Red Flags For Low Back Pain, Or Clinical Decision Making?

It’s only happened a couple of times in my career.

You know that feeling you get when something just isn’t right? You’re not quite sure what it is, but something just seems off?

Twice I’ve had people come in where their pain and limited mobility had me questioning if they needed a trip to the emergency room. In one instance I called a family member who took the patient in, and everything checked out fine.

The other instance, the persons low back pain was so extreme, it just didn’t add up. There was no history of trauma or anything else that suggested the hospital was necessary, but I could barely touch the patient during the treatment because their low back was so sensitive. Afterward, I recommended seeing a doctor, or emergency room, but they refused. I never saw them again, so I’m not sure what the outcome was.

So how do we know when low back pain is an emergency, or just really painful?

Traumatic Injuries And The RTC

In old First Aid terms, there were criteria we would use at the scene of an accident to quickly decide if a patient had to have spinal immobilization used and if they needed to be immediately sent to the hospital. 

It was called the RTC (Rapid Transport Category), and it was a simple list which made it easier to decide how to provide the appropriate care to a patient. While this isn’t as useful in a clinical setting, it could be invaluable in a sport, or outreach setting if some type of emergency were to happen and you are required to provide care. In a clinical setting, it would be helpful during your patient interview in case you weren’t quite sure why a patient is having the issues they are presenting with.

The RTC criteria include quite an extensive list of things to watch for. Not all of them would be applicable to us, but here are some that would be:

  • Mechanism of injury
    • Fall from greater than 20ft
    • High-speed accident
    • Pedestrian struck at speeds higher than 30 km/hour
    • Broken windshield damaged steering wheel, or airbags deployed
    • A rollover accident
    • Severe crush injuries
    • Any other people involved in the accident that result in a fatality
    • Electrical injuries (we always assume spinal damage with electrocution)
  • Anatomy of injury
    • Severe brain injury
    • Penetrating injuries to anything but the limbs
    • Depressed skull fracture
    • Pregnant woman with fairly moderate trauma
  • Findings in the Primary Survey
    • Decreased level of consciousness
    • Cardiac arrest
    • Suspected heart attack
    • Poisoning
    • Status Epilepticus

Particularly for us in the clinical setting the mechanism of injury should be one category to take note of. Hopefully, if someone has been through an accident that traumatic, they have already been to the emergency room, or at least a doctor to be checked out, but this doesn’t always happen. Sometimes a patient may play it off and just think they need to see a chiro, physio, or massage therapist and book in with you before ever seeing a doctor, or even calling 9-1-1 after an accident.

I’m sure we all see patients on a regular basis who have been in a car accident. Knowing those above criteria and being able to ask some of those specific questions in your interview may give you a better idea as to how severe their injuries could be. Or, if they played it off and haven’t been checked out, you may want to refer them to a doctor just to be safe.

Whenever I teach a first aid course we talk about the signs and symptoms of a heart attack. This is where there could be a bit of a red flag, as it is quite common for women to experience back pain associated with a heart attack. However, it would be back pain combined with other symptoms like chest pain, nausea and vomiting, sweating, and shortness of breath.

This is certainly part of our role as healthcare professionals to recognize and help our patients if this is happening. 

Photo by: Lucina Medina

The Red Flags Of Low Back Pain

There seems to be a wide array of information on the red flags of acute low back pain.

Most of the concern is driven toward four issues:

One red flag that is unrelated to specific disease was the onset of pain in patients under 20 years old. However, one study actually calls this a “dubious distinction” and shows that age alone combined with pain is not enough to be considered a red flag, as most of the participants in the study were diagnosed with non-specific mechanical spinal pain.

When we look at the risk factors associated with spinal fractures, most information cites major or significant trauma, age, a history of osteoporosis, and the use of corticosteroids as the red flags to look out for. A systematic review showed that all of the above combined with the presence of a contusion brought the probability of a fracture up from 4% to a range between 9 and 62%. An Australian study showed that when three red flags (female, over 7o years of age, severe trauma, and use of corticosteroids) were all present, the chance of a fracture went from 4% to 90%. So, when looking at red flags for fractures, one red flag alone is not likely an issue, but a combination of the red flags is more likely to result in a fracture.

The commonly used red flags for infection were:

  • Fever/chills
  • Use of corticosteroids or immunosuppressant therapy
  • IV drug use
  • Pain worse at night
  • Night and rest pain
  • Tenderness over the spinous process

But the same systematic review showed that there is a lack of standardization with these red flags, and the risk of serious disease in patients with low back pain is less than 0.1%.

