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The Role of Sports Massage in the Prevention and Management of Training Injuries: An Interview With Dianna Linden, MT, CFT, Part 2

by Charles Staley

(Part 2 of 2)

Introduction: In the first part of this interview, Dianna discussed the role of sports massage in an athlete’s training program, how to find a skilled massage therapist, and what actions to take upon the incidence of a training injury.

In part two, Dianna and I discuss the most common injuries that she sees in her athlete-clients, how they might be prevented, and we’ll also detail the importance of the feedback that a skilled MT can provide to an athletes coach or conditioning specialist.

— Charles Staley

Dianna Linden of Dianna Linden Sports Massage

CS: What do you think is the most important aspect of sports massage and what it can offer an athlete in his or her efforts to achieve new PRs in their sport?

DL: I think its role in injury prevention is one of the most interesting features a good massage done by educated hands can offer. If an overuse pattern ultimately results in an injury to that part or parts then the athlete is facing a break in optimal training, and instead is now busy finding a good team; doc, PT chiropractor, etc. to devise and implement a quick recovery paradigm.

That's not always easy to come by. No matter how good they are it always constitutes a set back in the progress that was being made. If that occurs late enough in the season, it can be disastrous.

I thought Mary Decker put it well in that quote we ended part 1 with, when she said, about working with Rich Phaigh, "My training runs became painless, with fewer injuries than in the past. And with my shorter recovery time, I soon began training at a consistently high level, better than ever before." Isn't that what every athlete would like to achieve and maintain? In USSR they considered recovery methods an important part of optimum performance, here it is generally not considered with much intelligence at all.

CS: Certainly, my athletes have similar experiences as well. Funny how we do everything possible to accelerate training gains per se, but virtually nothing to accelerate recovery in a planned, conscious way!

DL: Well yes, I was just about to say that it's not just about massage, either, it is about utilizing smart recovery methods in general. The training program, if well designed by the coach, considers the longer recovery usually necessary when max effort has stressed the nervous system.

Athletes could use jacuzzi, sauna, hot/cold alternating showers, TENS, to enhance blood flow and speed up the capacity for fatigued muscles to perform optimally without injury. As much talk as I hear on the various newsgroups about which training routine is best for the most gain, or "do I need to do assistance work for the rotator cuff?" I hear almost nothing about recovery strategies.

Dr. Mel Siff, who wrote Supertraining with Dr. Verkhoshansky and along with Michael Yessis, edited Sports Massage and Recovery, has thrown suggestions and considerations regarding recovery into the discussion arena, but I have never heard any athlete pursue the discussion. What I infer from that is that here, in the States, athletes do not consider recovery primary in importance when planning their training regimes. They simply notice when something starts to hurt, gets trained on anyway and then hurts more. That's what Mary was referring to when she said "I owe most of my high fitness level to Rich and his method of athletic massage. I know this is true because I don't get Rich's massage treatments when I travel for an extended period of time. Then, old injuries creep back and recovery time increases with each hard run."

CS: As I always say, training is only as good as your ability to recover from it, it's like how they say that music depends on the spaces between the notes, not just the notes involved— successful training is the same way.

DL: Massage can help an athlete sleuth out that which is not yet a full blown injury and eliminate most of it before it becomes a problem which interferes with training. I know that sounds like an outrageous claim, but it is my experience and the experience of several athletes who use sports massage as well. There's no way to measure this other than the subjective experience of athletes and coaches, I suspect. How do you quantify an injury which didn't happen? How do you measure that? Yet many athletes who use these recovery protocols know it to be true. We can feel those adhesions and trigger points in the tissues and erase them long before they show up by limiting function in sport. One of my mentors liked to call this working prodromally, using a word from medicine which means the interval between the earliest symptoms and the appearance of the full blown disease, the initial stage of a disease. If we can palpate the prodromes of trauma in tissues and clear out the schmutz before it becomes an injury which interferes with an athlete's training routine, that is the slickest way to work.

