Case Study: The use of Kinesio Tape as part of an Integrated Soft Tissue Treatment Plan

After much scepticism, and lack of available scientific proof on the effectiveness of Kinesio Tape in injury rehabilitation I decided to study Kinesio Taping with the KT Association UK in 2013.  I wanted to see for myself what was involved and more importantly what results could be gained by integrating Kinesio Tape to my treatment of clients with soft tissue imbalances.  From the simple tapings we began with on day one it was clear there was something to this technique, as we increased our range of motions by simply adding tape to either facilitate or inhibit muscle groups.
Over the course of the Fundamental and Advanced Concepts courses we learnt that in addition to muscular Facilitation and Inhibition, Kinesio Tape can also be used to achieve many other treatment goals.  Take for example ‘Mechanical Corrections’ e.g. aligning the tracking of the patella, ‘Lymphatic Drainage’ to help decrease inflammation, ‘Tendon Correction’ to support the healing process of tendon injuries and the ever useful ‘Space Correction’ tapings for pain relief.

To put this to the test, I selected a client with quite an acute problem to document the use of Kinesio Tape in her treatment and the results achieved.  The results were quite outstanding and I have gone on to use Kinesio Taping on many clients with a variety of issues, but the most instant results I have seen are with clients with osteoarthritis of the knee.
Case Description

The patient is a 57 year old female, presenting with osteoarthritis of the right knee.  The client had a fracture of the right femur 25 years ago resulting in a leg length discrepancy due to shortening of the femur on healing of the fracture.  The client has also had her C4 vertebrae removed and C3 and C5 fused resulting in neurological issues in the right leg meaning that pain is felt as tickling, hot as cold and cold as hot.  These injuries have culminated in early onset osteoarthritis in the right knee joint.    
The client plays 6-8 hours of tennis & squash a week and has been finding it increasingly difficult to move around the court.  The client has been receiving soft tissue treatment from me for 6 months which has helped increase flexibility and decrease pain but the condition of the knee has been deteriorating over the last couple of months.  In the days leading up to the first treatment using Kinesio Tape the client’s leg has been hyper-extending and she has struggled to bend the right knee.  The knee loosened up somewhat over the weekend and the client played a tennis match on the day of the first Kinesio Tape application and again the right knee began to lock out and the client could not bend her knee.  At this point the client requested assessment and treatment using Kinesio Tape.  Client has also been referred by her GP to see an orthopaedic knee surgeon for possible knee replacement.
Clinical Assessment

Subjective Assessment
Right knee significantly inflamed.  Client has been sitting with leg up straight to help alleviate swelling in the knee but leg then locked in hyperextension.  On playing tennis the right leg loosened up and some more movement was possible.  The following tennis game caused the leg to stiffen up once more and the client again lost the ability to flex the knee.
Objective Assessment
·         Knee Flexion – approx. 10⁰.
·         Knee Extension – Hyperextended approx. 15⁰ .
·         Knee Medial & Lateral Rotation – Not possible to test due to lack of knee flexion.
·         Rectus Femoris and Vastus Lateralis hypertonic.
·         Anteriorly tilted pelvis Right and Left.
·         ‘Glute Firing Test’ indicates lack of glute strength.
·         No pain on assessment but client indicated ‘tickling’ feeling on contraction of the quadriceps group. Note due to existing neurological issue ‘tickling’ relates to pain for this client.
Treatment Plan

The short term plan is to reduce the swelling of the knee and increase mobility.  We cannot undo the cartilage damage in the knee joint but the client wishes to prolong pain free movement until a knee replacement is performed to allow her to play tennis and squash.  We agree to aim to do this my ensuring her quadriceps remain strong but flexible, by reducing the swelling of her knee, increasing the proprioception and strength of her glutes and hamstrings to support knee flexion.
Session 1
Post tennis match a web space correction using Kinesio Tape was applied to the right knee.  Client could instantly increase knee flexion to 45⁰ which allowed the client to get about her days activities. Appointment made for a 60 minute treatment the next day.
Session 2 – One Day Later
In this session a number of soft tissue techniques were used to release tension in the hip flexors and quadriceps.  Light flushing and effleurage was used to reduce swelling around the knee joint.  Proprioceptive techniques used to engage the glutes and to kick start the rehabilitation of the hip alignment and its impact on the arthritic knee.
The following taping was applied as a ‘Functional’ Taping to Support the clients tennis match the following day:
  • Web Space Correction over the right knee to increase space and allow for greater drainage away from the joint itself
  •  Lymphatic drainage to reduce knee inflammation
  • Facilitate Quadriceps Group
  • Functional Correction to support knee flexion
  • Facilitate Hamstring Group
Following the three days of racket sports, the following taping would be applied as a ‘Recovery’ taping:
  • Web Space Correction over the right knee to increase space and allow for greater drainage away from the joint itself
  •  Lymphatic drainage to reduce knee inflammation
  • INHIBITION of Quadriceps Group
  • Facilitate Hamstring Group

