Training errors in the athlete, part 4

Underestimating the importance of proper recovery. When it’s time to work hard in a workout or competition you need to have some gas in the tank. That tank doesn’t get filled up without good recovery techniques like full days off, active recovery days, consistent sleep, compression, nutrition quality and timing, proper hydration and muscle maintenance.

If you start every competition or workout on a half tank, guess what happens? You go half as far with half the intensity. Sometimes that's intentional and planned. But many times it's not. Then as injury and overtraining occur, you have to ask yourself, “What am I really getting out of this?” In order to feel your best, remain healthy, and perform at your best, recovery is a huge part of the equation. Don't dig yourself into a hole that you can't get out of. 

Not working hard enough to produce a strong stimulus that the body wants to adapt to. Athletes are supposed to be constantly pushing their bodies on many of their training days. That’s how you become better, right? Unfortunately it’s also how you become overtrained, injured, stale, and burned out.

This leads you to constant training at a moderate effort on “dead” muscles. Or running the same distance every day. Monotony is the straw that broke the camel’s back. For runners, yes, you need days to emphasize aerobic conditioning in easy efforts ranging from 30 minutes to 3 hours. Other days you can have interval training that emphasizes anaerobic work at a really high effort for anywhere from 30 seconds to 5 minutes. Sure there’s a place for a moderately paced tempo run of 15 to 60 minutes, but not every day.

Strength training athletes need to avoid constantly using a weight that causes failure at 10, 12 or 15 repetitions. Or always doing just one set. If you are really after a change in performance, there needs to be a training cycle where the weight is significant enough to cause failure at other points, like 8, 5, or even 3 repetitions. And other times it’s fine to do 20 repetition sets. The point is, change the stimulus.

Indoor general fitness athletes are often one of the most guilty of this mentality. Three and four times per week they bounce from one cardio machine to another, being sure to start breathing harder and break a sweat at each machine for 10 or 20 minutes. They occasionally check their heart rate and compare it to the machine’s chart. No surprise to see a heart rate of 70% of the predicted maximum. And they wonder why they never see significant fitness changes.

Then there are the athletes that push a little harder but it’s just to that 85% level, which definitely hurts more. But then they struggle to sustain it as one steady effort for longer than 10 minutes (because it hurts) at which point the effort drops a notch. Meanwhile, other people in the gym are barely working at all.

In any sport, the key is variety. Variety in intensity, duration, training surface, speed, force produced, and direction of movement. Yes, you want adaptation to a consistent stimulus for a while but then you have to change that stimulus to continue making gains. 

Ignoring injuries when you first begin to have symptoms. Some injuries classically only hurt at certain times in their formation. That doesn’t mean they aren’t a problem. It doesn’t have to hurt all of the time to be a problem. Don't ignore it. Never ignore it. Yes, you can try to treat it yourself for a little while. That really might work.

But please make your life and my life easier by just coming to Physical Therapy within a couple weeks of the problem onset, even if it’s just for a consultation. If you don’t like what I have to say about it then seek another opinion. Regardless, if you intervene early, and start the right treatments, your recovery time is going to be drastically different.

For instance, if I see someone with back pain from a sacroiliac joint sprain in the same week they are injured, then they often recover in well under a week. If the sacroiliac joint has been a problem for 2 months and had no proper treatment, then buckle up for at least a month of consistent work. #getPT1st

Training errors in the athlete, part 3

Relying on ibuprofen, naproxen, acetaminophen or other over-the-counter drugs during and after exercise to counter muscle soreness. It’s one thing to take medications for a known sprain of a joint or strain of a muscle. Those are good reasons to use these medications because the level of tissue damage is drastically greater. In that case, if you normally do well with over-the-counter medications then, by all means, take them. But stay hydrated and don’t exercise heavily while taking them.

Our bodies adapt to exercise by rebuilding the minor tissue damage that occurs during the exercise, but with a little better structure. By using anti-inflammatories, recent studies indicate you are actually hampering some of your body’s normal recovery processes. Let nature run its course.

Focus instead on good nutritional habits, like eating during and immediately after exercise.  Patience and tolerance as your body recovers after exercise are key.

And please don’t take anti-inflammatories while you are exercising because:

• They can be highly damaging to your kidneys as you become dehydrated.

• They can impact your blood pressure negatively.

• There are also problems in the way the drugs act with higher body temperatures and can change otherwise normal processes in your body during exercise.

• Their intake can lead to intestinal bleeding, cramping, diarrhea and maybe even a trip to the emergency department if the dose is high enough and you’re dehydrated.

Not performing plyometric training. It’s probably not a good start if you are currently saying “What is plyometric training?” Plyometrics can be a great way to increase overall speed and power. They are also great for improving your confidence with foot placement and directional changes because more advanced exercises require agility as well. And if you have a hit a plateau in your training, they can help you break through it. That can be true for sprint athletes and endurance athletes. Keep your body guessing.

Lateral hops are a great plyometric Drill for many athletes

Not having goals, short-term and long-term. Is your long-term goal to be a 5K runner until you are 80? To stay in shape to chop two cords of firewood next month without back pain? To squat 300 pounds for a one repetition maximum in three weeks? To avoid a family history of cardiovascular disease with indicators like blood pressure below 130/75 until you are 50? Write your goals down. Determine a time-frame. Maybe six weeks short-term? Maybe six months long-term? It’s going to depend on the type of goal. And 40 years long-long-long-term? Remember the SMART concept for making goals - specific, measurable, achievable, realistic, time-bound. Simply saying “I want to be stronger and faster” is not specific, measurable or time-bound. Achievable and realistic, maybe. But how will you decide achievement of being stronger and faster without a measurement?

8 Shoulder pain and rotator cuff care tips

While shoulder pain can be caused by a variety of injuries, rotator cuff impingement is one of the more common causes. It can occur in a variety of people, younger and older. The rotator cuff is made up of four muscles on your shoulder blade that stabilize your shoulder joint, as seen below. Impingement occurs when part of the tendon is repeatedly compressed. It is often poorly managed with corticosteroid injections. Mechanical stress that would have caused these tendons to become painful requires mechanical treatments, not a drug, for true correction. 

You are at risk for rotator cuff tendon or "subacromial" impingement if you currently have or have had:

1. Decreased total shoulder motion - Can you get your arm straight overhead? Can you touch your hand all the way up to the bottom of your opposite shoulder blade?

