This question comes up a lot, and as more variations of each practice continually emerge, it becomes increasingly difficult to answer.....
A SIMPLE, one line answer (at the risk of overgeneralization) that many have used….acupuncture is aimed at the treatment of disease states and pain through insertion of needling specific points on the body’s surface with the intention of changing a person’s energy flow (or Qi), whereas dry needling aims to make changes to the target tissue by inserting needles specifically into that tissue.
Over time, the practices have started to gravitate toward similarity, as various forms of acupuncture have become more westernized and dry needling has incorporated more eastern thinking.
There are many forms of acupuncture practiced globally, although historians trace all roots back to China, with acupuncture documented as early as the second century. Like any practice, it has evolved over the years, but those rooted in traditional Chinese medicine are most familiar to people in the western world.
One example of the latter..some dry needling approaches teach using alcohol swabs on the skin prior to treatment, whereas others have adopted the eastern thinking that swabbing the skin with alcohol might could kill “good” bacteria.
More on the fundamental differences: One tenet of Traditional Chinese Medicine is that many conditions in the body result from disruptions to balance of qi, which is literally translated as “vital force.” Acupuncture emerged and continues to this day as one approach to restore body balance through realignment of qi. By strategically placing needles into acupressure points along meridians (or channels), through which qi is thought to flow, acupuncture will restore the balance of qi and manage pain or whatever other symptoms are being targeted.
Dry needling, sometimes referred to as trigger point dry needling, has traditionally been based on inserting needles to disrupt trigger points, which we could define as taut, localized ischemic bands. In layman’s terms, think of a “knot” in the muscle with limited blood flow. As dry needling has evolved, we’ve begun to appreciate more global effects of DN beyond simply breaking up these trigger points. When we stick a needle in the body, the effects are felt throughout many systems, not simply in the soft tissue it physically contacts.
Uses basically the same needles. They might differ in the specifics of which needles are used more often though. Needles can vary in length and texture, with different needle qualities having both plusses and minuses.
Generally speaking, you’ll see acupuncture using more needles and keeping them in for longer. It is not uncommon for needles to remain 20-30 minutes, or even longer. Many DN approaches practice a more “get in, get out” strategy; going directly for a trigger point with one or a few needles and then removing it when the acute twitch response has subsided, whereas acupuncture does not seek to make changes to tissue. But again, more and more dry needling approaches are teaching longer insertion durations as the role of the nervous system (not simply the target tissue) gains greater acceptance.
Neurophysiological considerations…while we know from ultrasound imagery that the insertion of a needle into the body causes some disruption to the body’s structure, modern thinking in the dry needling world also appreciates how this process can also have profound effects throughout the nervous system as a whole, from the release of chemicals known to decrease pain sensitivity.
Generally, DN inserts the needles deeper than acupuncture because the target tissue often lies far beneath the surface; there are some techniques even specifically targeted to “peck” the bone.
Both can be paired with electrical stimulation for an added treatment effect.
One criticism that has been leveled at dry needling from the alternative medicine community has been that dry needling as practiced by physical therapists is “only taught in weekend courses.” This critique represents a very superficial understanding of the educational pathway. Physical therapy education, which is now exclusively delivered at the doctoral level in the United States, includes intensive lab-based instruction in anatomy and physiology (again, at the doctoral level). Many physical therapy programs share the EXACT same anatomy lab facilities as MD/DO programs housed at the same institution.
For additional reading see, Notes from Structure and Function Dry Needling course
Allan Phillips, PT, DPT
Oro Valley, Arizona
Bottom line: If you have an injured limb and are unable to train as normal (or train at all), training the other side can still yield benefits of the injured side
Question time….Let’s say you injure your left knee. What is the best strategy for your training plan?
1 Push through pain no matter how bad it is. Don’t change your training plan. Rest is for sissies
2 Continue to train the right knee, so long as it doesn’t further injure or provoke symptoms in the left
3 Stop training both legs because you don’t want you’re right leg to become too strong relative to your left and develop an asymmetry
There is a “best” answer here and that answer is number 2. Answer number 1 is ridiculous, so we’ll put that one aside. Number 3 sounds compelling and while it wouldn’t necessarily be “wrong” to go that direction, there are several reasons why number 2 is better.
Again, this is all based on the caveat that the training you do for the uninjured limb doesn’t put the injured limb at further risk of injury or delay healing. For example, let’s say you were doing some single leg activities on the uninjured leg, but each impact sent a “shock” through the injured leg. Your best bet is to either find different activities or delay training the uninjured limb until it can be done safely without provoking the injured limb.