Homecare for the client included glute strengthening work and hip flexor & quadriceps stretches.

NOTE:  These tapings were tailored for this client’s specific situation and vary for all clients; I have used different tapings for different clients with osteoarthritis of the knee depending on the condition of all soft tissues involved.
Session 3 – One Week Later
Client has reported significant decrease in inflammation of the knee and increased mobility on the court.  In addition the knee has not locked in extension since the Kinesio Taping integrated treatment commenced.  In today’s session I taught the client how to ‘self tape’ so that she could tape her knee between sessions as we switch to a monthly ‘maintenance’ treatments to help maintain her flexibility.
Session 4 – One Month Later
Client has now reduced to taping to simply using the supportive taping for the days when she plays racket sport.  No longer requires the hamstring or functional limitation taping on the back of the leg & knee.
·         Knee Flexion – approx. 100⁰.
·         Knee Extension – Hyperextended approx. 10⁰ .
·         Knee Medial & Lateral Rotation – Very slight rotation available.
Outcome

Week 1 Progress Update
Swelling of right knee significantly reduced.  Increased range of motion but knee still feels unstable.

Week 6 Progress Update
Knee stability and range of motion increased and client is now back to playing 6-8 hours of racket sports a week.

6 Month Progress Update
Client has seen her orthopaedic consultant twice since initial treatment and her knee replacement has been delayed for at least another 6 months due to the increase range of motion in the knee and increased quality of life since treatment began.

Client Feedback
‘Before the start of my treatment, I was in almost constant pain, with my knee keeping me awake at night, permanently swollen and stiff. I was desperate to keep playing tennis and squash, but could hardly walk after a game and the pain was awful. It was affecting many aspects of my everyday life and making me feel quite miserable.
From the very first application of the Kinesio Tape, I felt an enormous improvement, with the pain greatly reduced and the stiffness gone. Over the weeks and months that followed, using the tape for five days every week, I noticed that the muscles around my knee were getting stronger and I can walk longer distances and without a pronounced limp.
I can now play tennis or squash on consecutive days and am moving much better around the court, with no stiffness in the knee afterwards. The swelling has virtually disappeared and I can walk without pain again and am sleeping better. The Orthopaedic Consultant was delighted with the improvement and my planned knee replacement has been postponed for at least six months.

It is hard to believe that such a simple, non-invasive treatment could make such a difference, but I feel like a new woman!’

Muscle Imbalance: The ‘Long’ and the ‘Short’ of it.

Ever had an ache, pain or strain that no matter how much you stretch it out doesn’t seem to disappear?  Well you certainly are not the first or even last person who has expressed this frustration to me followed quickly by ‘Can you just give it a rub for me?’.  Well maybe all this stretching and rubbing is just making the problem worse.  It is important that when you do have muscular pain that you understand the cause of it so you can treat it effectively and get you pain free again.
Muscles work in pairs, a glorious evolutionary trait.  If we look at the simple joint in this illustration, when we want to flex the joint forward, the muscle on the inside (the agonist) contracts and shortens.  In response the opposing muscle (the antagonist) relaxes allowing the joint to move freely without much obstruction.  The Central Nervous System (CNS) works tirelessly to ensure that the messages between these muscles exchange helping us to move without thought or issue.

