It’s All Rock and Roll!!

Foam Rolling and Self-Soft Tissue Release: The What, the Why, and the How

In the height of a boom in the fitness industry I am seeing more and more people picking up a foam roller and putting themselves through some pain. I often wonder if these individuals would see better results if they knew exactly what it is they were actually doing, why it may work, and how it works.

So What Does It Actually Do?

The use of foam rollers or other soft tissue release techniques are methods to help provide relief of tight, sore, and stiff tissues. They break down restrictions and barriers in the soft tissues with the aim to achieve this relief (Barnes, 1991).

The way we can apply these methods varies, we can be creative with what tools we use but as long as you understand the principles of how it may work and what you are trying to do there are a whole range of tools you can use.

Own Hands – you can use your own hands to rub, push, and pull yourself around much like a therapist would use their hands when treating you.

Foam Roller – you can utilise the very popular foam roller to lie on, roll on, sit on etc.

Cricket/Hockey/Lacrosse Ball – a simple hard ball can be used for a more direct pressure to roll on and press yourself on.

Barbell – a gym barbell can be used as an “extreme” foam roller for added pressure.

As we become more active, experience injury, and adopt bad posture our tissues start to form bonds and adhesions between each other. This then stops the tissues gliding freely past each other allowing normal function. Tissues can also become dehydrated, and lose its elasticity which causes them to stick to any injured or damaged part of the tissues. As these adhesions are the reason we feel stiff, sore, and our movement is restricted. Other symptoms are an altered alignment of our joints and bones, which then alters the angle and function of our muscles and joints (Boehme, & Boehme, 1991; Barnes, 1997; Curran et al., 2008; Swann & Graner, 2002).

No matter what tool you use the principle is the same for trying to breakdown the above bonds and restrictions. By applying both static pressure and a rolling, sweeping pressure friction is created between the soft tissues and your roller etc. which may aid the stretching and loosening of the soft tissues such as muscle, tendon, and fascia. This helps in the breaking down of the bonds formed between tissues. Any sustained or sweeping pressure can also increase blood flow through the expansion of the blood vessels to the restricted site which may aid healing and also help flush the restricted area. The physical stretching of the tissues helps with the restoration of soft tissue back to its normal state (Okamoto et al., 2013).

Some of the reasons self-soft tissue release benefits us, other than it feels good, are as follows…

(Shah & Bhalara, 2012)
1. It can aid correction of muscle imbalances
2. Increase our range of movement
3. Decrease the soreness in our muscles
4. Decrease increased muscle tone/spasm
5. Increase flexibility of bodily tissues
6. Maintain normal muscle length

So Why Do We Do It…

…To Warm Up…

We are always told to warm up before activity, and of late I have seen many people rolling around before they start their big weights session. The aim of this is to enhance their performance, if their muscles are “rolled” and released ready to work then their performance will be optimised. It may be something as simple as being less sore, having more range of movement, or because of changes in muscular function. Researchers have found some evidence that foam rolling may improve the body’s ability to recruit muscle fibres, and voluntarily activate muscles via improved communication between the central nervous system and the muscular system (MacDonald et al., 2013; Peacock et al., 2014). This communication appears to be improved by stimulating the connective tissue using our rollers or other tools which increases the feedback to the CNS and thus improving muscle function (MacDonald et al., 2013).

Foam rolling has also shown to improve the range of motion (ROM) without affecting the reducing force out or performance (MacDonald et al., 2013; Sullivan et al., 2013). As a result of the improvements in muscle activation, recruitment and range of motion the research has shown that foam rolling can actually help improve performance. Recent studies have shown foam rolling improves strength, power, speed, agility, and low-level exercise (Peacock et al., 2014). So if we can spend a few minutes rolling before working out or performing we may be less sore, have more movement, and our muscle may be able to function more effectively.

…Recovery…

Once we have exercised it often causes us to feel sore, and stiff the next day or two. This is known as delayed-onset of muscle soreness or DOMS. This phenomenon involves muscle soreness, swelling, temporary muscle damage, decrease in muscular strength and range of motion (Cheung, et al., 2003; Torres, et al., 2012). There can also be some effect on neuromuscular performance, which alters muscle firing and recruitment patterns (Cheung et. al, 2003). This would have obviously negative effects on any subsequent exercise bouts. So the people I see after exercise, like myself, who foam roll and stretch after exercise are doing so with the aim of reducing this DOMS and any negative consequences so they can train again in the following days.

Much like the studies mentioned before regarding performance, foam rolling has been shown to help recover performance after intense bouts of exercise. Recovery of sprint times, power, agility, and strength-endurance appears to be increased with foam rolling (Pearcey et al., 2015). Voluntary muscle activation, and range of motion seems to be also be improved, as in pre-performance studies, after intense bout of exercise with foam rolling (MacDonald et al., 2014). This is all great news for us as trainers if we can restore our performance, muscle function, and range of motion so we can train again the next day with just a few minutes of rolling. However, the major restriction is often the soreness of the muscles. Luckily, Pearcey et al. (2015) also found that foam rolling after intense exercise increased the pressure-pain threshold, which basically means that the soreness felt when the muscles are touched was significantly improved when foam rolling was done after intense exercise.