In the literature, the concept of training effects on one limb being felt on the opposite side limb is called cross education. And to the surprise of some, the evidence is quite clear that cross-education works. Unfortunately, what should be the standard of care (training the rest of the body at the highest level possible in a way that supports the healing process), is instead a novel concept to many.
There are several reasons why cross-limb education is not promoted more. One is that the medical process is often siloed and sees the world with tunnel vision. For example, most orthopedic surgeons are going to just look at the injury and not even consider. That’s not meant to be critical, it’s just the nature of their job. They’re good at going into a damaged body part and making structural corrections using surgical techniques. They aren’t paid to tell you how to train. Similarly, most PT’s in a “traditional” outpatient setting aren’t getting paid to consider the opposite leg (and in some cases are actively discouraged from looking anyplace other than the site of the injury…Not their fault, that’s just the nature of the system in which they work). uninjured limb.
What does the evidence say?....A meta-analysis by Green (2018) reviewed 96 studies on cross education involving healthy young adults, healthy older adults and patients, finding an average strength gain via cross education of 18% in young adults, 15% in older adults, and 29% in a patient population. Although prior meta analyses had shown conflicting results on gender differences and upper versus lower limb effects, the studies compiled by in the Green meta-analysis revealed no significant differences. Overall, the average cross body transfer ranged from 48%-77% in the compiled studies, meaning that the immobilized limb experienced strength gains of 48%-77% of the trained limb. Again, this isn’t just one study on a homogenous group of subjects…this is 96 studies in a variety of populations. (Another interesting finding was that electrically stimulation of muscles appeared to have a greater cross-education effect than voluntary stimulation).
WHY cross education works remains up for debate but most evidence points to neurological mechanisms as the primary factors. Per Cirer-Sastre (2017), “this owes to the fact that no significant vascular adaptations have been found, nor were any histological changes in hypertrophy levels, in enzyme concentration, in contractile protein composition alteration, in fiber type or in cross-sectional area.” In short, strength is function of the nervous system, and the effects of nervous system output are global, meaning not specific to any single body part.
Although the evidence has been relatively settled that cross-education does exist via single sided training, HOW to facilitate cross-education is less clear although a meta-analysis of ten studies by Cirer-Sastre, “to optimize contralateral strength improvements, cross-training sessions should involve fast eccentric sets with moderate volumes and rest intervals.
Finally, approaching this from a pragmatic standpoint, if you sustain an injury to a limb, you could continue training the other limbs and have three “good” limbs or you could stop training both the injured and non-injured arm/leg and have two “good” limbs. Which sounds better?
The concern about developing asymmetries is logical, but overall is far overblown. As we know from the research, the cross-education effect will mitigate strength losses from inactivity by an injured limb. Further, even if cross-education did not exist, you’re better off having to bring one limb up to speed rather than losing strength in both sides have having two limbs to return to normal. Simply makes no sense why you would voluntarily weaken a perfectly healthy limb. Even if an asymmetry develops during a recovery period, its not as though you were going to hop right back into peak training after you get over the injury. You might as well give yourself the highest “baseline” with a strong, healthy limb rather than let both sides regress.
Lara A. Green & David A. Gabriel (2018) The effect of unilateral training on contralateral limb strength in young, older, and patient populations: a meta-analysis of cross education, Physical Therapy Reviews, 23:4-5, 238-249, DOI: 10.1080/10833196.2018.1499272
Cirer-Sastre R, Beltrán-Garrido JV, Corbi F. Contralateral Effects After Unilateral Strength Training: A Meta-Analysis Comparing Training Loads. J Sports Sci Med. 2017;16(2):180–186. Published 2017 Jun 1.
History of Graston Technique… David Graston was competitive water skier; sustained injury but frustrated with poor results from other treatments; went and used jar top as a self massage tool and improved; used his engineering knowledge to create specialized instruments, hence the birth of Graston Technique
More than just scraping and making the skin red (people often associate Graston with these giant bruises, but contemporary thinking has evolved quite significantly)..