2. A rotator cuff muscle or tendon injury, like a strain or a tear - This would have been diagnosed by a medical professional.

3. A “frozen” shoulder - Also would have been diagnosed by a medical professional.

4. Poor trunk and shoulder blade posture - All people are guilty of this at some time or another. We round our backs and let the shoulders rock forward. We drop our heads forward and down.

5. Weak rotator cuff muscles - This applies to many people, even those that have labor jobs or athletes that demand heavy use from their shoulders.

6. Weak shoulder blade muscles - This occurs in most people, unless they are specifically strengthening these muscles and is often a result of the poor trunk posture. 

7. Irritable rotator cuff muscle trigger points (aka knots) - Applies to many people, unless they regularly have a deeper massage or routinely dig and smash on those knotted trigger points themselves.

Certain activities also make shoulder impingement more likely:

1. Long periods of work with the arms overhead

2. Participating in throwing sports, like baseball

3. Participating in swimming, especially freestyle, backstroke, and breaststroke

Combine any of these activities with the problems listed above and it is not unusual to start having shoulder pain from rotator cuff impingement.

Here is a list of items you can try to decrease the chance of developing a rotator cuff impingement issue or to address an early rotator cuff problem.

1. Massage the rotator cuff muscles with a ball, like a tennis ball, while leaning against a wall. A couple of these muscles are easy to reach because they are on the back of your shoulder blade. Move your body up and down and side to side while keeping a moderate pressure on the ball. Focus on the more tender areas. Perform for 1-3 minutes.  

2. Light rotator cuff muscle activity with your arm at your side. This could be as simple as the “isometric” exercises in the pictures below. Push 5-10 seconds with a minimal to moderate level of pressure. The goal is to perform repetitions without pain, not to create maximum force. More is not always better. Try just 5 repetitions of each position early and if that lowers your pain then attempt to work up to 20 repetitions over one week of time.

Hand pushes into wall 5-10 seconds from the shoulder. 

hand Pushing into wall 5-10 seconds from the shoulder. 

Hand or wrist pushes into wall 5-10 seconds from the shoulder. 

Wrist pushes into wall 5-10 seconds from the shoulder.

3. When sitting or standing, focus on remaining tall with your torso posture. Focus on the shoulder blades squeezing back even if it’s just a little more than your usual. A small change can go a long way toward decreasing stress on the shoulder muscles and tendons.

4. For swimmers, address any swimming technique issues such as crossing midline during the freestyle stroke. You may need to discuss this with a swim coach or a medical professional experienced with treating swimming athletes.

Copyright Johnson, JN in Physician and Sportsmedicine, January 2003

5. Move your keyboard and mouse closer toward your body if you work at a desk in order to keep your arms closer to your side and not reaching forward.

Screaming for shoulder and neck problems. 

Get a little bit closer...

6. Avoid working overhead. This is especially true if you have to push firmly with the arm, like while using a drill or paint roller.

7. Do not completely avoid moving the arm. This increases the chance of developing stiffness in the joint that could lead to adhesive capsulitis, otherwise known as a frozen shoulder. Please don't put your arm in a sling unless a medical professional determines there's a bone broken or you just had surgery on the shoulder.

8. Avoid heavy overhead lifting. Of course, heavy means different things to different people. If you *think* it’s heavy at all, it probably is.

Don’t let your shoulder pain stick around for too long. One to two weeks is reasonable if it is steadily improving from a moderate level of pain. In some instances, these suggestions can help shoulder pain. By no means are they meant to resolve a major shoulder injury though. They are not intended to provide diagnosis or true medical treatment. When in doubt, seek medical advice from a qualified medical professional.

If you have any questions about resolving shoulder pain with your work or hobbies, mail me at mountainridgept@gmail.com.

Training errors in the athlete, part 2

Poor hydration habits before, during, and after exercise. Our bodies are around 55-65% water. Humans can live for weeks without food but only days without water. We depend on good hydration for basic function of our systems. For athletic performance, the demand is even greater because athletes need to maintain a greater blood volume, sweat for temperature regulation, sustain tissue integrity, and repair exercise-induced damage and injuries.

Dehydration will decrease blood volume and with that decrease you won’t be able to cool yourself effectively or supply the working muscles with enough blood. If your core temperature reaches 103-104 degrees, the hypothalamus in the brain will just say “no.” Your movements will slow down and your entire nervous system will not function at its optimal level. And nobody loves that dizzy feeling of decreased blood pressure after you stand up from sitting or lying down when dehydrated.

As far as structure is concerned, hyaluronan molecules bind with water to keep your connective tissues, like cartilage and tendon, strong, supple and resilient. Keep the hyaluronan happy by staying hydrated! And we want the muscles to remain loosey-goosey!

Take in 5-10 ounces of fluid every 15 minutes in a warm to hot environment during exercise. Otherwise, try to keep your urine nearly clear. Don’t over drink though, as that can have negative consequences as well.

Avoiding strength training. People tend to gravitate toward what they enjoy most. For many athletes, they just want to do their sport and that’s it. Unfortunately, regardless of sport, some muscles and movements aren’t worked hard enough or frequently enough. We will become very good at using certain muscles, like the hip flexors, which slowly shuts down important muscles like the gluteus maximus.

Core strength is important regardless of sport because your trunk needs to be a stable base while the arms and legs move. As running guru and PT Jay Dicharry says, “You can’t fire a cannon from a canoe.”

A loss of muscle mass as we age can be counteracted (to some extent) with strength training. Overall, it comes down to being a healthy, well-rounded athlete -- and without strength training that’s not possible.

Being afraid to let go of a regimented training program. For those Type-A personalities this is difficult. Your long run doesn’t always have to be on Sunday. Some weeks, you might even need to skip that long run altogether. That twinge in your shoulder while swimming is trying to tell you something, so listen up.

Sticking to a “must do” mentality is a great way to dig yourself into a hole of over-training, injury, staleness, and boredom. That’s particularly true when you aren’t able to optimize the other aspects of training, like nutrition, soft-tissue work, compression, sleep, and so on.

I liken it to the “pay me now or pay me later” philosophy. Take an easier intensity day or a day off when you clearly need it or end up taking several of them in a row once your performance drops, you become ill, or you develop an injury.

The sacroiliac joint: An often overlooked cause of low back pain

At the base of your spine there is a really odd-looking bone called the sacrum. It joins with each side of your pelvis, making two sacroiliac (SI) joints. There’s not much motion at these sacroiliac joints. Beyond the sixth decade of life they probably don’t even move at all. Before that point, they move slightly with your normal activities, like walking.