The same can be said for malignancy, as the one big red flag, in this case, is a history of cancer. Yet “history of cancer” isn’t clear enough as it doesn’t specify how long ago the person was diagnosed or the type of cancer they had. There are several cancer types that apparently put a person at greater risk for spreading to the spine, but if the person didn’t have one of those types, or had it 20 years ago, the likelihood of spinal malignancy is probably a lot less than someone diagnosed recently.

The two most common red flags with Cauda Equina were saddle anesthesia (perineal numbness)  and sudden onset of bladder dysfunction. Either way, I’d be referring out for that!

One thing that came out of most of the studies I could find was one resonating point. Clinical decision making and judgment of the therapist to determine if the patient needs to be referred out is more reliable than the list of red flags. So in other words, when in doubt, refer out! There are some other things to take into account with this whole red flag discussion and one review makes a great point as to why screening for red flags isn’t reliable. As practitioners, we don’t actually screen, we manage low back conditions. They actually encourage watchful waiting for changes in symptoms, as evidence is showing that early intervention with low back pain may actually be more harmful.

One thing I hadn’t ever heard of was “yellow flags,” however, I found it encouraging that it was mentioned in a paper from rheumatologists. They listed these yellow flags as:

  • A belief that back pain is harmful or disabling
  • Fear of pain and movement avoidance
  • Tendency to low mood and withdrawal from social interaction
  • Expectation of passive treatments rather than believing active participation helps

Biopsychosocial approach anyone? It’s great to see these “yellow flags” being mentioned with the same importance as the dreaded red flags.

Overall, it is probably good to be aware of those red flags to help guide your clinical decision making, but they aren’t the be all end all like we once thought they were. The valuable thing will be your judgment call and also making sure to monitor your patients progress. If your spidey senses start tingling, and something doesn’t seem right, don’t hesitate to refer out, it’s better safe than sorry.

Massage Therapists, Athletes, And Mental Health

In the athletic community we are inundated with ways to improve physical strength; endurance; nutritional intake; psychological advantage. We have done a tremendous job of ensuring the physical health of our athletes, which is critical to their performance and physical well being.

One area that has been overlooked for quite some time, however, is their mental wellbeing.

As a Psychotherapist, I have had the opportunity to work with young athletes both individually and in group settings. Through this work, it became very apparent that there exists a need for athletes to have a safe space to consider, explore and discuss their mental health.

It is time to enlighten the sporting community to the benefits of supporting athletes’ mental wellbeing. As helpers in this area, we have the power to do so.

The reality is that with the amount of pressure our athletes experience in managing their sport as well as their individual lives they are being asked to cope with a tremendous amount. Research has informed us that 63% of student athletes struggle with mental health but only 10% seek help…10%!

That means the majority of athletes struggling with their mental health are doing so on their own. There are many reasons this occurs but basically, we can sum it up with stigma. Seeking help has a bit of a stigma to it, doesn’t it? Especially for athletes who are supposed to be strong and mentally tough.

Consider this: While working with a group of 11-year-old rugby players we were enlightened to see their fear at the thought of dealing with mental illness. Now when 11-year-olds are concerned about the stigma surrounding mental health, imagine how that looks as we get older and society continues to paint it with a dark brush.

Ways To Recognize An Athlete Needs Help

As helpers, we need to be even more vigilant in supporting those dealing with mental illness.

We need to be open and non-judgemental. We need to encourage complete wellness in our athletes and support, rather than inadvertently shame, those who need us.

As Massage Therapists, you are trusted professionals to those who seek your help. I mean what other professionals do people allow to put their hands on them; move their bodies in different ways, all with complete faith that you will help their condition?

Basically what I am so eloquently saying is: you’re in! You are an ally. You are someone who has the opportunity to be a change agent.

Think for a moment what you talk about with some clients while working on them.

I have had the opportunity to work closely with amazing Massage Therapists. I have witnessed them explore the physical concerns being presented and beautifully ask questions about what happened: where the pain is; what causes the pain; and skilfully inquire.

I have also witnessed the creation of trust, relationships, and a general camaraderie that exists between two people investing in one another for even a short period of time. This creates an incredible opportunity for you to explore further.

Does your athlete appear to be:

  • Withdrawn
  • Unable to concentrate
  • Not getting things done
  • Overwhelmed
  • Irritable
  • Unhappy
  • Indecisive
  • Tired/sick/run down
  • Experiencing recurring injuries
  • Recovering from concussion

Plain and simple does something just seem off?