Many variables to consider for best possible treatment…size of instrument, which treatment edge, shape of body part being treated, speed of stroke, length of stroke, type of stroke, target tissue length, angle of instrument edge, treatment duration…
I did go in without an intention of purchasing the instruments….but I ended up getting them anyway (in full disclosure, the military and student discounts did play a role in my decision to ultimately purchase)
I know the feeling. Been running along and then BAM…who just whacked the side of my knee with a baseball bat?? Oh, wait…there’s no one around…
Knee pain is one of the classic issues that can befuddle runners. The problem is that not all knee pain is created equal. Saying “knee pain” can mean any number of things, and quite often the problem is far away from the knee. Sure, we need to calm down the pain if we want to start moving normally, but long-term progress requires us to search a little deeper. The purpose of this guide is to help you as an athlete navigate what can seem like an unsolvable puzzle, especially when you’ve been trying to find a solution for weeks, months or even years.
What is the Endurance Exchange conference?..."USA Triathlon and TBI are introducing the Endurance Exchange conference in an effort to grow, inspire and support the triathlon community by collaboratively hosting the nation’s largest experiential triathlon summit where everyone within the multisport community can learn; share best practices, trends and innovations; network; and celebrate. Endurance Exchange replaces the TBI Annual Conference, which was initially scheduled in Tempe for the same dates. It also comprises two former USA Triathlon-hosted industry events, the USA Triathlon Race Director Summit and the Art and Science of Triathlon International Coaching Symposium."
Some notes from the lectures that I attended (there were 2-4 different lectures simultaneously in different rooms at the magnificent Sun Devil Stadium at Arizona State University)
Mental Health & Performance
Notes from Structure & Function Dry Needling Level I: FOUNDATIONS IN ORTHOPEDIC REHAB AND SPORTS PERFORMANCE
Stuff I liked…
What is plantar fasciitis (“PF”)? If you’ve had it, you certainly know it doesn’t feel very good! “Plantar fasciitis” is very broad term commonly applied to any pain on the bottom of the foot. Sometimes the condition is not plantar fasciitis at all, but instead a strained foot muscle or “fat pad syndrome” (more on that diagnosis later). Ultimately, for the patient, the specific diagnosis doesn’t matter too much because the treatment approach will be very similar (assuming we stay in the realm of orthopedics and aren’t dealing with a condition unrelated to muscles, tendons/ligaments or bones).
I call plantar fasciitis an “equal opportunity offender” because you’ll find it in elite athletes who dedicate insane training volumes to their sport but also in sedentary people who walk no further than the bathroom, and of course every type of person in between. In other words, you can get it from doing too much or from not doing enough.
Practically speaking, you’ll find plantar fasciitis manifested in several different ways. First, the classic presentation of plantar fasciitis is isolated tenderness toward the front/middle of the heel, at a landmark called the medial calcaneal tubercle. Although the pain might extend along the entire foot, for this version of plantar fasciitis, the hallmark is localized pain at that specific point on the heel. Additionally, patients with this presentation will often feel pain at its worst in the first step of the morning.
Another similar common presentation is pain further back toward the heel but still on the bottom of the foot over a broader area. This is sometimes called fat pad syndrome if the primary source of pain is the fat pad on the heel rather than the plantar fascia. But again, the causes behind the condition are very similar so the treatment approach should look similar as well.
Plantar fasciitis may also refer to pain in the arch of the foot. Again, this may be a result of true plantar fascia inflammation or it could be referred pain patterns from elsewhere in the body. It could also be a strained muscle, as there are many muscles on the bottom of the foot that perform a variety of functions.
1. CHANGE YOUR CADENCE
Changing to a faster cadence is one way to decrease stress on the foot. Cadence is a more complicated issue than footstrikes-per-minute, but do know that changing to a faster cadence is often accompanied by OTHER changes known to decrease loading, most notably a forward lean and shift to a more forefoot strike. My personal preference is that if you are going to change mechanics, let the mechanical changes emerge as a BYPRODUCT of focusing on cadence rather than flooding your mind with technical cues that may be difficult to implement in real time.
2. FIND SOFT RUNNING SURFACES
This isn’t possible 100pct of the time for everyone, but the sacrifice can be worth it. When I’ve been on the cusp of injury, I’ve done endless loops around a grass soccer field to get the mileage in while minimizing the risk of further injury. There’s precedent for this too at the highest levels of running, as USA Olympians Galen Rupp and Dathan Ritzenheim (both historically injury prone) have been known to do up to 20 miles around a 600m grass loop! As a caveat, there isn’t as much evidence to support this strategy as we might think. That said, anecdotally countless runners report fresh and rejuvenated legs after dedicating the time and effort to run more on grass.
