BY

Dr. John Mullen, DPT, CSCS

COR Physical Therapy and Personal Training
Swimming Science
Copyright 2015 G. John Mullen
All rights reserved

No part of this book may be reproduced in any form or by any electronic or mechanical
means including information storage and retrieval systems, without permission in
writing from the author. The only exception is by a reviewer, who may quote short
excerpts in a published review.

The information presented herein represents the views of the author as of the date of
publication. This book is presented for informational purposes only and does not offer
medical diagnoses or advice. For medical assistance consult your qualified healthcare
practitioner. Due to the rate at which conditions change, the author reserves the right
to alter and update his opinions at any time. While every attempt has been made to
verify the information in this book, the author does not assume any responsibility for
errors, inaccuracies, or omissions.

2
About the Author
Dr. John Mullen is a Doctor of Physical Therapy and Certified Strengthen and
Conditioning Specialist. At the University of Southern California, he was a clinical
research assistant at USC performing research on adolescent diabetes, lung
adaptations to swimming, and swimming biomechanics. G. John has been featured in
Swimming World Magazine, Swimmer Magazine, USA Swimming, STACK Magazine,
Sports Rehab Expert, and the International Society of Swim Coaches Journal. He is
currently consults for multiple clubs and colleges regarding dry-land and
rehabilitation/prevention programs, and the founder of the COR and Swimming
Science.

3
Acknowledgments
Special thanks from G. John Mullen:
Carlene Takaki
Chris Barber
Allan Phillips

4
Contents
About the Author .................................................................................. 3
Acknowledgments ............................................................................... 4
Video Database ................................................................................... 11
Foreword ....................................................................................... 12
Background ....................................................................................... 13
Core Training Theory ......................................................................... 15
Ecclesial Teaching .......................................................................... 16
Research Reproductions ................................................................... 17
What's Good ................................................................................. 18
More Research Contraindicating Spinal Flexion ........................................ 19
More Problems .............................................................................. 19
Non-Functional.............................................................................. 19
More Volume ................................................................................ 20
Progression .................................................................................. 20
Creating Core Strength .................................................................... 21
Types of Rehab/Core Training ............................................................ 21
Anatomy ........................................................................................... 25
Spine ............................................................................................ 27
Joints and Movement ......................................................................... 28
Planes of Movement .......................................................................... 28
Sagittal plane ............................................................................... 28
Frontal plane ................................................................................ 28
Transverse plane ........................................................................... 28
Spatial Movement ............................................................................. 28
Anterior ...................................................................................... 28
Posterior ..................................................................................... 28
Superior ...................................................................................... 29
Inferior ....................................................................................... 29
Medial ........................................................................................ 29
Lateral ....................................................................................... 29

5
 Proximal ..................................................................................... 29
Distal ......................................................................................... 29
Muscle Movements ............................................................................ 29
Action ........................................................................................ 29
Origin ......................................................................................... 29
Insertion ..................................................................................... 29
Spinal Flexion ............................................................................... 30
Spinal Side Bend ............................................................................ 30
Spinal Rotation.............................................................................. 30
Anterior Pelvis Rotation ................................................................... 30
Posterior Pelvis Rotation .................................................................. 30
Muscles and Tendons ......................................................................... 30
Tendons......................................................................................... 33
Ligaments ...................................................................................... 34
Bursae........................................................................................... 34
Joint Capsule .................................................................................. 34
Intervertebral Discs ........................................................................... 35
Vascularity in the Spine ...................................................................... 35
Vertebrae ...................................................................................... 35
Swimming Core Training ........................................................................ 36
Equipment to Build Core Strength ....................................................... 36
Muscle Length .................................................................................... 38
Iliotibial Band .................................................................................. 40
Where is the IT Band? ...................................................................... 40
What does the IT band do? ................................................................ 40
What does SMR to the IT Band Feel Like? ............................................... 41
SMR IT Band Summary ..................................................................... 41
Quadriceps ..................................................................................... 42
Where is the Quadriceps? ................................................................. 42
What Do the Quadriceps do? .............................................................. 42
What Does SMR to the Quadriceps Feel Like? .......................................... 43

6
 SMR of the Quadriceps Summary ......................................................... 44
Adductors....................................................................................... 45
Tennis Ball Adductors ........................................................................ 45
Where are the Adductors? ................................................................. 45
What do the Adductors Do? ............................................................... 45
What does SMR to the Adductors Feel Like? ............................................ 46
SMR to the Adductors Summary .......................................................... 46
Tensor Fasciae Latae ......................................................................... 48
Where is the TFL? .......................................................................... 48
What Does the TFL do? .................................................................... 48
What Does SMR to the TFL Feel Like? ................................................... 49
SMR to the TFL Summary .................................................................. 49
Piriformis ....................................................................................... 50
Where is the Piriformis? ................................................................... 51
What does the piriformis do? ............................................................. 51
What Does SMR to the Piriformis Feel Like? ............................................ 51
SMR to the Piriformis Summary........................................................... 51
Psoas ............................................................................................ 53
Where is the Psoas? ........................................................................ 54
What Does the Psoas do? .................................................................. 54
What Does SMR to the Psoas Feel Like? ................................................. 54
SMR to the Psoas Summary ................................................................ 55
Quadratus Lumborum ......................................................................... 56
Where is the QL? ............................................................................ 56
What Does the QL Do? ..................................................................... 57
What Does SMR to the QL Feel Like? ..................................................... 57
SMR to the QL Summary ................................................................... 57
Static Stretching .............................................................................. 58
Adductor Stretch ........................................................................... 58
Single Knee to Chest Stretch ............................................................. 58
Hamstring Stretch .......................................................................... 59

7
 Piriformis Stretch........................................................................... 59
Standing Iliopsoas Stretch ................................................................. 59
½ Kneeling Stretch ......................................................................... 59
Muscle Strength .................................................................................. 60
Where to Start? .................................................................................. 64
Core Strength Testing ........................................................................ 65
Medicine Ball Overhead Throw ........................................................... 65
Medicine Ball Rotational Throw .......................................................... 65
Reverse Overhead Medicine Ball Throw ................................................. 65
Phase I .......................................................................................... 66
Abdominal Bracing ......................................................................... 66
Straight Leg Raise .......................................................................... 66
Hip Abduction with Band .................................................................. 66
4-Point Hip Extension ...................................................................... 66
Phase II ......................................................................................... 67
March ......................................................................................... 67
Hands Over Head Curl-Up ................................................................. 67
Anti-Rotation with Band ................................................................... 67
Prone Alternate Arm and Leg ............................................................. 67
Phase III......................................................................................... 68
Hands Over Head Curl-Up With Partner Pulls .......................................... 68
Side Plank ................................................................................... 68
Anti-Rotation Walkout with Band ........................................................ 68
Swiss Ball Bridge ............................................................................ 68
Phase IV ........................................................................................ 69
Bosu Hands Over Head Curl-Up ........................................................... 69
Bunkie Knees Bent.......................................................................... 69
Rotation with Band ......................................................................... 69
Swiss Ball Bridge March .................................................................... 69
Phase V ......................................................................................... 70
Ab Wheel .................................................................................... 70

8
 Bunkie Knees Bent.......................................................................... 70
Medicine Ball Chop ......................................................................... 70
Super Dog .................................................................................... 70
Phase VI ........................................................................................ 71
Body Saw..................................................................................... 71
Bunkie ........................................................................................ 71
Torture Twist ............................................................................... 71
Double Leg Raise ........................................................................... 71
Phase VII ........................................................................................ 72
Bracing with Lat Pull Down ............................................................... 72
Bunkie with Hip Abduction ................................................................ 72
Suit Case Walk .............................................................................. 72
Single Leg Raise............................................................................. 72
Phase VIII ....................................................................................... 73
Farmers Walk ............................................................................... 73
Ab Wheel with Band........................................................................ 73
Waiter Walk ................................................................................. 73
Glute Hamstrings Raise .................................................................... 73
Phase IX......................................................................................... 74
Medicine Ball Throw Down ................................................................ 74
Kneeling Pallof Press ....................................................................... 74
Tight Medicine Ball Throws ............................................................... 74
Single Leg Glute Ham Raise ............................................................... 74
Phase X ......................................................................................... 75
Single Arm Medicine Ball Throw Down .................................................. 75
Kneeling Pallof Press with Extension .................................................... 75
Heiden ....................................................................................... 75
Medicine Ball Rotational Throw .......................................................... 75
Phase XI......................................................................................... 76
Monkey Throws ............................................................................. 76
Heiden with Rotation ...................................................................... 76

9
 Shot Put ...................................................................................... 76
Reverse Overhead Throw .................................................................. 76
Case Studies ...................................................................................... 77
Stiff Sam ........................................................................................ 77
Flexible Frank ................................................................................. 79
COR Low Back Pain Guide ...................................................................... 81
Pathologies ..................................................................................... 81
“Having” and “Feeling” Aren’t the Same ................................................. 81
Common Types of Injuries ................................................................... 85
Phase of Injury ................................................................................ 88
Physiological Steps ............................................................................ 89
Spot the Location ............................................................................. 91
Typical Rehabilitation for Swimmers with Low Back Pain ............................ 92
First and Foremost ............................................................................ 94
Rules and Regulations ........................................................................ 96
Return to Swimming Yardage ............................................................. 98
Case Study of Swimmer with Low Back Pain ........................................... 98
Return to Swimming Guide ................................................................. 100
Low Back Pain Taping Guide .................................................................. 102
Supplies ........................................................................................ 103
Preparing for Tape ........................................................................... 104
Taping Procedures ........................................................................... 104
Kinesiotape® QL Inhibition ................................................................. 104
Kinesiotape® Inflammation ................................................................. 105
Don’t Become an Addict! ................................................................... 105
References: ................................................................................... 106

10
Video Database
All the exercise videos and lectures can be found here.

The password is ‘cor123’.

Thanks again for your purchase!

11
Foreword
After the release of the COR Swimmer’s Shoulder System, I realized other than
shoulder stability, low back stability needs to be addressed. Since the release of my
first product, I expected to receive a lot of questions regarding shoulder health, but
core questions outweigh shoulder question. The reason behind the volume of
questions is because the core is a confusing subject, for both health and sports
performance.

I first treated a Masters swimmer with low back pain in Los Angeles and as a naive
physical therapist student, I thought low back pain was predominant in older
swimmers. However, after working with more club teams, I’ve realized low back pain
is common in swimmers of all ages. I realized learning and improving the core is
essential for swimming optimization and low back pain prevention. I have seen far
too many teenagers with low back pain secondary to high stress secondary to fast
swimming, but their core was lagging behind, impeding swimming optimization and
putting them at risk for injury. Once stabilization is achieved, sports optimization
training can be progressed.

Despite all the experts, low back pain continues to rise and I see far too many “elite”
level athletes with weak core stability and sports performance, From my experience,
this discrepancy is due to many overzealous coaches providing far too advanced core
exercises at a young age, many people not performing core exercises appropriately,
and single focus core training (on the anterior core or 6-pack muscles). Young athletes
have plenty of time for elite level swimming specific core exercises, but stability and
activation must be learned first prior to extreme sport specific movements.

Many older Master’s swimmers fall into a similar category. These athlete’s feel they
have performed enough core in their life or have misguided information, misplaced
precision, leading to poorly progressed and dangerous movements. It is essential to
have a safe, progressive and periodized program for optimal sports performance and
low back pain prevention. The goal of this product is to provide swimmers of every
age and caliber a systematic program for optimal swimming performance. Follow the
system and success in sport and health await you.

Keep Swimming,
Dr. John, DPT, CSCS

12
Background
The United States spends over 2 billion dollars annually on low back pain. Despite
this, everyone, especially athletes, have performed millions of sit-ups throughout
their life to obtain a “strong” core to prevent low back pain and optimize
performance. These views and myths and flaws contribute to low back pain and are
not only confirmed, but sometimes perpetuated by the health care community. The
most common myth is the association between diagnostic reading (MRI and x-ray) and
symptoms. Just because an abnormal structure is shown on an MRI doesn’t mean it is
the cause of any symptoms. In fact, approximately 50% of people have abnormal
spines on imaging. I know this is discouraging and potentially hard to comprehend, but
after time the body breaks down. Sometimes this causes dysfunction and alterations
in function, leading to impaired movement. These impaired or altered movements are
more likely the cause for injury and symptoms.

Another batch of people believe spinal flexibility is the key to a healthy back. I hope
to convincingly derail this myth, as instability is the root of many low back injuries.
The low back is the foundation of the body and if the foundation is unstable, certain
structures will fall and cause havoc. Providing an adequate base with stability is
essential for sports performance, but also everyday function. If the low back moves
excessively, on its own will, too much cumulative stress causing pain and dysfunction
in the future.

The concept of a stable low back is not synonymous with a stiff back. Keeping the low
back with normal range and adequate core control and stability is the underlying goal.
Utilizing core strength to move through one’s available range of motion will provide a
safe environment for every athlete.

Often times people perform exercises they find online for core strength, but little do
they know strength is only one component for elite performance. Moreover, improper
sit-ups are not the best exercise for the goal, despite what your 3rd grade drill
Sergeant Gym teacher instilled in your mind. The low back is the most commonly
injured area of the body. Every coach and athlete knows someone with low back
pain, unfortunately, these aches and pains come and go like rain in Seattle.

Now, performing some sit-ups won’t destroy your spine, but too often people “cheat”
through the exercise, neglecting actual core strengthening. Also, only focusing on one
plane of motion (moving the body in a sit-up) perpetuates muscular imbalances and
risk of injury. Let’s pretend your body is a ship. All ships go through the ocean
encountering many waves throughout their life. These waves are not typically

13
destructive, but can add up to cause damage. Unfortunately, waves are not the only
problem in the ocean. Tsunamis and tidal waves are also common, potentially
causing massive damage with one strike. Everyone hits many waves and include: poor
sit-up form, excessive spinal flexion exercises (sit-ups), poor lifestyle, diet, posture,
etc. These minute traumas, typically won’t cause injury, but can cumulatively cause
damage. Tidal waves and tsunamis are traumatic, acute injuries. Tidal waves will
can hurt even the strongest of ships and even sink poor constructed ships. Luckily,
everyone’s ship is not a static structure. The ship can be altered and transformed
from a wooden craft into a USS ironclad! This program will help you build your USS
ship and prevent waves from detouring your route and allow you to recover and
handle tsunamis as best as possible. When we are building the ship, we have to ensure
it is strong on all sides, as waves and tsunamis hit everywhere (strength). It is also
imperative to repair the damaged areas (length), so the frequent small hits don’t sink
the ship. Lastly, knowing how to turn on and off the core musculature (timing) can
help the endurance of the ship, not letting it run out of gas and help it speed away.

This e-book will help guide you through the DVD and provide a base level
understanding spinal stability, the foundation of sports optimization.

14
Core Training Theory
The core is one of the most discussed areas in rehabilitation and strength and
conditioning.

Sit-ups, crunches, and other ab exercises remain mainstays in many dry-land

programs, despite ample research showing the risks of repeated spinal flexion under
loads. Still, despite the apparent risks from repeated spinal flexion both in the water
and on dry-land, there is reason to believe that rotation or rotation combined with
flexion (rather than flexion alone) are most responsible for low back troubles in
swimmers. Despite this, many coaches prescribe core exercises, like Russian twists
which result in flexion and rotation.

Though many coaches and therapists have devolved into “anti-flexion paranoia,” it
remains a fair question of whether sit-ups and related exercises are the best choice
for training, given the multitude of potentially safer exercises available. One study
(Childs 2009) addressed a novel question of whether sit-ups could be improved
without doing sit-ups in a population of US Army soldiers. The US Army tests full sit-
ups as part of its mandatory fitness testing. Like a population of swimmers, the Army
has its own share of back problems, inspiring researchers to inquire about other ways
to improve sit-up test performance while sparing the low back from the stress of
repeated flexion.

In a gigantic sample size with 2,616 soldiers ranging from ages 18-35, authors broke
subjects into two groups: a traditional sit-up training group, and a core stability
group, which replaced their sit-up training with core stability exercises, such as glute
bridging and planks (See also, Add Adduction to Your Bridges). Subjects were tested
on the US Army Physical Fitness Test, which included a max sit-up test in 2 minutes.
Notable findings included:

“[Core stability training group] did not have a detrimental impact on sit-up
performance or overall fitness scores or pass rates.

There was a small but significantly greater increase in sit-up pass rate in the core
stability group (5.6%) versus the sit-up training group (3.9%).

15
There were no significant between-group differences in overall fitness scores or sit-
up performance.”

In sum, core stability training (without sit-ups) resulted in similar improvements in sit-
ups as the group that did sit-ups. Additionally, the core stability group was more
successful in bringing pre-test failures up to a passing sit up score than the group that
trained specifically for sit-ups, suggesting that isometric stability is a prerequisite
before adding motion.

Further, the study did not investigate which exercises transferred better to other
athletic movements. Still, we can conclude that for a gross motor skill like the sit-up,
specificity does have limitations, which gives coaches and athletes the opportunity to
exploit alternative exercises aimed at similar goals.

Finally, a critical, but often overlooked point is that quality control is far easier to
maintain with core stability exercises than with sit-ups, crunches, and other ab
movements. Regardless of what the lab tells us, it’s simply easier to ensure proper
form with core stability exercises in a large group. Clearly, limiting the amount of
core flexion can improve sit-up function, but what about spinal health.

The wake of this debate started when research was released correlating the problems
associated with repeated spinal flexion. These studies were done on cadaveric porcine
(pig) spines and resulted in disc herniations and the association between spinal flexion
and disc herniations began. This early research was performed by Dr. Stuart McGill
and lead the way for anti-crunch cults and activist for the New Rules of Lifting have
become dominant. These activists have transformed popular belief and have recently
made crunches seem more terminal than pancreatic cancer. While this simple
association seems appropriate, is the topic of crunches this cut and dry or are
crunches/sit-ups getting a bad wrap?

This confusion has led to a cloud of confusion and exacerbation of the inverse
knowledge theory, the more theories, the less is known about the subject. Don't
worry this comprehensive look at crunches and spinal flexion will tackle the 300-lb
obese coach in the room and cut the fat to looking at the bare bone essentials when it
comes to crunches/sit-ups regarding proper form, integration into programming and
methods for improvement.

Ecclesial Teaching
All professions have leaders and followers, coaching is no different. These leaders are
often highly vocal and persuasive, passing on their ideas and views on various

16
subjects. The followers are excellent at integrating systems and passing on
information. Unfortunately, the leaders can be too confident and/or wrong and the
followers can be too passive and gullible.

