Ruminations on sports, training, health, and wellness

Posts tagged “sports massage

The Illiotibial Band: Nefarious Foe, or Misunderstood Friend?

Runners, cyclists, and just about anyone who moves their legs on a regular (or irregular) basis has probably encountered the Iliotibial Band: a dense, fibrous tract of tissue running from the outside of the hip along the side of the thigh to connect just below the knee. And if you have experienced sensation associated with this tissue structure, chances are high that it was not a good experience.

afp20050415p1545-f1IT Band pain symptoms and range of motion inhibition, often referred to under the umbrella term “IT Band Syndrome,” is a common condition among individuals who engage in repetitive leg flexion and extension, and while exact figures for the entire population are unknown, some studies estimate prevalence over 20% in people who run or walk long distances. Symptoms usually present with pain in the lateral hip or the attachment at the knee, although sometimes tissue adhesions in the side of the leg cause pain when the structure is stretched, as in running or cutting movements.

The IT Band is itself not a muscle — structurally, it can be thought of as a long tendon tail attaching at the bony prominence at the top of the lower leg, just below the knee (at the prominent knob of the lateral head of the Tibia bone; it probably hurts a bit if you press on it), running up the side of the thigh, and fanning out to blend into the Tensor Fascia Latae hip muscles and Gluteus Maximus, which finally attach at the Iliac Crest, the upper rim of the pelvis (hence ilio-tibial). Like all tendons, the IT Band has little blood supply and nerve innervation, and is primarily composed of collagen, elastin, and fibroblast cells. While it cannot contract on its own, the muscles at the top of the hip (primarily the Tensor Fascia Latae) put tension on the IT band to abduct (bring away from the body’s center line) the hip and leg. Think of a rope and pulley system — the rope in this case represents the passive IT Band structure, serving to distribute the force applied to it from the other side of the pulley. This is particularly important in walking and running, where the leg involved in stepping forward during the “swing” phase of gait relies on the abductors and deep lateral rotator muscles of the hip to keep the pelvis level and stable. You may have seen runners or walkers whose hips “dip” with every step — this often indicates dysfunction in the Tensor Fascia Latae and hip rotators.

It is important to view the above graphic as a representation of the actual structure within the body; I like how the artist has indicated that the white tendinous fibers of the IT Band blend into the muscle tissue at the hip, but I think the characterization of the IT Band as a separate bundle of tissue laying on top of the surrounding muscle is a common misunderstanding, and refining our concept of the IT Band as it actually exists and functions in the body has great implications for practitioners and athletes alike.

the_muscles_of_the_leg_919014Our understanding of human anatomy comes largely from dissection of cadavers, wherein individual muscles and anatomical structures are identified by being excised with a scalpel from the surrounding tissue. This gives us a detailed sense of the three-dimensional body, but by manually separating the tissue, we also often tend to mentally isolate these structures and forget that the elegant, intricate musculoskeletal system recruits fibers from a broad range of tissues for almost every motion. Take a look at Leonardo da Vinci’s drawing of a dissected leg to the right (click to expand to full size). This intricate and amazingly accurate drawing from the early days of human anatomical study indicates the same fanning connective tissue structure in the upper hip as it blends with the hip abductor muscles, but we don’t see the same IT band structure drawn separately from the surrounding tissue — it’s more of a thickened strip of tissue that forms a groove in the side of the thigh. You may have seen athletes with highly defined, sculpted musculature who exhibit the same structure; the IT Band appears as a groove along the side of the thigh and forms a tendon bundle at the tibia attachment. Just as the connective tissue structure of the IT Band blends into muscle at the hip attachment, there is also a great deal of “feathering” into the muscles of the lateral thigh — namely, the lateral quadriceps and hamstrings.

