Aaah. Now my shoulder's gone.

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If you didn't know, I also blog about my training on testedtodestruction, however, it appears that it is more like my body that is destroying itself than me destroying gear.

As a bit of background, I had quite a lot of shoulder issues last year - pain on the acromion process whenever it was touched - which is odd as there are no soft tissues going over the process - and therefore, there should not be pain unless I bruised the bone. Which certainly did not happen.

The muscles all around the shoulder were short, and the entire right shoulder complex was raised - so I actually looked pretty lopsided. After having massage, it was clear that I had lots of trigger points around infraspinatus, supraspinatus and levator scapula, but even after relaxation of these muscles, some residual pain was still there.

After some more in depth research and movement research I noticed that the structure that was actually hurting more than anything was the long head of the biceps brachii - going anteriorly up over the shoulder complex. It was this that was in pain, and the shoulder was basically hunching over forward in order to slacken the tendon off, pulling the scapula forward, which caused an impingement on the bursae below the acromion process.

Bingo. Thats the reason for the pain.

For the past few months I have been taking time out of any overhead movement, pressing movements etc. and it seems to have got much better.
I went out and did a weights session last week - which turned out to be chest and arm work - and what do you know, the shoulder pain is back with a vengeance.

Plus side - I know exactly what caused it- and I shall be steering clear of overhead presses and excessive push-shoulder work for quite some time. I think static hold are ok - and wierdly enough, pulls are fine - so climbing is not actually affected.

Minus side - I'm back to square one on the shoulder issue - and rest is the only way forward for it. I shall be stretching and going back to rehab exercises, because if I don't, its just going to get worse.

A couple of thoughts on electrotherapeutic modalities

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Having been to a couple of physios in the past for various soft tissue issues- namely tenosynovitis in one of the tendons in my thumb, and once for a knee issue from fencing, the main treatment that was given to me was Ultrasound. The physios veered very much away from massage as a modality, and used a lot of the electric stuff.

There was also a lot of movement therapy, which was great, but only about 10 mins of actual manual therapy. This is fine as it is, but from a little research into clinical sports medicine I came across an interesting study on electrotheraputic modalities.
It would seem that electrotheraputic modalities have been tested on a clinic scale rather than a scientific scale. The study I was looking at specifically mentioned Ultrasound, which is marketed as reducing inflammation and promoting healing- of which apparently there is only limited evidence. Indeed, if ultrasound is being used as a modality, it should not be relied upon as the SOLE treatment, but should be used as part of a collection of treatments on the injury.
In my experience, this has not been the case, and has been relied upon as pretty much the only thing, apart from remedial exercises, to heal the injury.

Another thing thrown up by this study is that there is little evidence to suggest that ultrasound is of any use on Soft-Tissue injury (specifically overuse injuries)- BUT, it has been shown to work on non-union fractures - helping bone to regrow back together. There is a condition to this though - and that is that the Ultrasound used is LIPUS (Low Intensity Pulsed Ultrasound)- and that it is used for 20 mins a day on a daily basis.

Traditional ultrasound, by contrast can only be used for no more than 5 mins at a time, 3 times a week, which doesn't give enough time for it to actually work on soft tissue.

Now, I'm not saying that Ultrasound is useless for long term overuse soft tissue injury. From the reading I have done, it seems that it is good in accompaniment to other theraputic modalities. Obviously I'm a bit biased in saying that massage is one of the better ways in which to get that healing, but there are any number of modalities. Don't rely on just one of them though.

As a note, the information in this post has come from Clinical Sports Medicine, P140-142.
If there are any studies that dispute this, or you are coming at the Ultrasound thing from another angle, I'd be glad to read them and have my perspective changed. Please do point them out.

As they say, don't use science to prove you're right, use science to become right.

Climbing and Massage

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Why on earth would you want sports massage if you are a climber? Is there ANY relevance at all?
well....

When you exercise your muscles use oxygen, and give out metabolic waste products. For muscles to operate efficiently, they need to contract and relax - a bit like a pump, getting new oxygenated blood in, and getting old blood out and back to the heart and lungs again. Climbing is an interesting one as the muscles are generally contracted for large amounts of time, and not relaxed so much - which means the pump - which works to a point, is not as efficient as it can be.
The tighter the muscle contraction is held, the less oxygenated blood can get in to the muscle to give it nutrients it needs - and the less waste product it can transport out.

This is where your Pump comes from after a hard session - blood which sits in the muscles and doesn't get out - if you don't stretch at the end of a session, and the metabolic waste products are not released from muscles for a while, they can cause cramps, pain, and DOMS - delayed onset muscle soreness. That's the pain you feel up to a couple of days after a hard session.