This logic does not simply lie on crunches, but even coaching and training
philosophies. Often times, coaches continue to perform training programs which they
have seen work for a few athletes, but who is to say these athletes will not improve
with any program they believe in. The mind is a powerful tool and if athletes believe
in what they are doing and they are talented they will succeed if the program is at
least 50% (pulled this out of the air, but I feel at least 50%) at par with the best thing
for them. Another consideration is that there are multiple "perfect training programs"
for athletes.

This current mind set is the opposite of scientific reasoning and will continue to
impede progress in the sport. An open mind to all theories and belief must be
considered, then after all the considerations a proper approach and attack must be
applied, then reflected.

After looking at the research, it appears (like many things), spinal flexion exercises
can benefit your dryland training programs, unfortunately it is likely incomplete and
will increase your risk of low back pain.

Research Reproductions
Unfortunately, research and abstracts can be misleading and used to support certain
approaches without fully showing a complete consensus.

In the porcine studies noted earlier there were numerous "claims" made by
researchers and readers of the papers. The most glaring is this study wasn't directly
performed on humans, ...here are some of the questions regarding these studies:
Improper Regimen: This study did not mimic typical crunching regimens performed by
coaches or general population. This study used repeated lumbar flexion for
approximately 1,000 straight movements.

No Muscles or Disc? The pigs were also stripped off their muscle and the discs were
not functioning properly due to dehydration. Unlike theses pig, most of us
(synchronized swimmers may be an exception) have muscle to help protect the spine.
Moreover, we have disc filled with fluid allowing pressure to change due to the center
of pressure. For example, if we crunch forward, the fluid moves backward. If we lean
back, the fluid moves forward. These are generalizations, but fluid movement does
occur and help distribute pressure.

17
Spine Size: These models have much shorter spines, changing pressure distributions.

Proper Form: If done properly (we'll go over this later), the crunch should exhibit
minimum to no movement in the lumbar spine. In fact, all the motion should occur in
the thoracic spine with the lumbar spine stable. This stability is essential for all
athletes, especially for those who athletes who can do an elevated split while feeling
a mild stretch in the adductors...mild, flexibility and instability are close cousins,
make sure your athletes have proper stability to match their mobility!

What's Good
As a Doctor of Physical Therapy, I only hear colleagues discuss the problems and
potential harm of crunches/sit-ups. We are turning into a group of hypochondriacs
and I wouldn't be surprised to go to a clinic and see the whole place covered in bubble
wrap. Let's not kid ourselves therapists, benefits can occur from spinal flexion
especially in athletics when performed properly. However, excessive spinal flexion
and negligence of multi-planar strength is more of the issue!

● Improved Nutrition Distribution: A crunch will move disc fluid. This fluid will
move all over, but if basic physics prevail, the fluid should move towards
posterior.
● Athletic Performance: Believe it or not, spinal flexion will enhance athletic
performance. Spinal flexion is common during athletics. The recuts abdominus
is the main spinal flexor and spinal flexion is used repeatedly in swimming,
think as obviously as flip turns and as broadly as butterfly kicking.

Magical Number?
The piggy models have a finite number of spinal flexion movements before discs
herniated and chaos ensued. Despite the aforementioned "problems" with their study,
many health care professionals, personal trainers and coaches don't prescribe the
crunch secondary to this mythical number. However, there are many professional
athletes who have disproved to this issue. Many elite, professional and Olympic
athletes have performed millions of crunches throughout their life and not all of these
athletes exhibit low back pain. Are all of these people’s outliers or do they perform
proper technique? I don't think so.

Many of these professional athletes support crunches/sit-ups almost bragging about

the volume they perform daily. Legendary football player Herschel Walker boosts the

18
fact he performs 3,500 sit-ups daily! This may be a bit extreme, but no one can deny
is athletic prowess.

More Research Contraindicating Spinal Flexion

The three piggies study is not the only research paper looking at spinal flexion and
spine health. Numerous studies have looked at this movement and hypothesized the
risk/benefit of the movement. Search PubMed and you will find a plethora of articles,
it took me 10 minutes to find 13 articles doubting the efficacy of crunches and not
recommending the movement.

More Problems
The finite number of flexion movements isn't the only case against crunches/sit-ups.
Many people believe repeatedly performing this movement will lead to poor posture.
Spinal flexion focuses on strengthening and hypertrophy to the rectus abdominus. This
muscle runs from the ribs and sternum to the pelvis. If this muscle is over worked and
tight, it will shorten and cause a rounded back (kyphosis)...at least this is the theory.
Their theory is based on the idea of "adaptive shortening". Adaptive shortening is the
process of holding a muscle being statically in one position for a long duration,
causing a shortened muscle. Adaptive shortening is a physiological response to a
statically shortened muscle where the sarcomeres become overlapped and shortened.

Unfortunately, adaptive shortening is a long process and based on people wearing

slings and casts...a bit of a stretch (no pun intended) from crunches. Another flaw
this theory assumes is that the rectus abdominus only shortens during spinal flexion,
but, spinal flexion utilizes shortening and elongating (concentric and eccentric
motions).

A more appropriate concern is that the idea of crunches may create a muscle
imbalance and perpetuate/lead to injuries. This problem could arise if improper
programming is performed and each athlete performs an infinite number of crunches.

Another group of people feel that crunching leads to over working the chest, shoulder
and neck muscles leading to improper breathing. This does occur, but once again it is
due to poor programming and unqualified people running strength and conditioning
programs. Also, thousands of case studies of athletes make the argument against this
case.

Non-Functional
Now you may be convinced that doing crunches won't perpetuate dysfunction and give
you injuries, but are they functional, sport specific movement? Functionality with

19
every exercise is the biggest and best fad in lifting. I admit, I use functional training,
but not for everything! One must ask themselves, what is the desired output? Once
this is determined, then the appropriateness of functionality can be determined. I
train multiple sprinters who need to work on force production. I'm not going to have
them doing horizontal presses with 5 pound ankle weights. These athletes will be
doing heavy, explosive lifts to increase growth hormone release and overall force
production necessary to get their ass to the other end AS FAST AS POSSIBLE!!!
Functionality has its purpose, but don't be closed minded.

Proper Form
I mean, I've already been to numerous clinics where an unqualified volunteer
instructing "proper" exercise form to their clients. This runs rampant in personal
training where those with genetically gifted bodies are yelling at stay at home wives
to get their ass in gear to physical therapy/chiropractics where the patient is tossed
over to an assistant or aide.

As stated, there should be no lumbar movement during the crunch; movement should
derive from the thoracic spine. Therefore, the range of motion may be decreased, but
the effort required will still be high. Cue the athlete to move the chest towards the
sky, lifting their shoulder blades off the floor.

More Volume
Once again, the issue with crunches is not the movement, but the quality of exercise
and the volume combined with activities in life. For example, if you perform 3,000
sit-ups a day, then sit around all day with poor posture, an injury is likely. For
athletes, performing such a high volume is only training the low twitch muscle fibers
which are already stressed excessively in the pool! Therefore, doing tougher exercises
with lower volume will stress the type IIa/b muscle fibers more, create more strength
and provide more carryover for swimming. Then, progressing core exercises is never
done, just add more volume! Once again, why stress the type I fibers over and over,
add some intensity and add all the planes of motion!

Progression
The dryland mistake I see during crunches is with proper form and sequence. Proper
sequence must be achieved. Also, I feel the crunch should not be the beginner
exercise, if done properly this should be a moderate to advance abdominal exercise.
First and foremost, pure core stability with ZERO spinal movement must be achieved
in all athletics. Once stability is achieved, then sport specific exercises (long and
short axis) can be pursued, but not before stability is achieved!!

20
Creating Core Strength
Once again, the constant chatter surrounding the core in the fitness and rehabilitative
world has resulted in the inverse knowledge phenomena, the more theories on a
subject, the less known.

This phenomena occurred for many reasons:

1. Rehabilitation and conditioning are multi-factorial, impossible to study with
germ theory.
2. The sequence of events are as important as each event.
3. Politics, much of the research is performed and peer-reviewed by the same
people.
4. Turf wars, certain practitioners and trainers are attempting to take as much
territory as possible, yet unwilling to do what is most beneficial.
5. Egos dominating the most effective means of training. The dog with the biggest
bark, reaches more people, not the dog with the best bite.

In order to prevent succumbing to those pitfalls, it is essential to obtain information

through the following process:
1. Trial and error
2. Find a theory that works
3. Good objective findings and analysis
4. Implementing and re-checking

These ideas are from the storied physiotherapist Maitland and still apply today.
Personally, I feel regardless of how difficult, or long-standing the condition is - if you
do the right thing you will make changes immediately --- immediately. I'm not talking
about total improvement in low back pain or a second drop in a 50-free, but
addressing the correct problem results in immediate improvement.

The current culture of core training has been discussed at ad nauseum. Articles have
eloquently discussed sit-ups and others have interviewed renowned physicians.
Despite this expertise, back pain and dysfunction still exist, leading to gaps in
training.

Types of Rehab/Core Training

In Physical Therapy school at the University of Southern California, our professors
taught the use of classifying patients into classifications based on their type of
dysfunction.

These classifications include: specific exercise (flexion or extension based program

determined by McKenzie mindset), manipulation (symptoms less than 16 days, no

21
distal symptoms), stabilization (excessive ROM, young), and traction
(peripheralization of extension movement, positive crossed SLR) (Fritz 2011).

These groups are nice in theory and are a start for classification, but do not look at
the whole picture as germ theory is nearly impossible in strength training and
rehabilitation.

In fact, when this classification was investigated by Apeldom 2012 (Fritz was still on
the review, just not the primary investigator) it was suggested that “the
classification-based system as used in this study was not effective for improving
physical therapy care outcomes in a population of patients with sub-acute and chronic
LBP (Apeldom 2012)”.

This is the current evidence-based practice, despite research suggesting

ineffectiveness!

Drawing-in
This type of core training is recommended by most yoga instructors and some physical
therapist. Unfortunately, the name implies the problem, a hallow structure is
unstable, the opposite of core stability!

Studies suggest drawing-in minimally stabilizes the spine, not being effective for
reducing the kinematic response to sudden perturbation (Vera-Garcia 2007),
potentially leading to injury.

Bracing in Neutral spine

Many legendary clinicians and strength coaches recommend abdominal bracing. This
type of training involves maximally contracting your abdominals to provide stability.

Bracing decreases spinal movement in response to unanticipated perturbations and

increase posterior to anterior stiffness, compared to ADIM (Vera-Garcia 2007).Bracing
also reduces sacroilioal motion more than drawing-in. Bracing increases activation of
internal/external obliques, as well as all abdominals (McGill 2009).

However, bracing results in higher compressive forces than ADIM, the main argument
against bracing. Luckily, the spine doesn't buckle until 12,000-15,000N of pressure are
applied in compression (McGill 2006), suggesting compressive forces from bracing are
insignificant.

Bracing is commonly taught in the neutral position, a theoretically safe position.

22
Neutral spine is a theoretical concept with no concrete definition. This position is
different for everyone during different times. This concept is too abstract for most
with poor core stability, especially those with low back pain. Feedback is necessary
and this theory does not provide any feedback.

Bracing in Flexion-Bias
What does full abdominal bracing in flexion-bias do to the spine directly and
indirectly? Directly it is a flexion movment. Indirectly it is an extension movement
through the lumbo-dorsal fascia.

What does the multifidus do when it contracts? Its resultant vector force in one of
antiflexion more than any other.

Extreme lumbar flexion postures are characterized by the absence of EMG activity in
the lumbar erector spinae (McGill & Kippers 1994, McGorry et al 2001), termed the
flexion-relaxation response (FRR). A similar reaction has also been demonstrated in
the hamstring muscles (McGorry et al 2001).

I feel the lumbo-dorsal fascia is the medium of stability for the lumbar spine. Just
look at the anatomy and what is attached to it. I feel that all the different groups
attached directly to the fascia or indirectly apply tension to the fascia to BALANCE
forces acting on the spine. BALANCES - NOT MOVE. Everyone thinks of muscles
needing to move things. Yes, this applies to the prime movers. But remember, in the
spine the main prime mover is gravity and the spine must REACT. REACT.

I prefer bracing with flexion-bias for nearly every spinal client. I feel neutral spine
and ADIM are not as effective and require too much cognition and abstract thinking.
Abdominal bracing provides a stable base, with high muscle contraction, helping
instability, one of the main contributors in back pain.

Also, I am critical of the application of the research in the theory that the spine has a
limited number of flexion/extension cycles, then a herniation results, as these studies
were performed in vitro in rats with their muscles removed. I have also used bracing
in flexion-bias in many with non-acute disc herniations, helping them return to the
court, field, and pool.

Moreover, nearly everyone ends up with disc herniations anyway, so why does it
matter if the disc herniate? It is estimated 80% of healthy backs have disc herniations
and bulges and approximately 85% of lower back pain cases have no definitive
diagnosis.

23
Therefore, even if adding more compressive forces is more ‘damaging’ to the spine,
does it matter? If you are going to have herniations anyway, does it matter if this
occurs earlier than later, or is it more important to prevent your body against an
acute discogenic issue? This is the theory behind bracing with flexion bias, but now let
us review the antaomy.

24
Anatomy
A certain level of understanding is mandatory to ensure full acknowledgement and
optimization can occur. Ask any Olympian or professional athlete and they have an
adequate knowledge base pertaining to anatomy and physiology. I feel this
understanding helps these athletes make the next step as they can feel specific
muscles work and understand why they are improving. This next section will provide
the nuts and bolts to the anatomy of the spine and core. It is not comprehensive, but
a reference and guide to entice your neurons, for a more complete reference consider
any anatomy book.

The spine is made of multiple vertebrae held together by ligaments, joints, discs,
muscles, tendons, etc. There are three aspects to any joint stability; geometry,
dynamic tissue and inert tissue. In the spine the geometry is not good for stability.
The bones lie on top of each other like the leaning tower of Pisca. The joints are
planar or like two flat pieces of wood rubbing together. The inert tissue is the nuts
and bolts of the body. In the spine this is the ligaments that hold joints together and
the discs between each vertebral level. This is the primary cause of stability in the
spine. Unfortunately it is the part of the spine that is often at risk and damaged. The
remaining component is dynamic tissue or muscle.

The purpose of the trunk stabilization program is to train trunk muscles to act in a
manner decreasing excessive and destructive forces acting on the spine.
Top level swimmers, who avoid injury, understand the process of activating muscles
and groups of muscles. In fact, these great athletes can imagine the motor process to
activate the ideal motor units.

Motion at the spine may occur from conscious though and activation, or the activation
may result from a more subconscious process, unknown to the athlete. Injurious or
painful events can likely record these processes. Re-recording these perturbed
patterns is mandatory for proper core training.

As you’ll see, the core isn’t simply about muscle activation, instead neuroanatomy,
neurophysiology, are a few other players involved. This is why machines and other
devices will never mimic a spine or the motor units. Also, this is why isolated

25
movements, like those proposed by bodybuilders, offer low proprioception and likely
an inadequate challenge.

26
Spine

27
Joints and Movement
The spine consists of four main joints: zygapophyseal (facet) joint and the
costovertebral joints. These joints allow remarkable ranges of motion in several planes
of movement.

Planes of Movement
The following planes are described relative to the median plane, which bisects the body
vertically at the navel, dividing the body exactly into left and right halves.

Sagittal plane
A sagittal plane is any plane parallel to the median plane and divides the body into
unequal right and left halves. Moving your chest forward or bending over occurs in the
sagittal plane.

Frontal plane
A frontal plane is a vertical plane at a right angle to sagittal plane. If you draw a line
from one ear to another from above the head and then divide the whole body along this
line, the plane formed will be a frontal plane. If you made a snow angel or bent your
body to the right you'd be moving in the frontal plane. It is also known as coronal plane.

Transverse plane
A transverse plane is a horizontal plane of the body and cuts the body between top and
bottom halves. It is perpendicular to both frontal and sagittal plane. The rotation in
freestyle utilizes the transverse plane.

Any plane other than the above-described planes will be an oblique plane.

Spatial Movement
Anterior
Anything situated near or towards the front. When a swimmer bends forward, their
body is anterior to their body.

Posterior
Anything situated near or towards the back. If a swimmers arches their back and moves
backwards they are moving posterior.

28
Superior
Anything situated near or towards the head. When the swimmer's hand enters the water
it is superior to their body. The cervical spine is also superior to the lumbar spine.

Inferior
Anything situated near or towards the feet. If the swimmer pulls downward during the
catch, their hand is moving inferior or towards the feet. The lumbar spine is inferior to
the lumbar spine.

Medial
Anything situated near or towards the center. If during the catch phase the swimmer
moves towards the body, like a cross over catch, then their arm is moving in the medial
plane (near the middle of the body).

Lateral
Anything situated near or towards the outside. If a swimmer wiggles their hips during
freestyle they are moving their body laterally.

Proximal
Anything situated near or that is coming closer. During a flip turn, the swimmer is
moving their knees proximal to their body

Distal
Anything situated or moving away. If the swimmer pulls deep during the catch phase of
freestyle, then their arm is distal (away from the trunk).

Muscle Movements
Action
Movement educed by muscle.

Origin
Start of a muscle.

Insertion
End of a muscle.

29
Spinal Flexion
Curling the spine forward (bending over and touching your toes).

Spinal Extension
Bending of the spine backwards (back hyperextension exercise.

Spinal Side Bend

Bending side to side, this increases both strength and flexibility of the low back and the
abdominals.

Spinal Rotation
Rotation of the spine where you turn the spine around itself.

Anterior Pelvis Rotation

Occurs when the front of the pelvis tilts down and the back of the pelvis raises up.

Posterior Pelvis Rotation

Occurs when the front of the pelvis tilts up and the back of the pelvis tilts down.

