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Enhancing Overhead Shoulder Mobility

Enhancing Overhead Shoulder MobilityOverhead shoulder mobility is one of the things that a large majority of people could all improve on if addressed appropriately.  This seems to be limited in a very large percentage of people, especially in those with shoulder pain and dysfunction.  Perhaps it has to do with our seated postures or our more sedentary lifestyles, but regardless limited overhead shoulder mobility is probably going to cause issues if not addressed.

 

Enhancing Overhead Shoulder Mobility

Here is a clip from my brand new educational program with Eric Cressey, Functional Stability Training for the Upper Body.  In the clip I am assessing someone with limited overhead shoulder mobility.  During the assessment it became clear that he had a few issues limiting his mobility, but I wanted to demonstrate how a few simple manual therapy techniques can clear up this pattern rather quickly if assessed and treated appropriately.

It really goes back down to a proper assessment and know what you are looking for when assessing people.  This is just a very small clip of some of the great information we cover in our new program, which is on sale for $20 off this week (sale ends Sunday May 18th at midnight EST).   Click here or the image below to order now before the sale ends!

Functional Stability Training for the Upper Body

My Recommendations on Choosing the Best IASTM Tool

best IASTM toolsOne of the major points that I wanted to get across in my new online program teaching you instrument assisted soft tissue mobilization is that the tools do not need to be expensive to start using IASTM.

There are a wide variety of different tools that you can buy to perform IASTM, ranging from $5 to several thousands of dollars!

Luckily for you, it doesn’t have to be expensive to get started using IASTM!   Don’t get me wrong, you absolutely get what you pay for with the different tools, however price should not be an issue that limits your ability to start using IASTM.  If you have $5, you can start performing IASTM.

Over the last several years I have tried almost every IASTM tool on the market.  There are many great ones.  I am going to review several tools that I personally use and recommend.  I am going to start from cheapest to most expensive and overview the pros and cons of each.  When people are not sure IASTM is for them, I recommend starting with a cheap tool.  Once you get the hang of it and see the many benefits, you’ll definitely want to upgrade.

Consider this article your resource to choosing the best IASTM tool.

Before you get too far into the below article, I should say that stainless steel tools are the best.  People always ask me “what is your favorite tool?”  The tool I am currently recommending everyone purchase is the EDGE Tool by Erson Religioso.  It’s great stainless steel quality, affordable, and very versatile.  Plus, he’s offered my readers a special 10% discount off your entire order of everything in his store if you use promo code Reinold10!  He has a bunch of great tools, like his EDGE tool, cups, mobility bands, and even things like BFR units!

IASTM Tools

Buffalo Horn IASTM Tools

buffalo hornBuffalo horn is probably the cheapest and easiest way to get started with IASTM.  It is easy to find on the internet, cheap, lightweight, and effective.  If you are new to IASTM or just want to test it out, this is a great tool to begin with while being very budget friendly.  It doesn’t feel or resonate very well, the more expensive tools feel SO MUCH better, but buffalo horn is certainly an acceptable material to use for your first IASTM tool.  Certainly not the best option but I would rather you use a $5 tool than not perform IASTM at all.  If budget is your primary concern, start here, otherwise move down the list!

Jade IASTM tools

jadeJade is a gemstone and a definite step up from buffalo horn.  They come in many different colors, though there does not seem to be a big difference in quality between the colors.  I also like the shape in the image to the right, which gives you a few useful edges.  Jade tools are heavier than buffalo horn, but also more slippery if you get too much lubricant on the tool.  They certainly resonate more than buffalo horn but still not nearly as much as the higher cost tools, such as stainless steel.  Jade is more fragile than buffalo horn, so keep this in mind.  It isn’t the best if you are worried you are not going to be able to protect it well.  It is an option and another good beginner tool, but you’ll want to upgrade soon.

Bian Stone IASTM Tools

obsidian toolI would put Bian a mild step up from Jade.  They tend to be smooth but not shiny, so have a better grip to it.  I feel it resonates more than jade or horn, and actually have a decent feel to them, but again nothing like stainless steel.  Although not the cheapest, these are a great low-cost option and work well.  You will certainly feel a difference between these and the cheaper tools above.  These also are more fragile than other tools and should be protected like jade.  Don’t drop them!  Considering the mild increase in cost and the fragility of the stones, I again say this is a good beginner tool, but you’ll likely want to upgrade soon.  These are getting harder to find on Amazon too.