There are times that one SI joint becomes more mobile while the other tends to become less mobile. This can lead to low back pain. Pain from the SI joint can also be felt at the buttock, groin and thigh. 

If the SI joint were to shift from its appropriate position, it often happens with a lifting activity, particularly if the body twists while lifting. Asymmetrical hip motion can lead to SI joint problems, especially if you often squat deeply for work or exercise. The muscles listed below may also contribute to the sides of the pelvis being twisted out of place gradually over time.

An SI joint problem is frequently seen along with some or all of the following negative muscle adaptations:

• Decreased abdominal muscle activation or strength to provide core stability

• Asymmetric hip flexor, hamstrings, and piriformis muscle length or muscle tension

• Asymmetric gluteus medius, gluteus maximus muscle activation or strength

• Asymmetric lumbar muscle tension

The amount of time since injury can be a predictor of success or failure in patients receiving treatment. The sooner a patient comes into the clinic after pain onset, the quicker they have a correction of the problem and a decrease of pain. 

Sometimes I don’t see these individuals until they have been in pain for 1-2 months and then their pain takes much longer to resolve because they have negatively adapted in the ways listed above. They are often given medicine and treated based on their symptoms, but the problem is mechanical and can’t be fixed with medication.

SI joint problems tend to respond very well to Physical Therapy intervention. The injury typically requires a combination of hands-on manual therapy and therapeutic exercises to resolve. If the patient has been hurting for less than a week then there’s a great chance of rapid success, particularly with manual therapy.

Contact me at mountainridgept@gmail.com with any questions about sacroiliac joint injury.

Training errors in the athlete, part 1

Which of these are you guilty of performing?

Specializing in a sport and being entirely unwilling to deviate: Variety is critical for injury prevention, mental outlook, and general health. Unless you are a triathlete, pentathlete, or decathlete, you might find yourself unwilling to stray from the single sport you know. First off, you should strength train. Strength training is no longer an option; it is a requirement. Crosstrain before you get hurt (and you might not get hurt in the first place). Try something that is non-competitive and don’t turn it into a competition. (Yes, that’s probably hard.) Take a yoga class. Play pickup basketball with a couple friends or just shoot around. Try swimming. Just do something that is very different than your normal and do it often. This is especially true for young athletes who aren’t finished maturing. Research suggests that athletes who didn’t specialize at a young age can perform better as long as they were performing some form of athletics. The key for all of us is simply being an athlete.

Assuming your skills and technique don’t need further work: Skill work is primarily about training your nervous system to use a specific pattern. A good overall athlete has more options for movement patterns. Some patterns are highly ingrained and some are not. You want instinctive patterns to be close to an ideal. That way, when fatigue occurs you still demonstrate precision and efficiency. Every athlete could improve their performance with at least weekly emphasis on movement drills, strengthening specific motions, increasing muscle power output, and basically fine-tuning they way the nervous system creates each sports-specific motion. Regardless of sport, there’s room for greater efficiency and adding skills to your repertoire. Even running, which some people assume is innate, is a skill that should be broken into components for drill work. 

Training alone all the time: Sure, you are probably mentally tougher than the average bear, but this problem allows you to slack off occasionally when there’s no one there to push you. Which means you drop into the dreaded moderate efforts that lead to “dead” muscles, overtraining, and slower than optimal nervous system patterns. My motto is “there’s always someone faster and stronger.” Go train with that person at least once a week. A coach could assume part of the role of a training partner, so I’ll give that half an exception.

7 Exercises to Get Ready for Gardening and Yard Work Season

As I sit and look at the snow that should have surely been gone for the season, I am reminded of the approaching outdoor tasks that many of us jump into at springtime. It can be an abrupt change from winter’s dark and lazy days. Try these exercises at least a week before the outdoors tasks to get the blood pumping and move through some of the motions that gardening and yard work require.

Abdominal bracing:

Why it’s important: This is the most critical exercise in this entire list. Any lifting or carrying task should be performed with your abdominals active. Unfortunately, many people don’t do this and it is one of the reasons they strain their low back while lifting.

How to do it: The easiest way to learn abdominal bracing is while lying on your back with the knees and hips bent, feet flat. Place your hands at the sides of your stomach, just above the hard bones that stick out at the front of your pelvis. Imagine drawing your bellybutton toward your spine while tightening the abdominals. Your low back may flatten out a little, which is okay, but don’t overemphasize this. Hold the muscle contraction for 3-5 seconds and perform 10 repetitions. You must be able to breathe while holding the contraction so if you are holding your breath, keep trying. Once you have good control of these muscles lying down, try bracing while standing. After that is easier, try walking and light lifting while holding the abdominal muscles tight.

Chair squats:

Why it’s important: Squats are great to get your knees bending under a repeated load and increase thigh strength. The strength will be necessary to lift yourself to and from the ground and while carrying or pushing heavy loads.

How to do it: Think of this as a slow way to get up and down from a chair. Preferably, do this without the help of your hands. Start with a stance slightly wider than your shoulders. Lower slowly to a chair over 2-3 seconds. As quickly as you can tolerate, stand back up from the chair over another 2-3 seconds. You’ll need to stay toward the front of the chair. If you can easily go up and down a couple times, try not to even bear weight on the chair, just use it as a reference point to lightly touch. Perform enough repetitions to make your thighs feel tired, about 10-20 times. As you gain strength and confidence, you could take the chair away to squat deeper but realize there will be no surface to rest on before lifting back up to a standing position.

Golfer’s lift:

Why it’s important: The golfer’s lift allows you to take strain off of your back when performing repetitive and lighter lifting tasks from ground level. This may be as simple as picking up a tool or placing a seed in the ground.

How to do it: Most people have seen a golfer reach to the ground for their tee or ball. You are going to mimic that motion. Starting in a standing position, pivot your trunk forward from the hip of the weight-bearing leg. The other leg raises up behind you for every same degree the body goes downward. Lower down and return to standing. Emphasize keeping your back straight. You may want to hold onto a countertop or table with one hand when trying this the first few times. Repeat 10-20 times. Switch sides. Once you have the motion down, try it without holding on for balance.

Lunges:

Why it’s important: Lunges are another way to build those thigh muscles that help with getting yourself up and down to the ground. They also work hip muscles that help when you push down onto a shovel or pitchfork.