Massage helps get rid of these issues. It is not only good for helping with circulation - which is a very superficial part of the massage process.
I know some of you will have heard of Duputreyans condition- for those of you who haven't- look here http://www.ukclimbing.com/articles/page.php?id=1312 Massage - specifically a technique called Soft Tissue Release (or ART if you are American) can help as a preventative measure against this rather nasty condition.

I know a lot of climbers (myself included) who have had issues with the rotator cuff - a minor issue in saying I have a problem with the rotator cuff is which part of it?! There are from 4 to 12 muscles involved in the rotator cuff - depending on who you talk to. We can help- looking not only at the muscles, but also the fascia surrounding the joint complex.

Once injured, it is somewhat difficult to get it back to the exact working order that it was it previous to the injury. Preventative work may well be the way forward - maintenance massage once or twice a month, working out the kinks in the muscle and fascia through the areas that you use the most, getting an assessment as to how the tissues feel - whether you are working too hard, what feels tense, and what is painful - this self-knowledge will give you more of an idea of your body's overall health.

As a remedial modality, massage can help in rebalancing the muscles in the body. Be it for general posture, assisting in creating more body awareness and general proprioception, or even assisting in gaining greater flexibility. We can help you get better, or just get BETTER.

Back in the day- Mark Twight, Dr Death himself, advocated massage in his book, Extreme Alpinism, saying "deep tissue massage aids recovery. Treat yourself to a massage every 10-15 days. Shun those touchy-feely masseuses. Find someone who can dig, restructure and strip apart bound-up muscle tissue."
And more recently in his writings as director of Gym Jones- "Recovery is 50% of the process of training...Respect recovery... Deep tissue massage focused on restructuring muscle and fascia is a very effective monthly tool."

Eric Horst- writer of "How to climb 5.12", and more recently, "Training for Climbing" has said "Sports massage helps reduce the number of small and generally unfelt spasms that regularly occur in muscles. These spasms may go unchallenged by regular stretching and warm-up and left unchecked, may rob you of co-ordination and induce mechanical resistance and premature fatigue."

And our own Dave McLeod has said in "9 out of 10 climbers make the same mistakes" - "Consider experimenting with other stress relieving activities such as sports massage, stretching or yoga... don't underestimate the cumulative, long terms effects of poor recovery and management of training stress. It will put a lid on your improvement if you are ignorant of it. Treat your body nicely and it will return the favour."

Perhaps what Mark says is the most important. If you want to improve, if you want to get better, and, perhaps more importantly stay injury free, getting a massage isn't going to be about a relaxing, chillout massage. These are all very well for feeling nice and fluffy, and excellent if you are taking time out.
However, if you are training hard, and not resting enough, your muscles will be bound together with abnormal crosslinked fascia, it is likely that they may not be working efficiently, and your ability to get the maximum amount of power from them is compromised. Those muscles need to be worked on deeply, restructured, and made to be more efficient.

At Global Therapies we are versed in a number of types of massage from the relaxing, soothing "touchy feely" to the deep tissue restructuring, and fascial release side. We have the knowledge, we have the experience.

Sports Massage and Remedial Massage is beginning to become more popular at Climbing centres across the country - The Castle and the Arch down in London, Big Rock in Milton Keynes, The Barn in Devon.

We are proud to be helping climbers around the Manchester and Derbyshire/High Peak area recover more, and become better, harder climbers through recovery, restructuring and injury proofing. Don't wait until you break yourself, get a maintenance massage.

Pain

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We all experience pain, be it emotional or physical, at some point in our lives. Some people are lucky and only experience pain when they are injured, like when they twist an ankle running in the fells or cut themselves accidentally while chopping vegetables. Other people seem blighted with pain, going from illness to illness, often (and frustratingly) without a specific cause. But pain is pain, whatever the cause or reason for it. And the level of pain we feel is on a continuum, and it is difficult to be precise about this as ones own pain tolerance is unique. What is clear is that massage can be highly effective at reducing or eliminating pain, we'll see how below.

The degree to which you react to pain comes from many sources: biological, psychological, cultural - essentially pain is subjective because of who we are and what we have experienced and been influenced by in the past.

