First off, I’d like to thank you for taking the time to visit the AMP website and reading this article. The path that has led me to writing this has been a long and unique one, and it is my hope that some of the insights I have gained over the last 10 years of working as an Athletic Trainer, Strength Coach, and Manual Therapist may be useful to those out there seeking to help their athletes perform through not only optimal training, but recovery as well. It is in the Recovery arena that I feel my two cents may be the most useful, as it has been my task and privilege to return athletes at a variety of levels and sports to competition after injury, but more importantly, to keep them there. A daunting task yes, as there is a myriad of information and various schools of thought on the best way to do so, and filtering through all the junk out there to get to the core of what, in my opinion anyway, actually works best is what this and future articles will strive to achieve. So, for my first stab at this, I’d like to start to address the topic of Soft Tissue Therapy and Sustained Performance, a topic which may not get as much attention in the performance world as it should, but one I have found a high level of success in.
Soft Tissue Therapy and Sustained Performance
By Mike Stella, MTA, ATC, CES, PES
Director, AMP Recovery Lab
At its core, an athlete’s ability to perform in competition and training is directly correlated to their ability to recover from their last session. Some athletes out there need little in the way of recovery work and can simply perform at a high level all the time. These athletes are the statistical outlier, and far more athletes exist on the plane where they are in a constant state of being on the brink of physical breakdown and injury. I have experienced that many athletes respond positively to regular manual therapy sessions, whether it’s used as recovery between bouts of training or contests or as a corrective and therapeutic modality as part of an overall rehabilitative or reconditioning program. Obviously, all manual therapies and soft tissue techniques aren’t created equal, and this article isn’t to promote one over another. I think they all have their place and time, and largely their efficacy depends on the manner and reason in which they are used. One of the many reasons why manual therapies are difficult to study is because of their very subjective nature. Science needs repeatable results, however, soft tissue techniques vary widely from clinician to clinician, and responses from client to client. Definitely not a great recipe if you are looking for repeatable results, but there are more and more researchers beginning to take on this task. For the purposes of this article, I will be speaking generally about soft tissue therapies as a whole, their place in the training process, and leave specific techniques and treatment for future articles.
First and Foremost, Soft tissue therapy is one of my favorite injury prevention modalities…period. If you want to prevent injuries, then on some level manual therapy and soft tissue work must be part of the equation. Yes, it is more time demanding, but as an athletic trainer, it was my job to keep the athletes on the field, not just wait until they get hurt and send them to the doctor. Trust me, your athletes, coaches, and clients will thank you. If you yourself are not licensed to perform manual therapies, please find someone in your local community who is, and also willing to work collaboratively with you. If you are qualified, but maybe someone who hasn’t done a lot of tissue work in the past, starting with simple effleurage is a great way to begin injecting manual therapy into your training repertoire. Get a feel for soft tissue in a normal state, when your athletes aren’t injured or in a state of dysfunction/distress. With enough practice, you will then begin to feel where the dysfunctional areas are, like trigger points, adhesions, restrictions, and scar tissue. Physiologically, the pressure from even the simplest form of effleurage can work wonders for your athletes.
So, we must now ask ourselves the question, what are we trying to achieve? Treatment of injuries, restoring lost mobility, decreased pain, and an overall return to a normal autonomic state are all things manual therapies are used for. But what about for recovery and regeneration? Sure massage work feels good, but what effects does it have on our performance and recovery overall? These are difficult questions to answer, but I can tell you the athletes that saw me regularly for soft tissue work had far less injury evaluations during the course of a competitive season and performed at a higher level than those that waited to seek treatment until the wheels came off. To begin answering this, we will start simple, and state that what we are trying to achieve is a return to a parasympathetic state, the state in which our nervous system is more apt for healing and a general return to “normal.” This is achieved through moderate and sustained pressure, just at or below the “pain” threshold. I use the term pain very lightly here, because what I really mean is that “hurts so good” type of pain, not the teeth clenching, pool of sweat type. I know there are many people out there who believe for soft tissue work to be effective, it needs to be deep and painful, and this is simply just not the case. You don’t start a new training client with 400lbs in the squat rack, so why start someone with painful deep tissue work? Seems like common sense, but believe me, those folks are out there who just plow through soft tissue and put their clients in a state of stress that set off their sympathetic nervous system (fight or flight) like a mortar shot on the 4th of July. The best tactic is to generally introduce manual therapy by accessing the more superficial fascial layers first, and let your athletes acclimatize to that type of treatment, just as they would any other training program.
