T Nation

ART Case Study

As a number of you are aware, I took an ART vacation recently. I headed out of state for treatment with an ART practitioner that I knew by reputation was highly skilled.

I had a number of issues and muscular imbalances. I had a shoulder that was sore all of the time and that had limited/restricted ROM. I had a kink in my neck that I had had for YEARS. I had a case of lateral epicondylitis (Tennis Elbow), and at times the pain was painfully acute. Over time, one by one, I had given up bicep curls, overhead presses, dead lifts and pull-ups. And because of my bum shoulder, I wasn’t bench-pressing.

Even though ART is heavily touted and often recommended on the forum, I’ve found that ART is only as good as the practitioner. Some practitioners work MAGIC. Others, as would be the case with any profession, are still developing their skill set. If you’ve tried ART in the past and have been less than satisfied, I would encourage you to expand your search and seek out another practitioner. Get recommendations! ! !

With the help of Dr. Gregg, the ART practitioner who treated me, I wanted to lay out a little more specifically what some of my problems were, the work that was done on me, the results I got, and what I’m doing post-ART to support healing and rehab. Dr. Gregg is a member of T-Mag, and he’s agreed to keep an eye on this thread and answer any questions you all might have.

Before I get started, for the record, I’d like to explain what ART is and what happens when you get a treatment. I’ll be quoting/paraphrasing some of the material I received from Dr. Gregg.

Active Release Technique treats muscle, tendon, ligament and nerve injuries related to sports or other traumas. The concept of the technique is based on scientific literature that scar tissue is laid down in areas of trauma or overuse, impeding different muscle layers and nerves from sliding on one another the way they’re supposed to. When adhesions between muscle layers occur, pain and tightness are felt, which often results in limited or restricted ROM and altered biomechanics. If a nerve is restricted, then pain, numbness and tingling are the most common symptoms. This can lead to weakness in the muscle. Specific hand contacts and muscle movements are used to break up the restrictions/adhesions in order to restore normal biomechanics.

For those of you who have never had ART done, the simplest way to describe what goes on is that the muscle is first shortened; internal pressure is then applied to adhesions at different points along the muscle; and then the muscle is lengthened; i.e., moved through its full range of motion.

[Break Message @ This Point]

[Part II]

So with that out of the way, let’s start with my shoulder. In technical terms I had a secondary impingement with associated anterior instability. But that was only the beginning! I also had a tight posterior capsule and AC joint degeneration; i.e., crepitus, which is one of those bone-on-bone things. I injured my shoulder years ago, slipping off of a chair and landing on my right arm. I’ve had pain (a general soreness) ever since. It’s just one of those things I’ve lived with. But working out and bench pressing did not help the situation.

Nutritionally, I’ve substantially increased my intake of glucosamine sulfate and MSM. I’ve also started taking my 6g of EPA/DHA again.

Dr. Gregg used specific contacts and hit all the spots where adhesions were present. He treated the posterior capsule and the anterior deltoid (which is a bit overdeveloped, by the way, even though I don’t work it directly). He worked the rotator cuff muscles that were not firing properly. He worked on the AC joint and loosened pec minor. Not only did he use ART on my shoulder, he used microcurrent to decrease inflammation, Post-Isometric Relaxation Stretching Techniques and a variety of other rehab techniques to improve stability in my shoulder, reduce pain and increase ROM.

Just a quick plug for Dr. Gregg. He does ART on the whole body, of course. But his specialty is shoulder injuries. He trained with Dr. Dale Buchberger, who?s been a presenter at SWIS and who has been mentioned here on T-Mag in the past. Lucky me!

With all the kinks worked out of the different problem muscles related to shoulder function and stability, Dr. Gregg gave me specific exercises to do to maintain and build upon the good work he had done on me. He showed me stretching exercises for the muscles that previously were tight. He showed me strengthening exercises for those muscles that were stretch-weakened.

And so you understand, what happens when there?s a muscular imbalance, one muscle becomes tight, due to adhesions, and the opposing or antagonistic muscle becomes ?stretch-weakened.? The stretch-weakened muscle also ends up with adhesions that need to be worked out in much the same way the tight muscles need to be worked. That?s why in some case stretching exercises need to be done and in other cases strengthening exercises need to be done. Rehab recommendations are specific to each person, based on the muscular imbalances and issues with which they presented.

One of the things I found interesting was the set/rep scheme Dr. Gregg gave me for my rotator cuff strengthening exercises. My side-lying internal and external rotation exercises start at only 1 pound, 3x10. When I work my way up to 3x30, I’m allowed to go up one pound in weight. Max weight for these two exercises is 5 pounds. The reason for this is that the deltoid fires with any weight over 5 pounds. Muscular endurance is the goal, not heavy weight at low reps.