Muscles and Tendons

Muscle Origin Insertion Action

Psoas Major T12-L4 Vertebral Lesser trochanter Hip flexion,

bodies via iliopsoas external rotation
tendon Lumbar spine
flexion and
ipsilateral flexion

Iliacus Iliac Fossa Lesser trochanter Hip Flexion and

via iliopsoas external rotation
tendon

Sartorius Anterior inferior iliac Medial to the fibial Hip flexion,

spine tuberorsity via Pes abduction,
Anserinus external rotation
Knee flexion and
tibial internal
rotation

30
Gluteus Maximus Sacrum Lateral condyle Hip etension,
(Upper fibers) Gluteal surface ilium tibia via iliotibial eternal rotation
thoracolumbar fascia tract and abduction

Gluteus Maximus Sacrum Gluteal Tuberosity Hip Extension,

(Lower fibers) Gluteal surface eternal rotation
ilium and adduction
Thoracolumbar fascia
Sacrotuberous ligament

Gluteus Medius Superior gluteal surface Lateral Greater Hip abduction,

(Anterior fibers) ilium trochanter fleion and
internal rotation

Glututeus Medius Superior gluteal surface Lateral Greater Hip abduction,

(Posterior fibers) ilium Trochanter extension and
exeternal
rotation

Gluteus Minimus Inferior gluteal surface Anterior Greater Hip abductor,

(Anterior fibers) ilium (below gluteus trochanter fleion and
minimus) internal rotation

Gluteus Minimus Inferior gluteal surface Anterior Greater Hip abduction,

(Posterior Fibers) ilium (below gluteus trochanter extension and
minimus) external rotation

Tensor Fasciae Anterior Superior Iliac Lateral Condyle Hip abduction,

Latae (TFL) Spine tibia via Iliotibial fleion, internal
tract (ITB) rotation and
tensor fascia lata

Piriformis Anterior surface Greater trochanter Hip abduction,

sacrum apex extension,
eternal rotation

Adductor Longus Superior public ramus Linea Aspera Hip adduction,

(medial lip) internal rotation
and flexion to 70
degrees

Adductor Brevis Inferior public ramus Linea aspera Hip adductor,

(medial lip) internal rotation
and flexion to 70
degrees

31
Adductor Magnus Inferior public ramus Adductor tubercle Hip adduction,
(Anterior) Ischial Ramus femur internal rotation
and flexion

Adductor Magnus Ischial ramus Linea aspera Hip addution,

(Posterior) Ischial Tuberosity (medial lip) external rotation
and extension

Rectus Femoris Anterior inferior ilias tibial tuberorisity Hip flexion

(quadricep) spine and acetabular via patella Knee Extension
roof ligament

Vastus Medis Linea asperra: medial Tibial tuberosity Knee Extension

lip (intertrochanteric via patellar
line) ligament

Vastus Latis Linea Aspera: Lateral Tibial tuberosity Knee Extension

lip (greater trochanter, via patellar
lateral surface) ligament

Vastus Intermedius Anterior Femur Tibial tuberosity Knee Extension

via patellar
ligament

Biceps Femoris Ichial tuberosity Head of fibula Hip extension

(Long Head) (sacrotuberous Knee flexion and
ligament) tibial external
rotation

Biceps Femoris Linea aspera (lateral Head of fibula Knee Flexion and
(Short Head) lip) tibial external
rotation

Semimembranosus Ischial tuberosity Medial tibial Hip Extension

condlye (Oblique Knee Flexion and
poplitial ligament) tibial external
popliteus fascia) rotation

Semitendinosus Ischial tuberosity Medial to the Hip Extension

(sacrotuberous tibial tuberosity
ligament) via pes anserinus

Internal Abdominal Thoracolumbar fascia, Lower 3 or 4 ribs, Flexes and

Oblique anterior 2/3 of the iliac linea alba, pubic laterally bends
crest, lateral 2/3 of crest the trunk
the inguinal ligament

32
 Oblique, External Linea alba, pubic crest Lower 8 ribs Flexes and
abdominal & tubercle, anterior laterally bends
superior iliac spine & the trunk
anterior half of iliac
crest

Oblique, Internal Lower 3 or 4 ribs, linea Thoracolumbar Flexes and

Abdominal alba, pubic crest fascia, anterior laterally bends
2/3 of the iliac the trunk
crest, lateral 2/3
of the inguinal
ligament

Psoas Minor Iliopubic eminence at Bodies of the T12 Flexes & laterally
the line of junction of & L1 vertebrae bends the lumbar
the ilium and the vertebral column
superior pubic ramus

Quadratus Transverse processes of Posterior part of Laterally bends

Lumborum lumbar vertebrae 1-4 the iliac crest and the trunk, fixes
and the 12th rib the iliolumbar the 12th rib
ligament

Rectus Abdominis Xiphoid process of the Pubis and the Flexes the trunk
sternum and costal pubic symphysis
cartilages 5-7

Transversus Linea alba, pubic crest Lower 6 ribs, Compresses the

Abdominis and pecten of the pubis thoracolumbar abdomen
fascia, anterior
3/4 of the iliac
crest, lateral 1/3
of inguinal
ligament

Tendons
Every muscle has a tendon which attaches to a bone. The muscle actually turns into
the tendon and changing its composition before attachment. This tendon tugs on the
bone, moving it in the direction or movement requested. Tendons are part of the
dynamic stabilization in the spine.

33
Ligaments
Ligaments run from bone to bone and contain zero contractile properties. They lie
doormat, hoping nothing hits them or bangs against them. These ligaments are
numerous and span across the whole spine.

anterior attaches to anterior part of bodies and discs from anterior

longitudinal tubercle of atlas to the pelvic surface of sacrum, widening as it
ligament descends.

posterior attaches to iv discs and adjacent vertebral bodies within the

longitudinal vertebral canal, extending from C2 to sacrum
ligament

Ligamentum passes between both laminae of adjacent vertebrae from C1 to

flavum L5, attaching to front of the lower border of the lamina above
and back of the upper border of the lamina below: the medial
borders meet at the root of the spine

supraspinous band of longitudinal fibres running over and connecting the tips
ligament of spinous processes from C7 to sacrum and is continuous with
the posterior edge of the interspinous ligament

interspinous thin membranous bands between adjacent vertebral spines

ligaments

intertransverse pass between adjacent transverse processes: absent in cervical

ligaments region

Bursae
Around every major joint are multiple bursae, which act as cushioning pads.
These pads help reduce friction in the spine to allow movement. During musculoskeletal
injuries these bursae commonly become inflamed. This inflammation is known as
bursitis which is caused by either excessive rubbing or irritation that can be caused by
a variety of structures.

Joint Capsule
The joint capsule has the role of stabilizing the joint and preventing excessive motion.

34
Intervertebral Discs
The intervertebral disc are described as a jelly donut. They are composed of two
main parts, the doughy outside and the jelly inside. Outside is the annulus fibrosis
and inside is the nucleus pulposus. The disc act as a cushioning system, but at
approximately the 2nd decade of life these disc begin to lose their fullness (due to a
loss in hydration). These discs can go haywire and cause a lot of pain and dysfunction
or they can be asymptomatic.

Vascularity in the Spine

All spinal tissues contain a vascaular supply, except for the discs. The veins leaving
the vertebral bodies are the only veins in the body believed to lack flow-back vales.
This minute feature is essential, as we’ll discuss shortly. Simply, it allows the arteries
and veins to provide a protective mechanism and the ultimate hydraulic shock
dampening system.

Vertebrae
The spine consists of 12 thoracic and five lumbar vertebrae. The bodies of these
vertebra are like a barrel with round walls made of relatively stiff cortical bone. The
top and bottom of the barrel are made of a more pliable cartilage plate that is
approximately 0.6 mm thick, but thinnest in the central region (Roberts 1989). This
end plate helps transport nutrients, while the inside is filled with cancellous bone.

The architecture of the vertebral bodies determines how they handle weight,
specifically compressive load and fail under excessive loading. The walls of the
vertebrae are rigid under compression, but the nucleus of the disc pressurizes and
causes the cartilaginous end plates of the vertebrae to bulge inward, seemingly to
compress the cancellous bone (Nachemson 1960). In fact, the end plates fail first
during compression in a neutral position (Gunning 2001). In fact, it has been
suggested the vertebral bodies act as shock absorbers of the spine, opposed to the
spinal discs, as many suggest (Farfan 1973).

35
 Swimming Core Training
Once again, the standard of practice for swimming coaches, excessive crunches or
flexion exercises is not best. Now, I don’t believe you should never flex the spine, but
the core must have enough strength to stabilize the spine during many different
movements. This strength also doesn’t develop with abdominal drawing-in or sucking
in. Therefore, a combination of soft tissue muscles for maximzing musuclar strength,
combined with core stabilization and core neuromuscular re-education (muscle timing)
is essential. These exercises must begin with just the core, but then progress to full
body movements, helping the body transfer energy to the arms and legs, which occurs
during swimming. This strategy also decreases muscular imbalances and stress on
various structures, keeping an athlete healthy and enjoying the sport.

Equipment to Build Core Strength

To improve core strength and prevent low back pain, minimal equipment is required.
This equipment is recommended:

● Tennis Balls
Tennis balls are used to perform self-soft tissue mobilizations to improve the tone and
length of the muscle. These can be replaced with lacrosse balls or baseballs if tennis
balls are unavailable or a harder surface is desired.

● Resistance Bands
These functional training devices provide a simple way to add resistance to any
exercise. Start with lighter bands and progress to higher tension bands. We will use
these to improve muscle strength and timing.

● Foam Rolls
A foam roll is an excellent method to relax the sympathetic system and back
muscles (deep thoracic rotators). I prefer the white, less aggressive foam rolls, but the
black, high-density foam rolls also work.

● Swiss Balls
A Swiss ball is an excellent tool to implement the horizontal position, forcing balance
and core stability. This improves strength in a swimming-specific manner.

36
● Weighted Vests
Weighted vests are used to increase body weight and increase the difficulty of many
movements, especially explosive movements (plyometrics). A heavy rope is a simple
replacement if weighted vests are unavailable.

● Chains
Chains are another method for increasing body weight resistance for exercises. This
added resistance is more variable than a weighted vest and changes throughout the
movement. A heavy rope is a simple replacement if chains are unavailable.

● Mobility Stick
Mobility sticks are the rolling pins of mobility. Unfortunately, these devices are
commonly used incorrectly, as many muscles are too aggressively rolled.

37
Muscle Length
In my opinion, muscle length is the most important aspect for low back health.
However, poor tissue quality can also prevent core strength and impair coordination.
I've worked with many athletes who simply needed an improvement in muscle length
for symptom alleviation and/or improvement of strength. Muscle length discrepancies
also influence muscle strength and timing, as an excessively tight muscle may result in
reciprocal inhibition and early fatigue (Ge 2012).

● Good: it prevents movement and pain/injury to the area involved.

● Bad: it causes compensations and can lead to tight muscles.

Tight muscles lead to improper tone which is burdensome for many reasons:

1. Poor positioning of a joint.

2. Weakness (pseudoparalysis) to other muscles due to poor positioning.
3. Poor movement patterns at, or around, the muscles involved.

If a muscle lies in an inadequate position, it will be weaker and increase the risk for
injury. Here is a simple example to perform while reading. Raise your arms overhead.
Now, slouch and raise your arms again. If performed properly, the second time you
raised your arms you had less range of motion and potentially pain. I didn’t put a spell
on your shoulder; slouching altered your muscle length and put your body at a
biomechanically disadvantaged position.
Tight muscles will inhibit other muscles from working properly. Another example,
squeeze your finger as hard as you can.

Next, maximally flex your wrist and squeeze

your finger again.

If you did this correctly, you felt a significant

decrease in strength when your wrist was
maximally flexed. This changed the
length/strength relationship between your
muscles. Each muscle has an optimal firing
position that allows maximal muscle strength.
Daily habits (posture, sitting, sports) or

38
injuries put your body in suboptimal resting positions, which cause impaired muscle
firing.

From my experience, the following muscles need improved length, as they are
“cheater” muscles. These muscles try to stabilize the spine, although it is not their
primary job! As a result, they get overworked and tight, preventing proper movement.

Muscles (review table for specific locations)

1. Iliotibial Band
2. Quadriceps
3. Tensor Fasciae Latae
4. Adductors
5. Piriformis
6. Quadratus Lumborum
7. Psoas
8. Thoracic Spine

Compression on trigger points for 4-weeks has demonstrated significant improvements

in pain, mobility, and strength of the shoulder in office workers (Cagnie 2013). Self
myofascial releases (SMR) can apply compression to trigger points to almost all of the
aforementioned muscles. The recommended locations are based off the trigger points.
Unfortunately, not all of these muscles can be manipulated while alone; further manual
therapy is required in most cases of low back pain to improve muscle length of all the
aforementioned muscles. If you have low back pain which is persistent and not
improving, I recommend seeing a rehabilitation specialist you trust.

SMR are believed to improve myofascial trigger points and range of motion deficits
(MacDonald 2012). Self myofascial releases may also help arterial function and mobility
(Okamoto 2013). Stretching often stretches more than the muscle, resulting in more
instability (Kenal 1996; McMaster 1998). Therefore, a proper prevention and
rehabilitation program must assess muscle length restrictions locally and globally.

Moreover, recent research indicates self myofascial releases doesn’t impair force
production, a common concern with static stretching (MacDonald 2013).

For these techniques you will need a baseball, tennis ball, or foam roll, but first, follow
these rules:

Self Myofascial Rules:

1. Lie on the tennis balls with your knees bent, unless instructed otherwise.
2. The more sensitive or tender the area, the slower you should go (vigorous rolling
is rarely necessary). If extremely tender, just lie on the ball.
39
 3. Stop if the exercises cause pain.
4. Perform for 30 seconds – 3 minutes.

Iliotibial Band
Impairments: Muscle (s): Injuries:
Body moves side to side Iliotibial band Knee pain,
in free and back. Knee (ITB). iliotibial pain
pain, low back pain, syndrome,
impaired knee patellofemoral
extension (or pain syndrome, low
hyperextension). back pain, hip
pain.

The iliotibial band (IT band) is most associated with runners, but it can be irritated by
a slew of activities. This band is most aggravated after repeated stretching For
example, if a swimmer is bringing their knees too close together during the outsweep
of the breaststroke kick, then it will stress this band. This band also gets aggravated
when it compensates for other muscles not stabilizing the knee. This is common in
during squatting and lunges (specifically young girls, due to the width of their pelvis
requiring greater stabilization) with weak gluteal muscles.

Now, everyone who has gone to a swim meet or gym has seen people spending hours on
their IT bands trying to “loosen them”. First, the IT band is technically not a muscle,
but a longitudinal fibrous reinforcement to the fasciae latae. In fact, many are
beginning to discredit the IT band as a main contributor to injury, as they are learning
the TFL plays a larger role in many injuries. But, make sure not to overlook the IT band,
because it is commonly involved in low back, hip, and knee pain.

Where is the IT Band?

The IT band runs on the outside of the thigh, next to the quadriceps muscles. It runs
from the top of the hip and inserts into the lateral condyle of the tibia (shin bone).
Typically most trigger points are located a few inches above the knee. Often times
some harder devices (baseball or lacrosse ball) are necessary for this spot, as the band
is typically a hard rope, which some can actually grab!

What does the IT band do?

The main role of the IT band is to extend, abduct, and externally rotate the hip. This
band also helps stabilize the knee. As the leg extends during kicking, this muscle is
active, mainly as a stabilizer.

40
What does SMR to the IT Band Feel Like?
Typically the IT bands is not as tender as some of the other trigger points, but in cases
where it is tender, make sure to ease into the SMR. When starting, simply roll over your
outer thigh until your find a sweet spot. Once you’re on it, hold and relax!
Keep in mind, if the IT band is irritated, other spots are likely contributing, so don’t
spend all night like many do on this muscle!

SMR IT Band Summary

Purpose:

The iliotibial band is a common contributed to knee pain, specifically in breaststroke

swimmers and runners.

Directions:

Lie on your side with a tennis ball under your lower thigh, on the bottom leg, just
above your knee. Bend the top leg’s knee and place it flat in front of the bottom leg.
Push through your top leg and forearms to move the tennis ball.

41
Quadriceps
Impairments: Muscle (s): Injuries:
Poor kicking power. Quadriceps (vastus
Iliotibial band
Thigh pain, knee pain, lateralis, vastus
syndrome,
groin pain, impaired lateralis, vastus
patellofemoral
knee extension medialis, rectus
pain syndrome
strength. femoris).
Our “quads” are muscles that
people think they know — but
unfortunately, they have no idea.
The most common
misunderstanding of the
quadriceps concerns stretching.
Did you know that it’s actually
anatomically impossible to
stretch most of the quadriceps?
A lot of quadriceps aching,
stiffness and fatigue emanates
from an epicenter of “knotted”
muscle in the lower third of the
thigh, in the vastus lateralis, a Travell 1983
huge muscle — one of your biggest — that dominates the lateral part of the leg.
Stretching it is effectively impossible, but SMR is an option: although often shockingly
sensitive, SMR can also be quite satisfying. It also often complicates or contributes to
other problems in the area, especially knee pain, runner’s knee, patellofemoral pain
syndrome (PFPS), and breaststroker’s knee.

Where is the Quadriceps?

Your quadriceps “muscle” is actually a group of three large muscles and one smaller
one that merge just above the knee. They are:
1. Vastus lateralis on the outside of the thigh.
2. Vastus medialis on the inside.
3. Rectus femoris lying on top, right at the front of the thigh (it is drawn a little
too thick and beefy in the diagram here).
4. Vastus intermedius in the center (hidden underneath the rectus femoris).

What Do the Quadriceps do?

The smaller rectus femoris is the only one of the group that crosses both the hip joint
and the knee. It powers both of those big joints, whereas the larger three members of
the group — the three vasti — only cross the knee and therefore they can only move the
42
knee. One of the most important implications of this (and also one of the best ways to
visualize it) is that there is a problem with stretching your quadriceps. The “runner’s
stretch” is the typical stretch, yet this motion only stretches the rectus femoris.
Unfortunately, the rectus femoris only represents approximately 10% of the quadriceps
muscle mass!
The big underlying trio of vasti muscles is anatomically impossible to stretch strongly,
because they elongate only with knee flexion, which is blocked in most athletes due to
bulky hamstrings muscles.
This quirk of anatomy (which hardly anyone knows about) is just one more reason why
I think generic stretching is generally over-rated as a form of exercise, there are too
many misconceptions and unsafe practices out there!

Muscle: Insertion: Origin: Action (s):

Rectus Femoris Anterior inferior ilias spine and tibial tuberorisity Hip flexion
(quadricep) acetabular roof via patella ligament Knee
Extension

Vastus Medis Linea asperra: medial lip Tibial tuberosity via Knee
(intertrochanteric line) patellar ligament Extension

Vastus Latis Linea Aspera: Lateral lip Tibial tuberosity via Knee
(greater trochanter, lateral patellar ligament Extension
surface)

Vastus Anterior Femur Tibial tuberosity via Knee

Intermedius patellar ligament Extension

What Does SMR to the Quadriceps Feel Like?