Article: The Benefits of Running on Grass (Triathlete Magazine)
3. TRAIN SMART!
Probably the most important strategy of all. Smart training provides the right amount of stimulus for the body to adapt and become stronger; excess training provides a stimulus too great for the body’s adaptive capabilities. This doesn’t necessarily mean physical breakdown though. Pain could be a warning signal, especially notable given the high density of nerve tissue in the feet. With excess loading, the foot can become more sensitive to pain, meaning it takes less of a stimulus to provoke a higher level of pain than before. All this information returns us to the concept that the first line of defense against plantar fasciitis (or any injury for that matter) is to pick the right training loads.
4. SELF-MASSAGE YOUR FOOT
For self-massage, the simplest would be direct pressure. Just put your finger on a tender spot and hold it there. You can also massage along the foot, finding those “rough” spots or knotted areas and working them out. Though people often report mixed results from self-massage in other areas of the body, the foot tends to respond quite well, perhaps because the foot is so dense with nerve tissue.
Another form of self-massage is instrument assisted soft tissue mobilization. This is just a fancy term for using different objects to perform self-massage! There are plenty of commercial products on the market, some designed specifically for the feet. Everyone has their own preferences, from the hardness of a golf ball to the softness of the spikey ball. Of all the implements available the spikey ball seems to be the most well received.
Every is likely aware of the conventional advice to treat shin splints: R.I.C.E., stretching, a switch to softer running surfaces, training plan modifications, maybe a new pair of shoes or a change in running technique. While each of these techniques have merit as treatment approaches, sometimes you need to think a little outside stay on your feet with minimal disruption in training.
Now, before we treat "shin splints" it is important to confirm that shin splits are really what we're dealing with. For purposes of this article, we'll associate the term shin splints the diagnosis of medial tibial stress syndrome ("MTSS"). In the popular lexicon, shin splints are frequently associated with a myriad of diagnoses including anterior compartment syndrome, anterior tibial tendonitis and stress fractures or stress reactions, among others. The shin splints we'll discuss here involve pain along the inside of the shin as shown below.
“Girl push ups.” Such a horrible term. Thankfully, the term is not used so much anymore, giving way to the less derogatory “push ups on knees.” But terminology aside, I would argue that this form of push ups should probably be retired as well no matter what we call it.
If you want to give yourself the best opportunity to achieve one good push up or give yourself the best opportunity to do even more good push ups, then I believe there are much better methods to accomplish the goal, several if which I will cover in this post.
Don’t get me wrong…If someone just wants to crank out the reps and get a good ol chest burn, then have at it! But if the goal is to achieve your maximum physical potential, manipulating other variables is a better approach. The simple reason is that taking the push up down to the knees turns it into a different movement pattern. The push up is not just a chest movement – it also involves control of everything below, and even demands mobility from the feet, ankles and hamstrings.
Check this out: Here’s a group fitness member who some would label as having a “weak core” based on the picture. But would you believe her problem was actually a painful right big toe, which she is understandably hesitant to bend! When we offloaded her lower body with the band, she was able to place more weight into her legs and successfully perform a complete push up movement. Had she gone down to her knees, she would be missing out on all those positive qualities we experience from a regular push up position.
Last year I took on my first full Ironman at Ironman Santa Rosa. Circumstances were not ideal, given that I was fully immersed in an accelerated Doctor of Physical Therapy program. However, with some friends putting together a group trip to the race, I couldn’t pass up a chance to tackle the distance with a good crew.
A “proper” base build was totally out of the question. Rather than pass on the race, I took the attitude of “Do my best given whatever resources I have available.” If time is a limitation, then we make the most of the time we have (note: this doesn’t mean hammer every session…more on that below…)
Long training history and high training age help a lot. I did my first triathlon in 2001. Minimalism probably isn’t for anyone attempting a couch-to-Ironman program. But it can be done with a large fitness, base even if it comes from a single sport. Based more than 15 years of base, finishing this “long training day” was not an issue. It was simply how much can I sneak into the “zone of performance” without a high risk of complete blow up
Although I said not every day should be a hammer session, your training will definitely shift more toward the “quality” end of the quality vs quantity continuum. Let’s start with swimming (in full disclosure my swim was a disaster, but I largely blame that on a poor wetsuit fit rather than fitness). Swim people may be familiar with USRPT, or Ultra Short Race Pace Training. If you want the details of this approach, there are plenty of resources HERE
Sample USRPT workout
Repeat 50s on an interval giving approximately 20 seconds rest. Select a target time for each rep (say 40 seconds for example). Keep swimming until you swim a rep slower than 40 seconds. Once that happens, you sit out the next rep. Continue this pattern until you miss three reps.