How to do it: Take a step forward with one leg that is about 50% longer than your usual walking step. Drop your body straight down toward the ground over 2-3 seconds by bending both knees. The forward knee will need to bend more than the rear knee. Don’t go so far down the rear knee touches the ground. Keep your trunk tall the entire time. Push back up within 2-3 seconds and repeat. Perform 10-20 times. Switch sides.

Bent over rows:

Why it’s important: Bent over rows are a great method to build the shoulder blade muscles and the low back. It’s nearly impossible to do much gardening without bending over sometimes. And the rowing motion is a way to use the shoulder blade muscles you need to pull weeds, use a hoe or lift.

How to do it: You will probably want to do this with some light weights of 3-10 pounds in each hand. Bend forward from your hips, not your low back. In fact, focus on keeping the entire back from the neck down in a straight line. Once there, allow the weights to drop forward toward the ground and then pull the arms back toward you, as if you were rowing a boat. Squeeze the shoulder blades together. Do not shrug the shoulders up toward your ears. Drop the arms down and repeat. Perform 10-20 repetitions, or until fatigue begins in the back or arms.

Farmer’s carry:

Why it’s important: One of the most realistic exercises you can try is the farmer’s carry. As a gardener, you are going to frequently carry buckets of water, soil, and tools. And those are often carried on just one side of the body. This puts a large and awkward demand on the low back and abdominal muscles.

How to do it: This exercise will also require weights. You could use an actual bucket filled partially with water, sand or dumbbells or just hold a dumbbell of 5-10 pounds in one hand. Walk forward with the weight or bucket in one hand 10-20 steps. Turn around and switch the hand that is holding the weight. Walk back to where you started. That’s one repetition. Perform 5-10 repetitions. Start with easier weights and progress over a couple weeks.

Deadlift:

Why it’s important: Deadlifts should mimic the technique you use when lifting anything from the ground that weighs too much to allow you to use the golfer’s lift. Imagine lifting a bag of potting soil, heavy water buckets and even when starting out the movement with a wheelbarrow.

How to do it: You are doing a deadlift as an extension of the squats mentioned before. These are more advanced. You should try this first without weight to get the technique and then try to progress to 5-10 pound dumbbells in each hand. Begin in standing with the legs slightly more than shoulder width apart. Your hands and weights will slide along your thighs while you drop slowly toward the ground over 2-3 seconds. The trunk will need to lean forward slightly from the hips at the same time. Once your hands have gotten to the middle shins, return to the starting point over 2-3 seconds. Try 10-20 repetitions.

None of this information is intended to be medical advice. Always consult a qualified medical professional before beginning any changes in your typical activity level. Information provided is suggested for healthy, active individuals.

Let me know if you have any questions about preparing your body for exercise at mountainridgept@gmail.com.

What is dry needling?

Trigger point dry needling, or dry needling for short, is a manual therapy technique used to increase motion, decrease overall muscle tension, and break up the painful “knots” that often form within muscles. It is known as dry needling because there is nothing injected.

I discussed how muscles often generate pain in this previous post. This type of pain is frequently overlooked. 

Dry needling the low back. Image courtesy of Corridor Magazine, 2014

Why use dry needling?

Those knotted areas are known as “myofascial trigger points.” They are often irritable and chemically different than a normal section of muscle. One type of trigger point, the active trigger point, is often the root cause of pain. Not only will the knotted area often be painful, there can be pain very far away from the actual trigger point. This is known as “referred pain” and it might be the only pain a person even feels with their injury. Referred pain can be present just a couple inches from the source but as much as multiple feet away. For instance, the gluteus minimus muscle that is deep at the side of each hip is approximately 3-4 inches in length. It can cause pain all the way down the outside of the leg to the ankle and will trick some people into thinking they have a sciatic nerve problem. Trigger points in the rotator cuff muscles of the shoulder frequently cause pain in the arm, forearm and even the hand. They can mimic a pinched nerve in the neck.

What does dry needling feel like?

There are multiple techniques that can be used when performing dry needling. A simple technique would involve placing the needle within the tightened muscle area and letting it rest there briefly. This is very easily tolerated and feels like a pressure, but it can cause a mild aching sensation in the most irritable trigger points. Another technique involves using the needle to get the muscle to contract. Again, there’s usually a sense of pressure but the aching can be stronger. The contractions themselves are more uncomfortable but are well worth the result. This is because it is common for someone to have their pain stop or nearly stop after a single session of correctly applied dry needling. Their motion is very often improved too.

What types of injuries benefit from dry needling?

Several things tend to form troublesome active trigger points. Overuse of a muscle - simply doing too much, too soon -  is a common factor. This could occur with an athlete that increases their training to quickly. A muscle that has decreased strength but is placed under a high demand will also often have trigger points. This often occurs with our shoulder’s rotator cuff muscles. They usually aren’t as strong as they should be and when we suddenly decide to clean out the garage the trigger point pain starts afterward. Trauma that suddenly strains a muscle can also be a cause of active trigger points. The low back muscles have this issue frequently, especially as repeated injuries have occurred the years. Tendon injuries commonly benefit from dry needling the muscle that attaches to the injured tendon. One of the best times to use dry needling is for a neck or low back injury that is causing nerve irritation. Relaxing the deepest muscles around the spine can decrease the nerve pain.

Are there other ways to fix trigger points?

Yes and no. Some trigger points are near to the surface and can be treated with techniques like myofascial trigger point release or massage. However, some trigger points are very deep and do not respond well to these techniques because there is so much muscle and fatty tissue to get through. I tend to favor trigger point dry needling because it achieves a great result with much less time per trigger point site. I can often have a more positive impact with dry needling three sites in 90 seconds than myofascial release to a single site that takes 4-12 minutes.

Footwork Friday - Why am I developing black toenails?

Many runners develop black toenails, especially after longer runs. This is a very specific type of bruising known as a "subungual hematoma." It has often been believed that this is caused by the shoe's toe box size restricting the toes to so much that direct trauma and bruising develops. This isn't always the case, and The Gait Guys suggest that there is another cause in one of their older blog posts.

Many runners tend to curl their toes downward in an effort to grip the inner surface of their shoe. In addition to black toenails, another sign of this habit is the presence of a callus on the very tip of the toe. Curling your toes downward requires heavy use of the flexor digitorum longus and/or flexor hallucis longus muscles. Using these muscles is a way to gain stability within the shoe, but it is not a good habit. Regardless of the presence of black toenails, this should be avoided because these muscles are not built to produce larger amounts of power or engage in constant stability control.