Polycarbonate IASTM Tools

The next class of tools takes a step up and now includes plastic, or polycarnonate tools.  These tools are more durable than all of the above tools and tend to be custom shaped based specifically for manual therapy.  The shapes also tend to be larger, which is a good thing.  I prefer polycarbonate tools over the above natural tools for their durability.

dolphin polyThere is a clear winner in polycarbonate tools in my mind, the Dolphin by IAM Tools, based in the UK.  This is a “training” version of their stainless steel dolphin tool, but trust me, this is not just a training tool.  I love the shape, edges, and ability to grip.  Plus it is a bit larger than the above tools so you can work many different body parts.  This a good tool, but still nothing like stainless steel.

Stainless Steel IASTM Tools

Last but certainly not least are the stainless steel tools.  Let’s get this out-of-the-way first – stainless steel tools are by far the best tools for IASTM.  I definitely feel everyone should have at least one stainless steel tool if they are serious about IASTM.

You can’t compare the feel, resonation, durability, or even the weight.  I like a tool with a little weight to it.  Stainless isn’t perfect.  My number one issue is often related to grip as stainless steel can get VERY slippery during a session.  That is why the tools I use tend to have some feature that enhances the grip.  It is also easier to be aggressive with a stainless steel tool, so if you want to be gentle with someone, I would recommend using a different tool, at least initially.

There are two tools that you should highly consider.

edge toolThe first is the EDGE tool.  This is my recommended tool.  I think everyone should own one of these and it’s a great tool to start.  Think of this as the Swiss Army Knife of IASTM tools.  It has a bunch of different edges and a great ability to grip using the middle hole.  At only around $100, it is pretty hard to compete and is often most people’s first stainless steel tool.  It is a pretty versatile tool.

hawk gripsLastly, another great stainless steel option is a set of tools from Hawk Grips.  If the EDGE tool is the Swiss Army knife of IASTM tools, the Hawk Grips tools are the entire top-of-the-line Craftsman tool set!  These tools look really, really, familiar, right?  They are based off the most popular Graston stainless steel tools on the market but Hawk Grips are actually better than those tools!  They added a nice hash grip surface on each that really makes a big difference.

Hawk Grips offers a huge variety of tools, including my favorite the HG8 and the VERY popular HG1 handlebar tool.  There are also a lot of smaller tools designed to treat every body part.  These tools are more expensive, but are quality.  If you are looking for an entire set of tools and a version of IASTM tools just like the most popular ones, this is for you.  If you are not interested in the whole package, they sell the tools individually so you can slowly build your set as your budget allows

What is the Best IASTM Tool?

I don’t think there is a clear winner for each and every person.  If you treat a lot of athletes, you may want the Hawk Grip tools as they are larger and have a great variety.  If you just treat hands and wrists all day, you may want a smaller tool.  If you just have $100 to spend, the EDGE tool may be for you.

In all honestly, I use several tools together, and I bet you will too.  Start with what looks best for you right now, even if just a piece of horn, and as you see the benefits of IASTM start to expand your collection.  I have every tool on this list and I actually use all of them based on my goals, different clients, and body parts.

If I had to pick one, I would definitely start with the EDGE Tool.  It offers the most bang for the buck and is probably the clear winner in my mind for tools everyone should own.

Learn How to Start Performing IASTM Today!

Erson Religioso and I’s online educational program will teach you everything you need to know to start using IASTM today!  IASTM does not have to be complicated to learn or expensive to start using.  Learn everything about IASTM including the history, efficacy, tool options, different stroke patterns, basic techniques, advanced techniques, and how to integrate IASTM into your current manual therapy skills and treatment programs!

IASTM Technique 2.0 has now be released with updated research, new content, and now includes how to perform cupping and use mobility bands!

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How I Use Muscle Energy Techniques

Muscle Energy Techniques

The latest webinar recording for Inner Circle members is now available below.

Muscle Energy Techniques

This month’s Inner Circle webinars shifted gears a little bit.  Rather than talk about a specific injury or treatment focus, we discussed a general technique, muscle energy techniques.  I liked this approach as I think there are a lot of immediate clinical implications that will allow you to start using muscle energy techniques right away.  Here is just a few of the things we covered:

  • The history and background of muscle energy techniques from both the physical therapy and osteopathic fields
  • The effects and efficacy of muscle energy techniques
  • A review of some of the various different methods of using muscle energy techniques
  • How I use muscle energy techniques to increase motion, decrease guarding, reduce hypertonicity, perform joint mobilizations, and teach self-stretches
  • How you can start integrating muscle energy techniques into your current skill set.

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

5 Principles of Treating the Stiff Shoulder

5 Principles of Treating the Stiff Shoulder

The latest webinar recording for Inner Circle members is now available below.