So what happens when we have chronically tight or shortened muscles?   If our posture is such that we have a muscular imbalance, and believe me I am yet to meet someone who hasn’t, this chronic shortening of a muscle can cause a problem.  At a basic level, if the CNS is busy sending the ‘contract’ signals to the shortened muscles, it may also be sending the ‘relax’ signals to the opposing muscle on a consistent basis leaving these muscles in a weak state. Where this leaves us is with a muscle group that needs to be strengthened, not stretched, and a group of muscles that may not be causing you discomfort but that need to be stretched. 
Let’s take the hip for example.  I commonly see clients who have a forward (anteriorly) tilted pelvis (common in those who sit a lot, cycle a lot etc.) but come to me complaining of tight, stiff and sometimes painful hamstring and how stretching has not helped release the tension.  In many cases this pelvic tilt is caused by tight hip flexors, quads and lower backs.  This pulls the hamstrings and glutes into a lengthened, weak position giving the client this feeling of being tight.  I like to think of this as being ‘taut’ rather than being ‘tight’, if we release the real culprit or ‘tight’ muscles it takes the pressure off the ‘taut’ hamstrings releasing the tension and restoring balance.  At the same time we add some strength work for the abdominals, glutes and hamstrings restoring balance and hopefully getting you to a place where you feel great and prevent re-injury.  Have you ever thought that stretching your hip flexors may sort out your ‘taut’ hamstrings?  Maybe this illustration helps this make sense to you:

Simples!  I hope you now understand why sometimes we as therapists work the areas that are not causing you pain to get you better quicker and for longer.  If you have a persistent ache or pain it may be worth seeing your local sports therapist for a bio-mechanical assessment to see what is going in for you and then working together on a rehab plan to get you back to balanced.  Full solutions for full recovery! 

Related Links:
Jandas Muscle Imbalance Syndromes: http://www.muscleimbalancesyndromes.com/what-is-muscle-imbalance/

Self Help Sunday: Self ‘Energise’

While enjoying the balmy 18 degrees of sunshine in London today I bumped into an unusual character  – an American Bull Snake on the 10th tee box at Chingford Golf Club… seriously!! (see picture for proof!)  Kind of freaked out I asked the man sitting looking at him if he would be scared and bite me if I hit the ball when he duly informed me that there was no risk as his snake was simply ‘energising’ himself in the sun and was feeling pretty lethargic after a long winter.
What a thought?  Is that all its takes to ‘energise’ ourselves? If you were lucky enough to be out in that sunshine today I bet you are feeling energised, awake and quietly content right now?  Who didn’t smile when they felt those warm rays on their skin today?  Well I certainly did.

Sunshine is a natural anti-depressant, it raises serotonin levels reducing stress, anxiety and leaving us with that ‘feel good’ factor.  It can be hard coming out of our winter shell.  We, like the snake have maybe been feeling slugglish of late, a little down, tired or cranky but we have the ability to lift ourselves up and out of this slump and face Spring with a bounce in our step.
In case you are not convinced here are some awesome reasons why  a good walk in the Sunshine is the easiest way to improve your well being:
   ~ Sunshine increases the oxygen levels in our blood and the delivery of oxygen to the tissues of the body helping to keep our muscles feeling good and filled with energy.
   ~ Sunshine increases vitamin D levels in the body which in turn helps us absorb calcium, making our bones stronger.
  ~ Sunshine helps the body heal and can even kill bacteria! A natural disinfectant.
  ~ Sunshine boosts your immune system helping you to keep the sniffles at bay.
  ~ There is even some research pointing to Sunshine reducing blood pressure and the risk of heart disease.
I think that is reason enough to get outside and make the most of the Spring sunshine, don’t you?
See you next Sunday!

Pentony

The Experiment: Goodbye and Hello

I am sorry to hear that Carl Watts has decided to step down from the Experiment.  On the positive side though I am very glad to hear that he has decided to do so to spend more time with his family.  I completely believe in balance – in body and in life so this was the right thing to do.

‘ Apologies for the delay in this post
Carl spoke to me after Christmas and said that whilst he was striking the ball better than ever, he had been thinking over the Christmas period that he no longer felt he could commit to the experiment as he didn’t want to spend the time away from his children that competing again could lead to. As a father myself, I had brought this up at the start of our work together and always felt that this would be a problem and so we have brought to an end his experiment. Carl and myself remain good friends which is important to me.

