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Data Source: Zamparo P, Bonifazi M (2013). Bioenergetics of cycling sports activities in water.

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Tension of Kinesiotape Doesn't Matter for Floor Touch Improvement

Allan Phillips has discussed kinesiotape (KT) in two previous posts:
  1. Kinesiotape and Swimmers Part I
  2. Kinesiotape and Swimmers Part II
In his first post, he concluded:

"[o]verall the evidence is incomplete, but not definitive in either direction. Most notably, Kinesiotaping has not been tested thoroughly in combination with other procedures. It’s possible that taping may have different effects done as a standalone treatment versus when used to reinforce a clinical procedure (spinal manipulation, massage, dry needling, etc).

My personal opinion is that Kinesiotape may have actual effects but the mechanisms are still unknown. It may take several years to separate taping from the methods that it is frequently paired with. It is still too early to call it a placebo or alternatively, a miracle treatment. That said, because much anecdotal evidence exists with very little observed side effects (other than tape addiction), Kinesiotape deserves consideration as a method to improve muscle length, strength, and timing, especially when used to support other interventions."

Luckily, research is surfacing about KT and questioning the use of this tape, particularly the scientific reasoning behind its principles.

The study below analyzes how KT is applied and as Allan has said previously: 
"[k]eep in mind that research does not account for nuances in how tape is applied, as I can tell you firsthand that the craftsmanship of trained clinicians far exceeds “locker room” self-application. This may be one area in which clinicians are ahead of researchers. I’ve recently spent a lot of time volunteering in a clinic recently that frequently uses Kinesiotape. One point noting is that clinicians with formal training from tape companies have far more techniques in their arsenal than someone who just throws tape on areas that feel tight or sore. If you fully immerse yourself in the system, there’s actually quite a depth of thought in the techniques, even if those techniques have not been tested by formal research."

Does Kinesiotape Application Matter?

Thirty-nine females (18 – 27 years) performed the Schober test, marking the midpoint of the two posterior-superior iliac spines (S2 level) and then other two points 5 cm below and 10 cm above the initial level. The distance between the three points was measured in the standing and bent over position.

The subjects were split into three groups:

1)    Control.
2)    Kinesiotape without tension (just laying down the tape).
3)    Kinesiotape with tension (applying 15 – 50% tension on the tape).

Subjects were assessed 24 hours with the tape one, 48 hours with the tape on, and 30 days after the tape removal. The tape was applied for 48 hours.

Results of Kinesiotape Application

The average Schober test results before KT was 6.07 cm. No significant differences were found between the averages obtained from the Schober test before applying the KT, 48 hours with the tape on, and 30 days after the removal in any of the groups.

However, there were significant improvements for the KT with tension and without tension for the fingertip-to-floor distance at 48 hours.


Results of Kinesiotape Application

It seems KT with or without tension improves fingertip-to-floor mobility. This suggests the method of application may be over complicated and unnecessary for improvement in range of motion. The mechanism of improvement is still speculative. 

If looking to improve fingertip-to-floor mobility, consider applying KT with or without tension. These results may differ in people with low back pain or other conditions.

Reference:
  1. Lemos TV, Albino AC, Matheus JP, Barbosa Ade M. The effect of kinesio taping in forward bending of the lumbar spine. J Phys Ther Sci. 2014 Sep;26(9):1371-5. doi: 10.1589/jpts.26.1371. Epub 2014 Sep 17.
The Swimming Science Research Review educates coaches with ongoing sports science literature. With the influx of online information makes it difficult to stay up-to-date with informative, accurate research studies. The Swimming Science Research Review brings you a comprehensive research articles on swimming, biomechanics, physiology, psychology, and much more!

This monthly publication keeps busy coaches and swimming enthusiast on top of swimming research to help their programs excel, despite being extremely busy.

By Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University where he swam collegiately. He is the owner of COR, Strength Coach Consultant, Creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

A Swimmer's Guide to Pain

Take Home Points:
  1. How coaches talk to athletes about injuries may have an impact on return-to-sport timelines
  2. Coaches and parents should have a basic understanding of pain science to best communicate with swimmers
  3. Fear of movement can be crippling setting off a vicious cycle of pain and disability
  • I have a vertebra out of place
  • My back is out of alignment
  • My knees are bone-on-bone so I can’t do breaststroke
All of the above are common ways to describe typical injuries around the pool. And while there are often grains of truth in such statements, a narrow focus on the structural elements of injury inevitably ignores the psychosocial components in pain. This is one area where coaches and parents can play a key role in talking to injured swimmers and reinforcing what contemporary medical professionals understand about pain science.

Now, the purpose of this is not to dismiss the role of structure in causing pain. In fact, the extreme statement of “pain is all in your brain” is equally counterproductive to injury healing in athletes. Yes, certain pathologies are likely to induce pain, particularly when lesions occur in particular nervous system structures. However, what is unfortunate is that a misunderstanding of pain can thwart even the most carefully planned treatment and exercise regime.

Quite simply, the feeling of pain is driven by the body’s perception of threat. We know that
perception is key, not merely structural damage, as many studies have shown that pain-free subjects can have structural damage in similar rates to painful subjects, particularly for repetitive use conditions (trauma is a different story…). We have discussed this point previously in several posts including for:
Recently, Finan (2013) compared knee osteoarthritis patients classified into “high” and “low” severity. Somewhat surprisingly, those with high severity damage experienced less pain than those with low severity damage, as those with less damage were actually found to have more pain! There are several reasons why this may be the case, but the take home point is that damage is not automatically linked to pain. As such, coaches and parents must not mislead swimmers with a narrow focus on the injury and instead shift the focus to more productive areas such as function, mobility, and progression.