Some stuff can't be prevented altogether, even with the best of support.

Jackie Joyner Kersee got her gold medals at Seoul and Atlanta with a major hamstring tear, both times. Her team, in that case, was working locally on those tissues between each event using a number of modalities, ultra sound with aspirin cream, TENS, ice, gentle local transverse friction massage, ice, ice, and ice. When there was more than one trial or event on the same day, she was worked on locally to prepare those muscles for their next trial. She got a full body massage at the end of the day to relax her, increase blood flow to the muscles and generally get her ready for the next day's event. I can't imagine anything more stressful to hamstrings than heptathlon, yet, even with that tear she got the gold. In my opinion, that was a very skillfully applied recovery paradigm under the toughest conditions.

I studied with the massage therapist who was on that team led by Robert Forster, PT, working with several of Jack Kersee's athletes. He said one of his perpetual pursuits there was finding enough ice in Korea to keep treating the athletes, and to keep track of the zip lock stash. No baggies in Seoul to replace them when they disappeared.

CS: They should have called me! OK, now I know you are very conscious of your professional scope of responsibility (i.e, you can’t legally diagnose injuries), but with that in mind, I'd really like to discuss some of the problem areas that you commonly see in people, athletes especially. So, for example, let’s say that I have an athlete, like several cases that we’ve worked on together recently, and he is experiencing shoulder pain in the left shoulder. He's had a medical evaluation, and nothing was found with functional tests. So then, I bring the athlete to you, and you palpate their left scapula right over the infraspinatus, and they jump through the ceiling!

What does this tell you?

DL: Well, as you know, there are all kinds of pain. Workout pain is something all athletes learn to live with. I sometimes think that's why, when they have a pain in a muscle which indicates it needs some healing attention, they just don't distinguish that from the regular ongoing pain of working yourself to your limits. When I palpate the tendons of infraspinatus for example and the athlete rises to the ceiling like a great yogi, it usually means that there is micro/macro-trauma right where I am touching. This is another service which I think good sports massage performs. We can palpate from the muscle origin's teno-periostial, musculo-tendinous areas, through the muscle belly, on tomusculo-tendinous/ teno-periostial insertion. Where it is sharply painful defines the area of the injured tissue.

The athlete can learn to:

A: distinguish this kind of pain, which should be honored, not ignored and trained through, from regular workout pain,

B: gain a better sense of the current injury, how large an area needs to be iced after the next few workouts which would use that muscle in any way, which workouts to lighten up to ease it's load either as a prime mover or synergist and some specific modalities at home as well as exercises to do to speed its recovery. Most often I find trauma in the teno-periostial or musculo-tendinous junctures when it is micro trauma which builds unnoticed to macro from overuse in training. That's where I see the most sports injuries at the prodromal stage.

From my experience, physical therapists most often use ultra-sound, electrical stimulation, specific rehabilitation exercises and cold to enhance rehabilitation of injured tissues. Sports massage therapists use various massage techniques, depending on where the injury is located which could include active release, deep transverse friction massage, ice massage followed with cold packs to achieve that. Both ways work, but in my experience, without the specifically applied hands on techniques, the tissues often remain adhered or partially so, at the site of the lesion, therefore are more prone to re-injury.

It is as rare to find a good sports massage therapist who knows how to advise the best exercise protocols for rehabilitation of an injury as it is to find a sports oriented physical therapist with hands on skills who really knows how to work on the tissues. Personally I like to work in conjunction with other practitioners; physical therapists, chiropractors, acupuncturists to speed up reduction of acute inflammation, as well as the athlete's coach or trainer regarding an injury which needs to heal. It's not always economically possible, in which case we ad lib.

CS: Dianna, I've heard people complain for years about how painful Rolfing is or that they hurt for days after deep soft-tissue work. I know from personal experience that deep work in the muscles can be painless and there can also be various levels of pain. I also know you utilize techniques where, basically, the client determines how deep you go— can you elaborate on that?