You are accustomed to working with athletes so trust yourself. If something seems off it likely is. You may be hearing or seeing something in an athlete you know that you do not usually see or hear; you may be hearing or seeing something in a new client that seems unusual. Again, trust that feeling and ask some questions.

This can be done in a variety of simple ways:

Be Aware…Notice Opportunity

  • An event in the media can provide an opening to discuss something you may suspect is relatable to your athlete.
  • An experience a teammate or someone in their sport is going through can provide a nice opening.
  • A question they may ask you can provide an excellent opportunity to further inquire.

Pay Attention

  • Know their preferred method of communication. This will allow you to notice when something is different.

Start the Conversation

  • Please help me understand more about…
  • Be Curious!!!

Photo by: lindahaynes13

Creating Support Systems

If you have the opportunity to connect with coaches or parents this can also provide you with clues that something is not okay with your athlete. Take the time to inquire about any noticeable changes in behaviour. In doing so you may inadvertently create a support system for the athlete that otherwise may not have existed. How incredible is that?

What you might hear from parents or coaches:

  • Perfectionist tendencies
  • Lack of confidence
  • Preoccupied with failure
  • Making poor choices
  • Not being themselves
  • Unable to rebound
  • Struggling to cope

Seems easy enough, right?! Don’t let this list scare you away and prevent you from going there. Some of you may have noticed these things in the past but were not sure where to put them or perhaps, upon reflection, you are thinking of specific athletes where something felt off.

Without fail we come across coaches and parents who may have identified a potential mental health concern but have cautiously sidestepped the questions for fear of what to do next.

Well, I am about to let you in a little therapy secret I will keep no longer…ready for it? Here it is… You do not have to have the answers. Seriously.

Simply asking questions and showing individuals that you are paying attention and are concerned about their wellbeing is an amazing start. How refreshing for an individual who may be struggling to hear you say “I don’t know”. There is one thing you must do, however (perhaps I should have told you there was a catch before the big secret reveal) if you are going to take the opportunity to inquire, you have to follow up. Let them know that while you may not know how to ‘fix’ things you are going to connect them with someone who can help.

Have the name of a psychotherapist or psychologist on hand; support them in reaching out; refer them out to an appropriate professional. Whatever you choose to do just be sure to be a positive social responder who does not ignore, who does not judge, and who allows them to maintain their dignity in this difficult time.


Understanding And Managing Groin Pulls

I felt a little tweak on the inside of my leg, but kept playing anyway.

It was the final game of the tournament that weekend, so I knew I just had to get through the last period.

As the game continued, the pain in my inner thigh was getting worse.

Each time I pushed off and my skate cut into the ice it felt like a shock going up into my groin.

As soon as the game was over, I pulled some ice out of the beer cooler, wrapped it up and put it on the inside of my leg. It helped a little, (or it could have been the beer) but I had never felt something like this before.

The next day I had a snowboard trip booked for a week.

By the time I got up to the chalet, I could barely lift my leg. Going up a flight of stairs was almost impossible.

Just getting up out of a chair was excruciating. I was basically limping for 5 days.

I have never pulled my groin before, but holy was this painful.

Contributing Factors To A Groin Pull

A groin pull is common among athletes, especially in sports where the athlete is required to change directions quickly or where explosive movement is part of the sport.

Hockey and soccer seem to be the sports where a groin strain/pull is most common with athletes, but are also found in fencing, handball, football, cross country skiing, hurdling and high jumping.

A groin strain can be graded into three classifications and can involve any one of the six adductor muscles

There has long been a belief that Janda’s lower cross syndrome played a major role in what contributed to groin strains in athletes. 

In fact I did a case study in college on a marathon runner experiencing hip pain and based a lot of the treatment on this syndrome. But in talking to many of my pain science friends, it appears that this syndrome is not as accurate as we once thought. 

However there are parts to it, which I believe plays a role in an athlete experiencing a groin strain (this is where my pain science friends will probably want to correct me).

Essentially the thought was a muscle imbalance, or strength imbalance between the gluts and adductors and the strength of the gluts was pulling on the adductors, thus causing a groin pull.

Some of the research back then was pointing to this being a specific cause in hockey players (most hockey players have big butts from skating) and this being a major contributor to groin pulls in these athletes, although I couldn’t find any current research to support that, so we’ll just leave it in the past for now.

However there is a strong indication that weak adductors are a major contributor to these injuries. 

One systematic review compared 17 studies and found limited evidence to support the theory of weak adductors but it was dependant on positioning. At 45° during a squeeze test there was strong evidence of adductor weakness. 