DSC_0151Why is this distinction important? To go back to the previous rope and pulley analogy, we can refine this understanding to not just a single rope pulling on a single endpoint in a single plane of movement, but a network of pulleys pulling on a web of ropes that disperses tension across a wide area, with each structure interacting as tension is applied and released. The interactions are so intricate that even the most sophisticated biomechanics models can only provide simplified schematics of the forces at work in the living body. You may have seen similar art and architectural structures, called “tensegrity models” that exemplify this concept. Below is a video of renowned bodywork practitioner, researcher, and teacher Tom Myers showing an example of a tensegrity structure and how it relates to the body:

Watch how the model moves when Tom pulls on a piece of the elastic thread — look closely and you will be able to see other elastic threads disperse tension, with some going taut and others going slack, which changes the position of the rigid dowels. The model demonstrates how a rigid structure with limited elasticity can affect the contractile structures it attaches to. An example of this in practice might be flexion of the hip to kick a soccer ball. As the leg is brought up and the angle of the hip becomes more acute, the quadriceps fire to extend the knee and flex the hip. Since these fibers tie into the IT band, this motion exerts force along the length of the IT band, which will functionally rotate the leg inward (medially). To prevent rotation, the deep lateral rotators that run across the glutes must fire to compensate. This is a simplified explanation of the processes at work, but is meant to demonstrate the kinetic chain of events that occurs with movement and the forces at work to stabilize and compensate to promote strength, accuracy, and protect against injury.

Taking this same example a step further, suppose one of the muscles working in concert to accomplish the kicking action is weak or impaired due to injury or improper training. The Piriformis, one of the deep lateral rotators of the hip that runs beneath the glutes from the Sacrum to the Femur, is a common offender for hip instability and insufficiency. Without the Piriformis firing properly to prevent medial rotation, other muscles that may not be as well adapted for hip rotation must be recruited to preserve stability, including the Tensor Fascia Latae. The IT Band, already under tension from its connection with the Quadriceps, comes under additional tension from the Tensor Fascia Latae to pull the leg into alignment, putting even greater stress on the IT Band attachment at the knee. Can you see how this could lay the groundwork for pain, inflammation, and chronic injury?

The prescribed treatment for pain and tightness in the IT Band has long been stretching, manual therapy, and foam rolling along the length of the outside of the leg, which still assumes the concept of the IT Band as its own discrete, free-gliding bundle of tissue and discounting the connectivity to the surrounding muscle. I’m making the argument that this isn’t necessarily the most effective nor the best biomechanically sound approach to treating IT Band Syndrome symptoms. Stick with me here.

Think again back to the tensegrity model Tom Myers was playing with. If one segment of the elastic thread was under significant tension, it would produce slack on other thread segments — that’s how vector energy dispersal works. What if, instead of approaching the problem by addressing the tight thread, we look for ways to bring appropriate tension into the slack threads? This accomplishes the same goal of dispersing tension equally, without further assaulting already inflamed, sensitive tissue.

In the case of the IT Band, this translates to gentle stretching and mobilization of the Tensor Fascia Latae — remember, the IT Band itself is essentially a passive structure and translates tension from other muscle attachments instead of exerting any force itself — and rehabilitative exercise to strengthen the deep lateral rotators in the hip and glutes. I am not recommending this as a cure-all approach for every presentation of hip and lateral knee pain; always seek evaluation from a medical practitioner to properly diagnose pathology and pursue the best course of treatment. For everyday tight, tender IT Bands, here are three exercises that target the supporting musculature to promote balance and optimal movement patterns:

First, the Clamshell — the model in the video is using a resistance band, which can be omitted and introduced later as strength and mobility progress.

Next, the Glute Bridge; I like this single-leg variation because it requires more global hip engagement than a symmetrical bridge hip raise. Adjusting the angle of the raised leg (pointing more toward the ceiling) will help to recruit more low back, hip flexors, and hamstrings to maintain balance.

Finally the Triplanar Hip Exercise (one of my clients fondly refers to this as the “fire hydrant;” if you are a dog owner, you will quickly recognize why!). The model in the video has good form but I would recommend slowing down the pace for more accurate muscle recruitment. The three elements are full extension of the leg, lateral rotation, and flexion pulling the knee into the torso.