So why do some swimmers feel pain and others don’t, despite similar structural makeup (damage or lack of damage)? One explanation is that everyone has different sensitivities. Each swimmer’s sensitivity is driven by a myriad of factors such as previous injury, personality, training load, stroke biomechanics, among other factors. As pain scientist David Butler wrote to one patient suffering shin splints,

“Even a few years after an injury the brain holds memories of serious injuries and can react over time – almost trying to heal it again so it puts in a bit of useful swelling there which can irritate things. It gets a bit compounded when treatments don’t work or make sense and you start to worry - worry can make can make things more sensitive too. But this is all good – it will go.”

Conclusion

Many swimmers (and patients in general) are more comfortable with discrete explanations of structure. Unfortunately, a misunderstanding of the psychosocial elements of pain can often prolong the rehabilitation process as swimmers, coaches, and parents obsess about the structural elements of injury with laser focus! This commonly results in perpetuation of injury, creating a vicious cycle in which the swimmer is unable to successfully progress through rehab, despite best practices being employed via treatment and exercise. Ultimately, a proper understanding of pain can help guide swimmers back to function if injury strikes.

If you are looking for more information on pain and injury at the shoulder, consider purchasing the Swimmer's Shoulder System.

References
  1. Finan PH1, Buenaver LF, Bounds SC, Hussain S, Park RJ, Haque UJ, Campbell CM, Haythornthwaite JA, Edwards RR, Smith MT Discordance between pain and radiographic severity in knee osteoarthritis: findings from quantitative sensory testing of central sensitization. Arthritis Rheum. 2013 Feb;65(2):363-72. doi: 10.1002/art.34646.
Written by Allan Phillips is a certified strength and conditioning specialist (CSCS) and owner of Pike Athletics. He is also an ASCA Level II coach and USA Triathlon coach. Allan is a co-author of the Troubleshooting System and was selected by Dr. Mullen as an assistant editor of the Swimming Science Research Review. He is currently pursuing a Doctorate in Physical Therapy at US Army-Baylor University.

Us Old Swimmers...

This was an article submitted to Swimming Science. Although it lacks scientific literature or
references, it's anecdotes provide an necessary look into the possible long-term effects of the sport. Although the writer is just one person, so is Michael Phelps. Although opposing ends, Phelps and the writer are just one, uncommon result, with the author having a more likely result than Phelps.

 Coaches, parents, and swimmers remember exercise is a life-long journey. For some, you'll have great success during adolescents and teenage years, but always question...will this add up when I'm older? Coaches, realize you can help swimmers in the short- and long-term, just ensure safe programs and healthy environments for long term success. 


I have added some editor notes, which are indicated with brackets, enjoy!

Take it Laura

Warning to all coaches and swimmers,

Bodies break down. It may take only a few years, but when the former swimming athlete is progressing into middle age his/her body will scream out for pain relief. When doctors tell you, “swim, itʼs a non impact, great exercise" or  "It's good for you”, watch out.

Some of you know know that swimming is probably the last thing you should do, as the mere thought sends pain throughout the body. If you feel as though a nice easy thousand yards would be the right ticket for your swirling mind, then you realize the agony of pushing off of the walls and twisting your neck turns you into a blithering pain ridden fool and stops you.

Hear me out.

This is my story of the body versus mind and whatʼs become of a relatively honed body.

I was never a top ranked swimmer. I was among the thousands of girls who had very few athletic opportunities in the 1950ʼs-60ʼs. My father, who ran swimming pools throughout New Jersey, private country clubs, public pools and taught swimming at Seton Hall University introduced me to swimming at birth. He taught me and many others, and he introduced the “swimming meet” to the clubs. One day after I suffered a bad asthma attack my doctor told said. “Get her on a swim team. The humid water and breathing rhythm will help with the asthma. And it did. I remember the first day, at age 7, like it was yesterday [there is some conflicting research on asthma and swimming, despite the common physician recommendation].

Boylan Street Pool in Newark, 50 meters x 25 ydʼs. It was BIG! Lots of girls swam up and down the pool. The coach, “K”, greeted me and said, “You stay in the outside lane, and if you need to hold on there is the wall”....

“Are you kidding me!”

Thus began the years of up and back....

In those days, we didnʼt have weight training per say. We had K. Under Kʼs leadership we did pull ups from the pool to the deck. She filled buckets with cement and attached them to a rope and spindle, which we curled up and slowly let down, and we dragged each other on our pulling lengths. She used cut off broom handles for sticks to keep our hands out in front swimming freestyle. She had us meet at a local university in the “off” season to run the track, throw discuses and shot puts, and hop over hurdles. K was an Olympian runner! She yelled, she screamed and we did lots and lots of miles. K taught form in stokes. We did starts and turns for what seemed forever. We never thought we were wearing out our joints. No one did. Until...

Now, I have participated in many sports since then. I played basketball for the CYO, tennis when allowed at the clubs, and many pick up games of whatever was playing in the streets and parks of Maplewood, so my cross training was all on my own. I have sprained my ankles many times, broke a nose from an angry bat wielding brother, and flown off many a bike. But when, in the midst of a awesome beach volleyball game, I swung my arm to spike a shot, it stuck there....

Uhoh!

I tried to just go with it for months, I finally saw a doctor, who is a well known specialist in Boston who says, “Where you a swimmer?” [personally, this is a bold prediction by any physician, but whether it is from swimming or another overhead sport, there is a common shoulder presentation.]

Ah yes.

Hmmm swimmersʼ shoulder, he diagnosed! He knew from the tests that I had over used my shoulders from swimming, not from all the other sports. We scheduled the operation to clean out the shoulder of calcium deposits, bone chips and shave down the acomion to give rotation some room. He removed the bursa sack sewed me up I was good to go, until the next shoulder gave out.

He did the other side. Same procedure. The explanation for all this was “When you were swimming, those years, you didnʼt do the correct exercises to pull your shoulders back. You needed to do back strengthening exercises. Overall, youʼll be fine. You can swim, but use fins to eliminate the pressure on your shoulders while swimming laps." He then asked, "How are your knees?” Really! “Pretty good”.