A study done on Australian Rules Footballers demonstrated that weak adductors could be a factor in groin injuries. Their adductor muscle strength was tested weekly. Of the seven players that suffered a groin injury (over a two season period), they all demonstrated decreased strength in hip adduction two weeks prior and the week of their injury.(1)

While this is a very small study, it helps to support weak adductors as a possible contributor to groin injuries. 

Some other studies have shown there to be several other risk factors involved. With hockey players there was a greater chance of having a groin strain if you had a previous injury to the same area and less likely to suffer the injury if they had practiced in the off season.

When it came to soccer players, previous injury was also a risk factor but so was limited hip abduction. Groin strains were most common during the action of kicking the ball.

Either way it seems that weak adductors can be one of the contributing factors to suffering a groin strain. 

I also think (and this is strictly opinion) the motion of skating is also a contributor as the legs are continually going into extension, external rotation and abduction placing a greater strain on the adductors, but again, just opinion.

It would also be interesting to see the significance between player positions, if I even tried doing what the goalie in the picture below is doing, I probably wouldn’t walk for a month. 


By Mike Salvucci (Flickr) [CC BY 2.0 (], via Wikimedia Commons

Treatment Of Groin Injuries

During the acute stage you are going to follow your R.I.C.E protocol and rest the area.

  • R – rest
  • I – ice
  • C – compression
  • E – elevate

As the healing progresses (keep in mind if walking is difficult the person may be on crutches) manual therapy and exercises can begin, in the acute stages the injury will be too painful (depending on grade) to do much in the way of hands on therapy.

The acute phase should be getting better in about five days. If there is no progress, they should be referred to their doctor to check for other possible injuries like osteitis pubis, myositis ossificans or nerve entrapment.

Once it settles down, then try and determine which muscles specifically are having the issue by doing some manual muscle tests, although it may be tough to determine as it could be a group of muscles, not just one.

There aren’t many research articles I could find that specify exact methods or provide a treatment outline.

One recommends using muscle energy techniques, but it was referring to the sacrum for an anterior rotated innominate because of a positive standing flexion test, but research has since shown us that doesn’t happen.(2)

Another one demonstrated placing tension on the muscle with one hand while the other hand is used to take the leg into abduction and external rotation while the knee is fully extended, for use with chronic injuries.(3)

With the management of strains once the pain of the acute phase is gone, doing some manual therapy along with pain free stretching is recommended. As we have seen, some strengthening is going to have to happen as well. Having the patient begin some strengthening (if it is within your scope of practice) will be crucial in getting over the injury. Doing some balance exercises, lunges or walking up and down stairs pain free are some easy ones to start with. One of our biggest goals is to prevent this from becoming a chronic injury. As we have seen in some of the research, once someone experiences a groin pull it is then easier to re-injure the area again. Although I haven’t pulled my groin since that hockey tournament, I will never forget how painful it was. If I had gone somewhere for manual therapy, there is no way I would have let someone work on it during that first five days. Fortunately it didn’t become a chronic issue. And even though some may disagree, I’m still going to work into my hockey players gluts if they pull their groin!


  1. Turk P. IS THERE A RELATIONSHIP BETWEEN HIP ADDUCTOR STRENGTH AND GROIN INJURIES IN AUSTRALIAN FOOTBALL LEAGUE FOOTBALLERS?. Journal Of Australian Strength & Conditioning [serial on the Internet]. (2016, Oct), [cited January 9, 2017]; 24(5): 21-28. Available from: SPORTDiscus with Full Text.
  2. Brumm L, Carrier D, Nogle S, Johnson S. Looking beyond the soft tissue: illustrative case studies of groin injuries. Athletic Therapy Today [serial on the Internet]. (2001, July), [cited January 9, 2017]; 6(4): 24-64. Available from: CINAHL Complete.
  3. Weir A, Veger S, Van de Sande H, Bakker E, de Jonge S, Tol J. A manual therapy technique for chronic adductor-related groin pain in athletes: a case series. Scandinavian Journal Of Medicine & Science In Sports [serial on the Internet]. (2009, Oct), [cited January 9, 2017]; 19(5): 616-620. Available from: SPORTDiscus with Full Text.

Is The Use Of Oxygen A Placebo?

Forgetting to use it could be the difference between passing and failing a Sport First Responder test.

It has a wide range of uses in an emergency care setting, especially when dealing with your athletes in an acute injury or emergency.