Due to its size, the quadriceps group seems to be able to take a licking and keep on
ticking. Even when significantly “polluted” by trigger points, the quadriceps muscles
often fine, even with the presence of trigger points.
Even when they are polluted by trigger points, the quadriceps muscle often still feel
mostly fine and functional.
Even when they keep on ticking, a surprising amount of sensitivity to pressure can be
lurking in those thick tissues, particularly in the big vastus lateralis muscle. There is a
common trigger point there. One of the things that make SMR to the quadriceps is the
tendency for strong latent trigger points. This spot is somewhere in the bottom half of
the vastus lateralis muscle, a few inches from the knee. It’s not on the side of the thigh
and not on the top, but between the two — facing forward and out.
In that location, the vastus lateralis can be pressed against the bone underneath. While
pressure at virtually any location in the vastus lateralis is likely to feel potent, and is a
sure thing: with anything more than mild pressure, it is virtually guaranteed to generate
that classic “sweet ache” that makes us seek out SMR.

43
Since it isn’t actually possible to stimulate most of the quadriceps muscle group with
any kind of stretch, massage is a bit more important.

SMR of the Quadriceps Summary

Purpose:

The quadriceps can become tight from excessive sitting in our society. This can prevent
hip extension, an important motion during all sports (like dolphin-kicking, running).

Directions:

Lie on your stomach with your hands underneath your shoulders and the foam roll
under your thighs. Push through your hands to move your body on top of the foam
roll. Both legs may be on the thighs at the same time or you can emphasize one leg
by hooking one leg behind the other leg.

44
Adductors

Tennis Ball Adductors

Impairments: Muscle(s): Injuries:
Poor breaststroke kick
Groin strain,
power. Groin pain, Adductor longus,
patella femoral
knee pain, impaired hip adductor brevis,
pain syndrome, hip
strength, impaired hip adductor magnus.
bursitis.
range of motion.

The groin is a sacred part of the body to most

breaststroke swimmers and hockey players, as the
adductors are often aggravated. This complicated
muscle group performs many actions and has a lot
of bulk, similarly to the quadriceps. Yet, many
think a simple, boring stretch (like the butterfly)
can help out this complicated area! Now, this spot
is commonly neglected, but trust me if you do
breaststroke (even in IM), take your time and use
some hard tools, you can definitely discover some
new sensations you couldn’t even dream of.

Where are the Adductors?

The adductors run medial to the quadriceps, on
the inside of the upper leg. They are a bulky group
which has numerous starting and ending points. Travell 1983

What do the Adductors Do?

These muscles mainly perform … adduction or moving the leg towards midline. In fact,
they are the only muscles with adduction as their predominant role. However, their
roles become more complicated as you begin to look at them individually.

Muscle: Origin: Insertion: Action(s):

Adductor Longus Superior public Linea Aspera Hip adduction, internal

ramus (medial lip) rotation and flexion to 70
degrees

45
 Adductor Brevis Inferior public Linea aspera Hip adductor, internal rotation
ramus (medial lip) and flexion to 70 degrees

Adductor Magnus Inferior public Adductor Hip adduction, internal

(Anterior) ramus tubercle femur rotation and flexion
Ischial Ramus

Adductor Magnus Ischial ramus Linea aspera Hip addution, external

(Posterior) Ischial (medial lip) rotation and extension
Tuberosity

As you can see, some play a

role in hip extension, while
others flex the hip. Some also
internally rotate the hip,
while others externally
rotate. Overall, if you are
having some sort of groin
pain, one of these suckers is
the cause, just getting to the
exact spot is the tricky part!

What does SMR to the

Adductors Feel Like?
For most, using a foam roll on
the adductors is quite nice. For breaststroke swimmers and hockey players, a foam roll,
or more piercing, a baseball can be repulsive. Make sure, if you have a tight adductor
or a strained adductor you are easing into the SMR, and then once it is loosening up,
grab a baseball and find the exact location. Typically, the most tender trigger point is
located high, specifically near the pubic ramus. This is a tough spot to get to, but with
a bench or table, a baseball, and some body weight you can surely find the spot!

SMR to the Adductors Summary

Purpose:

The adductors can become excessively tight in breaststroke kickers. This tightness can
also contribute to adductor strains and injuries, as well as impair adductor strength.

Directions:

46
Lie on your stomach with your body propped on your forearms. Then, bring one thigh
to your chest while keeping your other leg straight and place the foam roll under the
thigh closest to your chest and roll the foam roll under the inside of your thigh.

47
Tensor Fasciae Latae
Related Muscle Injuries:
Impairments:
(s):
Poor kicking power. Nonspecific low
Pain in the low back, back pain,
hip, buttocks herniated disc,
(especially immediately “lower cross
under the buttocks), Tensor fasciae syndrome”, knee
side of the thigh, latae, gluteus pain, hip pain,
hamstrings, decreased medius, gluteus groin pain, anterior
hip range of motion minimus. knee pain,
(specifically internal sacroiliac joint
rotation), decreased pain.
low back range of
motion.

The tensor fasciae latae (TFL) is a small,

but deadly muscle. I’ve seen people lie
on this spot, thinking it wouldn’t be
tender and before I know it they jump
off the floor! Yes, this spot is a
scorcher, but it is worth it, especially if
you have limited low back or hip range
of motion.

Where is the TFL?

Nothing about the TFL is easy and
finding it isn’t an exception. The best
method to find the TFL is to grab your
pelvis with your thumbs facing forward.
The top of the TFL is directly behind
your thumb and the whole muscle is
about one inch wide and two inches
long.

What Does the TFL do?

The TFL is a tensor of the fascia latae;
the oblique direction of its fibers enables it to abduct the thigh and assists Travell 1983
with internal rotation and flexion of the hip.

48
 Muscle: Origin: Insertion: Action(s):

Tensor Anterior Lateral Condyle tibia Hip abduction, fleion,

Fasciae Latae Superior Iliac via Iliotibial tract internal rotation and tensor
(TFL) Spine (ITB) fascia lata

What Does SMR to the TFL Feel Like?

This is usually one of the most painful muscles for SMR. Lots of tears flow down the face
when a tennis ball hits the right spot. I see this trigger point on everyone, most of the
time being latent trigger points. Many people address the iliotibial tract and neglect
the TFL. Reaching the TFL is more difficult and a little tricky, but pays big dividends in
pain relief and hip mobility gains. Most every case of chronic knee pain, hip pain, and
low back pain will have an issue with the TFL.
If you find that SMR does not release this point, check the adductor group for trigger
points and weakness. These can help give a break to the overactive TFL.
Few people realize they have a TFL problem until their first experience on a tennis ball.

SMR to the TFL Summary

Purpose:

SMR to the TFL may improve poor hip internal rotation or alleviate low back, knee, or
hip pain/soreness.

Directions:

Lie on your side and put the tennis ball directly behind your hip. To find the proper
position, find your hip bone place the ball two finger breadths behind, and then lie
directly on your side with the tennis ball directly behind this bone

49
Piriformis
Impairments: Related Muscle (s): Injuries:
Piriformis
Poor kicking power.
syndrome, sciatica,
Pain in the lower back,
nonspecific low
buttocks, hip,
back pain, knee
hamstrings, sensations Piriformis, gluteus
pain (clicking or
down the entire back of maximus.
popping), groin
the leg, limited hip and
pain, herniated
low back range of
disc, “lower cross
motion.
syndrome”.
The ever popular piriformis
muscle! Most of you have heard
of the piriformis, if not sciatica
or ‘piriformis syndrome’. This is
the pain typically noted down
the back of the leg when the
piriformis pinches or
compresses the sciatic nerve as
it exits the sacral area.
So many conditions and
dysfunctions may be connected
to the piriformis muscle.
Referencing the picture, there
is typically pain near the sacral
Travell
notch, belly of the buttock
1983
region, and the outside hip.
Because of its intricate part in pelvic function and hip movements, when the piriformis
loses tone almost every surrounding muscle jumps on board to help stabilize the hips.
A torrent of events occur when you have rotational dysfunction in the hip socket, sacral
torque (twisting), the gluteus medius and minimus muscles go nuts with activity and
are loaded with their own trigger points. The sacrotuberous ligament now comes under
extra tension and pulls on the posterior fascial connective tissue slip from the
hamstrings, to the glute, to the lats working its way up to the head. Before you know
it, someone has an unknown cause of neck pain!
I have found that if the piriformis muscle is constantly a problem despite soft tissue
techniques and therapy it is usually a result of hip joint stability problems. The lack of
stability in the joint leads to chronic tightness of the hip rotators. A lack of hip
extension is often present.

50
Where is the Piriformis?
The piriformis is an easy muscle to find, it is located right in the middle of the butt
cheek! In fact, the piriformis is a land mark used to separate the top and bottom of the
gluteal muscles, as it lies deep to the all the gluteal muscles.
The top edge of the gluteus maximus muscle slices across the top of the buttocks on a
diagonal line, from the low back dimple to the bump of bone on the side of the hip
(greater trochanter). That ridge of muscle is fairly easy to find, even for the beginner.

What does the piriformis do?

The piriformis externally rotates the extended thigh and abducts the flexed thigh.
Abduction of the flexed thigh is important in the action of walking because it shifts the
body weight to the opposite side of the foot being lifted, which keeps us from falling.
Many people will have a problem with this muscle due to the fact that we sit on our
butts most of the day. Abduction of the flexed thigh also occurs in breaststroke, often
creating tightness in this muscle.

Muscle: Origin: Insertion: Action(s):

Piriformi Anterior surface Greater trochanter Hip abduction, extension,

s sacrum apex eternal rotation

What Does SMR to the Piriformis Feel Like?

Although the quality of sensation in piriformis is usually among the deepest, most
aching, and most relieving of all trigger point sensations in the body, about 25% of the
time it can be sharper and hotter and not so pleasant. This is particularly true when
the pressure is applied closer to the dimple/bump. This less satisfying feeling usually
indicates either that the pressure is too much on the tendon, and you can move a little
further down into the muscle body (probably only a few millimeters) to get to the “good
pain” — or it indicates a particularly sensitive trigger point, and there’s nothing to be
done except work through it slowly and gently.
The pressure tolerance of this spot varies widely from person to person — true of every
trigger point, but once again the piriformis is an especially good example. For those
who have suffered low back pain or work in a chair, this spot may be extremely sensitive
and require only gentle pressure. Others may easily tolerate a baseball on this muscle!
Start gently, and slowly work your way up to the desired pressure.

SMR to the Piriformis Summary

Purpose:

The piriformis is commonly tight in people with poor hip extension range of motion
(touching one’s toes), as it can restrict sciatic nerve mobility.

51
Directions:

Long sit with one leg straight and the other bent. Put the tennis ball on the outside
of your glute of the straight leg and roll the tennis ball on the outside of your hip.

52
Psoas
Impairments: Related Muscle (s): Injuries:
Poor dolphin kicking Nonspecific low
power. Pain in the lower back pain,
back, hip, thigh, herniated disc,
shoulder, knee, “lower cross
hypermobility in the Psoas, iliacus. syndrome”,
lumbar spine, spondylolysis,
hypomobility in the spondylolisthesis.
lumbar spine.

The psoas is a major issue on

almost 100% of the people you
will see. Because of our
sedentary lifestyle of sitting all
day, this muscle has a wicked
tendency to be loaded with
trigger points.
Unlike some of the other spots,
this muscle is best manipulated
by someone trained in soft
tissue, due to the awkwardness
of the position. However, if do
not have someone around, this
muscle can be manipulated … awkwardly by yourself. Travell
Stretching the psoas is a futile activity if it is loaded with trigger points. Release
1983 out
the knots first and then move into stretching the muscle. If you stretch without first
reducing the trigger points, there will be minimal lasting change in the muscle. The
psoas acts in reciprocity with the glute and hamstring muscles. Meaning, when the psoas
is contracted the glutes and hamstrings disengage and relax, often leading to other
movement dysfunction and potential injury.
In those with spondylolysis or spondylolisthesis, please consult a Physical Therapist and
beg for a myofascial release for a long period of time, you will dramatically see an
improvement in range of motion.
I’ll never forget the first time I saw myofascial release to the psoas, unfortunately it
wasn’t until my third year rotation at my doctoral program! I was working with a
stubborn, but brilliant Physical Therapist and we saw a hot shot high school football
player. This unfortunate kid had bounced around from therapist to physician to surgeon
with no improvement with his excruciating low back pain or limited range of motion.
Yet, after one treatment of approximately 10 minutes of myofascial therapy on the

53
psoas, he improved 45 degrees in lumbar extension! My eyes lit up as much as the
athlete’s that day!

Where is the Psoas?

This muscle sits deep and can be difficult to reach for the novice, but with practice you
can find it easily. Luckily, the body has given you a landmark to find this location, the
belly button. Simply take your hand and move it approximately two inches lateral to
the belly button and two inches inferior. Next, flex your hip and feel the muscle pop
into your fingers, look what you found!
Some may wonder how pressing on the stomach will get to the psoas muscle, but simply
understand the muscle is extremely deep and targeting it through the stomach is the
best option due to the mobility of the organs in the stomach. Luckily, muscles are
relatively fixed to bones, making them quite easy to find.
Muscle: Origin: Insertion: Action(s):

Psoas T12-L4 Vertebral Lesser trochanter via Hip flexion, external

Major bodies iliopsoas tendon rotation
Lumbar spine flexion and
ipsilateral flexion

Iliacus Iliac Fossa Lesser trochanter via Hip Flexion and external
iliopsoas tendon rotation

What Does the Psoas do?

This muscle predominantly flexors the hip, but also plays a role in externally rotating
the hip.

What Does SMR to the Psoas Feel Like?

These trigger points can be very tender – some with active trigger points would call it
piercing. The two superior points on the picture refer pain to the lower back. It is
surprisingly a very common cause of lower back pain; however it is not very common to
find someone who understands that bit of info. Back pain sufferers who cannot get
relief despite all types of therapy to the lower back, will usually have these points.
The lower insertion point of the muscle is prone to radiating pain into the hip, groin
and upper thigh.
An interesting observation is that if you have a unilateral psoas problem the lower back
pain typically goes up and down the back in a vertical pattern. If you have a bilateral
psoas issue it will usually present as a horizontal pain across the lower lumbar region.

54
One of the key pieces of advice I give to every coach is to assume the psoas is an issue.
It is either hyperactive or hypoactive. Very rarely is it functioning normally, even in
high end athletes. Imagine the prevalence in the typical person who sits on their bottom
all day.

SMR to the Psoas Summary

Purpose:

The psoas may limit spinal and hip mobility, as well as contribute to low back pain.

Directions:

Lie on your back with your legs on a bench or leg rest (elevated approximately 45
degrees). Next, with one end of a mobility stick perpendicular to your body, press
into the muscle. You can flex your hip to see if the stick moves, but once in the
correct position, hold.

55
Quadratus Lumborum
Related Muscle Injuries:
Impairments:
(s):
Excessive side to side Nonspecific low
movement in free and back pain,
back. herniated disc,
Pain anywhere in the “lower cross
low back, tailbone, Quadratus syndrome”, hip
lower buttock, lumborum, erector bursitis, opposite
abdomen, groin, side of spinae. shoulder pain.
the hip. Limited range
of motion of the low
back and hips, weak
obliques.
People usually don’t know about this
spot … until it gets massaged. Even
when they have low back pain, most
people are probably unaware that this
spot is the source of so much of it — it
often seems too high. But trigger
points in this location tend to refer
pain downwards, fooling us into
thinking our low back pain is lower
than it is.

Where is the QL?

Specifically, this spot is the
“thoracolumbar corner” a nook
between your lowest rib and your
spine — right where the stability of the
rib cage gives way to the relative
instability of the lumbar spine. Muscle
tends to bunch up around this joint
between the last of the thoracic
vertebrae and the first of the lumbar.
This sweet spot consists of trigger
points in the upper-central corner of the quadratus (square) lumborum (QL) muscle and
in the thick column of muscle that braces the spine. For simplicity, we refer to this spot
as the QL, although it is an impressive collection of muscle woven together almost like
a thick rope. There is hardly a location anywhere in this muscle group from skull to
sacrum that does not have the potential to be extremely tight … but there is almost
always a significant trigger point in the thoracolumbar corner.

56
What Does the QL Do?
The QL is an interesting flat sheet of a muscle, spanning the space between the ribs
and the hips. The QL has three major jobs, which is why it often needs work: it acts as
a prime mover, a postural muscle, and a respiratory muscle. Some people with back
pain also experience significant discomfort when breathing, because a cranky QL resists
elevation of the rib cage, and cramps up when pulling it down firmly on exhalation. You
can imagine the sense of relief people experience when this is resolved!

What Does SMR to the QL Feel Like?

Sensation in this area can feel hot and burning if the trigger points are severe, and they
can also feel breath-taking, so use caution. However, in the majority of people, a
blunted or gentler pressure will still produce the signature sensation of a deep, “sweet”
ache.
Simply locate the bottom rib, and then work your way inwards towards the spine.
Between the bottom rib and about an inch away from the spine is a corner or pocket
where you can almost push underneath the rib.
Sometimes this spot is difficult to locate, but keep exploring. Using a tennis ball or
baseball if it’s not too sharp, slowly push into that pocket, and press inwards and
upwards. Keep trying different angles and you are likely to find something really
attention-grabbing!

SMR to the QL Summary

Purpose:

The quadratus lumborum likely weakens frontal plane strength and can cause excessive
spinal mobility during freestyle (wiggling).

Directions:

Lie on your back, approximately 30 degree from vertical with the tennis ball one your
side in between your rib cage and pelvis.

57
Static Stretching
Although static stretching for long periods is not essential for improving core strength,
light stretching can also improve muscles which have undergone adaptive shortening,
long-periods of poor muscle position. However, must people overdo stretching or do it
at the wrong time. If you really have muscular imbalances considering adding these
stretches for 30 seconds each day after practice.

Remember, the purpose of stretching is to make the muscle and surrounding fascia
suppler and increase in length. The most important part of any exercise program is
compliance. This is particularly true for stretching exercises. When you stretch you get
an immediate increase in tissue length. This is due to the viscoelastic properties of the
tissue and improved stretch tolerance. However, the term elastic implies, this change
will not last long. When you repeatedly stretch muscle and its fascia; you get more of
a 'plastic' change in the tissue – a lasting change. To achieve this you must stretch daily.
Missing several days will put you back to square one.