All of the above evidence highlights the potential effectiveness of foam rolling on recovering from heavy exercise. It clearly has some potential to restore performance, muscle function, range of motion, and importantly reduce muscle soreness.

…General Maintenance…

The evidence for all the factors, such as increases in ROM and decreased soreness, discussed above would suggest that foam rolling and soft-tissue release would be very beneficial for those just looking to maintain a mobile and pain free life.

So How Do We Do It?

You have probably seen or tried yourself the standard rolling back and forth on the roller aimlessly. This is all well and good you may get some results from this, but you could gain so much more by understanding what you are doing.

When you are rolling I would use this to find the painful areas, almost like you are scanning the area for sore spots. Once you find a sore spot you can use some of the following techniques to help relieve it.

• Ironing – this is simply isolated deep rolling. So find your sore spot then take a deep breath in and on your out breath let as much weight sink onto the roller as possible. Then roll slowly, and controlled into this sore area. Rolling direction can be varied, so you can roll your body up and down, side to side, rotate your body as you roll. This is much like ironing the area out. I would keep the area very specific keeping your rolls small and deep, and simply just move around the area of the body once you notice improvement.

• Contract-relax – Again find your sore spot and place as much weight on it as you can, again taking your deep breath in and out as you do this. Then contract the muscle, in a static contraction and hold it for 5-10 secs, when you relax try to let more weight sink onto the area via the roller. Do this until you notice an improvement.

• “Lock and Load” – As well as sore sports you may find this area feels restricted during movement. SO with this short or tight tissue you can place a “lock” on the muscle near the tight area. This can be done by placing the roller, barbell, hard ball etc. across the muscle belly near this tight spot. Once “locked” you can then “load” and move the muscle into stretch through full range as far as you can. Keep the pressure on the muscle locking it in as you stretch, then you can release the lock once you get to the end of your range and return to start. You can then repeat on same area until improvement occurs or find another tight area.

Chest Release…

I use two tools when targeting my chest. Firstly I will “iron out” the chest using the cuff of a barbell much like a foam roller. This use of a barbell places more focused and direct compression and pressure.
To do this lie on the floor with the barbell at your side, take your arm to be released out to the side and place the cuff of the barbell diagonally across the fibres of the pectoral muscle. Wrap your leg over the barbell to apply pressure and use your other hand to roll gently over the muscle creating a wave of pressure. When you find a particularly tender or sore spot stick with this area until you feel improvement using small but deep waves of pressure.

I will move on to using a kettlebell once I feel an improvement from the rolling. This applies a more specific and direct pressure to the area I sense as being most restricted. This exercise involves more active movement and stretching of the pectoral. You can do this by lying on a bench raising your target arm straight up in front of you. Place the kettlebell on the area of the pectoral that is most restricted. Then apply as much pressure down as you can stand, then slowly take your arm down and diagonally out to the side. Once the end of range is reached release the pressure and bring your arm back up and replace the kettlebell and repeat. The placement of the kettlebell depends where you feel tightness or restriction. You can apply this to you recovery or warm up after/before your chest or upper body training days.

Thoracic Spine Release…

The foam roller can be used for this or you can make shift what’s called a “peanut”. This method is good for use before and after any overhead training days.

Lie horizontally on the foam roller placing it roughly near the rib level of the spine. With your legs straight and flat on the floor arch over the roller taking your arms straight above the head. Aim to get your hands to the floor, but don’t allow your hips to lift off the floor or allow your arms to bend. Some cracking or popping may be felt with this movement, but as long as it is not painful this is normal and may feel relieving. This can be done several times or until you feel an improvement in range of movement or feel looser through your spine.
Your peanut can then be used, which is basically two tennis balls taped together so it looks peanut shaped. Place this in a similar spot to where the foam roller was. The balls of the peanut should be placed either side of the spine and then work your way up toward the neck by slowly rolling over the peanut until you feel the muscle soften and soreness diminishes.

You can then lock into the muscle by lying on the peanut as above, then slowly performing a crunch movement to stretch these muscles for 10 reps, then reposition the peanut and go again. If you feel a particularly tight stretch when crunching hold the end position (top part of the crunch) for 5-10 secs then lower back down and repeat.

Quad Release…

Start lying face down on a foam roller so your target quad is on it. Then place as much pressure on it as you can stand. You can then slowly roll up and down the quad creating a wave of pressure, your leg can then also rotate in and out to create a pressure wave across the quad.

Once improvement is noticed in soreness of tightness, stay in the same position, and lock the tissue in by finding a tight spot and put as much weight as you can onto this spot with the roller. Once locked in slowly bend your knee, bringing your heel towards your buttocks. This should be done slowly so your quad stretches from the “locked” point. You can do 2-3 at this point and then reposition the roller to a different spot and repeat. The roller can be substituted for a barbell, or even a cricket/hockey ball for a more direct pressure, if you can’t achieve enough pressure with the roller.

Hamstring Release…

As with most of the above you can start with rolling down and up the hamstring using my foam roller by sitting with the roller under your thigh on the hamstring. Focus on one leg at a time rather than both so you can get more pressure on it.