What I didn’t realize is that the kink in my neck and my elbow problem were related to altered/dysfunctional shoulder biomechanics. All three (elbow, shoulder, neck) are part of a kinetic chain. A good definition of a functional kinetic chain is the integrated effort of the joints, bones, muscles, and the neurological system to move your body through space. In a DYSFUNCTIONAL kinetic chain, when one muscle can?t perform its job properly, other muscles try to take over and compensate/assist. Because of altered shoulder biomechanics, I ended up with a case of Tennis Elbow and that nagging kink in my neck that a lot of us have.

Going into treatment, my elbow and shoulder were my main priorities. Tennis Elbow is complex condition, with no quick or easy fixes. Not only are there micro-tears of the tendons and muscle coverings and inflammation, scar tissue is laid down, and the radial nerve can (and had, in my case) become pinched and inflamed. Tendons and nerves are slower to heal than muscle.

At this point it’s been about 2 weeks since treatment, and I’m thrilled with the improvement. It seems to be getting better every day. I can extend my arm fully without pain. Pain is reduced significantly and continues to improve. The adhesions were released, and muscle ?tone? (my subjective opinion, here) feels more normal.

My brachioradialis is weak, so Hammer Curls are part of my rehab, along with stretching. I’m looking forward to being able to DL and do pull-ups again. My plan is to start with mixed-grip pull-ups, which is similar to the hand position in the Hammer Curls. The pronated grip I used in Pull-ups, DLs and reverse Bicep Curls ending up aggravating/causing the elbow tendonitis (lateral epicondylitis) because of altered elbow biomechanics. So, I?ll start light and work my way back up, as my elbow allows.

Nutritionally, I’m taking high-dose r-ALA to help with nerve regeneration and healing and to suppress inflammation. I’m taking 100mg x 6. I was also prescribed stretching and strengthening exercises specific to my situation.

[Part III]

The last thing I’m going to include in the case study is a discussion about those things (muscular imbalances) that were affecting my squat. Who here on the forum doesn’t want to increase the weight they squat OR improve their form? (grin)

When I went for treatment, I was pretty well convinced that all my issues were upper body. But as part of the assessment, Dr. Gregg had me do something called a functional squat. A functional squat is just a squat without any weight. It’s an assessment tool that allows him to quickly identify lower-body muscular imbalances. I THOUGHT my form was pretty darn good, but quickly found out otherwise. My torso should have been more nearly upright; I lean way too far forward. Hip flexors, specifically my psoases, were tight. My knees tended to buckle inwards slightly due to weak adductors. And because psoases were tight, my spinal erectors were stretch-weakened. It’s the spinal erectors, of course, that are responsible for keeping the torso upright; i.e., nearly perpendicular to the floor. At least my heels didn’t lift up off the floor, which would have been an indication of tightness of the Achilles tendon, for those of you that are curious.

As it turns out, the tight psoases were also causing my hyperlordosis (exaggerated curvature of the lower spine). And it didn’t stop there. Since I had driven seven hours to get ART, I had that nagging pain in my lower back on the right side that I always get when I drive for extended periods of time. The reason for the low-back pain, once again, was tight psoases (also tight piriformis(es)) caused by sitting with bad posture for long periods of time in the car. I didn?t realize until after treatment (and explanation) that my foot position on the gas pedal aggravated the whole situation even further.

Dr. Gregg proceeded to work on the whole lower-body kinetic chain. Remember, nothing in a vacuum. He worked on the psoas. Calves were tight. It’s really stupid, but I never stretched them, even though I can max out the stack on the Standing Calf Machine. Since calves (gastroc & soleus, both) were tight, I’m sure you can guess that anterior tibialis was stretch-weakened since it’s the opposite/opposing/antagonistic muscle. The tightness in my calves and the stretch-weakened anterior compartment caused my foot to be constantly in plantar flexion, even while in a neutral position.

In a session or two I saw the benefit of the work done on my. My form, though not perfect, improved dramatically! As with all the other work done on me, I was given stretching and strengthening exercises to maintain and build upon the good work that had been done on me. The exercise that I’m most excited about is the Psoas Stretch. When I headed back to Tampa, I was instructed to stop a couple of times on the trip and stretch my psoases. For the first time in years I made it home without that nagging pain I usually get in my lower back.