Using supplemental oxygen therapy has been a major part of Sport First Responder courses over the years with various reasons for application including:

  • Shock prevention
  • Cardiac Arrest
  • Anaphylaxis
  • Carbon Monoxide poisoning
  • Asthma

However recently I have been hearing rumblings, the use of oxygen may be on it’s way out as an intervention and I recently worked with a sport med doctor who doesn’t use oxygen and downplayed its effectiveness.

But this practice is so hard grained into us, that with pretty much every patient we see in an emergency setting, they get oxygen.

But do we really need it in all cases?

Why The Use Of Oxygen

The biggest reason oxygen is used in these emergency scenarios is to prevent hypoxemia, which is a decreased level of oxygen in the blood, which then leads to hypoxia (oxygen supply which is insufficient to support life).

However there is also a risk of using too much oxygen which results in hyperoxia (too much oxygen in the system), if oxygen therapy is not used properly it can lead to complications, which also depends on the condition your patient is dealing with.

It turns out that hypoxia (which is determined by using a pulse oximeter) is the only evidence based reason to give oxygen to a patient.

The other reasons are based on the assumption that it will help prevent hypoxia and relief of symptoms in an emergency setting.


I’m sure we all remember what shock is from our time in college, but there is more than one type of shock and we should all be familiar with the various types.

Medical shock is the type we are mainly worried about as opposed to emotional or psychological shock resulting from a traumatic experience or an emotional event.

When someone is suffering from or going into shock, the body is redirecting blood to service the internal organs and keep them alive, which is why you will often see the persons skin turn pale, cool and clammy.

The extremities are not getting the blood supply they’re used to.

But within the classification of “medical shock” there are further classifications of types of shock:

  • Anaphylactic
    • life threatening allergy to a substance
  • Caridiogenic
    • failure of the heart to pump sufficient blood to the body, usually occurs with cardiac arrest
  • Hypovolemic
    • lack of blood in the body
  • Neurogenic
    • failure of the nervous system to control the size of blood vessels causing dilation, common with head and spine injuries
  • Respiratory
    • the lungs fail to get sufficient oxygen into the bloodstream, common with breathing emergencies, respiratory arrest
  • Septic
    • intake of a poison causes blood vessels to dilate

Within the license of a Sport First Responder we would treat all of these types of shock the same way, by putting the patient on oxygen at a 10L flow along with keeping them warm.

In the case of someone having a heart attack (caridogenic shock) there are studies showing the use of oxygen in the first 12 hours may be unwarranted, however would still be appropriate for the sport first responder or until the patient reaches the hospital.

But in some cases with angina attack, oxygen can help with pain relief.

This is also because in the stressful environment of being a first responder, to determine exactly when it is appropriate to administer oxygen (signs of dyspnea or heart failure), so would more efficient to give it to everyone until arrival at hospital.

Common breathing emergencies like breathlessness or asthma should only be treated with oxygen if there is hypoxia present, this is one of those areas where we have always put oxygen on a patient .

In dealing with traumatic injuries that would typically cause hypovolemic shock a study showed that only half of adult trauma patients actually required the use of oxygen in pre-hospital care, yet it was still being administered to everyone.

When it comes to using oxygen therapy for shock it looks like a bit of a mixed bag as to when it’s appropriate to use it and when it is not.

However our Sport First Responder guidelines at this point still say that oxygen should be used to either help prevent or to deal with shock.


Photo by: Offutt Air Force Base

Photo by: Offutt Air Force Base

Strokes, COPD And Other Emergencies

I know these aren’t typically seen in the Sport First Responder setting but it’s still important information to know in case you ever have to deal with it.

Again, these are all instances where oxygen would always be put on a patient having an emergency.

New research is showing us that it may not be the best approach.

In patients having an acute COPD (Chronic Obstructive Pulmonary Disease) we have always been told that high flow oxygen is the method to treat the situation.

Studies have shown that using reduced flow oxygen actually decreased the risk of mortality by 58% (1) and leads to worse clinical outcomes. (2)

Using oxygen with someone who is suffering a stroke is also coming under skepticism even though it too has always been promoted as an acute therapy. I’ve used it on patients several times because of the recommendations.

But newer studies are saying that unless there is hypoxia present, the use of oxygen should be avoided (although it is also referring to the first 24 hours of hospitalization).

The same article points out that unless hypoxia is present with a pregnant woman or someone experiencing breathlessness, oxygen should be avoided.

However there is still hope for our friend Oxygen.