To improve, we have found that stretching each muscle for 30 seconds daily will get
you results. Of course you can stretch longer, but at least do 30 seconds. You should
feel a stretch sensation, not pain. As with any exercise, if it causes your 'pain' – stop.

Adductor Stretch
Lie on your back with your knees bent. Tighten your stomach to make your back flat.
Keep your back flat and let your legs fall apart until you feel a stretch on the inside of
your thighs.

Single Knee to Chest Stretch

Lie on your back and bring one knee toward your chest. Let this leg fall out a bit as
this is the natural angle of the hip.

58
Hamstring Stretch
Lie on your back. Bring one knee toward your chest and grasp behind your thigh with
both hands. Keep the other knee bent. While holding the knee to your chest,
straighten your knee until you feel a stretch on the back of your thigh.

Piriformis Stretch
Lie on your back and place the arch of one foot on the opposite thigh just above your
knee. Grasp your knee with your opposite hand and pull across and up until you feel a
stretch in the buttock.

Standing Iliopsoas Stretch

Put one foot up on a table or other high object (depending on your height – no higher
than the knee). Point the foot that is on the floor into a pigeon toed position. In this
position, do a pelvic tilt or “tuck under.” You may feel a stretch in the front of your
thigh. If you don't, lean forward, leading with your hip and keep your chest in the
same position. You will feel a stretch on the front of you thigh, and in the groin area.
Hold onto an object with your hand to stay balanced.

½ Kneeling Stretch
Kneel on one knee with your other leg forward with your foot flat on the ground. Use
a table or chair to your side for balance and a pillow under your knee if padding is
necessary. Line up your body over the knee that you are kneeling on. In this position
do a pelvic tilt or 'tuck under' and you will feel a stretch in the front of your thigh.
Common mistakes are arching your low back or leaning forward which negates
the stretch.

59
Muscle Strength
I feel the primary problem with trunk stabilization is not that the spine can't move,
but that it can't move in a controlled fashion. Its check rein system is screwed up.
Muscles are inhibited from contracting – inhibited which means that you can try to
make them contract until the cows come home, but the only way they will is to
remove the inhibitors. I also feel that many muscles are too long and they suffer from
passive insufficiency. The self myofascial releases listed above can help improve the
overactive muscles, then the strengthening exercises can help improve the position of
the muscles which are too long. Just remember, a maximal contraction in the
shortened position is the best method for returning the long, lazy muscle to the
desired position.

After performing muscle strength, the central nervous system (CNS) has the raw data
allowing the deep core muscles to fire appropriately and not be dominated by the
“cheaters” of the outer core.

Altered CNS results in a changed sequence in the pattern. Its characteristics are:
1. The start of muscle activation is delayed, so that the order in which the
individual muscles are activated, changes. The non-inhibited synergists or
stabilizers usually become activated earlier.
2. The decrease of activity of the particular muscle in general; in extreme cases
the muscle remains almost electromyography (EMG) silent. This may lead to a
wrong interpretation that the muscle strength is zero. However, such a muscle
may be usually activated after adequate facilitation.

This is a change of proprioceptive input. Provides source of impaired / altered

proprioception input to the CNS. Garbage in = garbage out, resulting in movement
dysfunction.

Moreover, it is almost impossible clinically to differentiate the primary changes in

muscles from their secondary reaction due to an altered or impaired central nervous
regulation, as the quality of muscle function changes the cortex (Tsao 2011, Tsao
2010, Tsao 2010).

Therefore, providing the muscles raw data with flexion-bias exercises is essential for
the resolution of poor proprioception (muscle timing).

To move we need good central nervous system programing. For this we need raw
data, to feed the peripheral nervous system to REACT.

60
The core is an excessively discussed topic ranging for sports optimization to low back
pain. Everyone has heard and performed core training, but what are specific core
exercises for swimmers? Swimming is a unique sport being based on an unstable
medium in the horizontal plane, but what muscles are essential for optimal sports
performance and low back pain prevention? I have had many roles in the swimming
career, but no matter the setting low back pain and weak core muscles are present.
As an age-group and collegiate swimmer, I had many teammates with low back pain.
As a Master’s coach, I truly saw the damage of low back pain with swimmers. Nearly
every workout, I had one athlete fight through or become frustrated with recurrent
low back pain. As a National level coach, I still see low back pain. Just because one
is an elite swimmer, does not ensure core strength and low back stability, often times
these elite athletes were successful as youths and have been conditioned to find a
way to optimally perform, by any means necessary sometimes putting their body at
risk for injury.

Alterations in muscle timing have been shown consistently at the low back, but newer
research is suggesting similar alterations at the shoulders and all joints (Hodges 1996;
Ferreira 2004). Alterations in muscle timing are likely aided and persist by pain
(Stackhouse 2011; Hodges 2011). Moreover, pain may affect motor control and learning
(Hodges 2011). However, if these disruptions persist over time, they can become
implanted in the cortex and persist even after the pain/injury has resolved (Tsao 2005).
Janda termed this a functional lesion. These likely initiate from a compensation
strategy secondary to a painful stimulus. However, only resolving pain is unlikely to
restore motor control, suggesting muscle timing must also be addressed (Hodges 1996;
MacDonald 2009; Hodges 2011; Crosbie 2012).

Once maximal strength is achieved without compensations, muscle timing exercises

which force muscles to work congruently without compensations from global muscles is
key (Swanik 2002). Once mastered, incorporating other body parts, while maintaining
this activation can be practiced. Muscle timing exercises can also teach the athlete how
to apply the correct amount of force, not allowing them to over or under contract as
these misfires may result in injury risk (Maenhout 2012; Worsley 2012).

These exercises are a combination of planes of motion or enhance the ability to contract
and relax, an essential sporting skill.

Also, the sequence of core training progresses with the following:

● Isometric: Muscles are stationary, like flexing your biceps.

61
 ● Concentric: Muscles are actively shortening, like lifting a weight during a
biceps curl.
● Eccentric: Muscles are actively lengthening, like lowering your weight during a
biceps curl.

These are the three forms of muscle contraction, moving from easiest to hardest.
Many believe concentric muscle action is the hardest, but must more internal
muscular force is required for lowering a weight in a controlled fashion.

Also, our core training tests also progress from isometric, to concentric, to eccentric.
Just remember the following rules:

Rules
1. Maintain the abdominals braced at all times.
2. Do not let that position change AT ALL during the exercise.
3. Stop if the exercise causes 'your pain'.
4. Stop if can not keep the correct back position

Anterior Sagittal Plane:

Building strength in the front of the body is essential for swimmers, as many flexion
activities occur in the sport (turns, dolphin kicks, etc.). However, some swimmers still
have weakness in this plane of motion despite hours of “traditional core training”.
First, figure out if you have appropriate core strength in the anterior sagittal plane.

Frontal Plane:
Although the frontal plane is clearly different from the transverse plane, the
exercises for strengthening them are similar. Improving the frontal plane strength
helps keep the spine streamline during many swimming motions. Although it isn’t as
used as the transverse plane, it helps keep the spine straight and maintains
intervertebral disc health. Tremendous at developing the internal/external obliques
as well as the quadratus lumborum and multifidus (lower back).

Transverse Plane:
Developing rotational power is essential for freestyle and backstroke swimmers.
However, this neglected plane is inadequately strengthened with simply “Russian
Twists”. These exercises that allow the swimmer to develop rotary power but prevent
the bottom of the rib cage from leaving the pelvis.

Posterior Sagittal Plane:

62
Exercises that prevent the swimmer from going into hyperextension of the lower back
or using the low back extensors as a means to achieve hip extension. By training this
movement, we enhance the anterior core muscles’ strength and endurance and
preserve the integrity of the spinal anatomy. It is also great for improving the lordotic
lumbar curved posture (also known as ‘swayback’) commonly seen in swimmers.

63
Where to Start?
Creating a baseline point is essential for monitoring improvement. Instead of
recording silly volume, tracking the amount of power one can transit from the core is
truly a test for each swimmer. Before any of the 11 training phases, please record
your distance for the following exercises. Perform each phase until the exercises
become too easy, which should be 2 – 4 weeks. Also, perform these exercises 5 days a
week. This consistent volume will ingrain proper movement and core stiffness. For the
self myofascial releases and stretching, you can select which address your specific
impairments. If you are looking for a general guide, here are the suggestions:
SMR Duration

SMR Quadratus Lumborum 3 minutes

SMR Piriformis 3 minutes

SMR Tensor Fascia Latae 3 Minutes

Entire Static Stretching Routine

64
Core Strength Testing

Exercise Distance
Medicine Ball Overhead Throw
Medicine Ball Rotational Throw R
Medicine Ball Rotational Throw L
Reverse Overhead Medicine Ball
Throw

Medicine Ball Overhead Throw

Place a medicine ball overhead. Next, bring the ball back without arching your back
and throw the medicine ball as far forward as possible.
Medicine Ball Rotational Throw
While standing perpendicular to a sturdy wall or while standing in an open field, take
a medicine ball and rapidly rotate your back foot and launch the medicine ball
forward. If facing a wall, catch the ball by bracing at the elbows and shoulders.

Reverse Overhead Medicine Ball Throw

With a medicine ball, break at the hips, hip hinging, then launch a medicine ball
overhead. This will throw the ball behind you. Perform this exercise in an open field
and do not over arch the back upon throwing the ball.

65
Phase I

Exercises Repetitions Sets

Abdominal Bracing :30 3
Straight Leg Raise 5e 3
Hip Abduction with Band :30 3
4-Point Hip Extension 5e 3

Abdominal Bracing
Lie on your back, then posteriorly tilt pelvis and flatten your low back on your hand
which lies underneath the small of your low back. Ensure not to suck in or arch your
back. Maximally contract your core.
Straight Leg Raise
Lie on your back with one knee straight and the other bent. Brace your abdominals.
Lift the straight leg (keeping the knee straight) and then slowly lower it down. Do
reps or time for one leg and then the other.
Hip Abduction with Band
Lie on your back with knees bent. Put theraband loop around the thighs, above knees.
Keeping the abdominals braced, pull knees apart and then let them come together
slowly and under control. You will have a tendency to arch your back when you pull
your knees apart. Do not let this happen. Buy band here.
4-Point Hip Extension
In the table top position (hands under the shoulders and knees under the hips), gently
extend one leg back, while keeping the spine from arching, shifting, or rotating.
Return the leg slowly.

66
Phase II

Exercises Repetitions Sets

March 5 3
Hands Over Head Curl-up 5 3
Anti-Rotation with Band :30 3
Prone Alternate Arm and Leg 5e 3

March
Lie on your back with your knees bent. Next, brace your abdominals. Bring one knee
to chest. Hold it there. Then bring the other knee to the chest. Let one leg down,
then the other. Repeat.
Hands Over Head Curl-Up
Lie on your back with knees bent. Next, brace your abdominals. Lock your fingers
together over your head. Flatten back before initiating movement. Do a curl-up, until
the bottom of the shoulder blades come off the floor. Keep abdominals tight and back
flat at all times. There is a great tendency to arch your back as you lift. Do not let
this happen.
Anti-Rotation with Band
Securely set-up a band waist height. Next, straighten your elbows, grasping the band,
brace your abdominals, and walk out slowly as far as you can while keeping the hands
in line with the belly button. In this position, flex your elbows, then straighten them,
without letting the band deviate from the center line.
Prone Alternate Arm and Leg
Lie on stomach with or without pillow under stomach, as instructed. Tighten your
stomach and make the back flat. Have your arms over your head. Push your right arm,
left leg and forehead into the floor or mat. Lift the opposite arm and leg. DO NOT LET
YOUR BACK ARCH. YOU MUST ACTIVELY TIGHTEN THE ABDOMINALS WHEN YOU LIFT
YOUR LIMBS.

67
Phase III
Exercises Repetitions Sets
Hands Over Head Curl-up with
Partner Pulls 5 3
*Squeeze Ball
Side Plank :30 3 if breastroke
Anti-Rotation Walkout with Band :30 3
*Squeeze Ball
Swiss Ball Bridge :30 3 if breastroke

Hands Over Head Curl-Up with Partner Pulls

Lie on your back with knees bent. Brace your abdominals. Lock your fingers together
over your head. Flatten back before initiating movement. Have a partner pull on your
heels, attempting to straighten your leg (do not let them straighten your legs). Do a
curl-up, until the bottom of the shoulder blades come off the floor. Keep abdominals
tight and back flat at all times. There is a great tendency to arch your back as you
lift. Do not let this happen.
Side Plank
Form a side pillar or bridge with your abdominals braced by supporting your body in a
side-lying position with just one foot and one forearm touching the ground. Stack the
legs and place the hand of the upper arm on the hip. Keep your body in a straight line
and contract your glutes.

Anti-Rotation Walkout with Band

Securely set-up a band waist height. Next, straighten your elbows, grasping the band,
brace your abdominals, and walk out slowly as far as you can while keeping the hands
in line with the belly button. Slowly return without letting the band pull your rapidly
back.
Swiss Ball Bridge
On exercise ball get into a bridge position and hold. Remember to make back flat
and lift as high as you can without arching back. Once you've lifted as high as you
can, tighten the buttocks. Buy exercise ball here.

68
Phase IV
Exercises Repetitions Sets
Bosu Hands Over Head Curl-up 5 3
*Squeeze
Bench and
perform hip
internal
rotation if
Bunkie Knees Bent :30 3 breastroke
Rotation with Band 5e 3

Swiss Ball Bridge March :30 3

Bosu Hands Over Head Curl-Up

Lie with your back on a Bosu Ball with knees bent. Lock your fingers together over
your head. Brace your abdominals before initiating movement. Do a curl-up, until the
bottom of the shoulder blades come off the floor. Keep abdominals tight and back flat
at all times. There is a great tendency to arch your back as you lift. Do not let this
happen.
Bunkie Knees Bent
Form a side pillar or bridge by supporting your body in a side-lying position with one
arm touching the ground while stacking the knees on a small bench. Place the hand of
the upper arm on the hip. Keep your body in a straight line and contract your glutes.

Rotation with Band

Set a band at waist height. Next, turn perpendicular to the band and straighten your
arms. Slowly, rotate your back leg and arms forward, in a circular motion in a
controlled manner. Return slowly.
Swiss Ball Bridge March
On the exercise ball get into a bridge position. Have your knees close together and
your hands on the floor for support. Straighten one leg, let it down and repeat with
the opposite side. DO NOT LET YOUR BACK ARCH, OR PELVIS/SPINE MOVE IN ANY
WAY. YOU MUST STAY ABSOLUTELY STILL. Buy exercise ball here.

69
Phase V

Exercises Repetitions Sets

*Squeeze ball
and perform
hip internal
rotation for
Ab Wheel :30 3 breaststroke
Bunkie Knees Bent with Hip *Squeeze Ball
Abduction :30 3 if breastroke
Medicine Ball Chop 5e 3

Super Dog 5e 3

Ab Wheel
Kneel with your knees on a mat. Next, brace your abdominals and rollout on the
wheel. Do not let the back arch! Return slowly and controlled.
Bunkie Knees Bent
Form a side pillar or bridge with your abdominals bracedby supporting your body in a
side-lying position with one arm touching the ground while stacking the knees on a
small bench and lifting your top leg. Place the hand of the upper arm on the hip.
Keep your body in a straight line and contract your glutes.

Medicine Ball Chop

In a half kneeling position, brace your abdominals, then bring a medicine ball down
towards the down leg. Next, raise the ball slowly.
Super Dog
Lie on your stomach with one knee up to your chest and your opposite forearm on
the ground. Posterioly tilt your pelvis or “tuck under” maximally contracting your
abs and pinch your shoulder blade down and back towards your midline, then raise
your opposite arm and leg.

70
Phase VI
Exercises Repetitions Sets
Body Saw 5 3
*Squeeze
bench if
Bunkie :30 3 breastroke
Torture Twist 5e 3

Double Leg Raise 5 3

Body Saw
Body saw – with the feet suspended in the labile suspension straps, knees bent and
the Body saw – with the feet suspended in the labile suspension straps, knees bent
and the hands or forearms on the ground to support the weight of the body,
participants were asked to straighten their legs and “saw” back and forth as far as
possible over 2 s (i.e., 2 beats of the metronome). Once at full extension, the position
was held for 1 beat before the participant “sawed” back to the original knees-bent
position over 2 beats. The starting position was held for 1 beat before the next
repetition began.
Bunkie
Form a side pillar or bridge with your abdominals braced by supporting your body in a
side-lying position with one arm touching the ground while stacking the feet on a
small bench. Place the hand of the upper arm on the hip. Keep your body in a straight
line and contract your glutes.

Torture Twist
Lie with a bench underneath your hips and your feet securely held either by a partner
or under a stable surface. Lean back while contracting/bracing your abdominals until
your body is parallel to the ground, then rotate to one side holding at this side
isometrically for approximately four seconds on each side. Following the isometric
hold, rotate quickly to the other side and hold again.
Double Leg Raise
Lie with your torso across a sturdy table, draping your legs over the edge and grasping
the edges of the table, knees straight. Keeping the torso locked into place, raise the
legs, making sure to squeeze the glutes up top and prevent overextension of the low
back. Lower the legs to the starting position, keeping the spine stable and making
sure to prevent rounding the low back.

71
Phase VII

Exercises Repetitions Sets

Bracing with Lat Pull Down 5 3
*Squeeze
bench if
Bunkie with Hip Abduction :30 3 breastroke
Suit Case Walk :30 3

Single Leg Leg Raise 5e 3

Bracing with Lat Pull Down

Set up an elastic band or have a partner behind you. Tighten your abdominals by
bracing your core musculature. Next, pull down on the elastic band or against a stable
surface (like a partner) and maximally exhale your air. Slowly return the arms
overhead and relax your core.
Bunkie with Hip Abduction
Form a side pillar or bridge by supporting your body in a side-lying position with one
arm touching the ground while stacking the feet on a small bench and lifting the top
leg. Place the hand of the upper arm on the hip. Keep your body in a straight line and
contract your glutes.

Suit Case Walk

While holding a heavy weight in one hand (dumbbell or kettlebell) walk with long, fast
strides. Keep your chest up and don’t let your body rotate or arch.
Single Leg Raise
Lie with your torso across a sturdy table, draping your legs over the edge and grasping
the edges of the table, knees straight. Bend one leg toward the table, then while
keeping the torso locked into place, raise one leg, making sure to squeeze the glutes
up top and prevent overextension of the low back. Lower the leg to the starting
position, keeping the spine stable and making sure to prevent rounding the low back.