As my form improved, it became obvious that I had serious proprioception (balance) problems, more on my right side than on the left side. I was given exercises to correct that, too. Of course, I?m working on strengthening spinal erectors and adductors. I?m also stretching my calves, piriformis(es) and psoases. I know EXACTLY what I need to do so that I will have PERFECT form. Form before function, right? (grin)

Okay. So those are the highlights of a week of ART. My shoulder is at least 80% better (if not more). I?d bet that I have full (or nearly full) ROM. My elbow is improved and continuing to improve with every passing day. My squat form has improved, and I no longer have that kink in my neck! The hyperlordosis is less pronounced.

I consider my experience an unqualified success, and would recommend that you consider getting ART if you have overuse injuries, chronic pain and/or limited range of motion; anything sports related.

I would like to mention one last thing. I?ve heard about the great things that can be done in just one visit. I think it?s possible to see IMPROVEMENT in just one visit, but realistically you probably need to plan on a half dozen visits. IDEALLY those visits would be spread out over the course of a few weeks, so that the body and muscle tissue has a chance to regenerate/heal.

For those of you who would like to learn more about ART, there’s a book you can get on amazon.com called “Release your Pain, Resolving Repetitive Strain Injuries with Active Release Techniques,” by Dr. Brian Abelson. It’s written for the layman and has a foreword by Dr. Michael Leahy.

There are a number of articles here on T-Mag about ART. The trick is probably to do a search on Leahy, rather than ART. Dr. Leahy is the man who developed ART. As a starting point, check out ?The Real Miracle Worker, an Interview with ART Innovator Dr. Mike Leahy.? You can find it at http://t-mag.com/html/body_63real.html.

If any of you have any questions about ART, feel free to post them here. Dr. Gregg, the practitioner who treated me, is a member of T-Mag, and he?s agreed to stop by and answer any questions.

great thread tt an instant classic!

i was hoping you could describe or elaborate more on the exercises and stretches that were prescribed to you. that would be awesome!

Dr.Gregg, What degree do you have, I would like to know what is involved in becoming an ART Practicioner. I already have my Associates degree and I am going for my BA so What would you reccomend?, Kineisology or something like that?
Also, how much money do ART practioners usually make?

Thanks

Thank you for your excellent post Terry. Very informative.

However, I had previously bought the “Release your pain” book but found it to be nothing but a couple of hundred page advert for ART and it contained no details of ART technique - I was highly dissapointed with it’s content especially considering the SHIPPING I had to pay!

I live in a country where there is no ART and was hoping the book would teach me some basic techniques to use on my tendonitis but alas no!

Glad to hear your ART experience was a positive one and you are on the road to recovery!

Patch.

Dr. Gregg I know that you are able to work full body in ART & that you specialize in shoulder injuries, but I have an old injury (recently reaggravated) in the upper hamstring/gluteal area that affects the way I squat down. It is also accompanied with pain when shifting from a standing to sitting position or vice versa. Additionally, when I suck in my ab cage and bend at the ab cage, I get a pulling pain at the site.

I’m sure you’ll get a lot of these ‘do you think you can fix this?’ kind of questions, but I have yet to find someone that can even speculate what has happened, or have the ability to work on it.

Thanks for your time.

Great post Terry. Its nice to see such an indepth account of ART treatment rather than the usual aggressive screamings of ART when someone has an ingrown toenail. By reading your first hand experience and the results you received and continue to receive is making me think heavily of getting ART to relieve chronic tendonitis in my right shoulder.

Could you describe some of the stretching you use to increase the flexibility of your psoases?

I would like to thank you for this post and I’m sure a lot of people who are on the fence about ART treatment will find it very useful. Its nice to see a first hand account and the positive results you received.

Glad to see your problems are on the mend.

One last thing Terry, maybe you should do a one month progress post, then a 6 month post followed by a one year post so people can see if this is a quick fix or a complete removal of the issues that have plagued you for so long.

Tampa-Terry has done it again!

I just learned more about ART from her post (all of them) than I ever thought I could learn on this, or any forum!

I hereby nominate Tampa-Terry for poster of the week! And if there was a such thing-Poster of the month!

Great post(s) TT. I would love to spend some time with a good ART practitioner. My current economical situation does not allow for any exta spending, so i’ll have to wait. I’m young so no big deal.

However, One thing that I would really like to work on is I think something you said he helped you fix. I have a bad lower back curve, my pelvis is tilted foward and my gut sticks out as if I were fat but it really isn’t.

You called it a technical word but I cant remember it. I sit in front of a computer almost all day at work and I know my posture is bad, even though I do try to “sit up” as much as I can. But in truth, i’m a sloucher.