Perhaps I spoke too soon, ten years later I had my left knee meniscus trimmed. This was the second time a doctor said to me, “Were you a swimmer?”
“Yes.”
“Bet it was breast stroke.”
“Yes!”

He then told me I could swim if I didnʼt push hard off the walls [as a Physical Therapist, I'd be more worries about twisting the knee or large knee flexion].

All was going well until I turned sixty, and all hell broke loose in my body. I donʼt know if hormones are to blame, but doing workouts to stay in some kind of shape to avoid the dreaded weight gain, caused injuries that I couldnʼt shake. First a torn hamstring, then a strained Achilles tendon, and now a massive amount of arthritis in my right knee [all uncommon injuries in swimming. When asked Laura reports golfing, weight lifting, and officiating during this time period.]. Now the right knee!

So I see my knee guy and he sends me to his top surgeon and he says to me, “you were a swimmer right, bet a breaststroker!”

Ahh come on guys.

So, they canʼt give me anymore shots into it, cortisone or synvisc, or use any other delay tactic. Walking is wicked painful bone on bone and the wonder how I even can walk and when I'll soon need a total knee replacement.

I am throwing this out there because we need research to pass on to the new generations of swimmers. We need data from all us olʼ folks who swam and swam for preventing short and long term effects of swimming. I am a big believer in doing multiple sports. Overuse is hurting out bodies. Some of the techniques and equipment being used by coaches with their swimmers is hurting them. I officiate meets and watch young children walking around with ice packs wrapped on their bodies.

This is not good.

Knowledge and science is available. We need to pass it on. Parents and coaches need to develop their athletes without causing injuries.

Written by Laura Menza Wanco. Born and raised in New Jersey. She swam with the Watchung Lake
Swim Club an AAU team under the coaching of Catherine D Meyer, long time AAU Coach and Official with the US Olympic Committee. Laura coached summer club teams, was a lifeguard, and swim instructor in summer clubs. She started along with a group of former swimmers the Women's Swim Team at Seton Hall University in 1968 after a year of swimming with the men's team.

She started the Women's Basketball Team at Seton Hall University in 1971, from the Intramural teams. Coached Tennis at Summit High School, Mens and Women. Coached High School Swimming Team at Columbia High School.


She moved to Cape Cod, MA. where she started a team in the local health club and became an official. She has 
 officiated local, sectional, and state tournaments, swimming and diving and officiated at the NCAA Womens D1 championships.

Does Low Back Pain Resolve Itself?

Take Home Points for Does Low Back Pain Resolve Itself?
  1. Yes, low back pain typically resolves itself, yet underlying issues persist likely increasing the risk of re-injury.
Low back pain (LBP) is extremely common in the general and athletic population and swimmers
even have a higher risk of low back degeneration. Despite this frequency, no resolutions exist for eradicating pain. Luckily, most cases of LBP are acute and remiss over a month. This brevity in symptoms leads many not to seek treatment. However, resolution of pain, without treatment, may but a person at risk for a recurrent injury, as the recurrent rate of low back pain is extremely high.

This situation puts everyone in a bind, as everyone thinks they can wait out pain and get better. However, is waiting out the pain and having it resolve on it's own the best option? Sure, low back pain gets better in most people without any treatment, but is this passive treatment worth the risk of having a higher risk of recurrence?

Does Low Back Pain Resolve Itself?

Butler (2012) recruited fifty-four subjects without LBP and 33 people with a previous low back injury (LBI). In this study, electromyography of the core musculature and motion analysis was taken during the following task: 

“Subjects stood at a table (adjusted to standing elbow height) and performed three trials of lifting and replacing a 2.9 kg load using both hands in two reach conditions while minimizing trunk and pelvis motion. Subjects were required to move the load 4–5 cm off the table in a controlled manner and lower within a standardized 3-s count. An event marker identified lift, transition and lowering phases. Only the lift phase was examined given similar patterns were found for the two other phases. If trunk or pelvis motion was visible during the trial or upon review if the any of the three angular displacement traces exceeded 3, the trial was repeated (Butler 2012).”

The results showed a slight difference between the control and LBI, as the LBI group was slightly older and had a higher body mass index (BMI). Moreover, different movement patterns during the above tasks were noted between both groups. The LBI group also had higher muscle activation for the all the muscles except the external oblique, which showed decreased activation. 

Why is it Different?

All joints have passive structures (ie bones) and active structures (ie muscles). The higher muscular activation in the LBI group may be from a decrease in passive stability, requiring an increase in activity stability. Though high activation is assumed a good thing for stability, it may lead to increased fatigue and increased injury risk. This increases stiffness (stability) could also be a compensatory pattern for an underlying injury. A decrease in the external oblique activation may inhibit force distribution and overall core stability, as one muscle not working properly is theoretically disrupts stability according renowned spinal biomechanist Stuart McGill. 

These “scores indicates that the LBI group included individuals with inhibited as well as enhanced activation in local muscles, suggesting that there are potential subgroups. This may have implications for therapeutic interventions in that those with enhanced local activity may not benefit from therapies that focus on selectively activating deep muscles. Thus our results provide evidence of local muscle alterations although it is the first time that these impairments are reported during a functional but highly controlled task in those recovered from an episode of LBI (Butler 2012)”.

In summary, Butler concluded: “specifically, an overall increase in activity of abdominals and back extensors, increased agonist–antagonist co-activation strategy, reduced posterior oblique fiber activation and impaired local muscle responses to increased demand was found in the LBI
group.”

Practical Implications

Swimmers often have low back pain which symptoms quickly resolve. However, this study suggests underlying motor programming and impaired muscle activation exist after the resolution of symptoms. This makes it essential to seek rehabilitation or at least work on improving these imbalances, preventing a relapse. 

For some examples of core training, check out the COR Low Back Solution.