As an aside to this I will continue blogging the progress of a couple of my other golf professional students and look forward to sharing this with you.’
Andy Traynor, Chingford Golf Club, PGA Professional

On another note, Andy has asked me to work with himself and a young golfer a view to getting him on Tour in 2 years time.  I am very excited to be part of this team and look forward to documenting our progress in the coming months.
You can follow Andy’s blog at http://www.andytraynor.co.uk/ and I will blog on the biomechanical aspects here.
Releated Links

Sit Less & Breathe More: Breathing Yourself a Better Body

Breathing, the essence of life.   Oxygen fuels every fibre of our body, but are you getting enough oxygen to make your body as strong and as healthy as it can be?

A core element of our training as Sports & Remedial Massage Therapists is that deep, diaphragmatic breathing is essential in healing your body post injury.  The chemical reactions required within the body when healing an injury need oxygen as a component but it is also used to remove the toxins created in the process.  A lack of oxygen leads to a lack of good healing.  But I wonder is there more to breathing than fuelling our body’s chemistry? 

The Physical Side

Why is the activity of breathing any different from other activities we perform using our body, where if our ‘technique’ is poor it can cause dysfunction and imbalance?  What’s more is we breathe every second of every day so the impact is vast.   Let’s take inhalation for example.  The Diaphragm is the primary muscle involved and responsible for approximately 45% of the air that enters the lungs in normal breathing, we then have the Intercostal muscles responsible for another 25%. Finally there are group of muscles that act as a support including the Scalenes, Sternocleidomastoid and Pectoralis Minor that when contracted help to lift the rib cage up and out for that final 30%. 

Where I am going with this is that the most common breathing pattern I see in my clinic is the ‘Shoulder Breather’.  They generally come to me with a neck complaint, screaming Scalenes, raucous Rhomboids, you know the m.o. and more often than not the client also presents with an anteriorly tilted pelvis.  On examination it sometimes becomes clear that yes there are shortened, tight muscles that need to be released but in many cases a good long deep breath highlights that the Pectoralis Minor and Scalenes are the work-horses when it comes to breathing, while the Diaphragm is simply a passenger on the journey. Not only is this significantly reducing the amount of oxygen they intake with each breath but it is also causing them physical dysfunction and pain.

I find these clients are the ones who struggle to get relief; they have seen many therapists but always come back for more because the neck stiffness returns as the cause has not been addressed.   Is their breathing pattern the cause?  You can release the Scalenes all day long but if that client simply walks out your door and continues to breathe in the same way then there is no sustained relief.  You change their breathing pattern and suddenly it’s a whole new world! Their Diaphragm kicks in on inhalation, their abdominals engage on exhalation and this change in pattern starts to pull their hips back into line.  Your client has more energy, less pain and a stronger body that is starting to align itself against gravity. 

The Emotional Side

Anxiety, Stress, Restlessness, some of the horrors of our day to day lives.    Having suffered panic disorder in my younger years I can testify first hand to how important breathing is to not only physical but mental health.  Try this, next time your heart is racing, from fear, panic or simple over exertion, slow your breathing right down, try to get to that 7, 8 second breath and feel your heart slow down with it.  Breathing is an important part of Heart Rate Variability (HRV) which is linked with decreased stress hormones and improved heart function.  Good breathing engages our parasympathetic nervous system which releases those yummy neuro-chemicals that relax you, elevate your mood and combat physical pain.   Do you remember the last time you were stressed or anxious?  Were you holding your breath?  Were you holding tension in your shoulders?  Breathing can be the catalyst needed to break the cycle of physical and emotional pain.

All of this makes me wonder…… I often call our generation – ‘The Anxious Generation’ as the levels of stress and anxiety seem to be on an upward scale rocketing off the chart.  Why is it that we are so much more anxious than our ancestors given that we seem to have so much more?  More and more our lives revolve around sitting down – work, television, computer games, we sit more than we stand.  Sitting flexes our hips, inhibits our abdominals, our diaphragms and we are back to our ‘Shoulder Breather’ pattern, we are getting less oxygen and become more stressed.  Could it be something as simple as breathing properly could change things?  Well what is to stop you trying – go on, saturate your cells with delicious oxygen, practice deep diaphragmatic inhalations and follow strong and controlled abdominal exhale.  Why don’t you aim for 10 breaths a minute and see what it does for you?

Related Links:

Nutrition for Healing – Food for Thought?