5 Principles of Treating the Stiff Shoulder

This month’s Inner Circle webinars discussed several principles of treating the stiff shoulder.  We’ll cover:

  • The several types of “stiff shoulders”
  • Are we seeing shoulder stiffness more than we realize?
  • How to completely understand the anatomy and biomechanics of the glenohumeral capsule
  • Know when to push motion (and when not to!)
  • What should people with stiff shoulders do at home between sessions

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

Breathing Pattern Disorders

Chaitow ReinoldI was very fortunate to attend an intimately small workshop with Leon Chaitow last week discussing manual therapy approaches to breathing pattern disorders.  I have not been shy about sharing how much I have learned from Chaitow and his extensive body of work, so spending a day with him was awesome!

Below is summary of some of the main points of the course that I thought would be worth sharing.  These are all direct statements from the workshop and are from his textbook on Breathing Pattern Disorders if you want to learn more or see some of the efficacy and references.

What is a Breathing Pattern Disorder?

  • While 10% of patients in the US have diagnosed hyperventilation syndrome, far more people have a more subtle, yet likely clinically significant, breathing pattern disorder that involves being in a constant state of inhalation.
  • This leads to hypocapnia – the deficiency of carbon dioxide in the blood due to hyperventilation, leading to respiratory alkalosis, and eventually hypoxia or the reduction of oxygen to tissue
  • This is commonly seen in chest breathers, that essentially never fully exhale and utilize all of their lung capacity.
  • This essentially puts an individual in a sympathetic state and a subtle, yet fairly constant state of fight-or-flight
  • This can lead to changes in anxiety, blood pH, muscle tone, pain threshold, and many central and peripheral nervous system symptoms.  Some even mimicking cardiac problems.
  • Some of the most interesting info I learned were related to two studies that document the correlation between breathing and some of our daily activities.
    • In one, the study examined typing on a keyboard and showed that EMG activity of the scalenes and trapezius increased and thorax and abdominal activity decreased while typing.  Perhaps this is a primitive reflex but it causes us to breathe more shallow, with less diaphragm, and with more upper chest and neck.  Since we all likely spend a good chunk of our day typing, this is very prevalent.
    • In another, the study showed that people held their breath, increased their respiratory rate, and experienced sympathetic arousal when sending AND receiving text messages.

How to Assess Breathing Pattern Disorders

  • High scores on the Nijmegan questionnaire have been shown to be both sensitive and specific for detecting people with tendencies consistent with breathing pattern disorders.
  • Observe breathing patterns
    • Breath Holding – People can normally hold their breath between 25 and 30 seconds.  If less than 15 seconds may mean low tolerance to carbon dioxide.
    • Supine Breathing Hi-Low Test – Hands on chest and stomach, breathe normal – what moves first?  What moves most?  Looking for lateral expansion and upward hand pivot.
    • Breathing Wave – Lay prone, breathe normal, spine should flex in a wave-like pattern towards head.  Segments that rise as a group may represent thoracic restrictions.
    • Seated Lateral Expansion – Place hands on lower thorax and monitor motion while breathing.  Looking for symmetrical lateral expansion.  This is what expansion should look like:

  • Assessment of elevated and depressed ribs and clavicle.
  • Assessment of poor movement patterns.

Manual Therapy for Breathing Pattern Disorders

  • Based on your assessment, there are several manual therapy techniques that can be performed.
  • Leon is a big advocate for treating muscles that have increased tone or activity with muscle energy technique (MET).  Big areas to watch out for include psoas, QL, latissimus, upper trap, scalene, and SCM
  • Leon showed some MET techniques for the diaphragm, elevated ribs, and depressed ribs, as well as techniques to work on thoracic mobility.
  • Other techniques used include positional release, trigger point release, and Leon’s integrated neuromuscular inhibition technique, which is essentially a combo.
  • Lastly, not a manual technique but pursed lip breathing, which has been shown to relieve dysponia, slow respiratory rate, increase tidal volume, and restore diaphragmatic function.
  • Obviously there was a lot more.  I definitely recommend picking up Leon’s book on Breathing Pattern Disorders for more info on all these techniques.

Breathing Pattern Disorders

Some Take Home Thoughts for Me

  • Our daily posture and habits are feeding into subtle breathing pattern disorders in most of our society, this is probably more prevalent than we realize
  • We all have those patients that I always refer to as always in “constant tone” and suffering from neck pain, shoulder pain, and headaches.  I am going to start here first and then see what self-corrects with just some breathing techniques before jumping right in.
  • I also have a different outlook on people with chronic and uncharacteristic pain, perhaps breathing patterns disorders is a factor?
  • This definitely correlates with a lot of our emerging understanding of neuroscience.  But perhaps our brain’s response is being change by our breathing patterns?

