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Keyword: athletic trainer

By Ethan Konoza, ATC
Athletic Trainer
MUSC Health Sports Medicine

Flexibility in relation to the human body can be defined as the range of motion (ROM) of a joint that is largely affected by the muscles, tendons, and bones around the joint (Borges, Medeiros, Minotto, Lima, 2017). There are several methods to increase ones flexibility and ROM. Proprioceptive neuromuscular facilitation (PNF) in particular is a stretching technique that has been shown to effectively increase ROM and flexibility (Hindle, Whitcomb, Briggs, Hong, 2012). PNF stretching can be performed to increase passive range of motion (PROM) and active range of motion (AROM). Two of the most common methods discussed in the current literature of PNF stretching include a contract relax (CR) method and a contract relax antagonist contract (CRAC) method. The CR method is performed by lengthening the muscle targeted for stretch and holding it in lengthened position while maximal isometric contracting of the same target muscle is being performed for a set amount of time. This is then followed by relaxation of the target muscle while being passively stretched. (Hindle et al., 2012; Maharjan, Mallikarjunaiah, 2015; Muscolino, 2017). The CRAC method of PNF stretching is performed similarly to CR but with an antagonist contraction instead of passive stretching following relaxation of the targeted muscle. There are four theories as to why PNF stretching is effective in increasing ROM. These include autogenic inhibition, reciprocal inhibition, stress relaxation, and the gate control theory (Hindle et al., 2012; Maharjan, Mallikarjunaiah, 2015).

Muscle spindles and Golgi tendon organs (GTO) are two types of muscle proprioceptors that are protective in nature but also play an important role in how these proposed mechanisms work to increase ROM during PNF stretching. Muscle spindles are located within the belly of a muscle and senses stretch or lengthening of a muscle (Powers & Howley, 2018; Muscolino, 2017). When a muscle becomes stretched (lengthened) to a point the muscle spindle too is stretched. The stretching of the muscle spindle causes an impulse and an afferent neuron is sent to the central nervous system (CNS) through the spinal cord. The CNS receives and interprets this information. If a muscle is lengthened too far the CNS will send an efferent neuron to cause a reflex contraction called a myotatic reflex to contract (shortening of the muscle) to prevent any more lengthening to that muscle to prevent damage or tearing. (Powers & Howley, 2018; Muscolino, 2017). The GTO is another type of muscle proprioceptor that is located near the musculotendinous junction and is attached to muscle fibers. The GTO detects changes in tension within a muscle. When a muscle contracts (shortens) increased tension is placed upon the GTO (Hindle et al., 2012; Powers & Howley, 2018; Maharjan, Mallikarjunaiah, 2015; Muscolino, 2017). The shortening of the muscle causes the GTO to become stretched and in turn creates an impulse that sends an afferent neuron to the CNS by way of the spinal cord. The CNS then interprets this information sent by the GTO detecting a pulling force on a tendon. This pulling force can damage and injure the tendon. This ultimately causes another impulse to be sent to relax the muscle so that no more tension is place upon the tendon (Powers & Howley, 2018; Muscolino, 2017) This is termed the GTO reflex or inverse myotatic reflex as it has the opposite or inverse effect of the myotatic reflex created by the muscle spindle.

It is important to note that both muscle proprioceptors discussed are protective in their design. Due to this protective element, the GTO’s inhibitory type reflex in particular can be utilized in increasing the amount of stretch that can be placed upon a muscle. Isometric contraction of the target muscle causes tension to be placed upon the muscle and its tendon, which in turn activates the GTO reflex. The GTO reflex causes relaxation of the targeted muscle due to its protective nature. This relaxation of the muscle by way of the GTO reflex prevents excessive tension or stretching on the tendon to avoid tearing or damage. This relaxation of the muscle allows for further stretch to be placed upon the targeted muscle and in turn allows for increases in ROM and ultimately flexibility seen from PNF stretching.

While by design the GTO acts as a protective measure by sending an inhibitory reflex to the target muscle, we are essentially using this reflex as means of enhancing the effectiveness of the stretch. That is getting the muscle to relax so that we can further stretch the muscle. By adding tension to the GTO by asking our athletes to isometrically contract during PNF stretching we are triggering their bodies into sending this inverse myotatic reflex to inhibit any further contraction of that targeted muscle. This inhibitory reflex is what allows us to stretch the targeted muscle further. Stretching the soft tissue is just one area of the mobility and ROM puzzle. Optimizing mobility leads to proper execution of functional movements, which in turn reduces the likelihood of injury and ultimately improves performance.