DL: I've heard the same reports, in far more gruesome detail, I'm afraid. "Hurt for days, bruises after the body work" and other stories of torture in the hands of a "deep tissue" bodyworker. Yuk! Bruising is definitely a sign that the tissues were worked too deeply, adding insult and further injury to them. Some folks bruise easily— I'm not saying it can't happen, but when doing deep clinical work I always ask my clients to be Dick Tracy for the next two days and report any and all findings related to the areas of deep work. If there's ever any bruising we talk about nutrition, Vitamin C intake AND I lighten the work considerably in the next session. Deep bodywork is supposed to free tissues from adhesions, not injure them further.

I have one client who is 73— she was arthritic for many years with spurs and stenosis on osetoporotic vertebrae, she had polio in France before WW2 with some current residue from that, as well as the times when small chunks from her intervertebral discs broke off and wedged against nerves, immobilizing her with pain until they re-absorbed. She's so fragile that she simply can't exercise as she used to. She was an avid skier, swimmer and mountain climber. Now her connective tissue is sinewy and dried out and she has more than her share of aches and pains— always. Glucosamine has helped a bit and the body work definitely serves as an oil and lube tune up. In her massage we do lots of joint movements, compression for her trigger points which perpetually return like weeds in the garden, and I work through her muscles at some depth because they get adhered and need "fluffing up."

Among a plethora of other drugs, she's on Cumadin, has to have her blood viscosity checked sometimes every day. If I worked her with too much depth I'd hate to imagine what would happen. She gets a hematoma if a plant in the yard simply brushes her skin. Has new ones each week which she doesn't even know are there or how they happened. Part of what we do is inventory on that. We have worked together for many years now and the massage helps her function.

She still works hard in the world as the owner of a school, sitting on those little kid chairs while she relates to them at their level, which I'm sure contributes to the return of the trigger points. She's an example of someone who needs specifically applied bodywork techniques, the style and depth must be very carefully monitored. If I didn't work her with some depth we wouldn't get the schmutz out of those muscles. We've successfully done deep transverse friction massage on her supraspinatus and deltoid tendons after an overuse injury, but with utmost care and caution. That's by nature invasive work, but even in this case, possibly the most fragile human I'll ever work with, we could use it with some delicacy and get the job done without any bruising.

I had to find a referral for her when I was out of the country with an athlete for a couple of months. Because of how fragile she is, scary really, I referred her to a physical therapist with his masters degree who specialized in CNS injury recovery and had apprenticed with John Barnes, someone I knew had extra training in many hands on techniques besides those myofascial release methods. I talked to him for over an hour about her medical history and condition, suggested that he avoid mobilization of the vertebrae like the plague, just fluff and fold, oil and lube to the soft tissues, easy does it.

Apparently on their first visit he did another 45 minute evaluation, then, started with very gentle touch along the vertebrae, as she described it to me later. Didn't work the tissues at all, really just those movements along the spine. Next day she was flat on her back in the hospital with another episode of intevertebral disc breaking off and wedging against a lumbar nerve. It took the whole time I was gone to reabsorb. She didn't really correlate the vertebral mobilization with the event, wondered casually about those little movements of the spine, if they could have something to do with it, and we will never really know since correlation doesn't mean causation, but I won't refer to him again, and he was too embarrassed to even talk to me when I returned. So what's "deep?" His touch was so gentle, but the method he chose was challenging tissues which, in my opinion shouldn't ever be addressed on her at all.

The point is that deep doesn't really mean invasive and excruciating, nor does something which feels gentle necessarily mean benign. I once got a rub at a local trendy spa here in Santa Monica with one of their sports masseurs who did "deep tissue work." I paid top dollar for it but stopped the session in the middle. His idea of deep was to simply burn through my tissue with his elbows as deep as he could. He clearly did not know his anatomy, origins and insertions, nyet. Although he was offended that I politely told him to stop the session, the guy was dangerous and it was either him or me. When he pressed hard with his elbow directly on the spinous process of my lumbar vertebrae and right on the SI joint and ilium instead of the tendons attached just below, it became painfully clear that there was no way to salvage that session. This guy was licensed to practice in my city. Scary.