 

 

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3 Ways to Gain Shoulder Internal Rotation – Without Stretching Into IR or the Posterior Capsule!

Inner Circle Premium Content

The latest webinar recording for Inner Circle members is now available below.

3 Ways to Gain Shoulder Internal Rotation – Without Stretching Into IR or the Posterior Capsule!

The below webinar will help you understand:

  • How to assess loss of internal rotation and if it is pathological
  • Why loss of IR motion occurs in overhead athletes
  • Why you don’t want to torque the shoulder into IR if you don’t have to
  • GIRD doesn’t always mean posterior capsular tightness
  • How posture impacts shoulder motion
  • Techniques to immediately gain internal rotation

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

How Hard do We Push When We Stretch?

Over the last several weeks we have talked about how loss of knee motion causes arthritis and ways to improve knee extension.  I received several emails from people asking two questions:

  • How do we know how hard to push when trying to regain motion?
  • Can the devices designed to help restore motion be too aggressive?

To me, this is certainly a double edged sword.  If the cause of restriction is joint or soft tissue hypomobility, you will need to push to create gains but not so hard that we cause inflammation or excessive apprehension.  There is definitely a “feel” to determine how hard to push that I try to teach as a combination of the quantity and quality of motion.  Putting it another way, how well is the joint moving and what is the end feel.

An interesting study was recently published in Sports Health that actually looked at these questions to an extent.  Uhl and Jacobs measured the amount of torque produced during knee flexion stretching performed by physical therapsits, dynamic splinting, and static progressive splinting.

As you can see in the chart below, the typical amount of torque produced by a therapist was approximately 50 Nm of force.  The static progressive splint was closest with 21 Nm of force.

How Hard do We Push When We Stretch?

Interestingly, the dynamic splint provided a fairly low amount of torque.  I see this as a pro and a con.  It appears that a static progressive splint may be better suited to be used by patients in a typical stretching pattern of reps and frequency, while a dynamic splint may be best used for longer durations considering the lower load applied.

I was also actually surprised to see how aggressive one of the splints was, providing nearly 4x more torque than a therapist would while stretching!  I’m not 100% sure what to make of that but I tend to try to get moving quickly so that we don’t need to be so aggressive when we stretch!

Interesting info at the very least and something that I thought was worth sharing.  This may help us decide what type of device we may want to use when attempting to regain motion in the future based on each person’s specific goals.  The authors of the study also talk about how the specific amount of force observed using each method of stretching should impact our frequency and dose of motion activities.

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Assessing and Treating Loss of Knee Extension Range of Motion

Assessing and treating loss of knee extension range of motion is an important component of rehabilitation following any knee surgery.  We recently discussed how loss of knee extension range of motion may be one of the biggest factors associated with the development of osteoarthritis following ACL reconstruction.

The purpose of this article is to review some of the many methods of assessing and treating loss of knee extension range of motion to help maximize outcomes following knee surgery or injury while minimizing long term complications.

Assessing Loss of Knee Extension Range of Motion

There are many ways to treat loss of range of motion in the knee, however, proper assessment of range of motion is even more important.  A certain degree of hyperextension is normal, with studies citing a mean of 5 degrees of hyperextension in males and 6 degrees in females.  Simply restoring knee range of motion to an arbitrary 0 degrees is not advantageous.

The most important factor in assessing loss of knee extension range of motion is looking at the noninvolved knee.  As simple as this sounds, this can not be overlooked as you need to establish a baseline for what is “normal” in each patient or client.

The first thing I look at is simply grasping the 1st toe with one hand to lift the foot off the table.  My proximal hand can stabilize the distal femur.  This is a quick and dirty assessment but I always recommend quantifying the available range of motion.

To accurately measure knee extension range of motion, you will need to use a towel roll of various height to assure the knee is fully hyperextended before taking a goniometric measurement.

Knee Hyperextension

Other aspects of assessment that should be performed when dealing with loss of knee extension range of motion should include patellar mobility, tibiofemoral arthrokinematics, and soft tissue restrictions.  Patellar mobility is especially important after ACL reconstruction using a patellar tendon autograft.  Any restrictions in patellar mobility can have an obvious correlation with restricted knee extension.  Scarring of the patellar tendon can restrict superior glide of the patella and full knee extension.

These assessments will help guide our manual therapy approach to restoring normal arthrokinematics and range of motion of the knee.