These exercises are a great starting place to promote hip mobility and strength for runners, cyclists, swimmers, and active individuals in general. You can make them more difficult by taking away the stable base of the solid floor, for which Bosu Balls and wobble boards are excellent tools. These also make a great pre-activity warm-up or post-activity mobilization. If you have sciatica or back pain symptoms, consult a health professional before beginning these exercises, as excessive tension in the deep lateral rotator muscles can sometimes exacerbate nerve impingement symptoms. Always stop if you feel pain or pinching, and work within your abilities, progressing as your strength improves.

I hope this perspective on the IT Band sheds some light on its function and structures. This essential tissue mass in the leg is an important factor in all activity and movement, and healthy function will improve performance and prevent injury.


Relentless Curiousity

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It’s autumn in North Carolina, which can only mean three things: spectacular sunlit leaf color, a distinct uptick in latte consumption, and NCAA college sports in full swing.

I get the privilege of working with several Division I college sports programs, most notably my graduate school alma mater: the University of North Carolina at Greensboro. I’ve been feeling the Spartan love this week with lots of outcall sports massages in the athletic training room, and working with these talented young people never fails to keep me on my toes.

The Internet Age has given athletic people vast resources to learn more about sports, nutrition, physiology, training, and therapies. On the whole, I am impressed that the availability of knowledge seems to help my massage clients to be well-informed and discriminating consumers of information. People who participate in sports at a high level view their bodies as tools — their vehicles for recreation and competition. This insight frequently leads them to constantly seek and evaluate information that will improve their performance, health, and experience. It also means they ask practitioners a lot of questions.

It’s easy to view “why?” as a challenge: a threat to authority and credibility. But forcing myself to dig deep into the body of knowledge through the incredibly effective (and sometimes incredibly annoying) Socratic method makes me a better practitioner and helps me build a reputation among my clients that I am a trustworthy source of information. The college students I work with ask questions that often catch me off guard, and the exercise of thinking analytically and critically to construct a thoughtful answer is often a missing ingredient in massage education.

Let’s apply it to a common instruction massage therapists give to clients following a bodywork session: “Be sure to drink plenty of water after your massage.”

But why?

The pat answer many of us learn in massage school is “to help flush out metabolic waste.” But what does that mean, and most importantly, is it a rigorous and factual response to the physiologic processes at work?

To be thorough and deductive in crafting an answer, consider all the pertinent facts. Massage therapy has a demonstrable effect on blood and lymphatic circulation, because the mechanical manipulation of soft tissues introduces heat and pressure, which creates a mild inflammatory response. The body’s response to topical heat is rapid dispersal by dilating capillaries in the tissue, which decreases blood pressure because of decreased vascular resistance. To maintain homeostasis, the body responds to the drop in blood pressure by adjusting fluid uptake in the blood stream and changing heart rate to stabilize blood pressure. One important role the circulatory system performs is transportation of the surplus substances of metabolism and energy production and expenditure to the kidneys to be excreted from the body. An example is the process of converting protein into energy: the leftover substances include ammonia, urea, and uric acid, which are toxic if they remain in the body. Massage is not directly shown to release metabolic waste from soft tissues under study conditions, but in consideration of the peripheral responses to massage, appropriate hydration supports homeostatic processes to promote optimal muscle function and recovery. Most importantly: with the exception of a few conditions such as hyponatremia (abnormally low electrolyte dilution), drinking water is an appropriate recommendation for overall health an wellness; the risks are vanishingly small, and the potential benefits are great.

For many clients, this explanation goes in to way too much physiology detail. However, I think as a therapist, it is important to understand the complete picture and to be able to articulate it accessibly and intelligently. It establishes credibility and develops the ability to think critically and scientifically about the therapeutic intention of our work. It also helps me to be better able to talk about the effects and benefits of massage to other medical providers, which has made a huge impact on building my client base and becoming regarded as a skilled practitioner, able to get into a variety of unique opportunities as a massage therapist. For me, it’s simply not enough to regurgitate pat answers; I am voraciously curious and keeping current on research helps me to continuously refine my methods and understanding.