Someone with carbon monoxide poisoning should still be given Oxygen. It reduces the level of carbon monoxide in the blood in 40 min compared to 4-5 hours just breathing regular air. 

Even though studies have started to question the use of oxygen in emergency settings, it is still imperative to stick to your local guidelines when responding to an emergency with your athletes. Most of the studies outlined in this post were based on the reading of gas exchange in the bloodstream using a pulse oximeter. Your average Sport First Responder probably doesn’t have one of these in their kit, so it is ALWAYS better to err on the side of caution. Another caveat for the use of oxygen (that I have seen first hand at emergency scenes) is distracting your patient. Having a mask on that is delivering oxygen brings some comfort to a patient, especially with breathing emergencies. I’m not sure it could be considered a placebo effect, but it definitely helps to calm a patient down. The point of this post wasn’t to tell you not to use oxygen anymore, you most certainly should. It was more just to make you aware that there could be changes coming down the road and the next time you re-certify, things might be a little different. In the meantime continue using your O2 cylinders and keep those athletes safe.



1. Ntoumenopoulos G. Using titrated oxygen instead of high flow oxygen during an acute exacerbation of chronic obstructive pulmonary disease (COPD) saves lives. Journal Of Physiotherapy [serial on the Internet]. (2011), [cited September 12, 2016]; 57(1): 55. Available from: MEDLINE with Full Text.

2.Cameron L, Pilcher J, Weatherall M, Beasley R, Perrin K. The risk of serious adverse outcomes associated with hypoxaemia and hyperoxaemia in acute exacerbations of COPD. Postgraduate Medical Journal [serial on the Internet]. (2012, Dec), [cited September 12, 2016]; 88(1046): 684-689. Available from: CINAHL Complete.

Chain Of Command In Sports Massage

When I first started in the fire service, I didn’t fully understand why we had chiefs, captains and lieutenants, this thing we call “chain of command”.

All I knew was there were people telling me what to do and I’d better listen.

As I progressed it became more clear why this was necessary and how it applied to what we were doing.

I never gave it much thought outside of the fire service but have now come to understand how “chain of command” is applicable and necessary in sports and working with teams as a Massage Therapist.

While it can be a bit tough to understand (and some may find it insulting) there is a purpose and very good reason behind having chain of command in place. It is also important to understand how to work within it if you are going to be successful working with teams.

You may not always agree with how this type of organization works but if you want to work effectively and be part of the team, you have to work in accordance with the team principles.

Here’s why and how to do it.

Principles Behind This Organization Style

If you’re already working with teams you might be familiar with this, but if not it’s important to understand the structure.

Businesses, organizations and emergency services all operate under this kind of functional system in order to operate more efficiently and to work within it, you have to understand not only your role, but also the terminology behind it.

Here is some of the terminology, it may not be used extensively when working with a sport team, but the basics are the backbone of the way most organizations have things set up:

  • Chain Of Command
    • The formal line of authority, responsibility and communication.
  • Unity Of Command
    • A principle that each employee reports directly to one supervisor moving up the chain, ultimately all report to the main person in charge.
  • Span Of Control
    • The principle that establishes the maximum number of people or functions that any one supervisor can control, it’s typically three to seven but five is considered optimum.
  • Division Of Labour
    • This is the process of dividing larger jobs into small jobs to make them more manageable and efficient.

Below is how an organizational chart could look for a large team (obviously I picked hockey).

*This is just an example, not necessarily how any one team is set up.


Sport Massage Chain of Command


As you can see, the General Manager would ultimately be in charge with Logistics, Head Coach and Sport Med Doctor all reporting directly to him/her.

They would each then oversee their own group who would report to them.

In our case, the Sport Med Doctor would oversee the healthcare of the athletes with Massage, Strength, Chiro and AT all reporting directly to them, they would then convey the necessary information the the General Manager.

Remember, the above is just an example. It may be set up where the Massage Therapist reports to the Physio, who reports to the Doctor.

These lines of communication are essential in the function of any organization, since each person can only effectively manage five people (according to span of control).

Having things organized this way also gives the organization room to expand (or decrease) if necessary. For instance, the General Manager can add assistant GM’s as the organization expands giving them new branches of responsibilities and groups operating under them.

Understanding how you fit into these lines is essential, not only to your success, but to the teams success as well.

Know Your Role Jabroni!

Okay, so you’re not a jabroni, but it’s a good headline to get the point across.

If you’re selected to work in this kind of team environment, knowing your role is crucial.

The team probably even has a job description prepared for each person on the medical team, outlining each persons specific role. Not all the roles will be specifically medical.