A barbell can then be used to “lock and load”. This is done by placing a barbell in a rack, and then lift the target leg over it, resting the hamstring on the bar. Stand on the other leg for stability. Then drop your weight down pushing the hamstring into the barbell at a restricted point in the muscle. Once locked in slowly straighten the leg stretching the hamstring from the locked point, do 2-3 then reposition the leg.
Hip Flexor Release…

A kettlebell and a cricket ball can be used for this exercise. Lie on a bench, and bend your hip and knee so your foot is flat on the bench. Here you are targeting the high hip flexor (Psoas). Finding the hip flexor is often hard for some as they assume it stops at the hip. However, this area it is generally approx. an inch up from your “hip bone” and an inch or so in just off the side of your “abs”. Check you are in the right spot by pressing your fingers into the area and straightening and bending your leg and you will feel the muscle working. Once you have found it, bend your hip and knee again to bring your foot flat, and then place the ball in the area. Pressure is applied onto the ball and muscle by using a kettlebell pressing down on top of the ball. Once pressure is placed on the ball and locked in, straighten your leg slowly, and try lower it down off the bench to get a further stretch, release the pressure return and repeat. Do this several times or until you feel looser and improvement in hip flexor movement.

Take home message…

Many tools, and exercises are available to achieve the results of self-tissue release, and the internet is full of people demonstrating them. However, as long as you have a brief understanding of what it is, how it works, and how it may benefit us you can use it to your advantage without having to fork out for a therapist to apply it for you and you can find your own effective way of achieving results.

Be creative with exercises as long as you know where the tissues are that you are targeting, and how they work you will achieve success. The above are only a few examples that I use and work for me, there is no guarantee that they will work for you. The evidence for foam rolling and self-tissue release is in its infancy and is very limited at present so it is not a 100% guaranteed method, but the evidence does look promising.
Should anyone want a personal and specific stretching and mobility program please do not hesitate to contact me. This is something I can offer online with support throughout.

References…
Barnes, J. (1991). Pediatric Myofascial Release. Physical Therapy Forum – MFR Techniques.

Barnes, M. (1997). The basic science of myofascial release: morphological change in connective tissue. Journal of Bodywork and Movement Therapies, 1(4), 231–238.

Boehme, R. and Boehme, J. (1991) Myofascial release and its application to neuro-developmental treatment, pg. 5-8, 11-16, 80. Boehme Workshops, Milwaukee.

Cheung, K., Hume, P. and Maxwell, L. (2003). Delayed onset muscle soreness: treatment strategies and performance factors. Sports Medicine, 33(2),145–164.

Curran, P., Fiore, R., and Crisco J. A comparison of the pressure exerted on soft tissue by 2 myofascial rollers. Journal of Sport Rehabilitation, 17(4), 432–442.

MacDonald, G., Penney, M., Mullaley, M. Cuconato, A., Drake, C., Behm, D. Button, D. (2013). An acute bout of self-myofascial release increases range of motion without a subsequent decrease in muscle activation or force. Journal of Strength and Conditioning Research, 27 (3), 812-821.

MacDonald, G., Button, D., Drinkwater, E. and Behm, D. (2014). Foam rolling as a recovery tool after an intense bout of physical activity. Medicine and Science in Sports and Exercise, 46 (1), 131-142.
Okamoto, T., Masuhara, M. and Ikuta, K. (2013) Acute effects of self-myofascial release using a foam roller on arterial function. Journal of Strength and Conditioning Research, 28 (1), 69-73.

Peacock, C., Krein, D., Silver, T., Sanders, G. and Von Carlowitz, K. (2014). An acute bout of self-myofascial release in the form of foam rolling improves performance testing. International Journal of Exercise Science, 7 (3), 202-211.

Pearcey, G., Bardbury-Squires, D., Kawamoto, J., Drinkwater, E., Behm, D. and Button, D. (2015). Foam rolling for delayed-onset muscle soreness and recovery of dynamic performance measures. Journal of Athletic Training, 50 (1).
Shah, S. and Bhalara, A. (2012). Myofascial release. International Journal of Health Sciences and Research, 2 (2), 69-77.

Sullivan, K., Silvey, D., Button, D. and Behm, D. (2013). Roller-massager application to the hamstrings increases sit-and-reach range of motion within five to ten seconds without performance impairments. The International Journal of Sports Physical Therapy, 8 (3), 228-236.
Swann, E. and Graner, S. (2002) Uses of manual-therapy techniques in pain management. Athletic Therapy Today, 7, 14–17.

Torres, R., Ribeiro, F., Alberto Duarte, J. and Cabri J. (2012). Evidence of the physiotherapeutic interventions used currently after exercise induced muscle damage: systematic review and meta-analysis. Physical Therapy in Sport, 13(2), 101–114.

It’s All In The Hips!

Trapped in Squat Pain? Release Yourself!!

The squat involves a whole complex of joints and problems can occur at any and sometimes all of these joints. For this article I will look at pain within the hip joint complex during squatting. This is something I have experienced and had a lot people ask me about.

There are an infinite number of things that could cause pain in the hip and without delving deep into everything I want to focus on an impingement like, nipping pain that often occurs during deep flexion of the hip such as in the bottom of the squat. This deep flexion of the hip occurs during everyday activities too however such as stair climbing or sitting into a chair. Therefore it could be very debilitative for some if this pain is persistent and not addressed.

I have read around this subject and also analysed my own and others squat. Many of the people who experience this have some or all of the following symptoms.