The area under a toenail has a large blood vessel supply close to the nail bed, so bruising occurs more easily with any vessel damage. Gripping downward combined with a small forward/backward movement of the shoe causes a shearing force through the skin and fatty tissue of the toes. That repetitive pressure with this shearing force against the insole is thought to be enough trauma to disrupt the blood vessels. The solution? Don't grip the shoe with your toes.

Shorter runs usually aren't enough repetition to harm the vessels, but longer runs will. Especially as we fatigue we  rely more heavily on muscles that aren't fatigued as much during shorter runs. Trail running could cause a greater problem because the trail surfaces are unstable and the runner will more frequently seek stability by gripping with the toes. Also, there is a greater likelihood of steeper inclines and declines that will cause more sheer force of the foot against the insole.

Although there isn't existing research to back up this idea yet, it makes good sense. Next time you are running, think about what your toes are doing. If you are gripping the inside of your shoe then STOP IT!

Let me know if you have any questions at mountainridgept@gmail.com. 

Balance and proprioception: overlooked training for runners and athletes with knee pain and other leg overuse injuries

After reading the title you’re probably wondering a few different things:

1. “What does balance have to do with being a good athlete?”
2. “What the heck is proprioception?”
3. “What’s for lunch today?”

These issues come up time and time again when I work with injured athletes from many different sports. I’ll address the first two questions and you are on your own for that last one.

Let’s review some anatomy first. There are specialized nerves in your joints, ligaments, muscles and tendons that help sense position and movement of your body. That sense is referred to as proprioception. Without these and other specialized nervous system parts you couldn’t close your eyes and know how your body is positioned at any instant. And you couldn’t stand up or walk in a stable manner. Clearly you don’t absolutely need vision to know where your body is or you would be watching your feet while you walk or run, right? By sensing position, these special nerves are also part of what keeps us stable so we aren’t just stumbling around like a drunk college student on Friday night. But many of us, even some of the best athletes, have poor proprioceptive awareness. For so many of us these proprioceptive pathways aren’t challenged often, and then the “use it or lose it” principle kicks in. Especially as we age, we begin to lose the efficiency of these specialized nerves. As these nerves degrade we can’t precisely place each leg with athletic movement. This decreased precision leads to poorer biomechanics that can be related to overuse injuries. Also, a previous or current sprain at the knee or ankle ligaments will negatively impact your positional awareness and movement precision because of the damage that a sprain will do to these special nerve endings. All in all, aging, previous injury and a lack of training stimuli are going to degrade the quality of your movement precision.

Do you think you have good balance and stability? Let’s find out in a couple simple steps. Try these in your bare feet.

1. Stand on one leg as long as you can without touching anything and count slowly. How many seconds can you last on each one? Less than 30 seconds? In that case you’ve got a lot of hard work to do. More than 30 seconds? Well that’s a good start but we’re only getting started.
2. Now stand on one leg as long as you can with your eyes closed. I bet most of you aren’t going to brag about this one. If you don’t make it to 30 seconds on one leg with your eyes closed then there’s likely to be some room for improvement in this aspect of your training.
3. If you have some kind of superhero balance, try standing on one leg, keeping the eyes closed and tilt your head backward or turn your head to each side. This is really hard and will likely stop all but the best balancers.

So what are you doing to train this aspect of your abilities? I imagine several folks are going to say “nothing” because they didn’t know it was important. For what is essentially very little effort, I’d suggest working on your balance, stability, and proprioception to improve your running and prevent injury. Here are a couple ideas to address this area:

1. Stand on one leg with your eyes closed. Sound familiar? If you are able to stand steadily on one leg with your eyes closed on a flat floor then stand on an unstable surface like a folded towel or pillow with your  eyes closed. Or, you could try moving your head as mentioned earlier. Aim for 30 seconds of the most difficult, but achievable, level. Switch sides.
2. Single leg Russian dead lift. One of my favorite exercises. In a standing position pivot your trunk forward from the hip of the weight-bearing leg. The other leg raises up behind you for every same degree the trunk goes downward. Don’t round your back. Repeat 8-15 times until the hamstrings and buttock muscles tire. Switch sides. You can do this with and without weight. 
3. Single leg step down. Stand on a single leg on the edge of a step. Drop down very slightly by bending the weight-bearing leg, keeping your weight back on your heel. Return to the start position. Don’t let your bending knee travel too far forward beyond the front of your foot. Think about keeping your buttock back. Repeat 8-15 times, at least until your hip muscles and quadriceps are getting tired. Switch sides. You can also do this with and without weight. 

Let me know how you do with these activities at mountainridgept@gmail.com. Easy? Hard? These skills become particularly important for runners and other athletes with overuse related knee pain, ankle pain and foot pain.

Exercise Tip Thursday - Take at least one FULL rest day every week, maybe even two

It's not the actual running mileage, the amount of weight lifted or the hard effort that makes you instantly faster and stronger. It's during the recovery (rest) in the days after that your body adapts to the stresses from exercise. The muscles and fascia (a connective tissue) generally require about 48 hours to return to baseline in a well-trained athlete. Less experienced athletes often need a third day. More experienced might only need 24-36 hours. Back-to-back days of exercise result in an accumulation of fatigue and muscle damage. This is especially true if you keep using the same muscle groups. Unless you are an elite or professional athlete then you should probably be taking more FULL recovery days. If you absolutely must exercise to stay mentally sane, get in something super easy like a slow swim or easy walk during one of the recovery days (which means it isn't a true full recovery day but an active recovery day). Otherwise, do some of the workouts that you need in a combined fashion. That means if you run five days each week and lift weights on two days then at least one of those weight training days is going to overlap with a run day in order to have a full day off. A day off is the perfect day to do your maintenance like foam and ball rolling for 5-10 minutes. 

Like the sign says, I'll be taking a full rest day after this triathlon is over. 

Please send any questions to mountainridgept@gmail.com. 

Healthy Work Tip Tuesday - 3 More Desk Work Tips for Neck Pain and Back Pain

1. Be aware of your use of bifocal glasses. I’ve seen many patients that inadvertently stress the nerves and muscles in their neck by spending so much time with their head and neck tilted upward to look through the bottom of their glasses. This tightens the suboccipital muscles at the base of the skull and contributes to a “forward head” posture. Some have opted to use a single prescription lens to avoid this position. It also helps to keep your glasses up closer to your eyes and not at the tip of your nose.
2. Stand up every time you take or make a phone call.
3. Keep your low back in a neutral alignment from left to right. It’s the same idea as the neck. Constantly curving the low back's spine one direction so you can lean on your chair’s arm rest is a recipe for disaster. This can commonly lead to nerve compression at the low back as well as muscle length imbalances.