Depending on your past relationship with a team or whether you’re brand new can define what your role will be, or how you can function within the role they define and the scope that is laid out for you.

Initially you may have a very minor role. The A.T, Physio or Sport Doctor may be the ones who do all of the assessment and refer athletes to you only when they deem necessary.

Don’t take this as a slight against you if this is how things start out!

The team may have things designed that way because of insurance concerns, or because of past experiences which are totally beyond your control. Don’t forget, there is a broad spectrum of massage therapy certifications out there in addition to the broad spectrum of experience these other healthcare professionals in working with Massage Therapists.

The job description given to you may have you assisting equipment managers, helping with video, filling water bottles, or just cleaning up the dressing room.

Again, it’s not a slight against you or the profession, it’s just a role the team needs filled, so they might get you to help out by filling that role.

Now, the rest is up to you.

Personalities play a massive role in team sports. When you’re starting out be happy to fill whatever role it is they have designated for you. Leave the ego at the door. As you start to work more regularly with the team, your role can expand, it’s all about building that relationship (where have I heard that before?). As the trust builds between you and the other healthcare professionals in the group, so will your role and what you can do. It’s all part of being a team, not all jobs on the team are going to revolve around you doing soft tissue work on athletes. Nor is all the work for the other healthcare professionals going to solely revolve around healthcare for the athletes, it’s about pulling together for the greater good of the team. Like it or not there is still a hierarchy, these other therapists have more education than we do and may assume that we report to them, even though the team chain of command doesn’t display that. Back to those personalities, while some people will bring their ego and put it on display, that usually gets weeded out. You may just have to change your approach in dealing with people for the greater good of the team. If someones ego is getting in the way, it may be something you have to work around temporarily, but trust me it will be temporary.


Should Massage Therapists Stretch Athletes Pre-Performance?

Hey, can you stretch me out a little before the game?

Well, no but we can after the game, it’s best to not stretch before the game but I can help you with your warm up.

Teachers had told me that doing any kind of stretching on athletes pre-event can actually mess up their stride and make things worse (if you’re stretching out the lower body).

Recent research has shown that stretching doesn’t really do what we thought it did and has been argued that it may be a feel good thing as opposed to a therapeutic intervention.

So what about when your athletes want you to stretch them out, especially pre-event?

What Actually Happens During A Stretch

As new research develops we have come to learn that stretches aren’t actually lengthening a muscle, but rather it is the nervous system reacting to the tension placed on the muscle that causes the change.

I always thought that doing a stretch actually elongated a muscle but upon further reading, have come to understand things a little differently.

When we do a stretch and reach that point of feeling tension in the muscle, the GTO (Golgi Tendon Organ) monitors what’s happening and reports back to the central nervous system which then affect’s the muscles response to a stretch.

The nervous system feels the tension and then regulates how far it will allow the stretch to go.

While I used to believe that we were actually lengthening muscle fiber, I’ve come to learn it’s all up to the nervous system.

So then, if I stretch an athlete out before competition, am I actually messing up their stride?

Static Stretching

Static stretches are probably the most commonly used stretch, especially among amateur athletes and weekend warriors.

It’s the type where you place tension on the muscle for 10-30 seconds without much movement involved.

When it comes to athletes and their performance a few studies have shown whether this is helpful to do before competition.

One study  compared 12 college baseball players having stretching done as part of a warm up before throwing pitches. The results showed that doing static stretches as part of the warmup made no difference whatsoever.(1)

Another study done on 16 NCAA track athletes over four weeks showed that static stretching before doing 20 m sprints actually added time to their sprint, showing that stretching had a negative impact on performance. (2)

In an effort to mix things up, thirty teenage athletes were tested on doing dynamic exercise combined with static stretching as a pre-event routine. They were tested on vertical jump, medicine ball toss, 10 yard sprint and an agility shuttle run. The test showed that it might be more beneficial to combine the dynamic exercise with the static stretch in athletes performing power activities.(3)

It’s interesting to see that between the three studies there is a combination of upper body and lower body tests as well as a difference in muscle groups being tested.

Also, the tests were done on very different activities but all came back with either no effect or a negative effect.

So maybe my sport massage teacher was right!?

Not so fast.

Photo by: Ryan McGuire

Photo by: Ryan McGuire

Dynamic Stretching

Dynamic stretching is when there is movement and resistance applied during the stretch.