Common Symptoms. . .
• Pain that occurs in the front of the thigh and hip, feels like a nipping or catching
• Pain in the front or outside of the knee
• A feeling of tightness and congestion in this front thigh/hip area
• Pain in the lower back

On analysing the squat I then found some common dysfunctions or compromises evident on both my own and others squat technique. Things I found were as follows:

Signs of Dysfunction and Compromise. . .
• Knees may bow or collapse in with an inability to keep them pulled out
• There is an excessive forward lean of the upper body
• Arching and overextension of the lower back
• Shift of weight on to one leg
• Shift of weight onto the toes

What Could Be Happening? . . .
There is no one factor that will be responsible for a dysfunction, or pain. You should not rule out any pathology or condition so if the problem doesn’t subside with an attempt to self-treat then visit a medical professional. I have found both in myself, and others that there are some common factors present in individuals with squatting pain or activity related pain in the LPH complex. These factors are:

• Joint Dysfunctions
• Shortened, Overactive Muscles
• Lengthened, Underactive Muscles

Joint Dysfunctions. . .
Dysfunctions can occur at any point in the “chain” during the squat. However, for this article we will focus on the hip and pelvic area. If this joint is altered in terms of positioning this will have a knock on effect on the movement occurring at these joints and thus overall movement compensation. Another effect of an alteration in joint position is the ‘nagging’ or impingement like pain in the hip. Areas I have found to be dysfunctional in those (and myself) with this hip discomfort are as follows:

• Head of the Femur (Thigh Bone) sits more forward in its socket
Shirley Sahrmann proposed some familiar muscle imbalances to be contributors to this anterior translation. One of these is a tightness in the posterior capsule in combination with weak gutes prevents the femoral head from gliding backwards when the hip flexes, therefore the femur is forced forward. Along with this there is a proposal that one of the hip flexors (psoas major) is actually weak and unable to stabilise the hip into its socket. This allows this forward translation and creates the ‘nipping’ during a squat as the head of the femur can’t glide backwards as we flex the hip, instead it remains forward catching the soft tissues in the front of the hip.

• Anterior rotation of the sacroiliac joint (SIJ). . .
This is a very common alteration in the athletic and active population. A lot of people tend to be front dominant in their activities and therefore these front muscles become overworked and tight. A lot of people mention tight hip flexors when it comes to forward tilting of the SIJ and the pelvis. However, Sahrmann mentioned that the psoas may be actually be weak if the head of the femur is translating forwards. The psoas is a hip flexor but I believe the rectus femoris (one of the quadriceps, and hip flexors) is hugely responsible for anterior pelvic tilt. This muscle attaches to the inferior spine of the ilium and therefore if it is tight it will pull this and thus the pelvis forward. The psoas could still be weak and actually part of the reason the rectus femoris is tight as it may be working overtime to make up for the psoas weakness. If the glutes are also weak, as mentioned above, they will be unable to rectify any anterior tilt of the pelvis.

If the femoral head translates forwards as well as an anterior tilt of the SIJ and pelvis. This will close the space within the hip joint itself and therefore increase the likelihood of impingement and discomfort when moving through ranges of motion at the hip. During a squat you already close the angle between femur and pelvis so if there is an excessive amount of forward tilt even before we start squatting this will cause obvious problems.

Shortened, Overactive Tissues. . .
There are many muscles that could be involved in problems at the hip but for the purpose of this article I will discuss the major muscles I have found to be major contributors to hip pain during squatting.

• Rectus Femoris (part of the Quadriceps)
• Adductors (or groin muscles)
• TFL (outside of the hip, causing tightness in the Iliotibial band or ITB)
• Erector Spinae (lower back muscles)
• Piriformis (deep muscle in the buttock region)
• Hip Capsule

So when experiencing some form of hip pain assess these areas, if shortened they may feel tender to touch. One step to attempting to rectify your hip position and ultimately your pain would be to release these tight tissues. There are many ways to approach this, stretching, foam rolling and self-release, or deep tissue massage. These will be covered in the treatment section of this article.

Lengthened, Underactive Tissue. . .
• Gluteus Maximus (big glute muscle)
• Gluteus Medius (smaller glute muscle)
• Rectus Abdominis (“Abs” or “6-pack”)
• Transversus Abdominis (internal core muscle)
• External Obliques (muscles around the side of the core)

If these muscles are weak they are unable to aid the stability and proper control, and movement of the hip and therefore these compensatory patterns of movement and altered joint positioning occur. To attend to this issue, we do what we would normally do with a weak muscle, we train it to strengthen it and activate it. How we do this will be covered in the treatment section of this article.

Just for a second we will go back to the common dysfunctions and look at these in relation to the above contributing factors.

• Knees may bow or collapse in with an inability to keep them pulled out
This could be attributed to the tight adductors pulling the knee and thigh inwards, as well as having the weak glutes being unable to externally rotate the hip and pull the knee outwards. Therefore if you experience this bowing in of the knees then maybe try stretching and releasing the adductors and also strengthening the glute muscles in particular the glute maximus and medius.