In order to dive deeper we need to first have an understanding of basic tissue anatomy. To spare you the entire anatomy lesson, I’d like to bring up a single point we need to keep in mind when it comes to tissue work in general. We know the body is comprised of various types of connective tissues. Bones, tendons, ligaments, fascia, blood vessels, and even most of the tissue that makes up our nerves fall into this category. There are many schools of soft tissue therapy that claim that they act on one or a few of these types of tissue but let’s face it, you are applying stress to the area, and whatever types of tissues are in that area are being acted on. There really is no delineation of types of fibers when it comes to soft tissue work; they are all in there, so we are working on them all. In a sense, all the types of connective tissue in our body are essentially a different expression of the same basic components, and they are arranged as such so that there is really no clear example of where one type of tissue begins and ends, for example, tendon to bone. In a microscopic view, one end looks more like tendon and gradually it changes so that the matrix is arranged more like bone. So we don’t really need to get that fancy and start examining each individual type of tissue when it comes to basic principles of soft tissue work. Obviously, different techniques work more efficiently over specific areas, which we will address at a later time, but to begin; following the cues our body gives us is a great way to get started.
Now that we have cleared up the particulars, and again, this article is speaking in generalities for the sake of an introduction as to why soft tissue work is important for sustained performance. We all recall the concept of entropy from high school chemistry, which is essentially a state of random disorder. Now obviously, the human form has a general view of order and arrangement, and we can thank Thomas Myers, author of the popular book, Anatomy Trains, for bringing to light the fascinating lines our bodies create to move and deliver stress. However, when we look at the matrix of cellular components that make up the connective tissues,
more importantly the fascia that holds us together, it begins to take on more of a random disorder configuration. Most fibers will line up in parallel along lines of stress, while others are crisscrossed in random directions as fibroblasts spit out connective tissue fibers in any which direction. So putting this all together, we have fibroblasts, intracellular bodies which produce the nano-parts that our connective tissues are made of are in a relatively constant state of production. It is only when mechanical loads are placed on the system that they will begin to reorganize along the lines of stress. This is one of the basic principles of rehabilitation and strength and conditioning, which is that the body will organize along lines of stress, thus increasing resiliency to change. Most forms of soft tissue work are exactly that as well, mechanical loads on the tissue that will help those fibers organize to the stress. It is for this reason that I believe manual therapy can actually aid athletic performance while helping to prevent injuries, because we can help our athletes align their connective tissue fibers, adding to their tissue resiliency, thus creating a system in which more load can be transmitted through without structural compromise.
So far we have talked about general soft tissue therapy principles, and how regular tissue work can help aid performance gains while training. Next, let’s discuss the use of manual therapy in the recovery aspect of training and sports programs. As I stated in the opener of this article, recovery is extremely important to all athletes and teams, and can often be a difference maker over the course of a long competitive season. One of the ways I like to inject manual therapies is for the purpose of recovery. Massage has been shown repeatedly to aid in circulatory flow around the body, as well as help increase tissue quality over time. For all intents and purposes, blood flow is the name of the game when it comes to recovery. This is the whole, “good stuff in, bad stuff out” concept. It is important to keep in mind that every time we train or step onto the field of competition, no matter what the sport, we are doing damage to our body. Our body’s natural response is to repair the damage and make any necessary changes to be able to handle stress better in the future. This is a perfect time to add some soft tissue work to the recovery paradigm. Now maybe right after training isn’t always the most efficient time to do so, but I think at some point in the 48hr period following intense exercise, while the body is still in the inflammatory phase, we can really help our athletes recover with some tissue work. Increasing circulation and blood flow, and providing ample nutrients and oxygen to areas of high stress, obviously depending on the sport and athlete you are working with. This definitely is not the time for really deep aggressive soft tissue manipulation, which would just add more stress to the system, but definitely our Swedish strokes, or what is affectionately called in the sports world, a “flush.” A great hand in poker, and not necessarily a bad term for this purpose either, since essentially what we are trying to accomplish is flush the area with blood flow, and flush out any lactate or metabolic waste that may be built up in the area. I like this far better than using ice, but the explanation for that will have to wait for another time as well.
So what’s the moral of this story? The moral is that soft tissue work is not only for the spa, but it is a vital aspect of an overall training and conditioning program. Unfortunately, many athletes don’t have access to a manual therapist on a regular basis, but this is where techniques like foam rolling, massage balls and sticks, and any other soft tissue instruments come into play. Are they the same as a well-trained clinician? Absolutely not...but something is better than nothing. Proper education of the use of tools becomes very important in these instances, and when used correctly, they really help athletes and teams over the long haul.
Manual Therapy is one of the hallmarks of the AMP Recovery Lab. Here we not only teach our athletes effective soft tissue management strategies, but also give them access to regular soft tissue work. It is great when the performance coach and manual therapist can work together to achieve common goals, as these two aspects of training really do work hand in hand. This is where we work to correct faulty movement patterns, poor posture, injury predisposition, all while helping our athletes and clients achieve high levels of performance.