On a physiological level, the perception of pain is caused by the stimulation of nociceptors (sensory receptors) - either chemically, mechanically or thermally. The point at which a stimuli is perceived as pain is known as the pain threshold, and interestingly, this threshold is pretty similar for every person. It is how we react to the perception of pain which can be dramatically different. Some people are able to inhibit pain sensations, whereas others magnify them - for the reasons mentioned above. It is behavioural and emotional responses which either inhibit or magnify the perception of pain. So whether we are anxious about being hurt or withdraw from situations which may cause us pain, or whether we choose to accept that there is some risk of injury, is what makes us and our reactions to pain unique.

The nociceptors which detect pain send a signal to the brain via the spinal cord. That signal can be reduced by endorphins or increased by substance P (a neurotransmitter released from sensory nerves). Massage can influence these signals (for the better, i.e. reducing or removing pain sensations) and chemical responses, although the mechanisms of this are not clear.

What is interesting is that if somewhere in your body is painful (whatever degree or level that is perceived) then the muscles in that area can exhibit sustained contractions, which in turn restricts the blood flow through capillaries to the constricted area. The restriction of blood flow means that less oxygen is being delivered to the area and ischemia develops. Even a short exposure to such conditions (from a direct trauma or injury) can produce ischemic pain.  If local metabolism is increased like when a strong contraction occurs, then oxygen is burned quicker and the sensation of pain is not only apparent quicker but more intensely.

While the exact causes of ischemic pain are not clear there are contributing factors which can be identified: the presence of chemical stimuli (such as bradykinin or histamines - which are released when cells are damaged mechanically or chemically), when there is a build up of lactic acid, and when there is a reduction in the amount of oxygen delivered to the cells.

The original injury site (where pain sensations were perceived) causes the muscular contractions, that leads to ischemic pain and maintenance of those contractions results in a vicious circle because pain is caused by those very contractions. Associated with this are shortening of muscles and restricted range of movement - these can also cause more pain. When muscles become hypertonic they are excessively tight, have a shorter resting length with the myofibrils packed too close together - this reduces circulation and leads to restricted oxygen flow, and therefore pain. The aim of treatment needs to be to break the cycle, find the contributing factors, the location and what aggravates or alleviates the pain. Myofascial release, ischemic pressure and passive and active stretching of specific muscle fibres, reducing joint stress, normalising tissues, along with deactivating trigger points are all key. An assessment of your range of movement will highlight any tight areas and where imbalances are present.

Returning to nociceptors, the stimulation of nociceptive nerve endings are how pain is felt and these nerve endings are found throughout the body - in bones, cartilage, ligaments, tendons, fascia, bursa and neural structures. So damage to any of these will stimulate the nerve endings and you will perceive pain.
The longer a site is stimulated, either through mechanical damage (stretched fibres/structures, compression or trauma) or by chemicals (histamine or inflammation), the greater the risk of developing altered movement and compensation patterns. Think about a time you injured only one arm or one leg; your body will try to protect that area by avoiding its use, so the other (uninjured) side has to adapt its movement patterns to cope with either a weaker or painful opposite. Your body will not be functioning in an optimally biomechanical way. Even if you are not aware you are doing this, it can be happening because it can all happen at a microscopic level. And this is where massage can help to eliminate imbalances that can lead to longer term issues - which you would notice. Whether the initial pain source is your joints, ligaments, muscles, tendons, fascia or neural structures is essentially not important - they are all interlinked and will affect their neighbours both close and distant. This is why a remedial massage therapist will work on your feet, hips, back and neck if you have a knee problem. The pain you initially felt causes muscle spasms and tension throughout your body, so while you think your knee is the cause (and it may be), treatment has to look at the body as one unit. For treatment to be successful the fascia and muscle imbalances/tightness need to be eliminated and range of movement restored to normal. Part of that treatment will be the elimination of trigger points as mentioned above, but those are a whole topic of their own and we'll blog about TPs separately soon.

I've mentioned pain being the result of injury, but that isn't always the case. Poor posture (sitting at a desk all day), oxygen depletion (perhaps because you are stationary for too long or have restricted circulation), heightened anxiety levels or just your emotional state - these are all significant enough to trigger muscular contractions in a specific part of your body which can bring on that cycle of pain. Toxins build up and the metabolism in that area becomes impaired, leading to further damage to cells in the area. If this occurs over a period of time, it can even lead to scar tissue build up.