72
Phase VIII

Exercises Repetitions Sets

Farmers Walk :30 3
Ab Wheel with Band :30 3
Waiter Walk :30 3

Glute Hamstrings Raise 5 3

Farmers Walk
While holding a heavy weight in both hands (dumbbell or kettlebell) walk with long,
fast strides. Keep your chest up and don’t let your body rotate or arch.
Ab Wheel with Band
Kneel with your knees on a mat. Set up a band and have the band perpendicular to
your body. Next, brace your abdominals and rollout on the wheel while holding the
band. Do not let the back arch! Return slowly and controlled.

Waiter Walk
While holding a heavy weight overhead in one hand (dumbbell or kettlebell) walk with
long, fast strides. Keep your chest up and don’t let your body rotate or arch.
Glute Hamstrings Raise
With your partner holding the backs of your ankles, drape your body over the end of
a couch or sturdy table so that your legs are straight and secured. Make sure the
neck is in a neutral position and your arms are in the mummy position. Bend at the
hips and not the spine, getting a good stretch in the hamstrings. Raise the torso while
squeeze the glutes to lockout.

73
Phase IX

Exercises Repetitions Sets

Medicine Ball Throw Down 5 3
*With hip
internal
rotation if
Kneeling Pallof Press 5 3 breaststroke
Tight Medicine Ball Throws 5 3

Single Leg Glute Ham Raise 5e 3

Medicine Ball Throw Down

Grasp a heavy medicine ball with both hands. Next, raise your arms overhead, then
slam the ball down as hard as possible.
Kneeling Pallof Press
Securely set up a band head height while kneeling. Next, kneel on a mat and face
away from the band. Brace your abdominals, raise your arms overhead and slowly
return the arms down, without letting your body arch.

Tight Medicine Ball Throws

Face a stable wall. Take a medicine ball and hold in on one hip. Rapidly, throw the
medicine ball towards the wall at an angle and catch it on your other side. Don’t arch
your back, throw the ball quickly.
Single Leg Glute Ham Raise
With your partner holding the backs of on ankle (while the other knee is bent), drape
your body over the end of a couch or sturdy table so that your legs are straight and
secured. Make sure the neck is in a neutral position and your arms are in the mummy
position. Bend at the hips and not the spine, getting a good stretch in the hamstrings.
Raise the torso while squeeze the glutes to lockout.

74
Phase X

Exercises Repetitions Sets

Single Arm Medicine Ball Throw Down 5e 3
*With hip
internal
rotation if
Kneeling Pallof Press with Ext 5 3 breaststroke
Heiden 5e 3

Medicine Ball Rotational Throw 5e 3

Single Arm Medicine Ball Throw Down

Grasp a heavy medicine ball with one hand. Next, raise your arms overhead, then
slam the ball down as hard as possible.
Kneeling Pallof Press with Extension
Securely set up a band head height while kneeling. Next, kneel on a mat and face
away from the band. Brace your abdominals, lean back, then raise your arms
overhead and slowly return upright. Lower the arms, then repeat. Do not let your
body arch.
Heiden
Set up a bad waist height. Next, rapidly jump towards your side, landing softly while
breaking at the hips and knees. Step back slowly to return.

Medicine Ball Rotational Throw

While standing perpendicular to a sturdy wall or while standing in an open field, take
a medicine ball and rapidly rotate your back foot and launch the medicine ball
forward. If facing a wall, catch the ball by bracing at the elbows and shoulders.

75
Phase XI

Exercises Repetitions Sets

Monkey Throws 5e 3
Heiden with Rotation 5e 3
Shot Put 5e 3
Reverse Overhead Throw 5 3

Monkey Throws
While holding a medicine ball in one hand above your head, brace your abdominals
and throw down the medicine ball, while simultaneously rotating the hips. Catch the
ball on the return with the other hand, then rapidly repeat.
Heiden with Rotation
Set up a bad waist height. Next, rapidly jump while rotating your body, landing softly
while breaking at the hips and knees. Step back slowly to return.

Shot Put
While holding a medicine ball on one shoulder, brace your abdominals and throw the
medicine ball as far as possible, either against a sturdy wall or in an open field. If
against a sturdy wall, catch by breaking at the elbows and shoulders.
Reverse Overhead Throw
With a medicine ball, break at the hips, hip hinging, then launch a medicine ball
overhead. This will throw the ball behind you. Perform this exercise in an open field
and do not over arch the back upon throwing the ball.

76
Case Studies
Stiff Sam
The Dr. Detective series often issues swimmers with pain, injury, and or limitation.
This is a case of a triathlete without injury or pain, but limited spinal mobility
limiting his streamlining. Now, you may wonder why a triathlete requires proper
streamline, but when you think about it, streamlining occurs during the entire
stroke, not just off turns. The only difference is the arms are not overhead during in
water streamline. The names of the client in this scenario was changed to protect
their identity.

The Patient
Sam was a 32-year-old triathlete. He has completed 2 Ironman races and made the
Kona race. As a youth, Sam swam in high school, but began focusing on cycling and
running in college. Currently, Sam's strengths are the cycling and running legs of the
triathlon, with swim his weakest leg. Although he swam in college, he took over 10-
years off of training. For work, Sam is a software engineer, working 40 – 60 hours of
week, of constant sitting. He reports no pain.

Objective Out of Water Analysis

Despite swimming as a youth, Sam presented with limited shoulder flexion. Yet, upon
further examination, it was clear his shoulder limitation was not solely from poor
shoulder mobility, but perpetuated by poor thoracic spine mobility. This was noted
the patient had little change in shoulder mobility during spinal extension compared
to his normal spinal position. Sam also presents with excessive rib flaring and spinal
extension during overhead movements. Lastly, Sam had poor isometric frontal and
transverse plane strength.

In Water Analysis
In the water, Sam had a rounded midback and an arched low back during wall
streamline. During freestyle, was limited on the early vertical forearm. On top of
this, he swam in lumbar spinal extension and side-to-side movement.

Out of Water Intervention

In Sam's case, his in- and out-of-water impairments appeared to be correlated.
Therefore, an approach of improving soft tissue and neural mobility of the brachial

77
plexus and thoracic spine was paramount. In combination of this, a swimming core
training program focusing on improving core strength in the front, side, and back of
his body was implemented.

In Water Intervention
In the water, a focus on thoracic spine mobility, without overarching the low back
was implemented. He was also taught a behind the ears streamline position, with
the hope of improving spinal extension.

Summary
After 4-weeks of biweekly strength sessions and two in-water sessions, Sam improved
his pace by: 05 in the 100-yard freestyle. Despite this marked improvement in time,
he still doesn't present with a straight plumb line in streamline. Further work is
needed, but improvement can occur with small improvements.

78
Flexible Frank
The Dr. Detective series often issues swimmers with pain, injury, and or limitation.
This is a case of an Olympic Trial qualifier in the 1500-meter freestyle. Now, some
may think elite swimmers have little to improve, but this is never the case. As you’ll
see, a slight modification greatly helped this young man. The names of the client in
this scenario was changed to protect their identity.

The Patient
Frank was a 17-year-old swimmer. He was a heavily recruited for college swimming
and concentrating more on distance freestyle. As a younger swimmer, he was highly
versatile and always ranked Nationally in multiple events.

Objective Out of Water Analysis

The swimmer was a typical swimmer, rounded shoulders in standing, but plenty of
active shoulder motion. In fact, he had excessive shoulder blade mobility, as these
blades fluttered as he moved his arms above head. Visually, Frank was very thin,
but lacked must muscular definition in his core. He reported his weakness was an
inability to change speeds, which he felt was crucial during the race, as he often
negative split his race (swam faster on the second half of the race).

During the core testing, Frank was very strong during isometric holds, but weak when
integrating his arms. In fact, he couldn't pass the intermediate test for core strength
for the anterior sagittal plane of motion.

In Water Analysis
In the water, Frank had a beautiful stroke. He seamlessly created an early vertical
forearm in the pool as he cruised at mile pace. However, when asked to swim faster,
he had a tough time. In fact, he slightly changed his swimming position to one with
more low back arching. This change in position, likely dispersed the energy created
by the arms during the catch, wasting energy.

Out of Water Intervention

79
For Frank, we set-up a anterior core strengthening emphasis with arm integration.
We used abdominal bracing with arm pulling motions, as well as spinal flexion
exercises, focusing on lower repetitions and control.

In Water Intervention
Frank was instructed to slightly tighten his core during the catch, ideally stabilizing
the spine and not dissipating energy during the catch.

Summary
After 12-weeks of training, Frank dropped 10 seconds in his mile and over 2 seconds
in his 200 free. These improvements are clearly not from this work alone, but the
associated improvement in velocity during his shorter races makes me believe we
were on the right track. This decrease in core training volume also allowed him more
time for shoulder prevention work.

80
COR Low Back Pain Guide
Pathologies
Open any rehabilitation book and one can find a laundry list of low back diagnoses: non-
specific low back pain, disc herniation, disc prolapse, spondylolisthesis, and so on.
Fortunately, swim coaches don’t have to diagnose or treat low back injuries. However,
preventing these injuries is imperative. I will tackle the most common injuries
associated with swimmers and provide typical presentations for your reference.
Remember this information is not intended for diagnosis, but to provide an
understanding.

This list includes terms commonly provided to swimmers by rehabilitation specialists,

primary care physicians, or orthopedic surgeons. Remember, a diagnosis doesn’t always
correlate with the symptoms, and is sometimes used as a convenient label for insurance
classifications. Often times further probing is required to determine the cause of
current low back ailments.

The difficulty with treating low back pain is the variability between diagnostic
imaging and symptoms. In the second decade of life degenerative joint disease begins
and the space between your intervertebral disc diminished. Believe it or not, but
some of your high school or collegiate athletes may have degenerative joint disease, a
condition typically associated with nursing homes.

Another confusing diagnosis pertains to bulging, protruding, or herniating discs.

Sometimes these abnormalities can be the source of symptoms, but MRI any 30-40
year old on the street and there is likely to be multiple herniated disc. Herniated disc
can cause pain (if a nerve is compressed or the posterior longitudinal ligament is
being struck (a highly nerve innervated structure)), but typically herniated disc are
asymptomatic.

“Having” and “Feeling” Aren’t the Same

The previously mentioned pathologies are only a small portion of the injuries associated
with the low back.

This may surprise some of you, but sometimes stuff breaks/tears/inflames and you
don’t feel it. Conversely, sometimes you hurt, but nothing is wrong structurally. A
proper system of prevention and rehabilitation respects the complex interaction of
pain, dysfunction, and pathology.

81
Our medical system defaults to surgery far too often simply because most people don’t
know what else to do when something keeps hurting. Surgery is sometimes needed, but
should only be an option after other means have been exhausted in an effort to rebuild
a robust ship. Sometimes surgery is indicated and will correct the cause of injury, but
symptoms, signs, imaging, and other factors need to be assessed first.

The current typical evaluation and rehabilitation process after an injury is often lengthy
and inefficient. When low back pain occurs most swimmers try to swim through it for
two or three weeks, do an extra kick set, or skip the pulling set. Sometimes these
alterations are from your coach’s advice; other times you dig deep, reiterating the ‘no
pain no gain’ mantra. Hopefully, the symptoms will improve with these alterations.
But, if they continue an orthopedic surgeon or primary care physician is the next stop
(typically one week to schedule). At this time, diagnostic imaging (x-rays, MRI, etc.), a
cortisone shot, or a referral to a rehabilitative specialist (physical therapist, osteopath,
chiropractor, massage therapist, trainer, or supplement provider) are the typical
courses of action.

Let’s look at three options in detail:

1. M.R.I.’s: Often when a someone injuries they back the first line of action is an
MRI or a x-ray. Unfortunately, both of these images can cause false alarms and
chasos, as they can’t tell you if the defects found are a result of the injury or
were already there. A 1994 study in the New England Journal of Medicine found
that in a study of MRIs of 98 asymptomatic individuals, 82% of those MRIs came
back as positive for a disc bulge, protrusion, or extrusion at one level. And, 38%
actually had these issues at more than one level (Jensen 1994). Clearly, MRIs and
diagnostic imagin
2. Cortisone Injections: Cortisone injections are extremely beneficial in treating
inflammation. By the time many clients get to a physician's office (in two to
three weeks) the inflammation has dissipated! If the inflammation has resolved,
why get a cortisone injection? Cortisone should only be utilized if severe
inflammation is present. Cortisone also has long-term deteriorate effects on
muscle. Cortisone is a typical stop on the route to surgery when a physician or
therapist is not sure what the cause of the symptoms is.
3. Rehabilitative Specialist: These specialists commonly take a few weeks to
schedule an appointment, and when they see you they will work on your
symptoms. If handled “properly,” you will see this professional for two to three
weeks and have full symptom alleviation. Unfortunately, many rehab clinics, no
matter their specialty, rely heavily on modalities (electrical stimulation, ice, and
ultrasound) and exercises instructed by an assistant. These modalities are mildly
beneficial if used during the right phase of the injury, but are over prescribed
with high insurance payment returns.

82
This process is lengthy, resulting in long periods from the pool. Worst of all, during this
long drought, symptoms and joint function don’t always improve. Here are the common
routes after a low back injury, all of which are considered a “successful” approaches
by a health care specialist:

1. Brief Improvement: Upon return, many swimmers are asymptomatic and begin
to push themselves to make up for lost time. The body is activating different
muscles (a good thing, since the normal muscle pattern leads to injury). Sadly,
after feeling good for the first hour, fatigue occurs and old movement patterns
return along with the accompanying symptoms, which will likely cause a re-
injury.
2. Full Improvement: Another commonality is having full symptom alleviation after
seeing a rehabilitation specialist for four to six weeks, then returning to the pool
feeling like a wet noodle, having lost all neural feel that was developed
throughout the season. This puts the swimmer back to pre-season form, often
times making best times unlikely.
3. No Improvement: The last option is the worst of all. Upon return, after four
weeks of simultaneous electrical stimulation, ice, ultrasound, and tape, the
athlete finds their symptoms unchanged when swimming. Total symptom
alleviation is great on land, which is a large step towards success. However, in
this scenario the health care professionals do not take into consideration the
demands of swimming, failing to consider continual preparation necessary to
meet the demands of the sport.

Health care professionals don't understand the typical demands and annual routine of
swimmers. Unlike other sports, swimming is a novel activity which doesn't have an
extended off-season. For example, in football there is a lengthy off-season that is
utilized to build strength and speed. The season consists both of games and practice
sessions which allow time for maintaining off-season gains and preventing injuries. Once
discharged from two to three weeks of rehabilitation sessions, football players are able
to hop on the field and play (if symptoms are fully alleviated) without any decrease in
performance. This is due to the natural movements of football and their gains achieved
during the off-season.

Concurrent System
Unlike other sports, swim training is performed concurrently with the competitive
season. If a swimmer had a low back injury, then returned to the pool after not
swimming for three weeks, they'd belly flop off the block and be swimming like they
had machetes for arms! Swimmers need the neural feel and repetitive swim training in
order to perform optimally.

Once again, staying in the water is mandatory, nonetheless, many health care
professionals don't understand this necessity. On the other hand, many coaches are too
83
aggressive in trying to completely minimize time out of the pool, perpetuating an
injury, or aggravating the injury upon return.

Health Care Professionals

The two primary goals of health care professionals are to resolve the symptoms
associated with an injury and to regain the ability to perform all daily activities.
Unfortunately, for an athlete these goals may be in conflict with each other. When a
health care professional recommends to stop swimming to heal the injury, it impedes
swimming during essential times of motor development. Motor learning is more active
during specific developmental stages. If a young swimmer has low back pain, removing
them from the pool may impair motor learning, which takes countless hours in the pool
to potentially regain. Health care professionals approach the process of injury
improvement by relying on their scientific understanding of the body’s anatomy and
physiology.

In their eyes, any pain is viewed a sign of causing re-injury. This unrealistic approach is
their reasoning behind long absences from the pool.

Remember, any absence from the pool impedes “feel” and impairs performance. This
is an area that many health care professionals do not comprehend, since their main
goal is resolution of symptoms, not optimizing performance.

Swim Coach
At the other end of the spectrum are swim coaches. A Swim coach’s' goal is to build the
best swimmer possible. This process takes long hours in the pool, which can often cause
re-injury if the return to swimming is not increased systematically.

From what I've seen, coaches generally have three approaches to low back injury:

1. Swim through the pain to toughen up: Swimming through the pain oftentimes
makes an injury worse. This method is effective in some situations, like when
mental strength is being overcome, but many swimmers do not know the
difference between pain and injury, especially in the Nerf ball society today.
However, making an injury worse can perpetuate the inflammatory process. If
you swim through a low back injury, it likely causes areas of your low back to
continually rub against each other, feeding into poor muscle LST. This will make
the injury worse and lead to even longer periods away from the pool.
2. Stop swimming to heal the injury: This is similar to the health care
professional’s view. These coaches have a swimmer immediately discontinue
swimming from all activities. This approach commonly improves inflammation
and symptoms out of the water, but certainly impairs one's swimming ability.

84
 Staying out of the water also does not guarantee that the injury won't return,
completely heal, or occur again.
3. Grab a board and kick: Kicking is a great alternative to provide rest for the low
back, but using a board puts the low back in an inappropriate position,
potentially creating poor LST leading to symptoms.

To reiterate, symptoms do not always correspond with structural abnormalities.

Unfortunately, coaches and health care professionals often times looks past the
important aspect of the injury, the phase. The phase of the injury is driving most
symptoms and, hence, is the most important variable for improvement.

Common Types of Injuries

The low back is the primary site of injury in swimmers, but the low back is the second
most commonly injured site. In fact, ~8% of those competing at a 2001 International
competition experienced low back pain. Despite the anecdotal claims, few studies
have compared low back pain and degeneration in swimmers to a control population.
Also, comparing specific stroke specialists has also not been performed, limiting the
stress from each swimming stroke.

Many feel butterfly and breaststroke are the most problematic strokes to the low back
due to the amount of flexion cycles, but this website has already debunked the
flexion cycle debate. In fact, rotation actually increases spinal stress, due to the
shear stress at the joints.

Low Back Disc Degeneration

Kaneoka (2007) had fifty-six elite swimmers (M=35, F=21, ~19.6 years) and a control
group (38 recreational swimmers; M=24, F=14; ~21.1 years) underwent a magnetic
resonance image (MRI). Disc degeneration was compared between groups. Participants
also completed a questionnaire about their main strokes as well as their low back pain
history.