• There is an excessive forward lean of the upper body
This could be due to the tight rectus femoris pulling the body forward from the pelvis with a weakness of the core and glutes being unable to stabilise and pull the trunk respectively during the movement. It may also be the hip capsule tightness restricts the hip movement and therefore the upper body needs to lean excessively to achieve squat range of movement. Therefore if you notice a forward lean then try strengthening the whole core (abs and deep core) as well as loosening the hip capsule, and rectus femoris.

• Arching and overextension of the lower back
This one will more than likely be due to the tightness of the erector spinae muscles pulling the lower back into the arched position. But also the weakness and inability of the rectus abdominis to pull the spine forward, and the glute inability to pull the pelvis backwards and thus the lower back out of an excessive arch. Therefore when feeling this arch occur work on loosening those lower spinal muscles, and strengthen the glutes and rectus abdominis (abs).

• Shift of weight on to one leg
Now this could occur due to a simple imbalance of strength from one leg to another, a leg length discrepancy or previous injury. However, looking at the structures that are usually tight it could also be the tightness of the TFL because if the foot is fixed the hip cant abduct so contraction of this tight muscle will tilt the upper body from the hip causing some sideways lean and potential for a shift of weight to one foot. A weakness of the obliques will also mean that the core cannot stabilise itself in this sideways plane as well as it should. Therefore this tightness and weakness could be addressed if this occurs.

• Shift of weight onto the toes
This is usually due to ankle mobility restrictions due to tight calves and not directly related to the hip, however it could have a knock on effect because if this starts to occur it will cause compensations further up the chain. Therefore if this is noticed then it needs addressing.

Treating Yourself. . .

Addressing Joint Dysfunctions. . .
When it comes to adjusting this alteration in joint position and mechanics we need to physically manipulate this joint. This is usually done manually by a therapist however, there are many ways in which you can apply similar mobilisations yourself using resistance bands.

1. Addressing Anterior Translation of the Femoral Head
The issue is that the head of the femur is stuck in a forward position and doesn’t glide as it should in the socket which causes the discomfort we feel during movements of the hip. Good ways of addressing this situation are as follows:

• Kneeling Banded Mobilisation – attach a band at kneeling hip height behind you. Place your affected leg through the band and place it high up into the groin region so it covers the hip joint. Kneel on all fours. You should adjust you distance from the band to alter the tension, you want to feel the band pulling the hip joint back. Once you have a good tension you can rock back and forth sitting onto your heels and back. You can also rotate you hip in and out from this position by twisting your leg so you lower leg moves side to side. The direction of pull can be altered in order to pull the head in different directions and mobilise the hip in various directions. You can perform 30 or so reps with band at one angle and then change angle and do another 30. Do a couple of sets at each angle of pull and also the rotations.

• Standing Split Squat Banded Mobilisation – stand through a band attached behind you at hip height wrap around the affected leg. Then perform a split squat, leading with your good leg. Adjust your position to alter the tension on the band, tension should be enough to pull the hip joint back as you dip into the split squat. Do 15-20 for 3 sets.

• Banded Step Ups – attach the band behind you again and place your leg through it wrap up into the groin around the head of the femur. You then want to step up with the banded leg and perform your step up. Choose the tension wisely as you don’t want it pulling you off the step/bench, but you want enough to pull back on the hip joint. Ensure you get full extension on the step up and if you want to engage the core too try not to touch down with the trailing leg and raise it up so thigh is parallel to the floor before stepping back down. Do 10-15 step ups.

• Lying Wall Squat With Rotation – Lie on your back with your feet flat against the wall and hips and knees bent as though in the bottom squat position. From here you can allow your knees to fall out stretching the inside of the hip and the adductors (groin). Extra pressure can be applied by the hands for more stretch on this. You can also then cross one foot over the other knee, as though cross the leg. Once crossed you can press down on the crossed-leg knee pushing it towards the wall. This can be pressed and held or can be oscillated in and out stretching the capsule.

To make the banded exercises effective you should have enough tension so you can feel the band pulling the head of the femur feeling it glide slightly as you move.

2. Addressing Anterior Pelvic Tilt
This is a common problem and is a fairly simple fix if you put in the time and work. It comes down to primarily two things. Tight anterior (front) musculature pulling the top of the pelvis forwards, and under-active posterior (back) musculature not pulling the top of the pelvis backwards. This imbalance then has the overall forward tilt of the pelvis. This in turn then alters the position of the hip joint as discussed above. So based on this the way to approach this is simple. Lengthen the tight tissues, and activate the under-active tissues.

• Foot Up Hip Flexor Stretch – This is similar to the Bulgarian Split Squat. Place the laces of your shoe on a bench and lunge the opposite foot forward. Then drop your hips towards the floor, keeping the foot in contact with the bench. You are wanting to feel a stretch right up the quad and into the hip flexor, this can be further stretched by raising the arms straight above the head and keeping the torso upright as you drop down. You eventually are aiming to be able to get the trailing knee to the ground, getting the raised foot against the buttocks, whilst keeping the torso upright so knee, hips and shoulders are all inline. This should be held for 30secs once a stretch is found or can be gently oscillated in and out of stretch 20-30 times.

• Lying Quad Stretch – lie face down with legs straight out. Then grasp one foot behind you by bending the knee, pull the foot into your buttocks. Aim to keep the pelvis, hips and core flat on the ground. If you struggle to grab your foot without raising the hips or arching the back you can use a band or towel and use this to pull your foot close to your buttocks without compromising position of the hips etc. Hold this stretch for 30 secs and repeat 3 times.