If you are a consumer of massage therapy, I encourage you to ask your therapist questions about what he or she is doing and effects on the body. I think most therapists are like me — we get really excited when clients show an interest in our specialty and we want to share with you information that can positively impact your health, wellness, and understanding of your body. Learning about physiology and anatomy in school was like getting an owner’s manual to my body and I love sharing that feeling of empowerment through knowledge with my clients. I don’t think it’s appropriate to try to test therapists’ knowledge with “trap” questions, but to approach your therapist as a resource to broaden your understanding of health, wellness, and activity. Additionally, most massage therapists maintain an extensive referral network of other allied healthcare professionals, so even if we can’t directly answer your questions, we can almost certainly direct you to another expert who can.

Do you have a burning question about massage therapy, or are you a practitioner who has encountered great questions from your clients? Shout out below!


USAC Redux, part 1

It’s a pleasantly steamy early summer evening in North Carolina and I’m enjoying a glass of wine on my porch and watching the fireflies dance in my yard. The relaxation and leisure of my life in this moment makes my life in Europe the last couple months seem like a dream. But I loved the thinly veiled chaos of my work in Europe as much or more than the luxurious Sunday afternoon nap earlier today.

To bring this blog back up to speed, we have to go all the way back to the Koga Ronde Zuid-Oost Friesland in the middle of May, a one-day interclub road race in the beautiful verdant farmland and pristinely groomed villages near Appelscha, Netherlands. We had all gotten a few days to recover from the Peace Race and legs were primed, injuries nearly healed. This was a new race on the calendar, and a dream-race for staff — spectacularly comfortable nearby accommodations (with an equally spectacular breakfast buffet), a non-UCI race with no caravan and no designated feed zones on the course, minimal gear, food, and prep necessary. Our seven-man team lined up with the directive of racing forward, getting at least one rider in every breakaway move, communicating with one another, and staying out of trouble. Easy enough.

Once the riders were off, the director, mechanic, and I made our way back to the team car and proceeded to the first point in the race for open feeding, a picturesque tree-lined lane just after a section of pavé. These were not the helter-skelter cobblestones of Paris-Roubaix, but had enough of a crest in the middle to scrape against the undercarriage plate on the team car (which had been installed before Paris-Roubaix for that very reason). Coming off the first stretch of pavé, our smallest, lightest rider who was crushing cobbles for his first time ever streaked off the front of the peloton like a rocket. We knew already that we were in for a show.

We wended our way through the course circuitously and managed to feed the riders at 4 different places before feeding was closed. By the 3rd time we passed out bottles, a dozen or so riders had broken off the front, including 4 of our team. They were doing exactly as their director had instructed: racing forward, being conservative but appropriately aggressive, taking the race in exactly the direction they desired. After the last open feeding, we proceeded back to the finish line. Our director reported that the Dutch race organizer had actually expressed that he wanted the Americans to win, that it would be good for the sport. This attitude is wholly unprecedented in European racing; American riders have almost always been viewed as relatively unwelcome outsiders.

We waited at the finish line, getting bits and pieces of race reporting in Dutch that bode well for our team. I left my cooler bag of water and soda at the end of the barricades, strapped a podium bag with a fresh kit, wet wipes, and recovery mix to my back, and staked out a good position to get some photo ops. Soon we heard that a single rider had broken away off the front, and it was indeed our incredible time trial master who performed so spectacularly at the Peace Race. Minutes later, the race radio reported that two more riders had broken away while the fourth remaining USA rider blocked to let them ride. We realized we were about to see something incredibly special: a 1-2-3 podium sweep team victory.