Here’s the bottom line for swimming: quality rules. Don’t get sucked into the long slow distance approach that can be effective for bike and running. You don’t have to follow USRPT but you shouldn’t forget that swimming is a strength and technique sport.
That said, and this may sound contradictory, If there’s one thing I wish I would have done differently it is implement one weekly long continuous swim.
You might be wondering, why bother swimming if it is by far the shortest portion of the event? In my opinion, swimming has the greatest fitness carryover to other events and is also the one least likely to cause injury.
Another key component of swim training was pulling with paddles/buoy/band. Technically this is not pure USRPT (which forbids the use of “toys”) but because paddles/buoy/band is the most effective way to simulate wetsuit swimming, it deserves a place. Also, if you follow the philosophy of Brett Sutton, which I do to an extent, you’ll also realize the paddles/buoy/band combo is simply a good way to get good at swimming.
Run training. Two to three key runs per week. All other runs 30-60 minutes of easy running. The key runs included:
a) Short fartlek such as 15 x minute hard/minute easy
b) Longer fartlek such as 6 x 3 minutes hard/90 seconds easy
c) Easy to moderate paced long run of 10-12 miles (longest single run of the prep was 12 miles)
Ideally, run your long runs on hilly, soft terrain. This will protect your legs and also build run specific strength
There were times during travel during which I was time crunched. Sometimes the whole workout was 8-10 x 50-100m running sprints at 95% effort. If you can’t get in volume, be sure to get in some quality. But again, quality does not mean thrashing yourself with puke-fest HIIT workouts day after day…
Speaking of strength. I’ve often said that kettlebell swings have been a secret to maintaining bike fitness without actually biking lol.. My strength program was relatively informal, but was a mix of low rep kettlebell lifts (mainly the bent press) along with bodyweight (one arm one leg push up and pull ups). In my opinion, carving out some time for strength can be beneficial for health and injury prevention. The key is to find ways to limit the footprint that strength training has on the overall week.
Unless you live very near a gym, driving any significant distance for strength training during a minimalist Ironman approach is simply a waste of time because there is so much you can accomplish away from the gym
I wouldn’t use strength as a way to replace workouts, other than occasionally on the bike, but that was many weeks before the race. Using the grease-the-groove approach is effective if you have the latitude to make it work. That’s probably the most time and resource efficient way to accomplish what you need without borrowing time from swim/bike/run training. We often use “minimal effective dose” as a worn out cliché, but it really is the best philosophy in this context for strength
Biking was mostly Spinervals videos under one hour. Occasionally for shorter rides I’d pull something on youtube that seemed to fit the session objective (recovery, intensity, etc). Only once did I go over two hours indoors.
One of the keys to indoor riding was also the opportunity to spend time in the aerobars. Watch any Ironman and halfway through the bike, hundreds of athletes are seated up, out of the aerobars (quite the irony whenever you see an athlete on a $8,000 bike riding as unaerodynamically as possible). Despite low mileage, spending such a high percentage of my bike time in the aerobars was an example of “free speed.”
Longest ride outdoors was 75 miles, but done at a moderately intense effort on a bike path with minimal stops. You hear a lot about the magic century ride for Ironman, but how often are these done with traffic stops and even coffee stops, not to mention when in a group where you can’t safely hang out in the aerobars for long stretches.
Nutrition...This is one area where experience is especially valuable. With limited opportunities to truly rehearse race day fueling, you’ll have to rely upon what worked in previous races. This might scare some people but I also believe that many nutrition problems are really pacing problems. In other words, when people say “I didn’t get my nutrition right,” what really happened is they went out too hard on the bike and their stomach couldn’t adequately fuel a pace that was unsustainable from the outset
This part is hard to quantify, but I was especially attentive to fatigue from travel or other life events. Since the volume was low to begin with, there was no need to force anything. I’ve trained myself out of plenty of races over the years and I wasn’t going to make that same mistake for my first Ironman
Overall, it’s really not that complicated. Key points are mindset and expectation management. And then sticking to the race day plan. Having limited training volume simply reduces your margin for error but does not preclude a successful outcome. There’s an old saying that being 10 percent undertrained (and healthy) is better than being 5 percent overtrained. A minimalist Ironman prep is a perfect way to put this concept into practice. You may surprise yourself when you give yourself the chance to arrive at the start line fresh and chomping at the bit to go race.
Allan Phillips, PT, DPT
Oro Valley Physical Therapist, USA Triathlon Certified Coach
Allan Phillips, PT, DPT is owner of Ventana Physiotherapy