• Single Alternate Leg Wall Push – lie on your back next to a door frame. Bring the foot closest to the door frame up so it is flat against the frame, you want to have the knee as bent as you almost like this side is a deep squat position. Have the other leg out straight. Then you want to push hard down on the frame with the foot flat so the glutes are firing. Hold this for 20 secs or so, relax then repeat 5-10 times. Then you can swap sides so other foot is pushing down. This causes the glutes to maximally fire aiming to pull the pelvis back and into a better position, rectifying any anterior tilt.

• Single Leg Bridges – lie on your back with the feet flat and knees bent. Then raise one foot off the floor completely straightening and outstretching the leg. Then push through the flat foot, firing the glutes, and raise the hips off the floor until your knee, hip and shoulder is flat and in a diagonal line. Hold at the top for a second or two, keeping the core engaged, then lower under control then repeat. Do 3 sets of 15-20 reps.

You should also learn to adjust your own posture to help rectify any stuck hips or tilted pelvis.

• Stand up tall
• Squeeze and contract the glutes hard
• Flex the abs and engage the core and transversus abdominis so you stomach is pulled in and ribs pulled towards the pelvis slightly.
• Once all contracted you can ease off slightly as walking around in a fully flexed state is not comfortable, so ease off to about 50%.

3. Other Areas to Strengthen. . .
The following areas will help maintain good hip and pelvis as well as help stabilise the complex of joints and tissues.

• Superman – kneel on all fours and level your spine so it is flat, then attempt to pull your navel towards your spine without moving your spine or over-contracting your abdominals. To do this you should pretend you are trying to cut off your flow of urine mid-flow or clenching your rear passage. This is the best way to cue the Transversu Abdominis (deep core muscle) to activate. Once you can master contracting this muscle and keep core flat, then raise one arm straight out in front of you. As you do this raise the opposite leg straight out behind you, then lower them both and repeat with the other arm and leg. If you feel any movement in your spine or abs, or you feel your Transversus Abdominis turn off then stop reset and start again. Do 15-20 reps each side for 2-3 sets.

• Half Plank Progressing to Full Planks – the plank is often done wrong to reduce the difficulty of the exercise. The shoulders, hips and knees should be all in line with no sag of the stomach or arch in the lower back. If you struggle to do this without lower back arch, or a sag in the hips or stomach start with a half plank with the knees on the floor. Hold the plank for 30-40 secs for 3 sets.

• Straight Leg Reverse Crunch – Lie on your back and grasp some stable object behind your so your shoulders and arms are fixed still. Then squeeze your abs pulling your legs towards your chest, keep legs as straight as possible to avoid excessive firing of the hip flexors, you are only aiming to lift the hips off the floor so don’t need to fully bring legs into the chest. Also avoid any excessive folding of the pelvis. Perform 3 sets of 15-20 reps.

• Glute Medius Clams – lie on your side and bend the knees to 45° with one foot on top of the other. Then open the knees apart as far as you can without twisting your body or separating the feet. There may not be a huge movement you are looking to feel the outside of the glutes activating here. Do 20-30 reps on each side.

• Active Oblique Activation – lie on one side keeping the bottom leg straight and in line with the shoulders and neck. Bend the top leg to 90° out in front of you. Grasp the underside of your this thigh with your bottom hand. Place your top hand on the back of your head, with the elbow pointing to the ceiling. Then try touch your top elbow to the floor by rotating the core inwards, hold briefly at this point then rotate the core outwards, opening the body out and try get your back and arm flat on the floor, keeping you hand on your head. Again hold at this end point. Perform this for 15 or so reps. Check this link for a demo. https://www.youtube.com/watch?v=vxocwecYjqE

4. Foam Rolling and Self-Release
I could write a whole article on this area alone with the vast range of exercises available. However, I thought I would share a little gem of simplicity that can be used when trying foam rolling or self-release exercises. If you find an area that is tight or shortened you can pick up your foam roller, barbell or hockey ball etc. (something solid to apply pressure to the muscle tissue) and do the generic sit on it and roll. This may give you some relief but there is so much more you can do.

• Contract-relax – place the body area on the roller, hunt around until you find a sore, painful, tight spot. Once you find this spot hold as much weight over it as you can, holding it still on the roller. Then contract the muscle, in a static contraction and hold it for 5-10 secs, when you relax try put more weight onto the area via the roller. Do this until you notice an improvement in pain.

• “Lock and Load” – this is a concept I decided to term lock and load. If you find a muscle that is short or tight, you can place a “lock” on the muscle near the tight area. This can be done by placing the roller or cricket ball etc. across the muscle belly or near the tendon (depending where the tightness is felt in the muscle). Once the lock is in place you can “load” and move the muscle into stretch through full range as far as you can. As you do this keep pressure on the muscle locking it in. then you can release the lock and return to start. You can then repeat on same area until improvement occurs or find another tight area.

There isn’t any really right or wrong way to do this. Simply find an area that is tight and go at it using these methods as well as your generic sitting and rolling on a foam roller. For example if my quad feels tight just above the knee I will lie face down and place this thigh on a roller. The roller will sit at the end of the muscle at the top of the knee near where it starts to meet the tendon. Once there I will lock it in putting my weight through it. I will then move my heel towards my buttocks so my quad stretches. This pulls the fibres from the “lock” stretching the tight area.

