Athletes Treating Athletes

In the last post, we talked about how to manage the common symptoms of tendon injuries. This included using Rest, Ice, Compression, and Elevation (aka R.I.C.E.) to reduce pain and swelling. We also reviewed what A-T-A techniques are best for treating this type of injury.

To review, typical treatment for a tendon injury looks like this:

1) R.I.C.E. + gentle stretching. There should be no pain with stretching.

2) Begin using the foam roller to work on the muscles first (in other words above the tendon). The tendon is what attaches the muscle to bone. The goal here is to start getting slack into the muscle without aggravating the injury itself. No tennis ball work or active/joint mobilizations. The order should be foam roll the muscle above the tendon -> stretch -> RICE.

3) Begin using the foam roller over the tendon to tolerance. The order should be foam roll the muscle above the tendon-> over the tendon -> stretch -> RICE.

4) Begin using the tennis ball for cross friction. Remember, you will want to work perpendicular to the the tendon. Start with light pressure at one end of the tendon and work your way all the way down it. Repeat as needed (and as tolerated) with increased pressure. If it’s too painful- wait and try again the next day. The order should be foam roll the muscle above the tendon -> over the tendon-> cross friction -> stretch -> RICE.

How long do you need to R.I.C.E for??? Until it’s 100% gone.

The toughest part of the above treatment plan is using the cross friction technique. This is a deep muscle release technique that works against the muscle and tendon fibers to break up restrictions and adhesions. The movement relies on sinking deep into the muscle. Due to this pressure, there is actually very little side to side movement (1-2 inches at the most!). This prevents sliding over the skin as you want the skin and muscle to move together. To perform this technique you can use a tennis ball or your first two fingers depending on the size of the tendon. 1) Relax the muscle and let the tennis ball/you fingers sink in, 2) apply pressure (this is key!). 3) you always want to work perpendicular to the direction of the tendon. This prevents you from damaging it! apply pressure and then work in this direction (remember 1-2 inches max!). When done correctly, you should be able to feel uneven, hard, or even “crunchy” spots. Shoot for 2-3 minutes. Here is a video of how it is performed, click here.

In this post, I want to help give you a visual for the CF technique. Remember- the goal is to always to work perpendicular to the direction the tendon runs in. In the pictures below you will find all of the common tendon areas in the upper body. The tendons are shown in green. To use the cross friction technique, you will want to work in the same direction as the red line.

[NOTE: You will want to review the general anatomy and muscle/tendon palpation tips of these areas before trying to work specifically on the tendons themselves. Here are the links you will need- neck, back of the shoulder, front of the shoulder, bicep/tricep, forearm/elbow, hand.

Shoulder

Levator Scapulae

As you can see by the green line, the levator runs diagonal from the inside corner of the shoulder blade up into the cervical spine (neck). The lower portion of the muscle where it inserts onto the shoulder blade is a common place for tendinitis/inflammation and can even result in bursitis underneath the shoulder blade. To use cross friction on this area, you will want to work just above the shoulder blade and in the direction of the red line.

#1 Supraspinatus (at insertion on humerus/upper arm bone)

The supraspinatus muscle is one of the four rotator cuff muscles and begins on the back of the shoulder blade before moving to the front and inserting on the humerus (upper arm bone). To find this muscle, place your hand over the top of your shoulder until you can feel the spine of your shoulder blade. Follow that line to the outside of the shoulder and drop just off the edge of the bone. If you rotate your arm in/out, you will feel the tendon move beneath your fingers. The tendon runs in a diagonal direction versus straight up and down. Work in the direction of the red line.

#2 Upper (Long) Bicep Tendon

There are two tendons for the bicep muscle. One inserts deep while the other is more superficial (#2 in the picture above). To find this tendon, start with your hand on the bicep itself. While bending/straightening your elbow, trace the muscle upwards towards the front of your shoulder. As you get above the level of the arm pit you will be on the tendon versus the muscle. Again, bend and straighten your elbow to make sure you are on the right spot. If you do not feel it move under your fingers, stop and retrace the muscle. Work in the direction of the red line.

Infraspinatus (part of the rotator cuff)

The infraspinatus is one of the four rotator cuff muscles and begins on the back of the shoulder blade before inserting onto the back of the humerus (upper arm bone). To find this muscle, reach your opposite hand over your shoulder to find the spine of the shoulder blade. The infraspinatus lies just below that. To find the tendon, trace the spine to back of the shoulder just above the arm pit. Rotate your arm in/out (with your elbow at your side) and you will feel the muscle move beneath your fingers. You will two options to work on this tendon, one with the arm at shoulder height (pictured above) and one with the arm down at your side. If working on the area with the arm elevated, be sure to work in the direction of the red line above. If the arm is at your side the tendon runs parallel to the floor and a vertical direction will be needed for the cross friction technique.

Elbow

Lower Bicep Tendon

The lower bicep tendon crosses the elbow joint and inserts on the radius (one of the two forearm bones). To find this tendon, start with your hand on your bicep and trace it down below the elbow. Bend and straighten as needed to make sure. You should be able to feel it under your fingers as you move the elbow. The tendon runs in a slightly diagonal direction. Follow the direction of the red line when using the cross friction technique.

Tricep Tendon

The tricep tendon is easy to follow. Simply place your your hand under your elbow and then move up the back of your arm just slightly. Bend/straigten your elbow to make sure you’re on the right spot and then work in the direction of the red line.

Wrist Flexors

The wrist flexors all run up the forearm from the wrist to insert on the medial epicondyle. If you cup your hand under your elbow you will feel the two “knobs” on either side. These are called the epicondyles (the medial is on the inside closest to the body, and the lateral is on the outside away from the body). To find the wrist flexor tendon, place your thumb on the medial epicondyle and bend your wrist back and forth, you will be able to feel the common tendon move. Simply slide off the epicondyle and work in the direction of the red line.

Wrist Extensors

The wrist extensors all run up the forearm from the wrist to insert on the medial epicondyle. If you cup your hand under your elbow you will feel the two “knobs” on either side. These are called the epicondyles (the medial is on the inside closest to the body, and the lateral is on the outside away from the body). To find the wrist extensor tendon, place your thumb on the lateral epicondyle and bend your wrist back and forth, you will be able to feel the common tendon move. Simply slide off the epicondyle and work in the direction of the red line.