Jodi Schneider, MS, ATC asked for help with this caseload.
Q: I see a lot of non-specific thoracic pain in rowers on average around T4-8, report pain with rotation, occurs mostly on inside (if you're not familiar with sweep rowing, the "in" side is the side they rotate to, so they're already predisposed to rotational issues). Mobility is usually terrible in extension/ and bilateral rotation, MMT of lower trap/ rhomboids usually extremely weak, and all are classic Upper Crossed Syndromes
I spend a lot of time trying to open up front of hips with soft tissue (IASTM, manual soft tissue release), focusing on "in"side, psoas, superior quad, QL and paraspinals. Muscle energy for any rib dysfunctions, and thoracic rotations if needed. To address Upper Crossed syndrome, I also do soft tissue work to scalenes, pec minor, and follow that with deep neck flexor activation and scapular retraction. Home program I send them away with includes
-Hip flexor stretching maintaining neutral spine, with same side arm above head
-Pec minor stretching and self soft tissue release with tennis ball
-Wall/ Foam roller angels
-Side Lying T spine rotation or your open books
I have had good results once I started adding in a lot of hip/ anterior chain, but i have a few patients who just dont seem to respond to anything I throw at them and continue to have pain. Rowing will always have thoracic issues due to the repetition, and the force generated, but would love to hear any suggestions you have or how you would treat these patients.
A: Thanks for reading Jodi! I will only focus on the things you may have missed, but I have to admit, you have a great and comprehensive treatment program that is addressing a lot of the dysfunctions I would find in a population like this.
The cervical spine can refer down to around T6 or the inferior border of the scapula. Taking a page out of the MDT book, you may need to have them over-pressure their chin tucks with their webspace on their maxilla (I never have a patient push on the mandible) and have them push into cervical retraction until their sternum rises to make sure they are going to end range. Have them perform this minimum ten times hourly. Getting to true end range and hourly repetition gets all the benefits of self mobilization and can centralize the mid thoracic complaints better.
Hourly repetition of the "thoracic whip" may also help for self manipulation, this only works well in the case of rapidly changing ROM with treatment, and not the slower improvement seen with true tissue and joint dysfunction.
Also, have them sit with a lumbar roll in all sitting positions, this will eliminate creep stretching of the thoracic paraspinals and prevent the facets from going into an excessive up and forward position, limiting rotation and extension.
Unweight them and check their thoracic rotation actively and passively. Per the SFMA system, if they have limited thoracic rotation in WB, test the same motions unloaded (quadruped, buttocks on heels, on forearm on the floor elbow between the knees and the other hand on the head, have them rotate toward the upper arm actively, then passively). Check bilaterally, then perform the same test with the hand in the lower back, these test unloaded active and passive upper and lower segmental rotation.
|start position for lumbar locked upper body rotation|
|end position for lumbar locked upper body thoracic rotation|
|start position for lumbar locked lower thoracic rotation|
|end position for lumbar locked lower thoracic rotation|
If the movement was limited in loaded, but not unloaded, or actively, but not passively, you do not have a mobility issue, you have a motor control/stability issue. Check rolling as in this videos.
Upper Body Supine to Prone
Upper Body Prone to Supine
Lower Body Supine to Prone
Lower Body Prone to Supine, Thanks to SportsRehabExpert.com for great demonstrations and form!
The significance here is that these movement patterns are from development. We should all be able to do these from a very early age, and indeed learn how to do them in the womb. You will be surprised how many even elite athletes lose the ability to roll in one direction. This is a movement pattern that only requires enough strength to move actively, it is not a strengthening exercise (but it sure feels like it!) The difficulty comes from sequencing the movement properly, firing the correct line of muscles in the proper sequence, and not using your legs for upper body or assisting with your arms with the lower body rolling.
I would expect those that are not responding to your manual therapy and self care program have a lack of thoracic motor control due to their over rotation in focusing more on one direction. I would be fairly certain that many of them will have difficulty with upper body rolling in at least one direction, not cheating by using the legs (they should be dead weight). This movement may need to be broken down with wedges or foam rollers to make it easier to get the movement down. Do not have them practice the incorrect movement if they cannot do it right, that would just be enforcing poor movement patterns.
If they are also mainly rotating to one side, their hips are most likely missing rotation to the other side, check for rotation actively and passively, and mobilize if both are limited. If only active is limited, but not passive, again we have a motor control issue that needs to be addressed with corrective exercises. Let me know if you need examples of those.
I hope you find these suggestions useful and let me know how the rolling assessments work out!