Take Home Message. . .
If you are suffering with a nagging hip pain during your squats, or even just a noticeable anterior pelvic tilt (which could lead to hip pain) try addressing the above issues using the exercises above.

Basically all you need to consider is to lengthen and stretch the shortened tissues (listed above), and strengthen the weaker, lengthened tissues (listed above). By addressing these common characteristics you may help alter any alteration in joint and pelvis position, as well as create more space for the hip joint to glide during your squats.

You should always gain medical advice for any long lasting hip complaint that is not relieved with exercise or with time. The above is not an alternative for seeking advice from a medical professional it is merely what I have found to be successful for myself and some of my clients.

The Shoulder Complex Part 3: Rehabilitation Approach

Rehabilitating Yourself for Shoulder Impingement…

The primary concern for both the therapist and athlete/client when it comes to approaching shoulder impingement is the initial pain and discomfort that the athlete/client experiences. This often prevents them achieving the movements they require in their training etc. If they can’t achieve a good range of movement without pain they won’t be able to strengthen their shoulder in a full range.

This article will offer a general approach to treating shoulder impingement. It is based upon my successful experience in working with many athletes who have this complaint. It is in no way an exclusive list of exercises and the only way to approach this condition.

Manual “Hands-On” Treatment…

Many manual, and hands-on techniques can be applied to help reduce any muscular tension and mobilise the joint into a more optimal position with the aim of relieving any symptoms of pain. You can visit a therapist and receive massage, muscle energy techniques, and mobilisation techniques which will help significantly in relieving pain and discomfort through reducing tension in tight and overactive areas as well as freeing the joint capsule and creating more space in the “sub-acromial” space.

Some people are reluctant to visit a therapist due to cost etc. so visits to the clinic may not be an option. Therefore I offered these self-treatment options to these individuals, and it is that self-treatment option that is the focus of this article.

Much like any exercise program all the aspects of rehabilitation (mobilisations, stretches, strength, and functional exercises) should take a progressive path not to further irritate the structures within the shoulder. Without going through a full rehabilitation program breakdown I will discuss some of the successful exercises I have used in the past. The people I see often have had this complaint for a prolonged period of time or it is a recurring complaint. Therefore they are often able to achieve a reasonable range of movement but it may be uncomfortable. For those who have significant ROM losses you will want to adjust the level of the following to suit their condition or seek further advice or more remedial exercises.

Self-Mobilisations, Stretching, and Joint Play…

As discussed in the previous article the humeral head and whole shoulder complex can translate forwards and rise, which encroaches into the sub-acromial space. Therefore to help relieve this encroachment, compression and ultimately the pain and discomfort we can help physically mobilise this joint into a more optimal position.

The aim is to try to free the humeral head in its socket so it increases that space under the acromion. Manually this would be done by the therapist passively applying a force to the humerus causing it to move into a more optimal position. However, there are also ways of doing this by yourself which I have found to be very relieving for my clients. As we identified in part 2 of this article this alteration in shoulder position, and impingement can stem from tissues becoming over-active and shortened.

Weight Plate Chest Release
Lie on your back on a bench and place a kettlebell or weight on your affected side pectoral muscle. Take a deep breath then press the weight into the muscle as much as discomfort will allow, then raise the arm diagonally above the head whilst maintain the pressure on the weight. You will feel the muscle stretching from the point of pressure. As you lower the arm again release the pressure on the muscle. You can alter the position of the weight to find areas of the pec that are tight. Do this until you notice some improvement in pec range of movement or a feeling of improved flexibility through the muscle.
Pec rlease 1
Pec Release 2

Upper Trapezius Stretch
Stand on a towel and grasp it at your side with your “bad” hand. Your arm should be hanging at a resting length, then lean away from the towel with your upper torso and tilt your head to the same side (so your ear drops towards the shoulder). You should feel the towel pulling your arm down as you lean away, this causes the upper trap to be stretched. Hold this position for 20-30 seconds and repeat 2-3 times.
shldr_neck_supra_infra_levator_scap_traps_spek_cer_capi_scal

Banded Distractions
Once less pain is experienced this is a good addition. Attach a heavy duty band/rope/towel to a stable object/frame at just above shoulder height. Grasp the band etc. with your “bad” hand, turn your palm upwards, then walk your body backwards and shift your weight backwards so the band pulls the arm “out of its socket”.

From this position your can drop your chest towards the floor and rotate the body to loosen the joint capsule. Find areas that feel restricted and work into these. You can also then rotate the shoulder in and out keeping the arm straight. This has a stretching and loosening effect on the capsule as well as distracting the joint and freeing it up.
Band Distraction

Banded Chest/ Shoulder Opener
This helps open the chest musculature and front of the shoulders. Attach a band/towel etc. to a stable object or frame just above shoulder height. Grasp the band etc. with your “bad” hand then turn your whole body away from the band so your chest is opened right up. Again hunt around looking for uncomfortable tight areas then work into these by holding the position or oscillating in and out of this area. To incorporate the neck muscles into this you can turn you head away too. Play around with the height to achieve various stretches throughout the chest and front of the shoulders.
Opener

Lying Shoulder Drop
Lie on your back and raise your arms straight out in front of you vertically. From this position we are wanting the humerus to drop to the back of the socket. This will help free the space and improve our pain free range, especially flexion (raising the arms out to the front). To allow this drop of the shoulder, keep the arms straight and try relax the upper body, you should feel the space between the back of the shoulder and the floor reduce. Ideally you are wanting to feel your shoulder hit the floor on relaxation.