Don't forget about the muscles

To some this may seem like a silly concept, but I’ve noticed that many patients and clinicians aren’t giving muscles their due attention. Pain can be generated from a variety of structures in the body, and I often see that one structure is blamed while an entirely separate structure actually generates the pain. This is particularly true with muscles.

Take the low back, for instance. The public has a tendency to blame the intervertebral disks between the bones for their low back pain. Yes, the disks tend to degrade with age, but that is no guarantee of pain. Many times, we are trying to find a single structure to blame for what is really a long-term problem that stems from a lack of activity and poor postural habits that weaken and stress the spine’s stabilizing muscles.

Another issue to consider is that structures can interact to cause pain. At the low back again, consider that increased muscle tension will change how the spine’s joints move and will change the stress on the nerves that exit out of the spine. In this instance it may be necessary to treat multiple structures. Both the muscle and the nerves could be causing pain. Also, weak spine and hip muscles may have led to premature wear and tear on the spinal joints and disks. There can be a lack of overall stability in the hip and low back region. Treating one area is insufficient.

Trigger point Pain referral pattern from the gluteus minimus muscle http://www.triggerpoints.net/muscle/gluteus-minimus

I expect we partly have an educational bias to blame for this issue. If instructors didn’t spend time describing muscle pain and appropriate treatments, then it must not happen that much, right? Unfortunately that's not true. Prior to the work of Drs. Travell and Simons in the 1940s, few practitioners cared about “myofascial trigger points” or muscle pain referral. And perhaps it’s difficult for the medical profession and the public to accept that a muscle generated or trigger point pain isn’t going to produce an extraordinary finding on an MRI, CT or X-ray image. And no matter what tissue it is, imaging does not guarantee pain in the presence of a damaged structure. Sometimes people have pain with little to no visible tissue damage.

Often there are patients who do have a good understanding of the underlying problem because they are able to touch the affected tissue and have figured out that massaging or placing pressure on the correct muscles makes them feel better for a while. That’s a good sign that soft tissue treatment techniques would be effective. A good exam and assessment all of the appropriate structures is the key here. Physical Therapy and certain types of massage therapy would be excellent methods to treat this type of muscle pain. Following up the hands-on soft tissue work with strengthening exercises is a great option to prevent recurrence.

Please let me know if you have any questions about muscle pain identification and treatment at mountainridgept@gmail.com.

Footwork Friday - Runner's bump

I thought I would throw this one out there since it's recently affected my running on a small level. A couple weeks ago I noticed I was developing a small bump at the base of my anterior tibialis tendon after a long run. Getting old is such a great thing isn't it?! It hasn't really been painful but the bump will snap up and down if I have my shoes laced tightly. It's a synovial sheath irritation in the slick layer that allows the tendon to glide smoothly. 

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Runner's Bump

Ultimately, excess lacing tightness is what caused the bump to form. I have a habit of really cinching down on my shoe laces and this caused some increased stress on this area. Now, if I was to over-tighten the laces, it would cause the little bump to snap up and down under the laces and eventually swell even larger. So that's clearly not ideal. The repetitive snapping is annoying and might become painful with enough exposure. I'm not waiting to find out. Another factor that could contribute is frequent uphill running because it would cause you to increase the use of the anterior tibialis muscle and tendon, close the ankle joint up further and increase the friction across the front of the tendon against the shoe. My right foot collapses inward slightly more so the tendon may experience slightly more stress from that as well. 

As a result I've done a slight modification to my lacing pattern to relieve the area of its pressure. By changing the lacing pattern the bumped area reduced significantly in swelling and overall size. Applying ice is another good measure to help decrease localized swelling and pain. 

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These types of bumps will also sometimes occur at the Achilles tendon from the heel cup of the shoe rubbing the tendon repetitively. In any case you could modify the shoe by cutting out a small portion of the heel material that is rubbing or get into another pair of shoes that doesn't stress the area. 

Please let me know if you have any questions about shoe lacing patterns or tendons forming mysterious bumps at mountainridgept@gmail.com. 

Achilles tendonitis: Early self-treatment and when it's gone too far, Part 2

In part 1 you learned the basics of treating a recent onset of Achilles tendonitis. Much of that should emphasize the soft tissue mobility of the lower leg (which is more than just stretching). For those of you that don't have a grasp on how to be working on the soft tissue of your lower leg with foam rolling, self-massage and other techniques, check out my post and video here. 

If reduction of mileage, over-the-counter anti-inflammatories and ice don't help knock out the pain then it is very likely that you are no longer dealing with an inflammatory condition. The tendon area could feel increasingly stiff and tight after you have sat for a while and then place weight on the leg or when you first put weight on the leg in the morning after sleeping. When that initial inflammatory stage has started to pass in 2-4 weeks and you still haven’t gotten anywhere because you continue to have pain, then consider professional guidance. This is especially true if the injury keeps occurring or you notice the Achilles tendon itself remains swollen or is thickening in size or is forming hard nodules. Another issue to note here is that pain where the Achilles tendon attaches to your heel will often be harder to treat and slower to resolve. Indications for seeking professional help immediately would be: 

• any indication of bruising in the heel or Achilles area

• inability to bear enough weight to walk normally with that leg

• you felt a "popping" sensation at a single moment of injury

• you can't make your calf contract firmly to point your toes downward or can't perform a calf raise

If you feel any of these situations apply to you then you need more immediate attention with a medical professional. 

There are several things to consider with advanced examination and treatment. First being the findings of neurological and musculoskeletal exam. Second being running gait evaluation results. Third being training errors, footwear, terrain and so on. 

If you recently changed your running technique so that you land forefoot first and push off heavily from your forefoot then you might want to reconsider jumping into that abrupt change. If you are an aging runner this could be especially risky. There are often balance and stability deficits that result in poor control of the entire leg, which we will discuss in a future blog post. I would also suggest strengthening your hips. It is very common for me to see knee and ankle injuries on the same side as an athlete's weaker hip muscles. This feeds back into the stability control problem. Your movement needs to be precise.