Nutrition is not something I have thought in depth about when it comes to treating my clients.  Yes I cover the basics and understand the main things to consider but at a detailed level I simply haven’t gotten that far.  Just before Christmas a series of events changed this and made me realise more than ever just how important what you put in your body is to your overall health.

I attended a wonderful course at NLSSM in November last year with the fabulous and energetic Jenny Burrell www.burrelleducation.com on pregnancy and post natal massage.  One topic we discussed at length was how important nutrition was to new mums.  What I took away from this was that our bodies simply cannot heal or heal well without giving it the key nutrients it requires to produce all the bits and bobs necessary for healing.  Now write this down – Vitamins A, C, E and Zinc are the four most important things to remember.  I duly jotted these down with a note to look into it further in the New Year.


On that same weekend I picked up a copy of a super healthy cookbook to inspire me to create some nutritious and satisfying dishes….. that leads me to ‘the event’.  Exactly one week later I opened the cookbook and decided to cook some nutritious gluten free energy bars for me to snack on the go.  Dates, check, Coconut flour, check and off the blender went!  Seconds later it came to a stop.  In a hurry as always I looked on the underside of the blender and saw that one of the dates had a stone in it and it had got caught.  Well let’s just say I will never go near a blender blade again that is not plugged out!

I will spare you the gory details and skip to two days later with stitches in place, blender in the bin and my feet up on the couch.  I sat and thought long and hard about what to do.  My hands are my livelihood and it was imperative that my finger healed as quickly as possible when I remembered Jenny’s advice.  That was it – the perfect experiment.  Could I eat myself a healthy finger and fast? 

Nutrition In

So where to start? I am not a one for taking supplements as I believe that we should take vitamins the way the earth wanted us to – naturally.  So what followed was lots of google time to come up with the perfect healing menu:

Vitamin A

Carrots – the Vitamin A magic food.  Reading online just one medium carrot provides me with what I need for the day.  I went carrot mad – carrot juice, carrot soup, carrot salad.  I am pretty sure I had an orange tint to my skin for the last 6 weeks.  If you are not into carrots then lots of other foods provide Vitamin A – Dark Leafy Green Veg like Kale, Sweet Potatoes, Dried Apricots and Cantaloupe melon to name but a few.

Vitamin C

The easy one, I thought we all know how to get our vitamin C – citrus fruit.  Oranges quickly got added to my morning carrot juice.  More interesting were the not so obvious ways to add this key nutrient to my diet – chillies, bell peppers, again those dark green leafy vegetables with one stalk of broccoli providing your daily needs.  Broccoli my wonder veg!

Vitamin E

Now this was the difficult one, I had no idea what would provide me with my needs.  Scouring the internet the top hit was Tofu (no likey) but again keep looking and there will be something that works for you. Spinach (me likey), Avocado, Wheatgerm, Almonds & Sunflower seeds.  What I found hard was the volume you would need to eat to get your recommended daily allowance.  If I liked Tofu this might have been easier but I decided to get what I could where I could, adding spinach to juices, omelettes, curries, you name it – it had spinach in it.  Snacking on almonds and seeds, adding them to salads, just getting creative!

Zinc

Another surprising one for me – beef and lamb appear top of the tables which also helps me to tick the protein box.  Spinach (again), Pumpkin Seeds, Cashew Nuts and my favourite – dark chocolate. I had this one covered.

Nutrition Out

Well equipped with my plan of action to get my nutrients in I wanted to consider what needed to go out and that was more obvious given all the news on this at the moment – it was sugar.  When you eat sugar it upsets the homeostasis of the body, that wonderful balance that enables us to fight infection and repair the body.  When you eat sugar especially the refined type (this includes plain old granulated sugar but also white bread, white rice etc.) it increases the levels of cytokines in the body, an inflammatory messenger sending my body into inflammation mode.  Furthermore there are studies that suggest sugar also lowers the immune system during this time and which when added to the inflammatory response, makes healing well very difficult for the body.  And lest we forget undoing all the good work we are doing with the foods we are putting into our body to help with the process.   Well, that was my dark chocolate out the window!