CS: So those are some examples of what good "deep" work isn't, but what is it?

DL: Well, If the tissues have adhesions from injury or overuse micro-trauma building imperceptibly to macro-trauma in the musculo-tendinous or teno-periostial attachments, I find that deep transverse friction massage (DTF) is the most effective at getting that stuff out of there. Otherwise training will often cause it to reinjure on that same site as you commonly hear happening to folks who don't get it worked on. In tendonous tissue and ligaments DTF can be effectively done very soon after the injury.

Muscle bellies are another story, there are more and better ways to work stuff out of them, and the timing is different. DTF is painful and must be done right on the site of the lesion to be effective, not 1/4 of an inch away. I warm up the tissues well with moist heat and various massage strokes to generally soften the area first, that helps diminish the discomfort, but when we address the glued up spots it can go up to a 12 on a 10 scale of pain in a hot LA minute on the first pass.

One of the things I do is explain a pain scale I like to use. 10 is painful beyond endurance, 9 excruciating and too invasive to breathe and relax into, 8 is the maximum one can take and still keep the shoulders peeled off the ears, body non levitated, toes uncurled and able to breathe into it, somehow make space around the intense sensation without resistance while relaxing the rest of the body. Defining that scale works in several ways for me. First, some folks are so stoic they will never say "that hurts too much." I ask them to say "8" instead, no one has much trouble labeling a sensation an "8", no wuss connotations there. Also I can get them to tell me when it is a 4 or 6 or 7. If I see them curling toes but only reporting a 4 on the 10 scale then I don't go above 3. I can feel a person's translation of reality out a bit better with the numbers. People are so different in how they experience "reality". One client will fidget and say "Oh Oh!! Oh Oh!!" when we just barely touch an injured spot, another will say "Easy now" in a slow deep voice like he was instructing a yoga stretch. I actually find watching their choice of words and reactions to slightly painful sensations when I first begin to address something, very informative. It helps me figure out how best to work with someone. I don't ever like to work above an 8 on that scale even with DTF, 6s or 7s are better and still get the job done in my opinion.

CS: Very, very interesting— I remember being quite taken by this method when you first exposed me to it. You also do a lot with breathing, correct?

DL: Well, yes— in describing the possibility of breathing into pain, relaxing around it rather than resisting and tightening against it, explaining that we can stop at any number, modify the duration of the sensation, we have the capacity to break up the definition of what pain is and not fixate on it, resist it in the old unconscious way. How we experience pain and how intense it seems is largely a very subjective experience, even though we all share the same neurological mechanisms governing the delivery of that information within the organism of the self.

With athletes, because they are used to suffering through sets of tough reps in the gym, each cross fiber stroke is a rep and we do sets of 15 or 20 reps depending on how tender the tissue is. As it improves in texture after the first session the pain level diminishes as well so we can use more reps per set and get the 2 minutes of DTF done. On a first time visit, before someone actually experiences the results of the work, I do less reps and sets, maybe only 45 seconds to a minute per location to keep the session well within humane tolerance levels. When they come back after seeing improvement, it is easier to volunteer for more of the same and it hurts less besides.

With mom's, I remind them of their Lamaz or Bradley breathing techniques for labor. Works like a charm. They remember how to dissociate from that pain instantly, it was a really big and often long experience. We still do reps and sets on the cross fiber and they find it instantly easier to handle. It also accesses their memory of a big reward after enduring the pain of labor, not a bad induction.

By instructing folks to "make space" for and around the painful sensations the intensity of voluntarily directly addressing one's own pain diminishes.

Folks learn that they have the capacity for a dissociative experience with pain, how it is experienced can actually be modified, played with if you will.