So how do we fix these things? How do we eliminate the pain (which can range from debilitating to a slight niggle)? Well, we could take medication - either over the counter pain-killers, or prescribed medication. There are risks and side effects to any medication (always seek medical advice before taking any medication) which I don't need to go into here. We could remove the stimulus which is making us perceive and feel pain - sometimes easy, sometimes not - it all depends on whether that stimulus is obvious to us. We could also have some form of bodywork - the power of touch alone could be sufficient to relax someone enough to remove the pain source. Or perhaps you could have deeper, specific massage techniques which can be employed to deactivate those trigger points that are causing headaches, relax out spasming muscles and rebalance the body to return dysfunctional postural patterns back to functional efficiency. Whether the cause of pain is known or not it needs to be eliminated through intervention.

abdominal massage and spasming diaphragms

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If you've read the post about the Mount Famine race, you may remember I mentioned a spasming diaphragm. This is a bit of a wierd one which I first felt a good few years ago when I was running in Japan. (just for fun, I must hasten to add... trying to lose weight to get better at climbing)

Sometimes, as I was running, I would get a really really bad pain in the abdomen, on the right side, just below the ribs. I knew it wasn't stitch- I've had that before, and it went pretty much as soon as I stopped running, only to return as soon as I started again. I then didn't run for a few months, and when I went out for a run again, it didn't hurt.
Wierd.
Didn't think much of it until recently.

The most recent time I had that pain was in Mount Famine, when I was really pushing it, and the time before that was in a (fun) winter time trial over 5km with some of the guys down in Greenwich Tritons. I was fine for 4.75km, then I thought I'd up the pace- boom, within about 20metres I had that stabbing pain in the abdomen, and it didn't go until I stopped. Mount Famine- it came, but by then, I figured out what it was.

Looking at the abdomen- the pain I was feeling was just under the ribs, on my right side. When I finished a hard run, it was slightly tender to touch- but the real issue was just to the left of the xiphoid process at the bottom of the sternum. That REALLY hurt, and, pressure there recreated the pain pattern that I was feeling during those all out aerobic efforts.
What could that be? What muscles attach there, and have bearing on breathing? The main one is the diaphragm- hence my suspicions of the spasming diaphragm. One might call this a Breathing Pattern Disorder- not one that is induced necessarily by bad posture, but perhaps one that is induced by breathing too hard(!)

So I sat (well, lay) down today to have a quick check around and see if I could sort it out. We studied abdominal massage during the course at NLSSM, and I have to say that I somewhat under-utilise it with my clients.
Using a soft touch, I worked my way around the area, noting that the area around the xiphoid process was tender and referring pain, especially under the ribs, my main abdominals felt tight, and the tissue between the ribs- the intercostals were really quite tender... all of this is probably because of a long period of exercise, and not getting enough massage to the muscles- hence the problems.
So I worked on the offending areas, working in the correct direction (so as not to disturb the peristaltic rhythms of the gut), feeling where there were adhesions between organs and muscular walls, and doing some Soft Tissue Release, especially on the diaphragm- that was pretty intense, and not without some discomfort.

However. I now feel much freer, more relaxed, and much more at ease with myself. It would seem that the phrase "a knotted stomach" is not just a metaphor, but also a physical condition which can cause anxiety and concern.
So, if you go to a massage therapist, don't just expect a back rub- those soft tissues, organs and the like may well be in desperate need of some care. We are used to having our posterior musculature rubbed and soothed- so why not the anterior? It seems a little wierd, however, it is soothing, relaxing, and when done correctly, most rewarding.
I shall be using abdominal massage as a modality within a modality a lot more from now on.

yep- the knee is ok. Its my glute med that hurts now

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Thought I should probably write an update on the knee issue that I mentioned last week.
Its fine.

There we go.
The rest for a couple of days that I enforced on myself, along with the ice, compression and elevation for the first couple of days during acute and subacute phases appears to have done the trick. I abstained from deep squats for the next few days after that, though from an analysis of my squats, double legged squats do not appear to be the issue. Its the single legged ones that are the problem.
As I squat down, the knee starts tracking medially (inwards - toward the midline) which then strains the patella tendon- and at the point that I squat back up, THAT's when the tendon becomes overloaded. As it is at a biomechanical disadvantage while the pressure is being put through it, it is placed in a weakened position - the collagen fibres are not taking the strain as they do on a day to day basis, and the tendon becomes inflammed and tender to touch.

IF it was in the correct position, and I was squatting in a biomechanically efficient way, then the force generated would go through the tendon in the way it is meant to, in its strongest position, it would not become inflamed, and I would continue to build up muscular endurance.

Now, the issue with this is that when running, especially up and down hill, as fell running tends to demand, you rarely land on both legs at the same time. When you hit the floor, you do a mini squat - on one leg, on unstable ground. The chances are, you aren't giving the knee any chance to land in a biomechanically advantageous way... so therefore, more chance of being injured, and having a very tender spot below the knee cap, and maybe having to rely upon pain killers in longer races. (not a good idea, it masks the pain but the issue is still there).