To aid this you can grab a weight or simply a bag of objects to help force the humerus back. Once you have mastered the relaxation and you feel the shoulder drop back, you can then start to rotate the humerus outwards by turning your thumb away from your body. Ensure as you do this the shoulder remains relaxed back into the floor and doesn’t rise. If it does rise up, stop and relax again.
KB 1

KB 2

Strengthening/Activation Exercises…

Banded Scaption
Grasp a band/towel with each hand at each end. Hold this straight out in front of you with straight arms, then pull the arms apart and turn your thumbs out creating tension in the band/towel. Find a band/towel suitable that allows you to pull your arms out at a 45° angle. From here raise your arms above your head keeping the tension and angle maintained then lower all the way back down again maintaining the tension, angle and thumbs out.

Turning the thumbs out externally rotates the humerus which is the better position for achieving optimal joint space. By pulling the arms out as well as this external rotation engages the rear rotator cuff muscles which are usually weak in impingement. By incorporating this engagement with overhead movement it retrains the muscles to work together in this overhead motion. As we mentioned previously it is usually the fact that the rotator cuff muscles are firing enough to stabilise the humerus in these movements. So by doing this move we are forcing the rotator cuff to activate whilst moving the arms overhead.
Scaption 1

Scaption 2

Banded Protraction/Retraction
Start with protraction and attach a band behind you (or can use cable machines) at shoulder height. Grasp the band/handle out in front of you with a straight arm. Then you are aiming to push the band forward by thrusting your whole shoulder forwards and feeling your scapula slide around your ribs as you do this. Ensure you keep your arm straight and initiate the movement form the shoulder not bending the elbow (as this becomes a chest press which is what we don’t want). Do 2-3 sets of 20-30 reps on each arm.

Retraction is in the same set up only you now face the band/cables and grasp the handle. Then, again keeping the arms straight, pull the band/cables back. You are looking to move the whole shoulder and feel the scapulae squeeze together. Do 2-3 sets of 20-30 reps.
Protraction
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Banded Shoulder Rotations
For external rotation, and to work the infraspinatus and teres minor, attach a band at head height and face the band. Then grasp it with your hand, place your upper arm out to the side so it is parallel with the floor (at 90°) with the forearm vertical. Then pull the band backwards as far as is comfortable then relax back to the start position, ensure you keep the upper arm parallel with the floor throughout.

To work internal rotation, and the subscapularis, simply turn around with your back to the band. Then rotate the arm forwards pulling the band forwards. Again ensure you keep the upper arm parallel with the floor. Do 2-3 sets of 15-20 reps of both external and internal rotations.
ER
IR 2

Banded Squat to Row
For this you will need a light band, attach this at chest height in front of you. Grasp the band and walk back so there is moderate tension on the band when rowing your arms in. Ensure you can achieve a full range row, so elbows can be drawn all the way back. Once you find your starting position place the arms out straight in front, drop into a squat (engage core as you would any normal squat), rise out of the squat and as you reach the top row the band in. The band will want to pull your body forward but the idea is that you stabilise your body position whilst you row so you do not track forwards as you row the band in. Perform 2-3 sets of 15-20.
Squat to Row 1

Squat to Row 2

Once you can perform the squat to row with good stability and control. Set the band up as above but place a stepper in front of you. This time perform a step up bringing your trailing leg up so your thigh is parallel with the floor and you are balanced on one leg. As you get to the top of the step up, stabilise your body and then row the band in. Again as you row maintain the stability and minimise “wobble” or forward translation. To progress this further perform the row with one hand (the opposite hand to the standing leg). Perform 2-3 sets of 12-15 on each leg/arm.

The lower body and row exercises integrate the whole body, and activates the posterior system of the body which will help rectify any forward translation of posture. It also uses our target muscles in a whole body movement which is essential when wanting to achieve postural stability in everyday activities as we are never isolating one muscle group when performing our daily activities.

Further Strengthening Advice
In regards to any general strength work you are doing it should be pain free. If it is causing that nagging, nipping pain stop doing those exercises until your symptoms are relieved. Include the above into your current program, and even when your pain and symptoms have subsided use them as a warm up.

To really strengthen the shoulders as a unit work on all movements of the shoulder as you when strengthening any other muscles. Start progressing the weights lifted as pain allows. Put simply, short of providing a full rehabilitation program, work front and side raises, external/internal protraction/retraction, and overhead presses. When training these movements with weights however, don’t slip into the past habit of tightening the upper traps and chest to help you lift a heavy weight. Conscious think about the tension in these areas, and if you notice a rise in the traps or over-activation of the chest stop, relax and start again or drop the weight.

The above exercises are not a full rehabilitation approach, nor are they the “gold standard” for treating impingement, they are simply some exercises I have found to be successful with both myself and clients. Ensure you seek medical advice if symptoms continue without improvement.