For more examples, consider purchasing Dryland for Swimmers.

Reference:
  1. Butler HL, Hubley-Kozey CL, Kozey JW. Changes in electromyographic activity of trunk muscles within the sub-acute phase for individuals deemed recovered from a low back injury. J Electromyogr Kinesiol. 2012 Nov 28. doi:pii: S1050-6411(12)00195-2. 10.1016/j.jelekin.2012.10.012. [Epub ahead of print]
By Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University where he swam collegiately. He is the owner of COR, Strength Coach Consultant, Creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

Thoracic Outlet Syndrome: What it is, How to Spot it, a Case Report, and Prevention!

Take Home Points on Thoracic Outlet Syndrome: What it is, How to Spot it, a Case Report, and Prevention!:
  1. Thoracic outlet syndrome is a narrowing between your collarbone and first rib, putting pressure on your neurovascular structures.
  2. There are many neurovascular impairments at the shoulder.
  3. Monitor shoulder pain, symptoms, and alter sensation closely, and adjust prevention programs and biomechanics for greatest improvement.
Though shoulder impingement is the most common form of shoulder injury in swimmers, other cases of shoulder pain exist. These other syndromes impact other tissues, typically the nerual, arterial or vascular. Although these shoulder conditions are not well known, they still occur in overhead athletes. Asymptomatic pitchers even have impaired blood flow on their throwing side, a potential risk factor for Thoracic Outlet Syndrome (TOS). Some of these issues are treated conservatively, while others require surgery.

Types of Thoracic Outlet Syndrome

Knowing what occurs and the symptoms of tissues other than the muscular system is beneficial for a coach and rehabilitation staff. Here are some examples:
  1. Nerogenic Thoracic Outlet Syndrome: Compromising the brachial plexus. Symptoms are pain, numbness, tingling, and weakness. 
  2. Vascular Thoracic Outlet Syndrome: Compromising the venous or arterial system. The typical presentation includes pain, numbness, tingling, weakness, and/or the presence of vascular compromise. Venous TOS is more common than arterial TOS and is characterized by swelling and cyanosis, pain, and a heavy feeling. 
  3. Paget-Schroetter Syndrome: A thrombosis of the subclavian vein.

Clinical Tests for Thoracic Outlet Syndrome in Swimmers

There are manual and diagnostic test for identifying vascular compromise. Sadeghi-Azandaryani (2009) notes:

"Sensitivity of clinical tests was acceptable overall (mean 72%). The EAST test showed the highest sensitivity with 98%, followed by the Adson (sensitivity: 92%) and Eden tests (sensitivity: 92%). In contrast, the sensitivity of the Hoffmann test (47%) was low. Nevertheless, a positive EAST, Eden, Adson, Green-stone or Adson test was not associated with a poorer outcome (p≥0.05).

Systolic blood pressure was measured before and after exercise. Mean systolic blood pressure of the afflicted side in the group of patients with good or fair outcome (85.9% of all patients) showed an average systolic blood pressure of 123.1 ± 12.5 mmHg before exercise and 108.9 ± 12.8 mmHg after exercise (average decrease: 16.2 ± 9.6 mmHg). A decrease in blood pressure of more than 25 mmHg could not be found in this group. In the group of patients with a poor outcome, the systolic blood pressure before exercise was 140.6 ± 24.6 mmHg and 106.7 ± 21.8 mmHg after exercise (average decrease: 35.0 ± 14.1 mmHg). Statistical analyses showed that a distinct decrease in blood pressure after exercises was associated with a poorer outcome (p = 0.0027)."

Here are some of the most common tests:
  1. Roo's test: The patient stands and abducts shoulders to 90 degrees, externally rotates the shoulders, and flexes the elbows to 90 degrees. The patient then opens and closes the hand slowly for three minutes. The test is positive if the patient is unable to complete the test or experiences heaviness, numbness, tingling or pain.
  2. Adson's test: The examiner locates the radial pulse while arm is held in extension, external rotation and slight abduction. The patient is instructed to take a deep breath and turn head toward the test arm while extending the neck. If there is compression, the radial pulse will be diminished or absent. The goal of this test is to tense the anterior and middle scalenes.
  3. Costoclavicular test: The examiner palpates the radial pulse and then draws the patient's shoulder down and back. If the pulse disappears, the test is positive. The goal of this test is to provide compression of the costoclavicular space.
  4. Halstead maneuver: The examiner palpates the radial pulse and applies downward traction on the test extremity while the patient's neck is hyperextended and rotated to the opposite side. Absence of the pulse indicates a positive test.6
  5.  Wright test (hyperabduction test): The examiner palpates the radial pulse and hyperabducts the arm so the hand is brought overhead with the elbow and arm in the coronal plane. The patient takes a deep breath and may rotate or extend the neck for additional effect.
  6. Allen maneuver: The examiner palpates the radial pulse while positioning the shoulder in external rotation and horizontal abduction. The patient then rotates the head away from the test side.
Diagnostic tests also include a Doppler arteriography testing of the vascular system. If the compromise is neurogenic, nerve stimulation is sometimes used for diagnosis.

Example Swimmer with Paget-Schroetter Syndrome

The patient was a 21-year-old male swimmer who noticed swelling and pain in his non-dominant arm. The patient was advised to ice and rest his shoulder. Then, ten days after the initial heaviness, the symptoms returned and the patient was advised to seek emergency care where a Doppler venous ultrasound could be performed. The results were negative. The patient demonstrated a cease of the radial pulse, swelling, and limb cyanosis with the Wright’s hyperabduction test. He also presented with ⅘ strength on the affected side, but 5/5 strength on the non-affected side. Despite a negative Doppler venous ultrasound, the vascular surgeon suggested a venogram, since a Doppler venous ultrasound is best used as a screening tool, not for diagnostics, since it has difficulty specifically measuring the subclavian vein due to the bony structures. The venogram showed a major block of the subclavian vein, venous stenosis, and concomitant thrombosis.