Any care needs to consider the phase of healing that the tendon is in. The illustration below summarizes this nicely. Ultimately, we are interested in the Achilles having an appropriate level of collagen (scar) deposits and remodeling those deposits to support the injured area. That sounds simple but if you look at the time frame along the bottom axis of the graph you will notice that collagen is being placed as early as 3 days but needs to continue for weeks to months afterwards. Tendon healing, unfortunately, tends to lean toward weeks and months, which is why you shouldn't delay proper care and ignore the pain. This doesn't mean you won't be able to exercise during that time. 

PHases of injury healing, From Daly TJ: The repair phase of wound Healing, re-epitheliazation and contraction. In  Kloth CL, McCulloch JM, Feedar JA (eds.): Wound healing: alternatives in management. philadelphia, FA davis, 1990, p 15. 

Tendonitis and a tendinosis are both treatable with some of these techniques in common and some techniques being very different. Tendinosis, the more degenerative condition, requires heavy commitment to a home exercise program to perform strengthening exercises as well as manual therapy in the clinic to decrease scar adhesions, increase ankle motion and maybe even provoke an inflammatory response in the tendon area again. The strengthening must be performed frequently enough and with enough difficulty to force your tendon to adapt, similar to your normal exercise routine. The trick is knowing how much pain to push through. Both injuries can be treated successfully. 

Mid-stance of running gait

The good thing is the human body is adaptable. The bad thing is it takes time and effort. Depending on where you area in the injury process, you might be able to run again sooner with some simple running gait changes to decrease the Achilles tendon load, proper strengthening, balance training, decreased training stress and properly addressing calf muscle tissue integrity. 

To receive updates as each blog comes out, complete the form below. Email your questions to derek@mountainridgept.com. We'd like to get you back to working out and running as soon as we can. Please share this article with your running friends! 

Footwork Friday - Basic Lateral Agility Drills

Welcome to Footwork Friday where we introduce agility drills, strengthening, and muscle care techniques for the athlete who understands how important their feet and legs are in carrying them through to the next step in their active lifestyle. 

Runners and many other athletes don't get enough lateral movement in their training. This is why we tend to weaken in side-to-side movements and we also tend to become injured because of instabilities side-to-side. Even in an uninjured state, learning to stabilize the body to prevent lateral movement can be very useful to move quickly and safely across unstable surfaces like rocks, roots, grass and mud. As far as pure performance is concerned, increased lateral movement is an energy waste when you are trying to move quickly forward.

The agility efforts do not need to be long. The technique just needs to be as accurate as possible. Like I've shown in the videos, a 10-15 yard section is plenty long enough. Go through each drill 2-4 times. For any agility drill I recommend fully recovering between efforts because you are ultimately trying to train your nervous system, not your heart or lungs.

Initially, for the first drill, focus on keeping the contact light and not crossing one leg over the other. Strive for keeping the body tall. As you learn what it feels like to "stick" the outer leg, try to make sure your knee is staying straight over top of your foot. In other words, the knee doesn't bow inward or outward. It does need to be bent for a soft landing though. This is commonly done with an agility ladder but I prefer to do them in the middle of a short and easy run or a moderate distance run to keep the right muscles awake. As you get faster you can focus on lowering your body closer to the ground. 

For the second drill focus again on light and quick contact with the ground. Emphasize keeping your stance wide and pumping the arms directly forward and backward. I like to do this in the middle of my runs as well. Just be careful because it will skyrocket your heart rate and effort levels very quickly.

Have fun and let me know if you have any questions at mountainridgept@gmail.com

Healthy Work Tip Tuesday - 3 Desk Work Tips for Neck Pain and Back Pain

1. Keep your neck in a neutral alignment from left to right. Many of us tend to lean our heads to one side or the other. I’ve seen numerous patients who lean toward one side begin to have pinched nerve symptoms on that side, and that’s not a coincidence. Over time, it also tightens the muscles on one side of the neck while lengthening the opposite side. This creates further imbalances that can lead to pain and headaches.
2. Make sure your computer monitor is directly in front of you. Multiple times I’ve had patients who eventually pinch nerves in their neck and develop arm pain because they are turning their heads slightly to one side for long periods to look at their screens.
3. Stop crossing your legs. Chances are that when you cross your legs it’s always with the same pattern of right over left or left over right. Unbalanced habits like this stress the hip muscles asymmetrically. Make the hip muscles unhappy, and you will eventually make the back unhappy and vice versa.

Fixing overuse running injuries with Heather Parks

This week I had the pleasure of working with local runner Heather Parks on addressing some of her long-term running injuries. These old injuries include Achilles tendonitis, piriformis syndrome, and multiple ankle sprains along with current foot pain. She has been distance running since she was a young teenager and like many of us, has had some of her injuries show up multiple times. To compensate, she has done what many runners might do: try out different kinds of shoes, add an over-the-counter foot orthotic, ice the injured area and start training the core muscles more. Oh, and ignore some of the pain. Runners are great at ignoring pain and we consciously or unconsciously change our techniques sometimes. 

These adjuncts have given her some success, but neglecting proper treatment over time would lead her back to the same types of pain. Recurring themes are an indicator that something is mechanically deficient.

Now Heather is no slouch when it comes to running. She’s run in the US Olympic Marathon Trials. So she’s put big demands on her body in the past, responded well and come out on the other side with greater fitness. Our bodies become really good at improving efficiency within the constraints that they are given. If you learn to run fast with a decreased amount of hip motion, for example, then you have accomplished your goal of running fast but with less than ideal biomechanics. But how long can you keep up this high intensity and high mileage before something in the body begins to wear down prematurely because of the restricted hip motion? The same goes for restricted ankle motion. Someone that is in spectacular physical condition, like Heather, is going to be more resilient. But with time, mileage, and previous injuries, the little mechanical flaws start to add up and pain starts to creep in.

Increasing her intensity with track workouts and turning on the tight corners of an indoor track would stir some of these things up predictably. Running track turns are very repetitive when performed in the same direction and force us into a slight asymmetry with every step. Wearing racing flats would increase her pain as well. This is likely related to the lowered heel height of the shoe that places more load on the calf and Achilles tendon.  Despite decreasing her mileage earlier this week, Heather continued to have right heel pain multiple days later. She had a hunch her history of calf and Achilles pain could be related. And it is. But we’ll get to that later.