This is an application of a technique which the Ericksonian therapists utilize really well, dissociative phenomena in trance induction can be used to help people deal with pain by separating their conscious attention from the sensation. I combine that with the experience of modulating the intensity thus taking something autonomic and outside of conscious awareness and learning to cognitively control it, the act of bringing awareness into it, modifies its intensity somehow actually causes it to dissipate. It would be hard to explain why this works, but it really does.

By having folks give me feedback about what they are experiencing and defining the limits of what's an acceptable experience, we are also learning to define personal boundaries more clearly. Some folks are raised with fuzzy definitions of the authentic boundaries of self and other, so this, I think has positive carry over into life; saying what is too invasive or not what you want, clarifying what you do want, not assuming that another "knows" what you're experiencing but instead really having to describe it, these are all important communication skills in life. In this way, I think we are doing work on many levels working with "pain" this way. Still, it just sounds like "8!" when we're right there on it, not all that esoteric at all.

I should also mention that sometimes, pain is entirely avoidable, even though the tissues need deep work. There are many methods to get schmutz cleared out. Active release techniques are far less painful and invasive than some of the old Rolfing style strokes to clear adhered tissue, especially in muscle bellies. If a person contracts under your specifically applied pressure on a particular spot, they are

A: in charge of the experience and intensity, they can stop the contraction at any time.

B: contracting those fibers while you hold appropriate resistance is far less painful to start with

C: actively releasing them is more effective at disengaging adhered tissue from the muscles.

CS: I wondered if you would also just quickly cover myofascial release, since I hear you refer to it quite often.

DL: OK— Myofascial release is a sustained gentle stretching protocol which can be very effective for adhered connective tissue and requires more patience to just stay with it, than depth of contact. Trigger point compression therapy only uses about 4 pounds of pressure sustained on a TP then repeated a few times to get TPs out of the tissue. Although trigger points can cause all manner of referred pain and be very painful if one were to irritate them by rubbing across them, that is not how they are best worked out of the tissues, so the work does not have to cause discomfort at all.

If you warm up muscles with some gentle CRAC stretches and knead and jostle them, a lot of stuff just softens right up. When the injured site requires the direct DTF approach, I warm it up before I do the first set of DTF. After 15 strokes of DTF I then leave the area alone for a little while, do something else and let the tissues have time for the body's natural pain killers to rush into those tissues, then when we come back for the next pass the body's own pain killers are already working and it is a lot less painful to get in there for the next set. What an amazing self repairing vehicle the body is, remarkable really. Lots of ways to work with it rather than charge right in there and attack the glue. That might have been all we knew when Ida Rolf and Jack Painter were first teaching their deep tissue styles, but more has been learned since then about how the tissues respond to various techniques, though much more needs to be studied.

Not much funding for massage studies yet, so many unanswered questions remain.

CS: I think it's an underrated skill to be able to improvise in less-than-perfect conditions. And while I agree that a multi-disciplinary team of practitioners is the way to go, it does bring up the issue of communication— making sure that the right hand knows what the left is doing (how's that for an apt pun!).

DL: It works for me. You and I have come up against that problem more than once when collaborating with an athlete, eh? Mostly knowing what the athlete is also doing which he or she doesn't count as part of the training protocols but which can blow us out of the water, so to speak (since you like puns). Surfing all day several days in a row because the waves are up, "the best so far this year," starting on the day after increasing the loads in back training, then forgetting to mention it to you or me comes to mind. At the end of the week I am wondering why the erectors are tighter than a screaming steel guitar with micro trauma stranded throughout the spasm, when they felt fine just days ago and it didn't seem that those load increases were incrementally that profoundly taxing. Oh well, the best laid plans...

CS: Well Dianna, there’s just so much information here that I fear we haven’t even scratched the surface...if readers would like to contact you for consultations, referrals, etc., how would they go about that?

DL: They can either call me at (310) 394-1450, or they can e-mail me at [email protected] . And I’d love to hear from anyone who has an interest in the subject!

CS: Thanks again, and I’m sure you will!