The patient was then administration heparin and a tissue plasminogen activator (tPA) over a three day period in order to achieve thrombolysis.This improved the thrombus by 70%, indicating 30% of the vein had undergone permanent thrombosis. The patient was then prescribed coumadin and Lovenox as a blood thinner. Electromyography (EMG) was also performed to rule-out a neurogenic case of TOS, which demonstrated no muscle membrane instability.

The swimmer returned to the pool with great success (winning the conference in the 100 and 200 breast), then received a resection of the first rib. After the surgery, the patient complained of pain medial to the shoulder blade and demonstrated shoulder-blade winning. Manual muscle tests were performed again and noted 5/5 strength in all muscles. Fine-wire EMG was conducted again and showed normal signs of all muscles except the serratus anterior which demonstrated signs of denervation (likely due to surgical complications to the long thoracic nerve).

Despite the findings of the serratus anterior, the patient started a physical therapy program and home program which resulted in improved EMG readings for the serratus anterior, three months postoperatively.

Thoracic Outlet Syndrome Swimming Prevention Techniques

Steady Streamline:

If the arms move excessively during streamline, the upper arm and neural structures are stressed. Maintain a stable arm position during all streamline, especially dolphin kicking.

Flatter Butterfly:

Some swimmers (like Michael Phelps) press their chest down as they enter their arms in butterfly, delaying their pull. This creates a position with the arm above the chest, stretching and stretching the brachial plexus (all the nerves and vascular areas).  Try starting the pull earlier, not allowing a position of arms higher than the chest. 

Deep catch:

Many swimmers have a "catch-up" style stroke. Unfortunately, this increases stress at the shoulder joint and vascular system. If working on less stress, have the swimmer have a deeper catch as the enter the water.

Neutral Hand Entry:

Entering without hand entry is paramount for all shoulder prevention, as excessive internal rotation increases shoulder stress.

Shallow Backstroke Catch:

Entering with a deep catch in backstroke stresses and strains the neurovascular structures in the front of the shoulder...no good! Instead, have a wider, more shallow catch, similar to Missy Franklin's technique. 

Thoracic Outlet Syndrome Dryland Techniques

Foam Roll Thoracic Spine:



SMR Scalenes:




SMR Pectoralis:


Nerve Mobility:


First Rib Mobilization: 



Anterior Neck Strengthening:


Scapular Strengthening:


Summary on Thoracic Outlet Syndrome for Swimmers

Some cases of TOS require drastic treatment, like surgery (first rib resection). Instead of dealing with potential surgery, keep a close eye on TOS symptoms and begin early with treatment and technique modifications at the first instance of symptoms. 

These are only some technique modifications and treatments, as each person is individual and different stroke biomechanics and rehabilitation/prevention programs are necessary for each person. Moreover, just because some swimmers perform with techniques which increase shoulder stress, doesn't necessarily result in TOS or injury. Therefore, if you are suffering from TOS, see a rehabilitation specialist for guidance and individualization.

If looking for more injury prevention techniques, consider purchasing the COR Swimmer's Shoulder System.


References
  1. Nitz AJ, Nitz JA. Vascular thoracic outlet in a competitive swimmer: a case report. Int J Sports Phys Ther. 2013 Feb;8(1):74-9. 
  2. M Sadeghi-Azandaryani, D Bürklein, A Ozimek, C Geiger, N Mendl, B Steckmeier, J Heyn Thoracic outlet syndrome: do we have clinical tests as predictors for the outcome after surgery?Eur J Med Res. 2009; 14(10): 443–446. Published online 2009 September 28. doi: 10.1186/2047-783X-14-10-443
By Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University where he swam collegiately. He is the owner of COR, Strength Coach Consultant, Creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

Do Growth Spurts Increase Injury Risk?

Take Home Points on Do Growth Spurts Increase Injury Risk?
  1. It seems the injury rate increases during growth spurts, but research is very limited. 
Growing pains are common in children, yet the cause and treatment of growing pains are not well known. Some hypothesize growing pains occur from muscles pulling on bones creating discomfort. Others believe increase in bone size simply increases discomfort from an increase in mechanical pressure. 

Growing pains are one type of "injury" during growth spurts. Specific adolescent injuries also exists, which I commonly see for Physical Therapy

Adolescent Injuries

  1. Osgood-Schlatter's Disease: is a painful swelling of the bump on the upper part of the shinbone, just below the knee. This bump is called the anterior tibial tubercle. It is believed to occur in active children who's patella tendon pulls on the tibial tubercle. 
  2. Sever's Disease: inflammation of the growth plate in the heel of growing children, typically adolescents. The condition presents as pain in the heel and is caused by repetitive stress to the heel and is thus particularly common in active children. It usually resolves once the bone has completed growth or activity is lessened.
  3. These are just a few common musculoskeletal injuries effecting children. Many other injuries can occur during growth spurts and parents for decades believe children have a higher injury risk during a growth spurt. Combine this injury risk with chronic poor posture from computers/electronics and early sports specialization and you've got a high injury risk for child...scary!

Growth Spurts and Injuries

Now, before we jump to conclusions about the injury incidence and growth spurts, we should consult
the limited literature:

Yukutake (2014) had 654 baseball players aged 6-12 years, all male, complete an original questionnaire that included items assessing demographic data, developmental factors (increase in height and increase in weight over the preceding 12 months), and baseball related factors. Multiple regression analysis was used to identify the risk factors for elbow pain during the 12 months prior to the study.

The data collected for 392 players without omissions or blank answers were submitted to statistical analysis. The results found that 19.1% of Little League baseball players had experienced elbow pain in the 12 months leading up to the study. The analysis revealed that height and increase in height were risk factors that increased the risk of elbow pain after adjustment for demographic data, developmental data, and baseball related factors.