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It was breathtaking to see, made even more special from the Dutch race organizers and fans who said things like “magnificent!” The riders had truly raced forward, communicated with one another, and put on one heck of a race. Even at relatively small races like this, outstanding performances are widely recognized and not quickly forgotten — every other race I attended with the juniors team, someone mentioned the 1-2-3 podium sweep in Friesland.

After that, the team was on cloud nine. I had made a nice selection of sandwiches and race food goodies the night before, and had stopped at a roadside stand in Germany to buy several cartons of field-fresh strawberries as a special treat. Their excitement and satisfaction was as palpable as it was infectious; being part of the staff behind a big team win is almost as exciting as being out there on the road.

The next day we headed back out to the small Dutch village Lieshout, home to the Bavaria brewery, for an inter-club circuit race — something of a cross between a Belgian-style kermesse and an American-style criterium. The course was surprisingly challenging: hot and sunny with paver brick road surface, lots of turns and chicanes, and several raised roundabouts in corners. The juniors completed 65 kilometers, which is too short to permit or necessitate feeding, giving the staff a break and me a chance to indulge one of my other passions: race photography.

It was a heated race with an early two-man break by one of our riders and his trade team teammate from Hot Tubes Development, which the pack brought back until a bigger bunch got away and stayed away. It ended with a bunch sprint in which another of our riders gave it his all for a hard-fought 2nd, and our 4th podium in 2 days!

The team had such an outstanding, intense weekend that I got permission from their director to take them on a field trip to the nearby city of Maastricht, capital of Limburg with ancient roots dating back to Roman times. Today Maastricht is known for its vibrant city center shopping and dining district, with several beautiful churches and medieval structures still intact. Most of the riders had already visited on other trips, but it was the first trip for several of them, as it was for me. It was a great opportunity to have a nice lunch away from home base or racing with the guys, and to turn them loose while I did a little shopping and sightseeing.

The next day I had to fetch two more riders from the airport in Brussels, one of whom would join us for the upcoming Three Days of Axel race and the other who would ride Axel for his trade team, Hot Tubes Development, and join the USA team later in the season. After a nasty taste of Brussels traffic (some of the worst in the world; I got charlie horses in my legs in my sleep for days after riding the clutch for so long!) we packed up a truck and took the group to Zeeland, on the Dutch coast, to get a first taste of cobblestones and to deliver a couple riders to Hot Tubes.

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It was really neat to see such a large group of the best juniors in the United States in the same place at once. (If the one in the middle looks a little old to be a junior, that’s because he is our intrepid program director, William Innes). Cobblestones, sometimes called pavé, are a classic hallmark of northern European racing and riders who handle them with speed and agility forever have their careers defined by their excellence in “cobble crushing.” Nearly all of the famous spring classics feature sections of cobblestones, which range in difficulty from patio pavers to mud and moss-slick rock gardens more appropriate for mountain biking than road biking. Axel is known for its rough field cobbles with soft, grassy, muddy shoulders; they are as difficult to ride at high speed as they are dangerous, especially for riders without experience or proper equipment.

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With the team prepped and ready, it was up to me and our mechanic to get the bikes and remaining equipment shipshape. The courses of Axel are notoriously hard on wheels, so all the bikes were equipped with our special “Roubaix” wheels: aluminum Easton tubulars with heavy-duty puncture-resistant, wider tires. The wheels were an abnormally heavy setup for racing, but would give our riders the best possible chance at avoiding flat tires or crashes due to poor traction.

Unlike the Peace Race, the race organizers at Axel provide somewhat more edible food options, so I didn’t need to cook. From that standpoint it made the race logistics a bit easier on me, although I packed double of everything in the medical kit in hopes that it would be like carrying an umbrella when rain is in the forecast: preparedness would stave off necessity.

Prepping for Axel also gave me time to reflect on the weeks I had spent traveling to races in Europe, and I was truly sad that this would be my last race with the team. I knew they would get excellent care from other soigneurs as they continued their racing season, but the infectious excitement of racing had done its work and I was hooked. Had it been any other kind of hard work, I would have been looking forward to a respite, but I found soigneur work inspired an ethic and passion in me that I had never experienced to that extent.