85
Thirty-eight (68%) elite swimmers and 11 (29%) controls had degenerated discs at
various levels. Disc level L5-S1 was more frequently degenerated in the elite
swimming group. However, there was no significant relationship of low back pain
symptoms associated with this increase in disc degeneration. Swimmers had a lower
rate of low back pain, but back pain was more debilitating.

Hangai (2008) analyzed 308 well-trained university athletes (baseball, basketball,

kendo, runners, soccer players, and swimmer) and 71 nonathlete university students.
Disc degeneration was evaluated with a T2-weighted magnetic resonance image (MRI).
A questionnaire concerning low back pain was also performed.

86
Disc degeneration was significantly higher in baseball players and swimmers compared
to the nonathletes. There was an association between low back pain and degeneration
and the degree of severity of low back pain with disc degeneration.

The L5-S1 segment undergoes greater degeneration in elite swimmers. However, the
lack of associating symptoms brings to light the lack of correlation between defects in
imaging and symptoms.

Repetitive sports such as baseball and swimming appear to increase incidence of disc
degeneration. These sports also have greater rotation than the others studied, one
possible mechanism of degeneration.

Disc degeneration is a higher risk in swimmers compared to nonathletes, yet injury

rate was not significantly higher in swimmers. It seems low back pain and
degeneration do not correlate, at least in the acute term. Longer studies must assess
the degree of degeneration and injury rate later in life. Nonetheless, it seems
swimmers have greater degeneration, but not injury rate. Moreover, swimmers and
coaches should not be alarmed if an athlete undergoes an MRI and sees degeneration,
as degeneration is greater in asymptomatic swimmers.

Herniated Disc: This is a pathology where the interveteral disc pushes into the

Stenosis: The spinal canal narrows and compacts the spinal cord and nerves at the
level of the vertebra.

Scoliosis: Sideways curve of the spine.

Kyphosis: Rounding of the spine.

Sciatica: Pain and numbness down the leg.

87
IT band syndrome: Tightness and swelling in the ligament that runs down the outside
of the thigh from the hip to the shin.

Piriformis Syndrome: Irritation of the sciatic nerve caused by tightness in the

Piriformis muscle.

Spinal Instability: is when the spinal column cannot maintain its proper position
under normal functions.

Phase of Injury
The route to take after an injury depends on the phase and severity of the injury. There
are three main phases of an injury: musculoskeletal, sympathetic, and affective.

The majority of low back pain in swimmers is typically musculoskeletal. However,

sympathetic and affective pain does occur and must be addressed early if indicated.

Musculoskeletal and Inflammation

There are two types of musculoskeletal injuries: macrotraumas and microtraumas.
Macrotraumas are the big, bad injuries; you’ll know when they occur. Think of Willis
McGahee’s knee bending like a flamingo or a swimmer breaking their hand on a relay
finish. That is a macrotrauma, more specifically: fractures, dislocations, sprains
(injuries to ligaments), strains (injuries on muscles and tendons), tears (ligaments),
lacerations (deep cuts), and large contusions (bruises).

Microtraumas are typically chronic, overuse injuries. These injuries can start as
soreness and progress to certain macrotraumas (sprains, strains). These are sometimes
thought of as less serious injuries, but can transform into ugly, stubborn injuries.

Many athletes ignore microtraumas, trying to push through the pain. Whether this view
is self-aided or provided by an overzealous coach/parent, it will perpetuate the injury.
However, rest won’t necessarily heal the microtrauma either.

Nothing is worse than getting the courage to ask your coach to allow you to take a few
days off of workouts to recover, and upon returning realize that you feel like a wet
noodle or that your microtrauma hasn’t improved. This process has pushed swimmers
to quitting physically and mentally for years.

88
Physiological Steps
After any musculoskeletal injury, the body goes through specific steps to repair itself.
This linear process takes time and the body goes through each individual step, never
pulling on the lane line to skip a step.

Step 1 – Inflammation
Everyone is familiar with inflammation. The inflammatory process occurs within
seconds of every injury, but can linger for weeks or months with bad injuries or poor
management.

Inflammation is stemmed by the infiltration of cells, entitled neutrophils, during the

first 6-24 hours; they are replaced by other cells (monocytes) in 24-48 hours. These
cells will try to attack the inflammation and remove injurious agents. Phagocytosis is
involved in the process of engulfing foreign particles and releasing the enzymes of
neutrophils and macrophages which are responsible for eliminating the injurious agents.
These are two major benefits derived by the accumulation of leukocytes at the
inflammatory site.

Chronic inflammation is a different warrior. The key player is another type of cell, the
macrophage. Macrophages are large cells that can remain for weeks to months,
perpetuating injuries.

The classic signs and symptoms of inflammation are swelling, redness, throbbing,
radiating heat, and constant pain. These pains especially occur when you wake up in
the morning and last between thirty and sixty minutes. Also, just because you had the
initial injury four months ago doesn’t mean inflammation has resolved or hasn’t
returned, so pay closer attention to the signs and symptoms as opposed to the duration.

Step 2 – Repair
Once inflammation resolves (remember, this is not a constant duration), the body
attempts to repair itself. Humans and animals are amazing machines, living in an open
system with minimal tune-ups required. Think of your dog; if it hurts its leg it will lay
around allowing the body to repair itself. The body uses collagen, the body’s gum, to
repair injured structures. Unsuccessfully, it doesn’t always repair itself properly, as the
body lays collagen in an erratic, inefficient fashion.

Remember, the body is repairing in this phase, not repaired. Just because the injury
feels better, doesn’t necessarily mean it is fixed!

89
Step 3 – Remodeling
The last step is remodeling, which usually lasts anywhere from two to four months. This
lengthy process attempts to return the body to a “pre-injury” state, which takes time
to do properly. The body is now able to lay collagen in an orderly fashion that is optimal
for recovery and success. In this phase the body will begin to return to full strength and
function. However, the body is still more susceptible to re-injury during this time. It is
essential to pay close attention to any aches and pains.

Injuries almost always start off musculoskeletal in nature. Luckily, there are means to
speed the body through the aforementioned phases. However, each phase will occur in
order. As stated, the first phase of any injury is inflammation.
Resolving inflammation is essential for improvement of pain, as inflammation results in
excessive pressure on nerve fibers. This resolution is typically self-limiting, but
pharmacological and nutritional agents may also help. The uses of non-steroidal anti-
inflammatory drugs (NSAIDs) are beneficial for resolving inflammation and improving
short-term strength. Dr. Janda suggests taking any non-steroidal anti-inflammatory
drug (Aleve, Advil, etc.) to tackle an inflammatory injury. He suggests taking
approximately 600 milligrams three times a day. This is higher than the suggested dose
on the bottle. If taken with food, confirmed by your physician or pharmacist to confirm
no adverse reactions with other medication, and closely monitored for stomach
irritation (stomach ulcer), than no adverse reactions should be noted. If stomach
irritation occurs, discontinue immediately.

Curry powder (turmeric), garlic, pineapple, cocoa, tea, and blueberries are foods with
inflammation-modulating agents (Bernardi 2012). Also, balancing the omega-3 to
omega-6 ratio (often limiting omega-6 fats) is also beneficial (Bernardi 2012).

Ice, another popular modality for inflammation, has recently been scrutinized in the
treatment of inflammation. Ice is typically applied to an area for an extended time
period. However, it is likely ice also alters pain perception as it decreases nerve
conduction velocity and contributes to the gate theory of pain. This theory suggests
pain and sensation are interpreted by the same receptors. When ice is applied during
pain, this receptor is overloaded and only so much data can be interpreted.

Once inflammation has subsided, compensations (poor muscle length, strength, and
timing) are the causes for symptoms. As much as I believe muscle length, strength, and
timing are the common faults causing low back symptoms, sometimes structural
abnormalities and anatomy are the cause of symptoms and need to be corrected with
surgical means. If this is the case, surgery will be needed in order to correct the

90
problem. However, surgery should be the last option, to be considered once other
means have been exhausted and the proper ship has been built.

Sympathetic Nervous System

The sympathetic nervous system is commonly referred to as the fight or flight system.
This archaic part of the nervous system is located next to the thoracic spine. Precisely,
the sympathetic chain ganglia lie lateral to the 1st - 9th thoracic bodies and against the
anterior heads of the ribs.
After an initial noxious event, protective positioning of the affected limb results in
posture changes that decrease trunk mobility and thoracic intervertebral mobility
(posturing of the upper extremity may include shoulder elevation, adduction, and
internal rotation). This feeds into the system, overloading the sympathetic system and
causing ischemic (lack of blood flow) conditions or mechanical pressures on the ganglia,
which alter inflow and outflow of information. This can affect the nerve signals from
the low back. Sympathetic overloading can cause increased tone and “false” pain
signals (allodynia) or over-responsive pain (hyperalgesia).
Decreased mobility in the thoracic spine may lead to joint or soft tissue restriction that
may compromise blood flow or place mechanical pressure on the sympathetic chain
ganglia.
Symptoms such as sweating, swelling, skin redness, or unrelenting pain may be due to
spasms of the autonomic (in particular, sympathetic) neurons.
The sympathetic system is complex and this overactive system must be halted for
improvement. This is accomplished through gentle methods used to relax the body and
decrease activity of the sympathetic chain gang nuclei. Clients with these types of
symptoms react sporadically to treatment if it is performed recklessly. If sympathetic
involvement is suspected, seeing a health rehabilitative specialist is imperative.

Affective
Undoubtedly, emotions influence any pain or sensory state. The affective system is
controlled by emotional perceptions. Little is known about this system and
psychological consulting may be required to improve these symptoms.

Spot the Location

Low back pain is difficult to locate in many people, as muscles, ligaments and joints
often refer pain to other areas. In many, the cause of their low back pain is the muscle,
specifically a trigger point.

Trigger points may refer pain to a variety of locations. For example, the heart, which
is a muscle, can tighten up and refer pain all over the body. This incident, known as a
heart attack most notably refers pain down the left arm. The muscles of the low back
are no different. Some of the muscles' referral patterns make sense, as many of them

91
refer directly to the location of the muscle, but other muscles are different. In fact,
the anterior neck muscles often refer to the head, commonly entitled tension
headaches. Dr. Janet Travell extensively studied referral patterns and trigger points
and described them as a

“hyperirritable locus within a taut band of skeletal muscle, located

in the muscular tissue and/or its associated fascia. The spot is
painful on compression and can evoke characteristic referred pain
and autonomic phenomena.”

These hyperirritable loci are now classified as active trigger points which are commonly
caused by an increase in muscle tension, causing feelings of tightness, soreness, or pain
(Travell, 1983). Passive trigger points are also taut skeletal muscular bands, but are not
painful. Both types of myofascial trigger points are associated with a lower pain
pressure threshold and higher bradykinin, calitonin gene-related peptide, substance P,
TNF-alpha, interleukin-1 beta, serotonin and norepinephine. Moreover, pH of an active
trigger point is also lower (Shah 2005). Improving these hyperirritable loci is necessary
for those with a musculoskeletal issue (the most common in swimming). For these,
please see a physical therapist for guidance of which soft tissue exercises, ensure they
have knowledge in sports, hopefully swimming.

Typical Rehabilitation for Swimmers with Low Back Pain

During a musculoskeletal injury, inflammation, repair, and remodelling phases occur.
All animals try to protect themselves by preventing movement and harm, but, society
prevents rest and proper progression through these phases. If you hurt your arm, you’re
likely to fight through the pain either by swimming, writing, typing, driving, and so on.
This elongates each phase, leading to numerous compensations, often times
outweighing the initial injury. This forces our finely tuned body to need some
adjustments in order to fix the ship.

Just as ships float through many waves throughout the year, humans have many bumps
throughout the day: poor posture, impaired strength, excessive inactivity in the general
population, not to mention thousands of strokes in the pool. Luckily, our body can
typically manage these stresses if everything is in working order. But when a tsunami
occurs, the ship gets damaged, inflammation ensues, and compensations begin. We
must provide the ship with the proper tools to restore equilibrium. Luckily, cheap tools
are available to adjust the muscles with improper length, strength, and timing.

92
Compensations typically cause tight and long muscles. The tight muscles are overactive,
trying to prevent excessive motion at the injured joint. These tight muscles put the
body in an inefficient resting position, causing other muscles to elongate and weaken.

All of the strengthening exercises should be performed in the ‘bracing’ position unless
instructed otherwise. In this position, the abdominals are maximally contracted with
the pelvis posteriorly tilted. The theory behind this position is to improve muscle
strength in an “over-corrected” or shortened position in order to return the long, weak
muscles to normal resting length with normal strength. Bracing also provides a sturdy
base for movement. The core are like the hull of a ship, and without a strong hull a
disaster will ensue even with subtle waves. The compact position provides a solid base
to endure large waves. This compact position should not be practiced during daily
movement, but should be used during all exercises, especially the muscle timing ones
(see below).

Muscle length is equally, if not more, important as muscle strength and timing. Poor
resting position due to tight muscles can actually make you weaker. Self-soft tissue
mobilizations can improve these muscle length discrepancies.

The commonly used plans for returning a swimmer to the pool after an injury have
many flaws. Swim coaches and health care professionals have vastly different views,
both contributing to the problem. Swim coaches do not want their swimmers to miss
any time from the pool as they feel any missed time will prevent progress. Health
care professionals want swimmers to take weeks off from swimming to allow full
recovery. The appropriate approach lies somewhere between these two options

A typical health care approach to recovery from a low back injury includes numerous
“blank periods”. This is when a swimmer is not receiving care or swimming as they
wait to be seen by the next professional. After these sessions, the health care
professional expects the swimmer to return to the pool after their symptoms have
alleviated, but often times don't necessarily stress their low back for the demands
required in swimming. In their eyes, this is considered a successful treatment;
unfortunately time away from the pool causes an athlete to lose “feel” which can
only be acquired and maintained by spending time in the water.

This is the best-case scenario, but sometimes the symptoms never improve.
Sometimes the swimmer will continue to swim with the pain. Other times, the
symptoms may disappear and the swimmer will return to practice, hop in the pool,
go full throttle, only to have the symptoms return. This reckless approach will likely
cause a re-injury and add more “blank periods”.

93
Many health care professionals don’t know how to safely return a swimmer to the pool
with guidelines to benefit recovery. Applying continual, gradual swimming stress is
essential to see if the low back pain is improving, without irritating it. Therefore, it is
important to know their current pain level and have them progressively return to the
pool. Tiers of limitations can be used to gauge improvement, yet maintain neural
feel. Knowing an athlete's current level of pain will help in monitoring whether or not
their symptoms are improving, as it is unlikely for the athlete to go from 8/10 to 0/10
pain after a few sessions with the rehabilitation specialist, especially if these
symptoms are long-standing. Helping them progress with milder and fewer symptoms
allows the swimmer to see progress, keep their sanity, and stay positive as they
return to the pool.

After working with hundreds of swimmers, I began piecing together simple tricks to
speed recovery while maintaining “feel”, thereby preparing the athlete for a full
return to practice.

Follow these guidelines closely to ensure low back recovery, while maintaining “feel”
and strength in the water.

First and Foremost

Proper technique for injury prevention is essential. I’m sure not all of the readers will
agree with these biomechanical corrections for swimming propulsive reasons.
However, I recommend them because they will put less stress on the low back joints
and muscles, essential for recovery.

The most common biomechanical causes of low back pain in swimmers are:

Swimming “Up Hill”

Swimming with the chest elevated is a common error in swimming. In fact, many
swimmers feel they are swimming in a streamline position, when in fact their chest is
too high. This is likely from the lungs and prone position in swimming. Unlike other
sports, the lungs act as two balloons under the chest of the swimmer. This creates the
illusion that the swimmer is in a streamline, when they’re actually swimming up hill.
Overall, this position overactives the low back muscles, putting them under higher
stress.

Solution: Press the chest down, feeling like you’re swimming down hill.

Forward Breathing

94
Breathing in freestyle should be smooth motion, directly in the horizontal plane
towards the side. Unfortunately, many unskilled or young swimmers, and even some
elite swimmers, lift their head and breathe forward. Breathing forward increases the
stress on the low back.

Solution: Smoothly turn the head to the side when breathing, barely bringing it out
of the water for the breath. Until this is mastered, consider using a snorkel.

Hyper Undulation During Dolphin Kicks

Although most of the swimming research suggests otherwise, many swimmers and
coaches believe dolphin kick should be a full body movement for maximum force
production. Disregarding ideal biomechanics for speed, performing a large undulation
places excess stress on the low back, from the extra flexion and extension.

Solution: Decrease the body motion during the dolphin kick and perform more of a
knee oriented kick.

Lifting Chest During Butterfly

Once again, coaches can debate the ideal breathing method in butterfly until the
cows come home. However, if a swimmer breathes forward and lifts their chest too
high, they will overactive their low back muscles and increase their risk of injury.

Solution: If breathing forward, keep your head as low as possible, cutting through
the bow wave. Also, consider swimming with a snorkel or using a side breathing if
pain persists.

Spinal Flexion Turns

The flip turn undoubtedly causes spinal flexion. However, if a swimmer is having pain
during their turn, they can attempt to use more hip flexion than spinal flexion for a
simple method of reducing low back pain.

Solution: When approaching the turn, bring the knees towards the chest and
minimally flex the spine.

Low Back Breath Breaststroke

Many elite breaststrokers keep their hips low and arch their low back as they rise for
their breath. Unfortunately, this causes high stress on the low back.

Solution: When breathing in breaststroke, move the hips forward for the breath,
opposed to arching the low back.

95
Rounded Back Start
Like the turn, one must round their spine for a start. However, pressing the hips back
and keeping the chest and head in a neutral position can reduce the degree of stress
on the low back, making the start more manageable.

Solution: Keep the hips high during the start, by extending the front hip. Also, keep
the chest and head in a relatively neutral position.

Rules and Regulations

No more than 3
Knowing the pain level of a swimmer is important for determining when the swimmer
should return to the pool. A pain scale of 0 to 10 is commonly used, with 0
representing no pain and 10 representing unrelenting pain. For discussion of low back
pain, we will assume that the swimmer has at least a level of 1/10 pain. The typical
presentation of low back pain is a swimmer with pain only during swimming. Their
pain level is typically 0/10 at rest. However, once they start swimming, it is likely
their pain level will steadily increase. The 'No more than 3' rule allows a swimmer to
maintain their “feel” for the water, until the pain level reaches a 3/10.