Six days since the traumatic event I went to get my wound re-dressed, flinching as the doctor peeled away the layers I heard an inhale of breathe from the Doctor.  ‘When did you do this again?’ he asked,   ‘Six days ago.’ I responded too squeamish to look.  ‘Well it has healed fantastically! I don’t think we even need to re-dress this!’ he exclaimed.  One week later the difference was phenomenal, I was almost embarrassed to show people the scratch like scar after only 2 weeks as testament to my claims of trauma when relaying the grisly tale.

Amazing! Miraculous some would say.  Jenny I owe you one!

So where this finally brings me is to what this means to us as therapists or to you as someone suffering an injury.  Why would this be any different?  Straining your hamstring is a trauma, maybe on a different level but it still needs to heal and if your nutrition is not aligned with this it is going to take longer and heal less effectively leaving you with lasting problems.  Now when a client calls me my first port of call is nutrition, let’s work together to start that healing process before I even see you.   Food for thought anyone?

Related Links

Carl Watts – The Experiment Session 3

It has been 6 weeks since I last saw Carl, which is not ideal given the momentum we are trying to achieve ( my fault as I have been off on holidays!) but Carl has been busy training and following his homecare advice so I hope that this has continued to keep him moving in the right direction over the holidays.

We get chatting and Carl feels that he has started to stiffen up over the last few weeks.  Not only has it been Christmas and New Year, Carl has had moving house to contend with!  Lifting and moving heavy boxes is definitely not part of the homecare advice JCarl was pleased to find that although he feels a little stiff he did not put his back out which would have previously been a necessary consequence of the activity of moving. 
In other good news his neck/shoulder pain has subsided and he found that the Kinesio taping to hold his shoulder in position was a great re-education tool for his body to realign itself.  The icing on the cake – Carl claims his golf is as good as it has ever been! Great news when only 2 months into the new regime.

Treatment

Reassessment was kept to a minimum today so as I could give Carl as much hands on work as possible to keep progress moving in the right direction.

On touch Carl’s pectorals and biceps have relaxed substantially.  I can work at a deeper level and work through some of the trigger points at a deeper level.  Again we worked on getting Carl’s thoracic region firing by doing some proprioceptive work in this area.  It is clear that this area is still a problem area for Carl and we need to increase the strengthening work over the coming weeks.


Carl’s quads and deep hip flexors are still tight but respond more quickly to soft tissue work allowing us to release the tension more easily. Again we need to continue rebalancing Carl through the hip to help get his glutes, hamstrings and core working equally hard.

Homecare

We discussed and reviewed Carl’s current training plan in the gym to ensure that the exercises he was doing were not exacerbating any of the postural issues we are trying hard to correct. 

It is clear that Carl is still favouring exercises that work his quadriceps.  We discussed how he could change what he was doing in the gym to focus on his glutes and hamstrings more and also with some specific exercises for Carl to focus on in the coming weeks.

In terms of the upper body Carl has been doing exercises that should work through his shoulders and thoracic region but he.  On demoing for me how he executes these exercises it was clear that Carl’s starting position and release for each exercises may be the issue and he is engaging a lot more pec than back.  It shows the importance of having a Personal Trainer or fitness professional just check what you are doing now and again to ensure that you are targeting the right muscle before you work yourself into an injury or imbalance!

Next Steps

Continue with same homecare exercises but with a greater awareness of posture and what muscles are being engaged.   I am keen that before our next session we sit down with Andy Traynor to look at how Carl’s swing is progressing.  Are we seeing a difference in his swing now that his body is realigning? Update coming soon.

Carl Watts – The Experient Session 2

It had been a week since I saw Carl and I was keen to get a little deeper in this session so we can start making headway in his realignment.    Our priority in today’s session is to continue work on correcting the upper and lower cross syndrome we identified but firstly I will start with reassessing Carl to get a clear picture of where his body is following a week of rehabilitation.  In addition to reassessment there were a couple of other tests I wanted to perform:

1)      Glute Firing Pattern

Given the degree of anterior tilt in Carl’s pelvis and also the fact that it is likely to have been in this position for a long time there is a risk that the Glute muscles have been inhibited – in simpler terms ‘turned off’.  This is due to the process within the body which involves the muscles working in antagonistic pairs i.e. when the muscles on one side of joint contract, the muscles on the opposite side relax to allow ease of movement.  Given Carl’s hip flexors have been contracting hard for so long it is possible that the Glutes have been constantly receiving messages to relax which over a sustained period of time have left them lethargic and lazy letting the hamstrings do all the work.