Did he give you any streching, strengthening tips that could help with this. Obviously I have to keep working on my posture, but if I can help speed up the process that would be cool.

Thanks

Good stuff. I notice that I have poor form as well in the body weight squat, and will address these aggressively. Interestingly, my right (dominant) glute medius is WEAK. Thanks for the tip on cuff exercises, as I was going heavier and heavier but no realize that my deltoid is firing.

Hi TT

usualy its BOMBS coming from you, superb info.

I have a question about the new ART book. since I live overseas Im limited to that…

do you or the doc anything about it?

(www.releaseyourbody.com)

thanks

Lior

Terry: Great post…thanks for sharing your experience. I had some great success with having muscle pulls treated, but have had no luck with my shoulder with two different practitioners including Dr.Kinakin,(SWIS founder) who I saw for six months, but was unable to provide me with significant, long term, relief.
I would definately be interested in hearing what your Practitioner has to say here at t-mag and perhaps pick his brain a little.

great post. I was very interested to read that as I have gone for one ART session in the past after reading about how one session can sometimes “fix” the problem and I was a bit dissapointed. Your post has encouraged me to schedule multiple sessions over the coming weeks and once and for all fix this shoulder (and whatever else may be associated with my shoulder pain). I am now having a hard time washing the left side of my body, putting on my seatbelt while in the passenger seat and I haven’t benched in over 3 months.
Thanks for sharing your experience TT!

Terry/Dr. Gregg,
There are a nearly infinate number of ways to perform an external rotation exercise, varying the body psoition, the shoulder position (forward flexion, lateral flexion). What is a good starting point for rehab/prevention? 2? side lying L flys and seated with knee supporting the elbow? I may have been using too much weight, recruiting the deltiod. Also, Mel Siff recommended full range cable crossovers. The description that I have read was unclear to me. Basically I can see 4 “X” position exercises. low pulling high, both sameside cable and reaching across and high pulling low, same side cable and opposite side. Your opinions?

P-Dog, the best way for me to do that will be to list the exercises or stretches I’m doing specific to the muscular imbalance for which it was prescribed. I’ll go over everything I’ve got, review it with Dr. Gregg and post it here. Give me a day or so.

jeep69, I’m not Dr. Gregg, but I do know that he has his DC degree and that he is ART certified. He has to go in at least once a year for CE on the ART. There are also different levels of ART certification, the best probably being Instructor Level, though that may not be exactly what it’s called. If you want more info on ART certification, check out www.activerelease.com. It’s not required that you be a DC to do ART. Some practitioners are massage therapists. However, having received ART of questionable value in the past, I think I’d prefer to have someone with as much training in anatomy, kineseology and biomechancis as possible.

Patch, thank you for pointing that out. Yes, definitely the book I mentioned is NOT for people who want to learn ART technique. It’s a great book to read if you’re wanting to find out more about what the heck ART is. I think it would be a great book for prospective ART patients. That’s it’s intended audience.

PGA, you’re an excellent candidate for ART. ART does great stuff for athletes suffering from repetitive use and strain type injuries. Think about tennis players, baseball pitchers, GOLFERS (grin), and marathon runners. Each type of athlete tends to have problems, pain and overuse injuries specific to their athletic endeavor. I hope Dr. Gregg will explain the shoulder tendonitis to you. Not only can it be fixed, there are things you can do to keep your shoulders healthy so you never have to deal with it again!

Re the follow-up, good idea! One of the points I tried to make (though probably not very clearly) was that getting ART done is only the first step. I have to do my part, too! It doesn’t help to get ART and then go back and repeat all the bad things I was doing before (like not stretching?). Establishing new habits and doing/following the rehab recommendations is critical to old injuries never recurring. All that said, I can see going in once a year for a tune-up and a structural reality check.

ZEB (grin)

(For those of you who don’t know, ZEB always teases me about my grins.)

Vegita, you’re talking about hyperlordosis. Sometimes they just call it lordosis. The psoas stretch was one of the things that I was prescribed. Hopefully, Dr. Gregg will be by shortly to elaborate. There may be more involved than just tight hip flexors (i.e., psoases).

For everyone who asked, I tried really hard to explain the psoas stretch to someone, and words just don’t get the job done. So I wrote out instructions and attached pics. It’s in a MS Word document. If you’d like a copy, PM me with your email, and I’ll send it off to you.