Commonly known as PNF (proprioceptive neuromuscular facilitation) which has a few other titles under it like:

  • Contract Relax
  • Antagonist Contraction
  • Hold Relax with Agonist Contraction

Essentially you passively stretch the patient, then they contract the muscle against your resistance for a short count and you’re able to passively move the limb or joint into a greater range of motion after they resist.

This is where things change up a little bit with your athletes.

A study on 12 track athletes (yes I know these are small numbers) who train for explosive power, showed that dynamic stretching of the hamstrings increased jump height, yet decreased after static         stretching.(4)

It doesn’t just have an effect on explosive power either.

A study was done to see how it would effect balance, agility and reaction times on the upper limbs. 31 female high school athletes were tested by doing 3 min jogging, then either dynamic stretching, static stretching or rest. Again dynamic stretching won. (5)

Two more studies show that dynamic stretches are a benefit.

One was on female basketball players and their bicep brachii muscle, which recommended dynamic stretches for explosive maximal exercise. (6) The other showed that dynamic stretches for 20 seconds prior to a vertical jump improved not only height, but hip and knee range of motion. (7)

So apparently not all stretching is created equal.

However, the question is why?

There was a study done where heart rate and electromyography (EMG) data were collected and it showed via the EMG that a fast dynamic stretch is linked to greater nervous system activation and prepares an athlete better. (8)

It always goes back to the nervous system.

However now that I have written this post I also have a caveat to the whole thing. After years of working in hockey, one thing I know for sure is: athletes know what they like. They also know their bodies and performance routines better than your average weekend warrior. Before every game or competition athletes like routine, don’t mess it up. If they regularly have you stretch them before a game and want it, then explain why a dynamic stretch is better and ease them into it if they’re not used to it. Also important is to know your sport. Most of the studies listed in this post were very specific for certain movement. Warming up Usian Bolt before a 400m sprint is vastly different than taking care of Sidney Crosby. A sprinter has under 10 seconds to perform, whereas you can help a hockey player warm up, then he goes out for a 10 minute pre-game skate and warm up before the actual game. Your warm up is not going to have the same effect in two drastically different sports. Either way, try to educate and don’t screw with their routine, they really don’t like that.



  1. Haag S, Wright G, Gillette C, Greany J. Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players. Journal Of Strength And Conditioning Research / National Strength & Conditioning Association [serial on the Internet]. (2010, Feb), [cited July 18, 2016]; 24(2): 452-457. Available from: MEDLINE with Full Text.
  2. Nelson A, Driscoll N, Landin D, Young M, Schexnayder I. Acute effects of passive muscle stretching on sprint performance. Journal Of Sports Sciences [serial on the Internet]. (2005, May), [cited July 18, 2016]; 23(5): 449-454. Available from: MEDLINE with Full Text.
  3. Faigenbaum A, Kang J, McFarland J, Bloom J, Magnatta J, Hoffman J, et al. Acute Effects of Different Warm-Up Protocols on Anaerobic Performance in Teenage Athletes. Pediatric Exercise Science [serial on the Internet]. (2006, Mar), [cited July 18, 2016]; 18(1): 64. Available from: SPORTDiscus with Full Text.
  5. Chatzopoulos D, Galazoulas C, Patikas D, Kotzamanidis C. Acute Effects of Static and Dynamic Stretching on Balance, Agility, Reaction Time and Movement Time. Journal Of Sports Science & Medicine [serial on the Internet]. (2014, June), [cited July 18, 2016]; 13(2): 403-409. Available from: SPORTDiscus with Full Text
  6. VEEVO M, ERELINE J, RISO E, GAPEYEVA H, PÄÄSUKE M. THE ACUTE EFFECTS OF WARM-UP, STATIC AND DYNAMIC STRETCHING EXERCISES ON BICEPS BRACHII MUSCLE FUNCTION IN FEMALE BASKETBALL PLAYERS. Acta Kinesiologiae Universitatis Tartuensis [serial on the Internet]. (2012, Dec), [cited July 18, 2016]; 1839-46. Available from: SPORTDiscus with Full Text.
  7. Murphy J, Nagle E, Robertson R, McCrory J. Effect of Single Set Dynamic and Static Stretching Exercise on Jump Height in College Age Recreational Athletes. International Journal Of Exercise Science [serial on the Internet]. (2010, Oct), [cited July 18, 2016]; 3(4): 214-224. Available from: SPORTDiscus with Full Text.
  8. Fletcher I. The effect of different dynamic stretch velocities on jump performance. European Journal Of Applied Physiology [serial on the Internet]. (2010, June), [cited July 18, 2016]; 109(3): 491-498. Available from: MEDLINE with Full Text.