      2)      Thoracic Rotation

This is a key movement in the golf swing.  In order to get the amount of torso rotation required in the golf swing it is not enough to simply rotate at the lumbar spine as this only gives you about 40 degrees on average.  The thoracic spine can rotate up to 30 degrees so it is vital that we have good range of motion in this part of the spine to get maximum rotation and therefore power into the golf swing.  Given Carl’s lack of movement in the thoracic region in our tests last week I am keen to test the rotational aspect today.               

Assessment
Firstly I started with reassessment of Carl’s hips which showed a real change, both hips are now aligned relative to each other, i.e. no rotation and in addition the degree of anterior tilt has reduced by about 30%.  On discussion with Carl he described how he can physically feel this change, his abs feel like they are ‘on’ and he feels them engaging in his day to day activities where he had not felt them before.     I then moved on to test Carl’s Glute firing pattern.  On both the right and left side it was evident that the Glutes are not acting as the main hip extensor – something we need to correct as soon as possible.

Next we moved on to the upper body where on assessment of Carl’s cervical spine/neck there is still a level of restriction and his head is still sitting slightly forward although Carl has reported some improvement in his neck stiffness which is a start.

Carl’s shoulder girdle is still of concern and this is something I plan to work more deeply on today. In addition to his Pectoralis (Pec) Major and Minor being overly short and tight his Biceps are so contracted that his elbows are slightly flexed when in a relaxed position.  Although not a primary function of the Biceps Brachii muscle, it can impact on the Shoulders range of movement given its attachment to the scapula.  In Carl’s case I see this as an additional layer of dysfunction causing the rounding of his shoulders and the lack of scapula control we have seen so this is something we need to address to fully balance out his upper body.

Finally, I move on to assess the amount of rotation in Carl’s Thoracic Spine.  What I see is that Carl’s does appear to rotate to quite a degree, but on closer inspection what I see is that his shoulder blades are responsible for most of this rotation, by bringing his shoulders forward on the side he is rotating it appears he has rotated fully, but while focusing on the thoracic vertebrae themselves you can see that the movement is quite restricted.  I found a simple but interesting article on why stiffness in this region may cause lower back and neck pain both of which Carl experiences:

Treatment Plan Session 2
Today I will continue to work on releasing Carl’s Hip flexors & lower back using a variety of soft tissue and neuromuscular techniques.  In addition I have also included some proprioceptive/retraining  work on the Glute muscle group to help kick start Carl’s training and homecare to get more stability in his hips.

Moving on to the upper body we will open up Carl’s chest and release his neck to restore normal range of motion.  Today we will also focus on some retraining techniques on his lower and mid trapezius to start getting more control into his scapula.  Thoracic rotation is something we will address in a later session as until we get more balance through the chest, neck and back I think we will make little headway.

Finally I ended today’s session by applying a functional Kinesio taping to Carl’s shoulder to bring it into a neutral position.  This is not a therapeutic taping but will give Carl a sense of where his shoulders should be, and will also help over the next 3-4 days as he starts his homecare.  I don’t want Carl to rely on this taping but I think it will be interesting to see how it feels to him and also how it felt while hitting balls given he is going straight to a coaching session today.

Home Care
I want Carl to continue with his three exercises from session 1 as they are clearly yielding good results.  In addition there are three aspects to work on over the next 4 weeks until our next session:

·         New Exercises:
  •         Glute strengthening/hip stabilisation exercises
  •        Rhomboid & mid/lower Trapezius strengthening
  •        Pectoral & Bicep stretching

·         Previous Exercises to Continue:
  •        Hip flexor stretching, in particular Rectus Femoris
  •        Lower back stretching
  •        Breathing rehabilitation exercises

Training Considerations
Given Carl can already feel physical changes within his body we discussed what this means for his golf game.  It is important that Carl continues to train through these changes as there is a risk that his game will appear to get worse as his body starts to react to these changes.  The compensating actions that he has been doing to make his swing work we will no longer be required but he will have to relearn how to hit the ball with his more balanced, stronger body. Carl agreed that he would be continuing to work on his swing with Andy Traynor through our period of body work.