Wild (2012) looked at ACL injury rates in adolescent boys and girls, noting girls have a higher ACL injury rate from:
  1. The effects of changes in estrogen levels on the metabolic and mechanical properties of the ACL
  2. Changes in musculoskeletal structure and function that occur during puberty, including changes in knee laxity, and lower limb flexibility and strength. 
  3. How these hormonal and musculoskeletal changes impact upon the landing technique displayed by pubescent girls.With limited research, limited conclusions are possible. 
However, the risk of injury increases during periods of growth. Unfortunately, recommendations now are purely theoretical. Some would suggest decreasing activity during maturation, but these are the peak years of motor learning. Instead, decreasing training volume and varying activities may be the best solution. This website has brought up the idea of a "swim stroke count", similar to a pitch for baseball. However, swim stroke counts may not be effective nor practical as many other factors influence musculosketetal stress on maturing bodies. Looks like we need more research on maturing athletic children!

References:
  1. Yukutake T, Nagai K, Yamada M, Aoyama T. Risk factors for elbow pain in Little League baseball players: a cross-sectional study focusing on anthropometric characteristics. J Sports Med Phys Fitness. 2014 Apr 9.
  2. Wild CY, Steele JR, Munro BJ. Why do girls sustain more anterior cruciate ligament injuries than boys?: a review of the changes in estrogen and musculoskeletal structure and function during puberty. Sports Med. 2012 Sep 1;42(9):733-49. doi: 10.2165/11632800-000000000-00000. Review.
By Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University where he swam collegiately. He is the owner of COR, Strength Coach Consultant, Creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

Are Ice and NSAIDs Beneficial for Recovery?

Take Home Points on Are Ice and NSAIDs Beneficial for Recovery?
  • Ice helps decrease pain, but does increase muscle damage.
  • NSAIDs restore function, but improve bone, but not soft tissue healing.
The use of non-steroid anti-inflammatory drugs (NSAIDs) and ice are common staples in
sports medicine. Yet, the use of these modalities has recently received resistance from some online experts (Kelly Starrett, Dr. Gabe Mirkin). Despite this criticism, these modalities are still frequently used, sometimes ad libium. Now, before I make a notion on these modalities, it is important to understand the injury process, below is an exert from the COR Swimmer's Shoulder System.

Everyone is familiar with inflammation. The inflammatory process occurs within seconds of every injury, but can linger for weeks or months with bad injuries or poor management.

Inflammation is stemmed by the infiltration of cells, entitled neutrophils, during the first 6-24 hours; they are replaced by other cells (monocytes) in 24-48 hours. These cells will try to attack the inflammation and remove injurious agents. Phagocytosis is involved in the process of engulfing foreign particles and releasing the enzymes of neutrophils and macrophages which are responsible for eliminating the injurious agents. These are two major benefits derived by the accumulation of leukocytes at the inflammatory site.

Chronic inflammation is a different warrior. The key player is another type of cell, the macrophage. Macrophages are large cells that can remain for weeks to months, perpetuating injuries.

The classic signs and symptoms of inflammation are swelling, redness, throbbing, radiating heat, and constant pain. These pains especially occur when you wake up in the morning and last between thirty and sixty minutes. Also, just because you had the initial injury four months ago doesn’t mean inflammation has resolved or hasn’t returned, so pay closer attention to the signs and symptoms as opposed to the duration.

Once again, the inflammtory process initiates every injury. This process is beneficial in restoring the body, but does decrease strength. This decrease in strength is why many seek improvement [well and the pain]. This has resulted in the use of the two most common modalities NSAIDs and ice. Unfortunately, these two modalities may prevent the normal physiological reaction of an injury. This impairment is thought to alter long-term improvement. However, many people take NSAIDs and ice for short-term gains. If someone needs improvement, for a quick return to the pool, then NSAIDs and ice are beneficial. However, the use of these modalities likely decreases long-term recovery, perhaps increasing the risk of re-injury. Unfortunately, most of this research is based on rodents, not humans and as I've mentioned before, rodents have different inflammatory processes! This makes the research nontransferable to humans ... oh well! Nonetheless, lets look at the research we have!

NSAIDs on Healing

The authors reviewed the effectiveness of NSAIDS and selective (COX-2 inhibitors) NSAIDS on soft tissue and bone healing. A total of 44 articles reviewed (9 on soft tissue and 35 on bone healing). Thirty-nine of these articles were on animals and 5 on humans.

No humans studies have been done on humans assessing the interaction between NSAIDS and soft tissue healing. Of the studies reviewed, there is a controversy between the administration of selective and non-selective NSAIDS after surgery, as many studies suggest detrimental effects on bone and soft tissue healing. However, the literature on this subject in humans is minimal.

It appears inflammation mediated by prostaglandins is necessary to improve bone healing. However, in soft tissue injury, growth factors are more important and prostaglandins less involved. This suggest NAIDS are likely beneficial in soft tissue, but potentially not bone healing.

Improving inflammation is necessary to decrease symptoms, however the use of NAIDS during bone repair may impair recovery, therefore only use NSAIDs in soft tissue injuries. However, more human clinical trials are necessary before a definitive answer is possible.

NSAIDs on Gut Bacteria

One potential hazardous result of NSAID consumption is the potential loss of integrity of bacteria, making the gut permeable to harmful substance.

Nine male trained cyclists underwent small intestine lining permeability in four different conditions (Van Wijck 2012):

1) during and after cycling after intake of ibuprofen

2) during and after cycling without ibuprofen

3) rest with prior intake of ibuprofen

4) rest with prior ibuprofen intake

The small intestinal lining was evaluated by providing the subjects a sugary drink, then assessing the amount of human intestinal fatty acid binding protein (I-FABP).

The ibuprofen conditions took 400 mg of ibuprofen the night before and 1-hour prior to cycling on a fasted stomach. The cyclist performed roughly 90 minutes of cycling at moderate/hard cycling.

