helpful in the repair and especially remodeling phase of inflammation. Graston is also very effective for chronic or long standing soft tissue adhesions especially causing range of motion restriction for a joint. Graston technique has been effective in clinical trials at Ball Memorial Hospital and Ball State University in Muncie Indiana. It has been part of the kinesiology graduate curriculum at Indiana University for athletic trainers.
Fascial Manipulation (FM) is taught by Warren Hammer, D.C. and Antonio Stecco, M.D.. This work focuses on treating what is known as individual "myofascial units" or trigger point locations along a "myofascial sequence" or specific chain of trigger points. These points are similar in location to acupuncture meridians. Extensive research is continuing on this very effective technique that has been practiced in Europe for years and is now being taught in the United States by Dr. Hammer and Dr. Stecco.
FAKTR-PM also addresses the issue of once pain has occurred after an injury, what are the consequences to movement patterns of the athlete after the injury has occurred? This technique uses hands-on therapy during corrective exercise to restore fascial "gliding" using functional movement patterns during treatment to restore proper timing and sequence to complex movement. This technique was developed by Tom Hyde, D.C., Greg Doerr, D.C. and Vince DeBono, D.C. These sports docs also utilize the above mentioned techniques to complement their own unique approach to treat athletes.
Guy Voyer, D.O. teaches workshops on affecting fascia through specific stretches and is ground breaking in sports therapy and performance.
For specialized stretching, Stretch to Win is utilized by many professional athletes to maintain movement and function.
One of the most effective tools at your disposal in providing mobility is the "Stick". This popular tool is like a rolling pin for muscles and fascia. In a blog by Joe Heiler, P.T., he recently mentioned Charlie Weingroft, P.T. and his use of the "Stick". How many clients or patients do you have with tight hamstrings? Want to be an instant hero with that client or patient? If they present to you with a tight hamstring stretch, use the stick on the back of their calves, hamstrings and lower back. Spend about 90 seconds on each location then have them stretch again. Nine times out of ten their range of motion will instantly improve and you get the well deserved credit! The "Stick" is a must for every trainer, coach and doc working with athletes.
Remember that the biggest risk factor for injury is a previous injury. After an injury or pain occurs, ligament, tendon, muscle and fascia need to be treated to restore normal function and movement at the location of injury. But what happens to movement patterns to the athlete after an injury? Studies have shown that even after the pain is long gone and tissues have healed, altered movement pattern is still a crucial issue and needs to be addressed. For instance, studies have shown that once an injured ankle has been healed function and strength of the gluteus maximus will be altered. How important is this muscle for power production and speed? With altered movement pattern on one side, an asymmetrical pattern can then develop in comparison to the other. How prevalent are hamstring and groin injuries in your players? Asymmetries are the second biggest reason athletes are injured and we are just talking about non-contact injuries.
For example, assessing injury risk and reducing that risk is one of the most important issues facing football players in high school, college and beyond. Durability is a key component in this equation. Of course, it is easier to prevent than to treat an injury and one of the most important tools to assess how well your player’s move and to address asymmetries and/or dysfunctions is the Functional Movement Screen (FMS) created by Gray Cook, MSPT. In about 10 minutes and with seven basic movement tests, the FMS can predict the risk of injury in your athletes and provide a means to provide precise corrective exercise strategies. The FMS is also an effective tool that helps you know when it is appropriate to refer out to a licensed healthcare provider. The head strength coach of the Indianapolis Colts, Jon Torine, uses the FMS as the foundation for their training program.
A comprehensive and effective approach to training, playing and injury treatment including the use of assessment tools and soft tissue techniques that work hand-in-hand together is your best bet to provide that competitive edge that not only leads to a winning season but provides a solid foundation for your athletes to minimize risk of injury, fulfill their athletic potential to the fullest and provide durability now and in the future whether they continue on in competitive sports or not! It never hurts having as many tools as possible in your toolbox for your athletes and this is a short list of the most effective tools for soft tissue treatment and functional movement available.
If you are a personal trainer you probably have limitations as to how much soft tissue or "hands on" work you can provide legally. In the network of professionals you work with, make sure you know of at least one soft tissue expert or become one yourself. Spend the extra time and money by getting a massage therapy license or becoming an athletic trainer and then taking courses on the latest in soft tissue treatment. Adding tools to your toolbox is not only professionally and personally satisfying but financially lucrative as well. The competition is getting stronger in the fitness/training world. Developing competence and mastering your craft makes all the difference in the world for your professional and personal well being! Good Luck and keep growing!
Dr. George practices in La Jolla, CA and integrates chiropractic care, rehabilitation and performance training. He is a Certified Chiropractic Sports Practitioner, a Certified Strength and Conditioning Specialist and treats and trains amateur and professional athletes. In addition, he has lectured to athletic trainers, physicians and strength coaches on the Functional Movement System it’s use in injury prevention and treatment. He is also an instructor for the Functional Movement Screen.He can be contacted at Dr.George@SBCglobal.net.