JP, you’re welcome. I’ll leave the analysis and recommendations to Dr. Gregg. (“Where is that guy,” she said sweating profusely & wiping brow)

glute-spanker, as was mentioned by Patch, it’s not a book that teaches technique. It’s a book that raises a person’s level of awareness about what ART could do for them. It does show a few things, but what made my experience such a positive one was the fact that excercises and stretches SPECIFIC TO MY SITUATION AND MUSCULAR IMBALANCES were prescribed for me.

You and I might both have a shoulder problem, but the underlying issues and imbalances could be VERY different. So for that reason, I hate to see a generic program or list of exercises recommended WITHOUT AN ASSESSMENT BEING DONE.

Magnus, I’ll be interested to hear myself. BTW, he’s from Canada. You might be able to catch up with him there in June for treatment. Drop him a PM.

donder1, that’s EXACTLY the same thing I had going on. It even affected my sleep.

But once again, before you commit your resources (time and money, both), be sure to check out your practitioner and get references. I checked with irondoc (an ART practitioner himself) and Goldberg. That’s how I found Dr. Gregg.

TT, the timing of your article (as always) is impeccable. I am going to see an ART practitioner this Saturday for some shoulder/neck/upper back pain, and I think it is possibly related to a pinched nerve in my neck from a year ago that has never completely healed. I was seeing a chiro last year when it happened, and he practiced ART, but I don’t think he was particularly adept at it, and I am looking forward to trying someone who specializes in it. The shoulder pain is evident mostly when benching, especially when I add close-grip benching to my workout cycle.

I am wondering if you (TT/Dr. Gregg) have any advice on questions to ask the practitioner before/during/after treatment to see if they are qualified. I understand that asking certain questions won’t in and of itself decide if they are qualified or not, but I figure it could help. I did get the doctors (Drs. Heddles and Drynan) from the activerelease.com, so I would imagine they are qualified, but it couldn’t hurt to ask. Any advice you can offer on how I should approach the appointment would be appreciated. Thanks!

Hey Terry, where is dr. Gregg located? I’m making a wild guess that you live in Tampa, so if you drove south, he might be in my neck of the woods (miami.) Thanks…

Does anyone know of a good ART practioner in the San Diego area (Southern California)?

AllBizNiz, I think you’re just about the luckiest guy on the forum! (grin) Dr. Gregg is relocating to Jupiter, Florida, which is about 30 minutes above West Palm Beach. When I treated with him, he was in Atlanta, Georgia.

It was worth the 7-hour trip, I tell you, but I’m thrilled that he’s going to be located in my “backyard,” so to speak, in the next month or so.

johnnychimpo, you bring up a very good point. There are a number of people out there who will tell you they’re trained on ART, but that doesn’t mean they’re certified. I consider ART certification a BARE MINIMUM. Even then, some practitioners are still getting up to speed and developing their skill set. Do your research and find someone GOOD! I was disappointed with my first experience and THRILLED with my second experience.

I’ll tell you how I found Dr. Gregg and how I decided to treat with him. Originally I asked Goldberg who he used because he’s always recommending ART. Goldberg’s a PL, strong, big & hardcore. I figured if he thought his guy walked on water, the guy probably knew what he was doing.

I called the office and Dr. Gregg got on the phone and talked to me for a good 30 minutes about what I needed to do to get the most out of my treatment. My elbow was in flare-up mode/acute. He was generous with his time and knowledge both. I also learned his specialty was shoulders and that he had trained with Dr. Buchberger. So because of the time he spent with me and because of his area of expertise, I chose him over the other practitioners in the office.

From there I checked references with irondoc, an ART practitioner here on T-Mag. irondoc is in Pennsylvania, and I asked whether I should treat with him in Pennyslvania or go to Atlanta. irondoc told me to go to Atlanta, that he knew the guy personally and that he was extremely competent.

Even then, driving 7 hours and staying for a week to treat with someone I had never treated with before was an act of faith, but I wasn’t disappointed. Dr. Gregg came in twice on his days off to treat me because I had traveled so far. That was above and beyond the call of duty in my book, and because of it (and his skill and talent, of course), he’s got MY business for life!

I probably drove the poor guy crazy during the 6 days I treated with him. I “interviewed” him for 6 days solid! I kept asking him what he was doing, why, what was wrong with me, and what I could do when I went back home to make sure it didn’t happen again. He spent considerable (extra) time, showing me stretches and exercises. That was (almost) the best part of the whole experience.

jp_dubya, I’m going to defer to Dr. Gregg on this one. I could tell you what I do, but I can’t tell you why or why one approach might be better for you than another.

What are your goals, needs and issues as it relates to your doing external rotation exercises?