How to sort this issue out?
I may have mentioned this in a previous post, but it boils down to a weak gluteus medius and deep lateral rotators. The best way to describe this muscle to imagine your shoulder- there is a large muscle covering the the shoulder- you can easily see how it influences movement in the shoulder. The gluteus medius does pretty much the same thing over the hip joint, being involved in almost every movement of the hip.
The lateral rotators - of which there are 6, rotate the hip outwards, and help prevent the upper leg diving in toward the midline as you single leg squat. So it's these muscles that need to be recruited and built up to prevent the knee diving, which, in turn, will stop the pain the knee.

The fact my glute med hurts after Mount Famine yesterday means that it has been overworking, needs a bit of rest, a bit of massage to get the waste products out of it, and blood back in, some foam rollering, and then a bit of strength work.

Slow single leg squats, in front of a mirror, ensuring the knee is tracking where it should be, accompanied by balance drills on a wobble board.
Simple.

The main take away from this is, if you have a knee issue, and there has been no specific trauma to the knee, chances are, your knee is NOT the problem, only the symptom.
If you see a massage therapist about your knee, and they start looking at issues in the hips or feet - that is a good thing. They are looking for the fire - not the smoke.

Mount Famine

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Well, what a race. Brutal is a word you could use.
We got over to Hayfield with plenty of time to wander up and have a quick look at the final run in- and also at the start. Which is quite a daunting crazy hill straight up the side of a hill with a large amount of rather lush vegetation.
Changed and numbered up, I was running my first race in club colours- Glossopdale, and having had a couple of races in which I was put somewhat at a disadvantage by letting others charge off and waiting til the back to start, I thought I would go in with a slightly different race tactic of going hell for leather up the slope, and seeing how things pan out for the rest of the race. Maybe not my greatest tactical move ever.

3,2,1, off we go, not so much running as scrambling over the roots, brambles and through trees, then it gets steeper, and someone remarked that it was like breaking out of prison. (prison? which prison was that guy in?!). and after a mercifully short time, we were back on the flat and going oh, not flat, but up to the dragons back up toward Mount Famine itself.
I had done what I wanted, and was within spitting distance of the fast group, and slowly bleed places as I shuffled my way up the hill, trying with all my might to get my pulse back down to somewhere resembling a non-max HR. It didnt work.
So for the next couple of km's I steadily dropped back down the field, but not so much that I was particularly worried. I seem to be slower than average on the ups. Something of a theme in my running, and by the time I was at the first peak, I was with a team mate who indicated to the steep incline to our left and said- yup we've got to come back up that in a minute.
Down, up and down into the clough, I managed to hold my place there, but on the climb back up I had nothing. overtaken by another 3 guys, and then, after scrambling my way back to the top of Famine, a real hands and feet job, I turned and saw another of Glossopdale in close pursuit. Damn.

I stumbled off the top, leaden legs swinging my way toward home, back down the dragons back, finally managed to take back one of the places robbed of me on that last climb- (his shoe laces were coming undone by that point, so it didnt really count), and on, down into the the wood- nearly catching another who had caught me- when Dave comes past me saying "come on Tim"... nice- my retort... "I'll be with you in a minute".

We over took the next guy and he homed in on a- I think he was a Dark Peaker, but I just didn't have the legs in me at that point. I knew we were 400metres from home, and I'd done myself in. My breathing was laboured and my diaphragm was beginning to spasm. It would respond really well to Soft Tissue Release, or a session of MET, but at the end of a race, they aren't really an option. I was a good 30 metres behind them, and just about managed to stay in touch. The distance ground away, and I stopped concentrating on the guy behind, and followed Daves heels. He took the DPer on a short incline, then he was taken back, we hung a right, then a quick left into the play park, was still a good 30 metres behind, the funnel came into view, and even though a few moments ago I honestly thought I was a gonner, and my lungs were bursting somehow, from somewhere my legs started going, bang, it was like the other two had slowed down- I guess they hadn't because they were racing for the line, but in those last 20metres I had the final burst of speed and dropped them both, not even 5 metres from the end.

Just pipped them at the post- going so fast Lynne 

didn't have a chance to catch my face... (probably a good thing)

54.47 by my watch. (didn't know that til I looked on the computer- I was so excited by the end I forgot to stop my watch).

Me at the end. Watch still running

Nice to see so many of the Glossopdale lot out, and nice to feel properly knackered at the end of it as well. Couldnt stay for cake as my contact lenses were playing up.
Tactics need to be developed somewhat. As does my climbing...