In both exercise conditions, the I-FABP levels gradually increased with cycling. However, cycling with ibuprofen ingestion resulted in even high levels of I-FABP.

These results show cycling alone increases both gastroduodenal and small intestinal permeability. This difference increased with ibuprofen intake. This is thought to be from splanchic hypoperfusion, reducing the blood to the gut and including injury to the enterocytes. One of the major pathways suspected for GI damage is:

“to be involved is the inhibition of COX isotypes 1 and 2, resulting in local inflammation and vascular dysregulation, ultimately reducing perfusion and promoting mucosal integrity loss within the splanchnic area (Van Wijck 2012)”.

Unless ergogenic benefits from NSAIDs exists, swimmers should not use these medications prior to exercise. Moreover, inflammation may yield greater results in endurance sports. One flaw with the study is the fact the athletes were fasted while taking NSAIDs. However, one note is the athletes were fasted during this test, this may have increased the intestinal lining to susceptibility.

For rehabilitation, NSAIDs may still be beneficial, but at this time it is not certain if the benefits outweigh the risks.

Ice and Muscle Damage Healing

Eleven male college baseball players underwent two trials: sham application and topical cooling. Each trial was used five sessions of 15-min cold pack application to the exercised muscles 0 hours, 3 hours, 24 hours, 48 hours, and 72 hours after eccentric exercise training.

The eccentric training protocol consisted of 6 sets of 5 eccentric contractions with 2 min rest between sets at 85% of their maximal strength. Muscle hemodynamics (hemoglobin most notably), inflammatory cytokines (multiple interleukins), muscle damage markers (Creatine kinase), visual analog scale (VAS), and muscle isometric strength.

After topical cooling, rapid and sustained elevations in total hemoglobin and tissue oxygen saturation were noted. Also, creatine kinase was noted in both trials, but was elevated after topical cooling. Inflammatory markers were not changed following cooling. VAS was not different between groups, however topical cooling significantly increased rating of fatigue post-exercise. No significant differences were noted in strength between groups.

Increased muscle damage, most notably the creatine kinase increase, was apparent in the topical cooling group. This is thought to occur from the rapid deviation in blood supply to the muscle.

Using ice after practice improves muscular soreness, but appears to increase muscle damage due to rapid changes in ischemia. Therefore, unless injured topical cooling should be avoided.

Ice and Blood Flow

Nineteen subjects participated in this single-blinded, where the clinician was blinded. There was no history of lower extremity injuries for the past 6 injuries. Each participant visited the laboratory four separate times where baselines were measured at the first two visits, then the next two visits a trial of ice (750-g of crushed ice placed on the medial gastrocnemius) and a control trial.

“There was a significant correlation (r = 0.49) between subcutaneous tissue thickness and change in intramuscular temperature immediately after treatment (P = 0.05) for the cryotherapy condition. Significant correlations were also found for change in temperature during the rewarming period and change in blood volume at rewarming (r = 0.53, P = 0.033) and change in blood flow at rewarming (r = 0.56, P = 0.025) for cryotherapy (Selkow 2012)”.

Microvascular perfusion of the gastrocnemius did not decrease from baseline with cyrotherapy was applied, despite the decrease in subcutaneous temperature. The result was different than past studies, as many think cryotherapy decreases blood flow. This may be from no alterations noted in the microvascular.

In the healthy population, cryotherapy appears not to alter blood-flow. Therefore, benefits and risks associated with cryotherapy application for inflammation may be negligible. However, next research must look at inflammation specifically. Until then, the effects of ice for injuries seem purely for slowing nerve conduction to gate pain.

NSAIDs or Corticosteroids for Recovery


Zheng (2014) performed a systematic review of all the high-quality studies comparing NSAIDs and corticosteroid injections, a total of ten full articles. Overall, 267 patients were analyzed and of the six studies two focuses on rotator cuff tendonitis patients, two on shoulder impingement syndrome, one studied frozen shoulder of diabetes and the other investigated shoulder pain.

Of these studies, NSAIDs and corticosteroids did not have a significant difference in pain improvement. Corticosteroids were significantly better for remission of symptoms. Five of the studies reported range of active shoulder abduction and note NSAIDs did not significantly improve the active shoulder abduction compared to corticosteroids. The studies assessed were 4 – 6 weeks in length.

Compared to NSAIDs, corticosteroid injections provide faster relief. However, comparisons of other therapies and conjunctions of therapy are needed, as well as longer study periods and follow-ups.

My Recommendations


If you are injured, stop exercising. If the pain is non-stop, see a rehabilitation specialist like a physical therapist. At this time, apply ice, as it does reduce pain and doesn't seem to alter blood flow. However, apply the ice for a short period, as it may increase muscular damage. I suggest applying the ice for up to 10 minutes and remove it for 20 minutes. Only ice immediately after the injury, ~6 hours after the injury. If you are competing at a meet and must perform, NSAIDs can help decrease pain and restore function. However, if you are not in a rush for return, try not to ice and consider compression instead. Compression helps naturally clear the fluid from the joint, facilitating recovery. When you are able to move comfortably without pain, do so. Movement also helps move fluid out of the joint and restore function. However, do not move into pain, as this can alter movement patterns and impair function. 

Try and prevent using NSAIDs, unless unrelenting pain exists and the injury appears muscular. If recovering from an injury, a corticosteroid injection is likely better than just NSAIDs, but remember other rehabilitation is needed. 

We have much more research needed on the subject, but it isn't clear that ice and NSAIDs are a “no brainer”. Until more research is performed, I'll continue the suggestions I've made for years, if you're in no rush, let the inflammation naturally make it's way throughout the body, giving yourself rest and compression for improvement. Once you're able to move naturally do so! However, if you are in a rush, like at a big competition and need to get in the pool, NSAIDs and ice can help!