Borges, M. O., Medeiros, D. M., Minotto, B. B., Lima, C. S. (2017). Comparison between static stretching and proprioceptive neuromuscular facilitation on hamstring flexibility: systematic review and meta-analysis. European Journal of Physiotherapy, 20. 12-19.

Hindle, K., Whitcomb, T., Briggs, W., & Hong, J. (2012). Proprioceptive Neuromuscular Facilitation (PNF): Its Mechanisms and Effects on Range of Motion and Muscular Function. Journal of Human Kinetics, 31: 105-113.

Maharjan, J., Mallikarjunaiah, H. S. (2015). Proprioceptive neuromuscular facilitation stretching versus static stretching on sprinting performance among collegiate sprinters. International Journal of Physiotherapy, 2, 619-626.

Muscolino, J. E. (2017). Kinesiology: The Skeletal System and Muscle Function. MO, St. Louis. Elsevier

Powers, S. K., & Howley, E. T. (2018). Exercise physiology: Theory and application to fitness and performance. New York, NY: McGraw-Hill Education.

By T. Ryan Littlejohn, ATC, CES
Certified Athletic Trainer
MUSC Health Sports Medicine

Does your son or daughter play sports? According to the Open Access Journal of Sports Medicine, three out of every four families have at least one child playing school sports. This leads to another very important question: does your child have adequate medical coverage at their school? Having an athletic trainer or other qualified medical person onsite to address athletic injuries is essential for every school. According to the American Orthopedic Society for Sports Medicine, high school injuries account for an estimated: two million injuries; 500,000 doctor visits; and 30,000 hospitalizations a year. Furthermore, the CDC reports more than half of these injuries can be prevented and, many of these injuries are overuse injuries. Overuse injuries are caused by athletes not resting enough from their sport causing repetitive trauma to their body. A certified athletic trainer is a highly-qualified medical professional that can address these issues and many other athletic injuries. They are able to treat a variety of sports injuries and help keep the cost of medicine down, reducing hospital and doctor visits. Athletic trainers are trained in areas of prevention, rehabilitation, evaluation assessment, immediate care, and organization administration. This includes responding to emergencies by providing CPR and calling 911 when necessary. The statistics for injuries are alarming; however, it can be addressed by having adequate coverage for these athletic events. Hiring an athletic trainer is essential for every school’s athletic program and if there is some doubt look at these statistics; providing coverage alone, could bring a lot of peace of mind to many parents.

Athletic trainers are essential in triaging various types of athletic injuries on and off the field prior to allowing an athlete to return to play. It may be necessary to refer to a physician for clearance, particularly in head injuries in order to safely return the athlete to physical activities. Concussions are constantly in the media these days, with a great deal of discussion regarding health risks, both short and long term, in various sports; so it is very important to make the correct call when allowing an athlete to return to play. As a certified athletic trainer, I would like to share an interesting case about an athlete’s experience with a concussion. Hopefully, by sharing these types of experiences, it will help health care providers determine when it is appropriate for an athlete to return to play after a head injury.

In this case, a high school football player was hitting a pad in practice then fell down, hitting his head face first on the ground. He somehow bounced off the pad and then hit the back of his head on the ground. The player immediately experienced dizziness and headaches. However, he had no loss of consciousness, so I directed him sit out of practice and then evaluated him. I used the SCAT5 concussion assessment exam, which is tool that is used at all levels in order to evaluate a concussion. The score on test was slightly elevated due to his symptoms, which helped me promptly diagnose a concussion, so I instructed him to see his doctor for a formal evaluation. His mother took him to his primary care pediatrician and the doctor performed a basic exam where he only checked his eyes and asked about his current symptoms. The doctor subsequently wrote a note to clear him return to play. When I received the note, I was concerned because his symptoms had not completely resolved. I put him through intense running exercises and his symptoms immediately returned. Because I was concerned about the athlete’s persistent symptoms, I sent him to one of our sports medicine physicians, Dr. DeCastro, who commonly treats many of our concussions with MUSC Health Sports Medicine.

It is essential that physicians and athletic trainers to work to together when dealing with head injuries, so an athlete does not fall through the cracks. This head injury could have been more serious or even fatal if it had not been caught and the athlete held out of sporting activities. Currently this athlete continues to recover, but it has been nearly three months since the injury and this athlete continues to experience post-concussion symptoms. I would like Dr. DeCastro to share his experience from a physician’s point of view.   