Our next session is in January, in the meantime Carl is going to continue to progress with the homecare and I am hoping to see a marked difference in the new year.

Read Andy and Carls Blogs here:

http://www.andytraynor.co.uk/

One Leg Longer than the Other?

Many clients come to me with this issue but it’s rarely because their leg is physically longer and it’s something we straighten up pretty quickly.

This is a thoughtful article on the issue and might be a useful explanation for you:

http://www.massageworld.co.uk/massage-articles/a-myofascial-approach-resolving-leg-length-discrepancy-and-pelvic-misalignment

Carl Watts – The Experiment Session 1

Today I met Carl Watts for the first time and what a treat that was!  Carl is a friendly, enthusiastic man who is truly motivated to achieve his goal on getting that tour card back.

We started with a full bio-mechanical assessment. I try to assess each client as if I didn’t know what sport they played as not every golfer fits the stereotype. It’s important to look at each person with fresh eyes rather than jump to the ‘things’ you would expect to find.

Top to Bottom Summary of Findings in Session 1

On initial view of Carl in a resting standing posture there is a clear imbalance between right and left.  His right shoulder drops down and this follows through the rest of his body resulting in a rotation towards the left.  Another point of interest is that Carl’s breathing seems very shallow and is very much so an upper body breath with little use of the diaphragm and abdominals.

Upper Body

  • Carl has a posture summarised by Janda as Upper Cross Syndrome, see illustration below from www.erikdalton.com, resulting in restricted range of motion (ROM) in his neck.
  • What is more unusual is that this is more pronounced on this right side but is still present on the left to a lesser degree.  This also translates to the lack of scapular control Carl exhibits on his right hand side compared with the left.

  • Another deviation from the Janda model is that Carl’s head is less forward but points upwards as if trying to correct itself in some way but leading to even more tension on the back of his neck which is common complaint on discussion with Carl.
  • Shoulder ROM restricted range of motion.
  • Full Range of motion in wrists.



Lower Body

  • Carl has another condition summarised by Janda – Lower Cross Syndrome. This is quite commonly seen alongside upper cross syndrome resulting in an ‘S’ posture.
  • Again this is more pronounced on the right side and Carl complains of pain in his right knee when doing hip flexor strengthening.  This also correlates to the rotation we see through Carl’s torso, although the left hip is not in a posterior tilt, it is dropped back compared with the right.
  • On assessment Carl’s Rectus Femoris muscle is tighter than his Psoas so we will start here.
  • Carl’s lower back is stiff and lacks movement.  This lack of movement is evident through the lower and more so into the mid thoracic spine.  On flexion of his trunk there is little to no movement in this region.
  • Hip flexion is restricted and hamstrings are taut but not short, the anterior pelvis tilt is likely to be causing this apparent lack of flexibility.
  • In addition Carl’s hips are both laterally rotated and his ankle range of movement is very restricted particularly in dorsi flexion.

On discussion with Andy Traynor, Carl’s coach, my findings match up nicely with what Andy is seeing in Carl’s swing.  His lack of hip stability and flexibility  is manifesting itself in a loss of power in Carl’s downswing as his body moves to compensate/re-balance in spite of his restricted movement.

The number one priority for Carl will be getting his core and hips stable, strong and flexible and his home care reflects this.  I also feel that this restoration of balance in the hips may resolve some of the lower and upper body issues we are seeing.

Treatment Plan Session 1

The main focus of today’s treatment is to begin work on correcting Carl’s hip alignment.  I used a variety of techniques to release the hip flexors and lower back.  I also started work on engaging Carl’s diaphragm and abdominals to encourage a full and complete breathing pattern, this will be followed up by home care to start training Carl to use his core when breathing which will also help to start to correct some of the upper body issues we identified today.
Home Care
  • Hip flexor stretching, in particular Rectus Femoris
  • Lower back stretching
  • Introduce Yoga to training regime
  • Breathing rehabilitation exercises

Remarks for Next Session

  • Test Glute Strength/Firing Pattern
  • Test Thoracic Rotation
  • Retest Hip Alignment
  • Continue treatment for hips and start upper body treatment
Check out Andy and Carl’s blog to find out how ‘The Experiment’ is going!

Recommended Links
http://www.jandaapproach.com/the-janda-approach/jandas-syndromes/