References

By Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University where he swam collegiately. He is the owner of COR, Strength Coach Consultant, Creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

Inflammation in Sports

Inflammation in sports is a baffling subject. Some view inflammation as beneficial, while others consider it detrimental. This subject is confusing as inflammation occurs in seemingly two different scenarios. For example, how can inflammation after exercise be beneficial, where inflammation about injury is harmful if both are the same process?

This article tackles the difference between inflammation after injury and exercise while providing a practice approach for using common anti-inflammatory medication.

Spotting Inflammation
There are five attributes to inflammation in sports:
  • Redness, swelling, heat, pain, loss of function
Moreover, pain all the time (not only during movement) and pain in the morning are typical signs of inflammation. Increased joint fluid increases pressure on pain receptors (nocioceptors), causing pain all the time. If pain is worse in the morning, it is likely inflammation surrounds the joint, as muscle contractions did not pump the fluid away from the joint during sleep. This increased fluid increases the pressure on pain receptors increasing pain during the morning.

Exercise Induced Inflammation
Many feel inflammation in sports help long-term strength gains as inflammation repairs damaged muscle fibers following exertion. Mishra in 1995, determined supplementing a strength training group with anti-inflammatory medication had an acute increase in strength, compared to the control group. This increase persisted at 7 days, but at 28 days the medication group experienced a step back, as their maximal muscle tension dropped by about 1/3 of their maximum tension.

It appears anti-inflammatory medication resolves acute exercise induced inflammation resulting in increased strength, as it would allow them to recover and be stronger, as they less sore from the muscle fibers being destructed during the exercise.

However, the mechanism which NSAIDs improve acute performance has not been justified:
“anti-inflammatory doses of ibuprofen reduced CK activity but not the neutrophil response or other indirect markers of muscle injury during recovery from eccentric arm exercise (Pizza 1999).”

After training Gulick performed an analysis of many types of treatment and concluded:

“none of the treatments were effective in abating the signs and symptoms of DOMS. In fact, the NSAID and A. montana treatments appeared to impede recovery of muscle function (Gulick 1996).”

Therefore, it seems NSAIDs improve acute strength with NSAID, but it seems to prevent overall recovery of muscle and strength gains.

This is perhaps from NSAIDs masking the amount of damage during exercise, allowing the body to do more damage without allowing proper recovery time. Don't beat yourself while you're down!

No study has directly studied NSAIDs on in-water strength, but one could guess NSAIDs would impair in-water strength development. This loss of strength impairs swimming progress as in water strength (especially of the upper body) correlates with speed (Hsu 2000).

Injury Induced Inflammation
After any musculoskeletal injury inflammation occurs. This process increases the volume of fluid in an unwanted area. When too much fluid is in a confined area, the amount of mechanical pressure increases. This mechanical pressure presses on nocioceptors and causes pain. Pain inhibits strength and athletic performance, therefore resolving this mechanical pressure is mandatory to move the injury from inflammation to remodeling.

The best method to improve this is with homeopathic and over-the counter medication. Combining Ginsenosides and Large volumes of NSAIDs helps inflammation by helping the medication reach 'titer level' or the minimum effective level (Read more about tips to improve shoulder inflammation) (note: take with food and watch stomach irritation).
Once the inflammation subsides, discontinuing the anti-inflammatories is essential for improving strength (see below).

If you are looking for short-term improvement whether you are at a competition or injured, NSAIDs acutely improve strength. However, if you’re seeking long-term strength gains, do not use NSAIDs to trick the body into working harder or not letting inflammation to aide full repair and remodeling, essentials for muscle strength.

Last Point
Lastly, the chronic use NSAIDs appears damaging to tendons.

In rats, Dimmen 2009 determined:
“We found a significantly lower tensile strength in rats given both parecoxib and indomethacin (anti-inflammatory medications) compared to the control group. Stiffness in the healing tendons was significantly lower in the parecoxib group compared to both the placebo and the indomethacin groups. The transverse and sagittal diameters of the tendons were reduced in both the parecoxib and indomethacin groups. Both parecoxib and indomethacin impaired tendon healing; the negative effect was most pronounced with parecoxib (Dimmen 2009).”

This has not been proven in humans, but is worrisome nonetheless.
Summary
Make sure you are not abusing NSAIDs and use them properly, as overuse is damaging and reckless. Follow these simple guidelines:
  • Only take NSAIDs after an acute musculoskeletal injury
  • Discontinue intake after inflammation resolves
  • Do not take NSAIDs after exercise unless at a competition, where performance not strength gains are most important
References:
  1. Pizza FX, Cavender D, Stockard A, Baylies H, Beighle A. Anti-inflammatory doses of ibuprofen: effect on neutrophils and exercise-induced muscle injury. Int J Sports Med. 1999 Feb;20(2):98-102.
  2. Gulick DT, Kimura IF, Sitler M, Paolone A, Kelly JD. Various treatment techniques on signs and symptoms of delayed onset muscle soreness. J Athl Train. 1996 Apr;31(2):145-52.
  3. Dimmen S, Engebretsen L, Nordsletten L, Madsen JE. Negative effects of parecoxib and indomethacin on tendon healing: an experimental study in rats. Knee Surg Sports Traumatol Arthrosc. 2009 Jul;17(7):835-9. Epub 2009 Mar 19.
  4. Hsu, K. M., & Tsu, T. G. The relationships among shoulder isokinetic strength, swimming speed, and propulsive power in front crawl swimming. Medicine and Science in Sports and Exercise. 2000 32(5).
  5. Defreitas JM, Beck TW, Stock MS, Dillon MA, Kasishke PR 2nd.An examination of the time course of training-induced skeletal muscle hypertrophy. Eur J Appl Physiol. 2011 Mar 16.
By G. John Mullen founder of the Center of Optimal Restoration, head strength coach at Santa Clara Swim Club, creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.