Dr. Alec DeCastro, Chief of Primary Care Sports Medicine, MUSC Health:

Concussions have garnered a lot of media attention over the past few years, and are prevalent in football but even in non-collision sports. The Center for Disease Control (CDC) recently estimated that 1.7 million people in the U.S. suffer some form of traumatic brain injury every year, which is twice the number of heart attacks that strike Americans each year. About 75 percent of those brain injuries are considered concussions or other forms of mild injury. And 80 to 90 percent of people will recover from a concussion within a seven to 10-day period, according to the National Institutes of Health (NIH).

The hype regarding concussions has caused a lot of trepidation in sports, particularly after the recent movie starring Will Smith. Actually, the condition discovered in the movie by Dr. Bennett Omalu is called chronic traumatic encephalopathy (CTE). Education regarding concussions is the key, and recognizing early signs and symptoms may make all the difference for athletes, parents, and coaches. The CDC has created an initiative called Heads-up Concussion, which has resources and tools to help recognize, respond to, and minimize the risks of concussion.  

It is important that the physician and athletic trainer to work together and apply an individualized approach to the diagnosis and care management of athletes with these types of head injuries. One of the most valuable factors in managing concussions is the athletic trainer’s comprehensive knowledge of the individual athlete. It may be imperative that whoever works most regularly with the athlete reviews his or her treatment. The athlete’s history, behavior, and risk factors need to be included as well in order to figure out the best patient-centered care plan for speediest recovery of the athlete’s concussion.

Treat the Athlete, Not the Body Part

I recently attended a medical conference in New York, focusing on current sports medicine concepts in baseball.  The presenters were sports medicine providers including members of the sports medicine teams from both the New York Yankees and Chicago White Sox. The conference was outstanding, discussing some of the most current research and treatment techniques for injuries afflicting baseball players from the Major Leagues to collegiate and youth athletes.  There were over 20 different presenters from orthopaedic surgeons, physical therapists and athletic trainers; one of the biggest take home messages I learned was that there is little absolute consensus on treatments for different injuries.  There are a variety of different diagnostic and surgical approaches to a variety of shoulder and elbow injuries.  However, there was one consensus that ran through each section; the importance of core strengthening and stability as part of the athlete’s daily work-outs and rehabilitation process.

The idea of treating the entire athlete is not new; it is something that is discussed at almost every sport medicine conference and a topic that I have presented on a number of times in the past.  Unfortunately, players, coaches, and parents do not always have access to this information.  So there can be a lot of misconceptions out there amongst the non-medical population with regards to baseball players:

  • My shoulder hurts so I need to just rehab my rotator cuff
  • I want to throw harder so I need to hit the gym and get stronger
  • I lose my control the deeper into the game I throw, so I need to throw more in practice

For ideal results in performance, injury prevention and rehabilitation, the athlete’s entire body has to work in symmetry.  It is not about just one body part or one muscle group; it is about the entire body working in harmony to achieve a common goal.  So for the athletes that I work with, their programs focus on a variety of body parts from the rotator cuff to the peri-scapular musculature (latissimus dorsi, trapezius muscles, rhomboids, serratus anterior) to core and pelvic musculature, to the lower body.  The goal is to build strength, stability, and muscular endurance throughout the entire body to support the demands of their sport. 

You may now be thinking, how am I going to do this, my workout will take hours?  There is definitely a time and place for isolation, but the majority of the time, you can combine exercises to achieve the desired results.  There are still thousands of different exercises that you can do, but here are my top 6 exercises that I give to the majority of my throwing athletes to incorporate into their workouts:

  1. “Y’s” –  bilateral shoulder scaption prone on a stability ball
  2. “T’s” – bilateral shoulder horizontal abduction prone on a stability ball
  3. Bilateral scapular retraction to external rotation prone on a stability ball
  4. “I’s” – bilateral shoulder extension prone on stability ball
  5. Push-ups on stability ball or BOSU ball with holds
  6. Shoulder external rotation while in a side plank position

* Exercises should include high repetitions with little to no weight (zero to two pounds at most) focusing on slow controlled movements, body mechanics, and alignment. 

One of the athletic trainers at the conference said that “throwing programs should always be written in pencil, since they are constantly changing to meet the needs of the individual athlete.” I could not agree more, but I also take this philosophy to include all strengthening, rehabilitation, and maintenance programs. Every athlete is different and their program should be tailored to meet their specific needs, focusing on the entire athlete.