Documenting Knee Range of Motion

I took a poll of a large group of students coming through my clinic in the past and found that there was great confusion regarding how we document hyperextension of the knee.   Is + or – when defining a numerical value?

Let’s say that someone has a contracture and is sitting in 10 degrees of flexion and is unable to straighten their knee.  That would be +10 degrees of flexion, thus has to be -10 degrees of extension.  They are on two ends of the spectrum.

Still, using a + or – can be potentially confusing, so I have long taught my students that we should document range of motion using the A-B-C method.  Other authors, such as Dr. Shelbourne, recommend this method as well.

  • If a person has 10 degrees of knee hyperextension and 130 degrees of knee flexion, it would be documented as 10-0-130.
  • If a person has a 10 degree contracture and loss of full knee extension with 130 degrees of knee flexion, it would be documented as 0-10-130.

Using the A-B-C method eliminates the potential for confusion while documenting.

Treating Loss of Knee Extension Range of Motion

There are several ways to improve knee extension range of motion, however, if a person is struggling with this motion I have found that self-stretches, low load long duration (LLLD) stretching, and range of motion devices can be superior to us cranking of a already cranky knee!  Allowing gentle, frequent, and progressive load to the knee is usually more tolerable for the person, especially those that are sore or guarded in their movements.

The intent of this article is to discuss some specific independent strategies to enhance knee extension range of motion.  Other skilled treatments should focus on patellar mobility, soft tissue mobility, and other aspects of manual therapy for the knee as needed.   However, patients will need to perform stretches at home to assure good outcomes.

Self Stretches for Knee Extension Range of Motion

Two of the first stretches that I give patients following surgery are simple self stretches for knee extension.  The basic version simple has the patient applying a stretch into extension by pushing their distal thigh.  The second and slightly more advanced version, has the patient press down on their distal thigh while using a towel around the foot to pull up and simultaneously stretch the hamstrings.

Knee Extension Stretch

Towel Knee Extension Stretch

Similar to how we assess knee extension range of motion, you will want to use some sort of wedge under the heel to assure that you are restoring full motion.

Low Load Long Duration Stretching for Knee Extension Range of Motion

For the person that is having a hard time achieving knee extension, my next line of defense is usually LLLD stretching.  Several research articles have been published showing the benefit of LLLD stretching in achieving range of motion gains.

I prefer performing LLLD stretching for knee extension in the supine position rather than prone knee hangs (follow the link to learn why).  This has always been a more comfortable and thus more beneficial position for me.  To perform this exercise, place a towel roll or similar item under the heel to allow full knee extension and then a comfortable weight over the distal thigh.

Low Load Long Duration Stretch Knee

The purpose of this exercise is to be gentle and to hold the stretch for several minutes.  I typically use anywhere from 6 to 12 pounds and hold the position for at least 10 minutes.  If the person is fighting against the weight, then it is too aggressive.  Lower the weight and you’ll see better results.

Don’t forget that you can apply moist heat to the knee simultaneously for even more benefit.

LLLD Knee Stretch with Heat

Devices for Knee Extension Range of Motion

I am also quick to prescribe a range of motion restoration device for people that may be struggling with range of motion or are not moving their knee enough throughout the day.  I have tried some of the dynamic splinting in the past but found that many people would rather control and hold a sustained stretch rather than have the brace apply a dynamic stretch.

The two devices I have used and enjoyed are from Joint Active System (JAS) and End Range of Motion Improvement (ERMI).

JAS Knee Brace        ERMI Knee Brace

Both devices allow the patient to apply their own tolerable LLLD stretch at home.  This is helpful as frequent movement throughout the day is always beneficial.

Personally my criteria to use these devices is usually when I perceive the person will self-limit themselves and avoid motion.  I will get a device in their hands early so that they can move their knee more at home and have a feeling that they are controlling the restoration of range of motion.  We probably resort to using these devices when it is too late and the patient is already too stiff.

These are just some of the many ways to assess and treat loss of knee extension range of motion.  Considering how important it is to restore full knee extension after knee surgery, properly assessing early signs of loss of motion and effectively treating the knee to avoid long term loss of motion is critical.

Learn Exactly How We Evaluate and Treat the Knee

online knee seminarIn our online course at OnlineKneeSeminar.com we discuss the many pathologies of the knee, including ACL reconstruction. We outline a progressive program that starts preoperative and goes until the athlete is ready to return to their sport.  If you are interested in learning are full approach, our course has a lot to offer. You’ll learning exactly how we evaluate and treat the knee and become an expert at knee rehabilitation.

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