It is unrealistic to expect any swimmer with a history of low back pain to jump in the
pool and have 0/10 pain. The 'no more than 3' rule allows the swimmer to swim until
they reach a 3/10 pain level. This rule is based on the belief that 0/10, 1/10, or 2/10
pain is not causing more injury or inflammation. However, if a 3/10 pain level is
reached, it assumes more irritation, damage, and inflammation will ensue. When the
pain reaches 3/10, the first pain plateau, changes to the swimming routine need to be
made. Once a 3/10 pain level occurs, it is best to rest and allow the low back
irritation to dissipate. This is accomplished by having the athlete kick on their back,
eliminating low back stress (with streamline unless this prevents resolution of the
3/10 pain level). Hopefully a swimmer’s pain will not reach between a 4/10 and 7/10
while in the pool, because they will have stopped at the 3/10 level and proceeded
with directions on how to adjust their practice routine.

If the swimmer has a 3/10 or greater pain at rest, it is best to have them stay out of
the water, it is likely the cause is inflammation or sympathetic pain. If this is the
case, it is recommended to see a health care professional.

This approach is effective when the athlete is seeing a health care professional on a

96
regular basis and their symptoms are continually improving. If the symptoms are not
improving with a rehabilitative specialist, either find a new one or consider taking a
break from doing the activity which causes the symptoms. As much as I realize
maintaining “feel” is important, keeping a swimmer’s low back away from the knife
of surgery is even more important.

Solution: Have the swimmer swim the typical workout until their symptoms reach
3/10. Once a 3/10 occurs, have them kick on their back with their arms at their side
or in streamline (if their symptoms don't increase with streamline) when their
symptoms reach 3/10. This allows them to stay in the water and keep “feel” while
minimizing low back stress. Moreover, most swimmers can do main sets and intervals
with fins, keeping them involved in practice and their face in the water. If they have
3/10 symptoms prior to practice, discontinue for the day and have them seek
treatment for inflammation or sympathetic pain.

No Kickboards
It is especially recommended not to use kickboards if someone has low back pain.
Most cases of low back pain in swimming occur due to overworked muscles in the low
back. Kickboards hold swimmers in extension, exaccerbating low back stress. pain
occur due to repeated overhead motions, leading to musculoskeletal pain.

This will perpetuate the pain and is easily replaced with the swimmer kicking on their
back. In fact, to prevent this dangerous position and prevent re-injury, I will have
swimmers kick without a board for an extended period after the symptoms resolve
(approximately one month).

Solution: Kick on your back in streamline if symptoms are less than 3/10; if symptoms
are greater than 3/10, have them kick on their side or with their arms next to their
side.

No Fins or Zoomers
Fins and zoomers increase the demand on the legs. Many of the leg muscles (the hip
flexors and extensors) cross the hip joint and attach around the pelvis. When these
muscles become engaged, they can stress the low back and exaccerbate symptoms.

Solution: Kick without equipment.

Proper Pacing
During times of stress, the body adapts. At the end of a race, the body adapts to
finish. Unfortunately, these adaptations are often inefficient and hazardous. At the

97
end of a 100-m race (when the swimmers slowed ~7.7%), their biomechanics shifted
from using more adduction to more shoulder internal rotation. This adaptation will
increase low back stress and risk of injury.

Solution: Attempt to even split your race and decrease the amount of time
undergoing poor, injurious biomechanics.

Return to Swimming Yardage

Knowing how much yardage to begin with is difficult. I often suggest starting with
1,000 yards of backstroke and freestyle. Once again, if pain increases past a 3/10, I
suggest kicking on your back until it returns to a 0-1/10. After this, I suggest adding
500 - 1,000 yards every 3 days with a maximum of 1/10 pain. Once you're able to
swim 3,000 yards, I suggest adding butterfly and breaststroke (ideally on separate
days, to know which the irritant is).

Case Study of Swimmer with Low Back Pain

The Dr. Detective series often issues swimmers with pain and injury. This is a case
of a young female swimmer with recurrent low back pain. Despite seeing the top
orthopedics in the area and receiving cortisone injections, she continued to have
pain during swimming. Unfortunately, this case, like many, required a thorough
analysis of her swimming combined with therapeutic intervention. All names in this
report have been changed to protect the identity of the patient.
The Patient
Isabel was a 15-year-old swimmer. She was ranked in the top of her age group in the
Nation, with her best event being the 200-yard butterfly. Isabel reports low back
pain on both sides of her low back. She states the pain is as bad as a 6/10, which she
feels sometimes during the day (after repeated standing), during heavy dolphin
kicking, and kicking with a board. She first reports low back pain when she was 13-
years-old and received 6 months of physical therapy. During the first 3 months of
physical therapy she did not swim, reporting improvement in pain. During this
treatment, she received a lot of core training focusing on abdominal hallowing. Upon
returning to swimming, she reports pain. After another year of training with pain,
she saw another orthopedist who took a x-ray and an MRI. The x-ray noted a stress
reaction in her lumbar spine, with the MRI noting inflammation. The orthopedist
performed a cortisone injection. Isabel reported little improvement with the
injection. When I saw Isabel, I noted clear frustration with her low back, as she was
once again not swimming from the recommendation of her physician. She was also
fearful or returning to swimming, as she has had frequent pain upon returning to
swimming.
Objective Out of Water Analysis
98
Upon meeting, I had Isabel perform simple range of motion exercises and found
limited spinal mobility with pain upon extension. During core muscle testing, she had
low core activation in the anterior sagittal plane. This was the only testing
performed.
Out of Water Intervention
Much of the first session involved patient education about stress reactions and the
differences between these and spondylolisthesis and spondlylolisis. After these, I
performed manual therapy on the psoas musculature, attempting to reduce their
tension. This greatly improved spinal mobility and reduced spinal extension pain by
50%. Treatment on the following sessions involved manual therapy of the hip and low
back musculature, combined with strategic flexion bias core strengthening, avoiding
the painful spinal extension. Isabel picked up exercises quickly, demonstrating
superior motor control, but had much difficulty in the posterior saggital plane, often
extending the spine during hip extension. The last phase of the treatment involved
spinal and hip differential motor control training.
In Water Analysis
In the water, Isabel showed a great early vertical forearm (EVF), as well as a skilled
ability to find streamline. She did demonstrate a highly mobile dolphin kick, most
notably with using excessive low back extension.
In Water Intervention
Isabel is a typical presentation of spinal hypermobility. In swimming, spinal
hypermobility can benefit butterfly (and to some degree breaststroke) by creating a
larger range of motion force production. Unfortunately, this hypermobility can
overstress the spine, especially if the swimming core musculature isn't engaged.
Therefore, external cues were provided for reducing spinal mobility during
underwater dolphin kicking. At first, Isabel slowed during her underwater dolphin
kicking, but reported no pain after the adjustment. At the month follow-up, she
reported similar dolphin kicking times as previous with no low back pain during
kicking.
Summary
When children have success in swimming, it is difficult to justify a change in
biomechanics. As the old adage goes, if it's not broke, why fix it. Well, if a swimmer
is having pain at such a young age, it is broke and requires fixing. Keep this in mind,
when working with young swimmers, remember age-group success doesn't translate
to elite success and it is much easier to make a change in biomechanics in a younger
swimmer than when their older!

99
Return to Swimming Guide
Below is an example 6 week return to swimming program, she swam once a day, six
times per week, for the entire six weeks. The swimmer also did not perform any
meets during this six weeks.

The swimmer had non-specific low back pain initially and she received 2x/week of
physical therapy for the entire 6 weeks.

Day Yardage Strokes Highest Pain Level Notes

1 1000 Free 3

2 1000 Free 2

3 1000 Free 1

4 1000 Free 1

5 1000 Free 1

6 2000 Free 2
Performed
1,700, then
7 2000 Free, Back 5 kicked 300.

8 1750 Free, Back 2

9 2000 Free 1

10 2000 Free 1

11 2000 Free, Back 0

12 2500 Free, Back 0

13 3000 Free 0

14 3000 Free, Breast, Back 0

Performed 3000,
then pain during
fly. Kicked last
15 4000 Free, Breast, Fly 7 1000.

16 4000 Free, Breast, Back 3

17 4000 Free, Breast, Back 3

18 4000 Free, Breast, Back 2

100
 19 4000 Free, Breast, Back 1

20 4000 Free, Breast, Back 1

21 4000 Free, Breast, Back 1

22 5000 Free, Breast, Back 0

23 5000 Free, Breast, Back 0

24 5000 Free, Breast, Back 0

Performed 4800,
pain during fly.
Kicked last
25 5800 All Strokes 4 1000.

26 6000 All Strokes 2

27 6000 All Strokes 2

28 6000 All Strokes 2

29 6000 All Strokes 1

30 6000 All Strokes 1

31 6000 All Strokes 1

32 7000 All Strokes 1

33 7200 All Strokes 0

34 7400 All Strokes 0

35 6900 All Strokes 1

36 7100 All Strokes 0

37 7200 All Strokes 0

38 7400 All Strokes 0

As you see, there were days when the pain exceeded 3/10. This is expected as
recovery from an injury isn't linear. Nonetheless, sticking with a plan, which
emphasizes rehabilitation (ideally with skilled physical therapy), progressive addition
of swimming volume and strokes, and biomechanical adjustments can enhance the
recovery a low back pain.

101
Low Back Pain Taping Guide
Tape has been used to improve posture and alleviate symptoms for years. However,
the different types of tape and taping procedures can be complicated and frustrating.
I’ll be the first to admit; I’ve tried a lot of different taping procedures and couldn’t
even cut tape at my first internship! I had a drill sergeant of an instructor. The first
day he handed me a pair of medical scissors to cut some strips of tape, then he left
the room. Five minutes later he returned to see a flustered student with a few strips
of tape with what appeared to be bite marks. I can honestly say I did not chew
through the tape, but the serrated edges had him convinced otherwise.

At this internship I learned the fundamentals of taping and preparation, as well as

various beneficial taping procedures. Since then I’ve experimented with different
tape, various procedures and sometimes different colors (for some reason all the guys
want bright pink). With all this trial-and-error, I’ve developed the most
comprehensive and simple set of taping procedures. I guarantee you will cut tape
better than I did on my first day!

Everyone has seen someone wear tape, whether around their ankles for support or on
an Olympian’s low back. Despite the commonality, the reasoning behind the
effectiveness of taping is scarce. Taping falls into the inverse knowledge theory: the
less that is known about a subject, the more theories there are about it. Hence once
can consider taping a complex area in prevention and rehabilitation.

While I admit there is limited evidence to support tape or the physiological reasoning
behind its effectiveness, it is useful for our purposes because tape can be a great
adjunct in prevention and symptom alleviation. In my eyes, taping can be used to
improve muscle length, strength, and timing discrepancies, and it is readily available
in sporting goods stores. Here are some theories on procedures and effectiveness:

● Length of Muscle
Some taping textbooks and procedures feel that tape strictly inhibits muscles from
activating. For instance, if an athlete has tight muscles, then one could use tape to
inhibit to lengthen these overactive muscles. This can restore proper muscle timing
and strength, since overactive muscles can alter normal resting position and strength.

● Strength of Muscle
Opposing muscle length, certain taping techniques are theorized to improve muscle
strength. This increase in activation or strength can improve muscle firing patterns,
allowing a swimmer to perform a given task with the proper muscles.

102
● Timing of Muscle
Tape can provide adequate cuing of dormant muscles, helping them fire at
appropriate times. I feel muscles have the capacity to perform specific tasks, but
various circumstances (injury, compensations, etc.) lead to improper position.

This poor position can lead to altered muscle firing patterns and impairments.
Luckily, specific feedback can provide cuing for a muscle to fire properly.

● Inflammation
Inflammation is a different beast. After any acute injury there is a large inflammatory
component. Inflammation causes an increase of material in a confined space. This
increase causes certain structures to rub against one another, potentially causing
compensations and other impairments. Tape can be used to dilute the inflammation,
decreasing the volume and preventing compensations.

Supplies
There are hundreds of different tapes with special features on the market. In my
experience, three types of tape will give you the most bang for your buck, allowing
you to improve muscle length, strength, and timing:

● Kinesiotape®
Popularized during the 2004 Olympics in volleyball, Kinesiotape® was developed by
Dr. Kenso Kase, a Japanese physician. This type of tape can be placed directly on the
skin and is optimal for inhibiting or activating muscles, as well as improving
inflammation. This tape is friendly and not as aggressive as other forms of taping.

● Cover – Roll (Optional)

This tape is purely used to protect the skin. Even if you don’t have sensitive skin, I
highly recommend this type of tape to prevent any skin irritation. It is the base for
the next form of tape.

● Scissors
Like I said, it took me a while to learn how to cut with medical scissors. Then when I
got it, I figured out I could just use regular scissors. The current pair I use looks like it
came in my pre-school kit, but it gets the job done, efficiently and effectively.

● Rubbing Alcohol
Rubbing alcohol is used to clean the skin prior to application and will help the tape
adhere to the skin.

103
Preparing for Tape
Luckily, the low back is a fairly hairless joint. Therefore, shaving is not needed for
most athletes. However, a certain amount of other preparation is needed. Prior to
taping, it is essential to confirm that the swimmer has no allergies to any tape or
adhesives. If the athlete does have allergies, then DO NOT TAPE THEIR LOW BACK. If
they are not allergic, tell them to remove the tape immediately if the taped area is
itchy, red, bumpy, or in their opinion is making them worse. These side effects are
rare, but proper instruction is mandatory. If the athlete has no allergies or skin
irritation with the tape, instruct them to wear the tape for as long as desired (even in
the water) if no irritation occurs. Tape typically stays on the skin for three to five
days, but realize water submersion and excessive rubbing will remove the tape
sooner, but is not contraindicated with taping. Next, place rubbing alcohol on a towel
and clean the area to be taped. This will clean the skin and allow proper adhesion.
That’s it! Simple as pie!

Taping Procedures
The following taping procedures are indicated for different reasons. Use one
procedure at a time and track progress!

Kinesiotape® QL Inhibition
This procedure reduces the muscular activiation of the quadratus lumborum, a
common “cheater” muscle in the low back. For this procedure, clean the skin with
rubbing alcohol, then:
 Teach the athlete how to put this muscle on stretch by bending forward and
away from the side you’ll apply the tape (if placing the tape on the left, have
them bend down and to the right).
 Cut one four-inch rectangle with Kinesiotape®.
 Round the edges of one end of the tape.
 Split the non-rounded edge in the middle, ~3.5 inches.
 Round the edges of the two split pieces.
 Cut the split piece which you plan on applying next to the spine by ~.5 inches.
 Bend the tape at the intersection of the tape and where you split the tape.
 Rip the tape, removing the base piece.
 Place the base piece on the athlete at their posterior superior iliac spine (PSIS;
back dimples).
 Have the athlete perform the motion you taught them.
 Place the shorter end parallel to the spine.
 Round the longer piece in a ‘C’ motion with the open end towards the spine.

104
  Rub in tape, securing it to the skin.

Kinesiotape® Inflammation
This can be used to improve inflammation after an acute injury. Initiate with cleaning
the skin with rubbing alcohol, then:

 Cut two four-inch rectangles with Kinesiotape®.

 Round one end on both pieces of tape.
 Cut a diagonal line on the straight side of the rectangle.
 Cut four skinning strips straight side of the strip.
 Place one piece of tape adhering the rounded edge to the low back.
 Apply tension and slide the longest strip towards the center of the spine.
 Apply tension and slide the rest of the strips progressing towards the center of
the spine.
 Place the other piece of the tape towards the center of the spine.
 Apply tension and slide the longest strip toward the other piece of tape,
intersecting these two pieces.
 Progressively apply the same tension to the rest of the strips.
 Rub in the tape to ensure adhesion.

When to use:
Use during any acute injury where inflammation is indicated.

Don’t Become an Addict!

Despite these beneficial claims, tape should be used as an adjunct to injury
prevention and symptom improvement, not as the only method. It is not the be-all,
end-all method for improvement. Tape should also not be utilized for prolonged
periods of time, as dependency can occur. The duration of time for using tape is
tough to predict, but as the low back or discrepancy improves, the frequency of tape
application should be decreased. Tape can help to a certain point, but is commonly
used as a security blanket and crutch when specific muscles need improved length,
strength, and timing to reach full recovery. Taping is a short-term, not long-term,
solution, and if used improperly can perpetuate injuries and muscular imbalances.

105
References:
1. Kase, Kenzo, Jim Wallis, and Tsuyoshi Kase. Clinical Therapeutic Applications
of the Kinesio Taping Method. 2nd ed. Print.
2. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS.
Magnetic resonance imaging of the lumbar spine in people without back pain. N
Engl J Med. 1994 Jul 14;331(2):69-73.
3. Bracing improves core stability testing greater than hallowing (Haladay 2013).
Haladay DE, Miller SJ, Challis JH, Denegar CR. Responsiveness of the Double
Limb Lowering Test and Lower Abdominal Muscle Progression to Core
Stabilization Exercise Programs in Healthy Adults: A Pilot Study. J Strength
Cond Res. 2013 Dec 13. [Epub ahead of print]
4. Kaneoka K, Shimizu K, Hangai M, Okuwaki T, Mamizuka N, Sakane M, Ochiai N.
Lumbar intervertebral disk degeneration in elite competitive swimmers: a case
control study. Am J Sports Med. 2007 Aug;35(8):1341-5. Epub 2007 Apr 3.
5. Hangai M, Kaneoka K, Hinotsu S, Shimizu K, Okubo Y, Miyakawa S, Mukai N,
Sakane M, Ochiai N. Lumbar intervertebral disk degeneration in athletes. Am J
Sports Med. 2009 Jan;37(1):149-55. doi: 10.1177/0363546508323252. Epub 2008
Sep 17.
6. Childs JD, Teyhen DS, Benedict TM, Morris JB, Fortenberry AD, McQueen RM,
Preston JB, Wright AC, Dugan JL, George SZ. Effects of sit-up training versus
core stabilization exercises on sit-up performance. Med Sci Sports Exerc. 2009
Nov;41(11):2072-83. doi: 10.1249/MSS.0b013e3181a84db2.
7. Yanai, T., & Hay, J. G. (1966). The mechanics of shoulder impingement in
front-crawl swimming. Medicine and Science in Exercise and Sports, 28(5),
Supplement abstract 1092.
8. Suito H, Ikegami Y, Nunome H, Sano S, Shinkai H, Tsujimoto N. The effect
of fatigue on the underwater arm stroke motion in the 100-m front crawl. J
Appl Biomech. 2008 Nov;24(4):316-24.
9. Pollard B. The prevalence of shoulder pain in elite level British swimmers and
the effects of training technique. British Swimming Coaches and Teachers
Association; 2001.

106