The hour has grown late, my candle has begun to flicker, my laptop battery is waning and (most upsetting of all) my glass of wine is empty; we’ll pick this up next week with the pavé pandemonium of Three Days of Axel!


The Power of the Human Hand

IMG_4707I’d like to kick off this blog by sharing some about one of my favorite things that I get to do in my job: teaching the massage lecture and lab unit for UNCG’s Master’s of Athletic Training education program treatment modalities course.

I’ve been teaching the class for the past 3 years, 2 of which while I was a Sports Medicine master’s student myself. Most people know athletic trainers from watching sports on TV, as the windbreaker-and-khakis-clad medical staff rush onto the field from the sidelines and tend to injured players. The bulk of athletic training, however, occurs behind the scenes in high school, college, professional, and industrial settings. Athletes put their health and well-being in their trainers’ hands, and these dedicated professionals address every need: the treatment, prevention, and rehabilitation of injuries, optimized fitness training to increase athletic ability, monitoring and recommending nutrition habits, and even the athletes’ psychological mindsets.

I’m not an athletic trainer — I am a licensed sports massage therapist — but I took a variety of athletic training courses in graduate school and I came to deeply appreciate athletic trainers’ unique skills and responsibilities. I’m lucky to use this nuanced understanding to help aspiring athletic trainers think differently about the fundamentals of their treatment protocols.

I  won’t deny that it’s hard to come into a classroom full of allied healthcare professionals as a massage therapist and expect them to immediately accept what I have to say, so this year I started with a video from TED. We only watched the first 2 minutes or so, but the whole thing is very worthwhile.

Dr. Verghese’s powerful argument for the role of touch and ritual in medicine is a great jumping-off point for my case for the reemerging emphasis on manual therapies in athletic training. The research on sports massage is finally catching up to the millennia-old evidence-based practice of hands-on techniques to promote recovery and treat injuries. A seminal paper from last year by Crane, et al. demonstrated physiological changes at the cellular level in tissue that received massage following an exhaustive workout that were not present in the untouched limb — the cells showed signs of hormone activity promoting cellular repair, immune changes, decreased inflammation, and formation of new healthy mitochondrial tissue. Dozens of other studies are showing promising results that echo one main point: in many cases, massage improves recovery, but in absolutely no cases have studies found that it can cause harm. Very few treatments can boast such positive results.

Mechanical manipulation of sore or damaged tissue can help tight or circulation-impaired tissue to regain its original resting length and balance. Carefully applied neuromuscular pressure can decrease pain symptoms and ease myofascial trigger points. Massage can slow the atrophy of tissue that must be immobilized due to injury, and increase lymph and blood circulation to supply nutrition to healing tissues. The science supporting sports massage makes its potential advantages abundantly clear, and sports medicine professionals of all types are increasingly expected to be familiar with its techniques and applications.

During the three hours we spent together, I felt a shift in the athletic training students’ attitudes as their preconceived notions began to erode. As they practiced a few hands-on massage techniques and carefully observed me demonstrate my methods, it was like watching gears visibly click into place and appreciation emerge. We talked about a variety of real-life conditions they had dealt with and how they could be addressed with massage or other treatment modalities, and the students came up with great ideas and questions that I hadn’t even considered. I watched with pride and admiration as 10 aspiring trainers realized the enormous potential for treatment that they already possessed and carried with them wherever they went — their own hands!

Few things get me more excited and inspired as seeing young people engage with science, medicine, and discovery in a new and innovative way. I love teaching that class so much because the students I work with give me hope for the future of my profession, of sports, and of healthcare. Through recognizing the legacy of our medical forerunners and synthesizing their methods with emerging science and technology, we can accomplish extraordinary things; sometimes, all we need is the simple power of touch.