First, let’s look at her examination findings. Initially, I noticed a significant right calf muscle atrophy (smaller muscle). When instructed to do a calf raise onto her forefoot Heather did 20 repetitions on her left side but only managed 10 on the right side - and the technique was lacking. She demonstrated weakness of both hamstrings groups (but worse on the right). Her right gluteus medius muscle at the hip was a grade weaker than the left side. She was unable to squat fully to the ground while keeping her entire foot in contact because of the shortness in her lower leg muscles. She was also unable to squat fully because of her tendency to be reliant on her quadriceps muscles and is unaware of how to to use her hip muscles for strength and stability. When squatting on a single leg her right knee tended to drift toward the midline of her body, which is a sign of poor hip control, again linking back to the weak gluteal muscles. Her single leg balance with her eyes closed was better than many people at 16 seconds on the right leg and 12 seconds on the left leg but I’d rather both of them be at least 30 seconds. Heather could hold a side plank on her right side for 45 seconds but could manage only 25 seconds for the left side.

Right calf with decreased muscle mass

Watching Heather run on the treadmill, it was noticeable that she occasionally had her right leg land closer to her body’s midline instead of directly under her hip joint. I never saw the left leg do this. This was not a huge amount by any means, about ¾” to 1” of deviation. Less experienced and weaker runners commonly land with both of their feet heading toward midline, often because of decreased hip muscle strength or activation issues. Also, it was apparent that her right ankle was rarely moving through its full available range of motion and this would cause her to prematurely lift her heel from the ground during the running stride and lead to a rocking over the base of the big toe. It also caused the right heel to whip out just before her foot lifted from the treadmill. By relying on the foot to do the work of the ankle she has demanded more from the muscles and tissue within the bottom of the foot.

Left heel remains in alignment

Right heel whipping laterally

In general, many of these are meaningful asymmetries, or imbalances. Distance runners don’t do well with asymmetries because we go through thousands of repetitions and then fatigue later in a run makes any flaw even more catastrophic. Heather’s physical examination correlates well with her running technique. She uses what strength and motion she has to perform the task of running. Can we fix a couple things? Yes!

Afterwards, I used trigger point dry needling on her right foot to help with the tenderness and pain there. I also used the needling at her lower leg to loosen some of the calf muscles. This did cause soreness at her calf but upon standing, her heel pain was gone. I then taught her a handful of exercises to reinforce the motion increases at the ankle and teach her how to allow the ankle’s available motion. This ankle motion will not translate directly into her running right away and will first take work in her home exercise program. She also started working on the “penguin walk” activation exercise to help her learn to use the gluteus medius more on the right side with running. Heather was able to return to running at a high level on the same day with a 6 mile tempo run at 6:30 per mile pace with minimal pain.

We will meet again in the next couple weeks to see how she is progressing with her exercises and spend more time on the manual therapy required to increase her ankle motion and decrease stress on the foot and lower leg.

Footwork Friday - Foot muscle rolling

Welcome to Footwork Friday where we will be introducing agility drills, strengthening, and muscle care techniques for the athlete who understands how important their feet are in carrying them through to the next step in their active lifestyle. While you are beating the heck out of your feet out there, think about the health of your feet every so often. Our feet can be very resilient, but when they start to go south then bad mechanics tend to snow ball, leading to other leg and hip injuries. Take care of them before they head south. 

Today's topic is simply about rolling the muscles of the feet. It seems simple but I want you to do it correctly. Sure, it's fine if you sit in a chair and roll a golf ball up and down the length of the bottom of the foot. Many people do this and that's great and easy to do. I just want you to realize that you may be neglecting two of the most important muscles: abductor hallucis and flexor hallucis brevis. This is because they are on the inside of the foot. And they do a ton of work stabilizing your inner arch. 

To get to them you have to pick up your foot and roll the inside of the arch and heel with a massage stick, golf ball, dowel rod, etc. I've colored the abductor hallucis muscle in red and flexor hallucis brevis muscle in purple in the photo below. Don't roll onto the bones.

Abductor hallucis (red), flexor hallucis brevis (purple)

If you want a primer on my version of proper rolling altogether, see my earlier post here. 

As an aside, if you are having pain more toward this inner side on the bottom of your foot then there's a good chance it can come from these muscles, not the plantar fascia that is often blamed. 

How to effectively roll and loosen muscles for soft tissue maintenance and athletic success

It seems that several people know they should be foam rolling or doing their soft tissue maintenance but few are actually doing it or know how to do it. The video is much more detailed and I use two areas for examples though the techniques could be used on most muscles in the body. Be warned that the more aggressive the technique then the more likely you are to get sore.

***Not to be taken as medical advice. Techniques are intended for healthy, uninjured, active individuals.***

Consider the following tips:

• Your best location is on a carpeted floor, larger rug, or a yoga mat to provide just a little cushioning but otherwise is very firm
• Proceed more conservatively until you realize how your body is going to react
• Only roll or release the same area once every 2 days until you see how sore you are going to get and then you could do it daily
• It should be uncomfortable, maybe 5/10 on the 0-10 pain scale but will improve with consistent work.
• The most tender areas tend to need the most attention but don’t overdo it
• The steady holding techniques should noticeably improve in a matter of minutes.
• Steady pressure techniques should be maintained until the muscle progresses from tender and uncomfortable to not tender and a sense of pressure only
• You will have to shift your body weight to vary the pressure
• It’s ok to have referral discomfort from the muscle which would be an aching, not a pins and needles or tingling sensation
• Be cautious of numbness or tingling sensations further away from the area you are working on as you could be compressing fragile nerve structures
• Start with shorter bouts of rolling or pressure and go longer or aim for more reps when it becomes harder to find involved areas
  • beginner 10 reps or 20-30 seconds of rolling
  • advanced 40-50 reps or 2-3 minutes of rolling

The main techniques, regardless of device are:

• BEGINNER: strictly rolling up and down the full length or partial length of the muscle while the muscle is more relaxed
• BEGINNER to MODERATE: rolling up and down the full or partial length of the muscle while the muscle is under a stretch
• BEGINNER to MODERATE: moving the local joint through motion while you sustain a pressure on a specific tighter area in the muscle
• MODERATE to ADVANCED: placing a sustained pressure on the muscle at a specific tighter, tender area in the muscle and waiting until it doesn’t feel tender any longer
• SUPER ADVANCED: placing a sustained pressure on the muscle at a specific tighter, tender area in the muscle while it is under stretch and waiting until it doesn’t feel tender any longer