Guest Post by:

Lindsey Clarke, MS, ATC, CMT
Athletic Trainer
MUSC Sports Medicine

I’m sure you’ve heard the sayings “no rest for the weary” or “Jack of all trades”.  I’m willing to bet someone was referring to an Athletic Trainer when they said that.  Attempting to describe a day in the life of a Certified Athletic Trainer would be like an astronaut describing what it’s like being in space…you just don’t know until you’ve done it for yourself! Okay, so that may be a bit dramatic, but the demands of this position are very unique, and unlike most jobs out there.  Certified Athletic Trainers(ATCs) are highly qualified health professionals who are trained in preventing, recognizing, managing and rehabilitating injuries that result from physical activity and sports.  They are part of a team of sports medicine specialists, that if when injured, help get you back on your feet and back in action as soon as possible…all while pulling some pretty unorthodox hours.

While they’ve been behind the scenes and on the sidelines long before, the American Medical Association has recognized athletic training as an allied health care profession since 1990.  As an important part of a comprehensive healthcare team, the certified athletic trainer works under the direction of a physician and in cooperation with other healthcare professionals, athletics administrators, coaches and parents.  ATCs work in a variety of different professional settings, including:

Professional and collegiate sports                       Sports medicine clinics
Secondary and intermediate schools                   Occupational settings
Performing arts                                                          Law enforcement and military
Hospital emergency rooms and rehab clinics        Physician offices

If an athletic trainer works with a sports team, their hours will ebb and flow with the offseason, preseason, and regular season. Trainers working in hospitals and clinics may have a more regular schedule and often conduct outreach work at various locations.  While there are various settings, the basic duties are common across the board.

Prevention of Injury  Injury prevention is one of the most important roles an ATC has in dealing with any athlete. While managing injuries once they’ve happened is our bread and butter, pre-participation screenings, development of strengthening programs, education of sport specific equipment, and hydration and nutrition counseling are just a few examples of ways to help avoid injury.

Recognition, Evaluation, and Assessment  Athletic trainers must possess the skill to recognize, evaluate, and assess athletic injuries in order to care for them properly, and apply those skills to the field.

Immediate Care  In the event of an injury, it is imperative that the athlete can be cared for immediately and appropriately. It is crucial that in emergency situations, athletic trainers act without hesitation in responding with knowledge and control.

Treatment, Rehabilitation, and Reconditioning  Providing daily treatment helps manage any niggling aches, pains, or minor injuries. Rehabilitation helps minimize injury time and allows the injury to fully heal. Reconditioning, or sports-specific training, is very important to regain the optimal physical condition of the athlete and helps minimize chances of re-injury upon return to play.

Organization and Administration  There is much more to being an athletic trainer than simply caring for athletes.  It is important for the athletic trainer to be prepared for any situation.  This includes developing emergency action plans, policies and procedures for safe participation, facility operations, and maintaining compliance with all safety and sanitation standards.  In addition to all this, accurate athlete/patient files and injury reports must be kept up to date, and regular communication with coaches and physicians made on a daily basis.  ATCs often handle insurance as well as being responsible for staying on top of budgetary issues when making supply orders.  In smaller organizations, planning travel and accommodations can fall to the athletic trainer as well.

Professional Development and Responsibility As in every other profession, athletic trainers hold the responsibility of playing a part in the professional development for the athletic trainers while obeying and adhering to all laws and guidelines that impact the athletic training profession.  This includes doing the necessary work to maintain certification and licensure, and helping advance the athletic training profession. According to the Department of Labor, 46 states require trainers to be licensed or registered.  It is important for athletic trainers, now more than ever, to education the public on the importance of athletic trainers and our profession.

 Dependent on the setting, certain responsibilities and hours may vary, but the one common denominator is that an athletic trainer's day may change from day to day and even hour to hour. Flexibility (to both schedule and personalities), empathy, patience, creativity, strong decision-making skills, and being even-tempered are all qualities that not only a good, but effective athletic trainer make. Most importantly, you must be a good listener.  Possessing the ability to react to a situation all while maintaining a strong controlled attitude is only half the battle…you must be able to connect with your athlete and gain their trust.  Athletic trainers are hard-working and passionate in caring for and helping their athletes.  They’re usually the first to arrive and the last to leave all just to be repeated the next day.  Sometimes working upwards of 60+ hours a week, athletic trainers make tough decisions in high-pressure situations on a daily basis.  Our athletes’ lives are quite literally in our hands…caring not only physically, but emotionally for them can be quite stressful.  So, the next time you see your trainer eating their yoghurt with a tongue depressor because they forgot their spoon, reading through their home-study continuing education course all while filling one of many water coolers over their lunch break, just give a little thanks for these un-sung heroes that keep these bodies in motion moving.


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